1. JE Vaccines-Monjori Mitra

Report
Japanese Encephalitis Vaccine
Dr Monjori Mitra
Associate Professor
Institute of Child Health Kolkata
Issues to Consider
•
•
•
•
Epidemiological status
Currently Available Vaccines
New Vaccination Modalities
The Clinical Trial Currently Underway
Japanese Encephalitis Virus
History
• Minor epidemics of “summer encephalitis in Japan since
at least 1870; large outbreak in 1924 causes 6,125 cases
with 3,797 deaths
• Initially called Japanese type B encephalitis to differentiate
from epidemic encephalitis lethargica, type A encephalitis
• Virus first isolated from the brain of a fatal case in 1935
• Isolated from Culex tritaeneorhinchus in 1938
• Now known to be the principal mosquito vector in most of
the geographic distribution of the disease
Epidemiology
• Primarily a disease of rural Asia
– Vector mosquitoes proliferate in close association with birds and pigs
– Birds and pigs are the major amplifying hosts
– Many other mammals and reptiles infected as well, long term viremia
documented in bats, others
• Culex tritaeniorhynchus the principal vector but many other
mosquitoes are competent and can transmit
– C. pipiens
– C. quinquefasciatus
– Species of Aedes, Anopheles
• Virus overwinters in mosquitoes as well as vertical transmission
• Traditional seasonal spread (spring/summer) heavily impacted
by rice paddy flooding
Cattle May Serve to Modulate JE Activity
Photo by George Risi
Incidence and Prevalence
•
Commonest cause of encephalitis
in Asia
• In hyperendemic areas half of
all cases occur in children
under 4 years of age, nearly all
before age 10
• Nearly 100% seroprevalence by
adulthood in heavily infected
areas
• Epidemic and endemic forms
•
•
20,000 cases and 6,000 deaths
annually a gross underestimate
Mathematical modeling predicts
175,000 annual cases, 43,750
fatalities, 78,750 with disability
Incidence and Prevalence
• Ratio of apparent to inapparent
infection ranges from 1:250 in
susceptible Asians to 1:63 in
adult US marines, 1:18 in Torres
strait outbreak
• Ratio affected by age, virulence
of the strain of virus, cross
protective immunity from other
flaviviruses (dengue)
• Risk to travelers 1 case per
50,000 months of exposure
Epidemiology
• Geographic range
expanding; new areas
infected by
– Viremic migratory birdsGuam, Saipan
– Windblown mosquitoesTorres strait of Australia
Uttar Pradesh
Epidemiology
• July 2005 an outbreak began in
northern India and Nepal; by
November 10, 2005 Uttar
Pradesh and Bihar had 6097
cases, 1400 deaths (23%
mortality)
• Outbreaks clearly related to
difficulties and expense of
currently available vaccine
Bihar
Epidemiology
Japanese Encephalitis Virus is transmitted to Humans by the bite of infected Mosquito
species.
Different mosquitos genera and species of mosquito serve as intermediate host and
transmit JE virus.
•Anopheles species: •Culex species: •Mansonia species:-
hyrcanus, subpictus
tritaeniorhynchus, vishnui
annulifera, indiana
Pigs & birds are primary reservoirs wherein the virus is maintained & amplified
30- 50,000 overt JE cases and 10,000 deaths reported annually worldwide (likely
underreported).
30% of survivors suffer from lasting damage to central nervous system
In India JE has shown increasing trend in occurrence and expansion of disease to nonendemic areas in India
In JEV endemic areas, JE is primarily a pediatric disease
Dr. Goetz Reiner 11
JEVirus –Transmission, Prevalence, Risk
Key risk groups
Military deployed to
endemic areas
Travelers
Expatriates in rural areas
Residents of rural areas
in endemic locations 12
JE Vaccination Program – Overview
JE campaign States & districts
1
Andhra Pradesh
10
2
Kerala
2
3
Uttar Pradesh
34+1
4
Goa
2
5
Assam
11
6
Bihar
6
7
Haryana
6
8
Karnataka
7+1
9
Tamil Nadu
9+1
10
Maharashtra
8
11
West Bengal
5
JAM MU & KASHM IR
HIMACHAL PRADESH
Map showing 112
JE vaccination
campaign districts
PUNJAB
UT TARANCHAL
HARY ANA
SIKKIM
RAJASTHAN
ARUNACHAL PR.
UT TAR PRADES H
ASSAM
NAGAL AND
MEGHAL AYA
MANIPUR
TRIPURA
JHARKHAND
MIZ ORAM
WEST BENGAL
BIHAR
GUJARAT
MADHYA PRADE SH
CHHAT TISG ARH
ORISSA
D&N HAV ELI
MAHARASHTRA
12
Manipur
5
13
Nagaland
2
14
Arunachal Pradesh
1
15
Uttarakhand
1
Total
112
ANDHRA PRADESH
GO A
KARNAT AKA
A&N ISL ANDS
PONDICHERRY
TAMIL NADU
LAKSHADW EEP KERALA
The JE Mass vaccination Drives (
Campaigns ) Coverage
No. of
States
covered
No. of
Districts
covered
Target
population1-15 years
Total JE
vaccination
campaign
coverage
JE vaccination
campaign
coverage %
S.No.
Year
1
2006
4
11
10531554
9308688
88.39
2
2007
9
27
21758223
18431087
84.71
3
2008
9
22
20040262
16881941
84.24
4
2009
10
30
27170604
18097182
66.61
5
2010
8
19
9336609
7626354
81.7
2
9
7659936
7495380
97.85
118
96497188
77840632
80.67
6
2010*recampaigns
Total
* Based on the emergence of new cases JE/ AES and low coverage as
per CES report in 9 districts 2 states , it was decided to conduct re-campaigns
JE vaccination campaigns - Year coverage
2006 - 2011
Coverage%
JE vaccination campaigns - Year coverage
100
80
88%
97.9%
84.7% 84.2%
66.6% 69.6%
60
40
20
0
Year of Campaign
Around 78 million children have been immunized in the
JE vaccination campaigns from 2006 – 2011
Around 4 million children have been immunized
with JE vaccine under RI
JE Vaccination Campaign
2006
JE Vaccination Campaign
2007
JE Vaccination Campaign
2008
JE Vaccination Campaign
2009
JE Vaccination Campaign
2010
Japanese Encephalitis Disease
•
•
•
•
Incubation 6-16 days. Spectrum from
mild febrile headache to severe
encephalitis
Headache, fever, nausea, vomiting,
drowsiness. Abdominal pain and
diarrhea common in children
Progression over several days to severe
disease
– Dull, mask-like facies
– Muscular rigidity
– Cranial nerve palsies
– Tremulous eye and extremity
muscle movements
– Generalized and localized paresis,
incoordination, pathologic reflexes
Seizures frequent in children, <10% of
adults
Associated Press
Clinical Manifestations
•
•
•
•
Death in 5-40%
Some deaths after acute
fulminant course, others from
cardiopulmonary complications
with prolonged coma
Children under 10 more likely to
die or have residual neurological
defects
Poor prognosis associated with
–
–
–
–
–
–
Respiratory dysfunction
Babinsky’s sign
Frequent or prolonged seizures
Prolonged fever
Albuminuria
High viral replication in the brain
Source: Reuters News Agency
Epidemiological Data
24
Type of vaccine: 1) Live attenuated vaccine (SA 14-14-2 strain) 2)
Inactivated, Vero cell-derived, alum-adjuvanted vaccine (SA 14-14-2 strain)
3) Inactivated Vero cell-derived based vaccines (Beijing-1 strain)
Schedule: 1) In China, the first dose of the live attenuated vaccine is given
subcutaneously at age 8 months, followed by a booster dose at 2 years of
age. In some areas, an additional booster is offered at 6–7 years of age.
Protection for several years may be achieved also with a single dose of this
vaccine. 2) Primary immunization of the inactivated, alum-adjuvanted
vaccine consists of two intramuscular doses, 4 weeks apart 3) The
inactivated (Bejjing-1-) vaccines: three doses at days 0, 7 and 28, or two doses
given preferably 4 weeks apart (0.25 ml for children <3 years, 0.5 ml for all
other ages).
Booster:
The duration of immunity is not well established for the above vaccines.
1) the live attenuated vaccine, a booster dose is recommended in some
countries.
2) the Japanese vaccines, a booster is recommended after year 1, and
thereafter every 3 years.
3) the inactivated, alum-adjuvanted vaccine, one booster is recommended 12–
14 months after completion of the primary immunization; the possible need for
further boosters to be determined.
Adverse reactions: Occasional mild local or systemic reactions
Before departure: The immunization series should be completed at least 1 week
before potential exposure to JEV.
Efficacy of the SA 14-14-2 Vaccine against Japanese Encephalitis.
Effectiveness of One Dose of SA 14-14-2 Vaccine against Japanese Encephalitis
N Engl J Med 2009; 360:1465-1466April 2, 2009
Kumar R et al. N Engl J Med 2009;360:1465-1466.
Immunogenicity and efficacy of Live Attenuated SA 14-14-2
Several studies have demonstrated an excellent immune
response after a single dose of SA 14-14-2 vaccine, with
neutralizing antibody responses produced in 85%-100% of
non-immune children.
Several field trials in China have yielded protective efficacy
rates above 95%. One early case control study found 80%
vaccine efficacy in children receiving one dose and 98% for
two doses.
A more recent study in an endemic area of Nepal reported
99.3% efficacy of a single dose. One year after immunization,
a follow up study in the same region reported efficacy of
98.5%.
Global Advisory Committee on Vaccine Safety - The SA 14-14-2 live attenuated JE vaccine
GACVS has reviewed safety aspects of this vaccine at two of its meetings (twelfth, held on
9-10 June 2005, and fifteenth, held on 29-30 November 2006). GACVS reviewed data
related to the safety, immunogenicity and efficacy of the vaccine, and scrutinized data on
co-administration with measles vaccine.
GACVS concluded that the short-term safety profile of live JE vaccine appears satisfactory
and that there appears to be a high level of vaccine efficacy after the administration of a
single dose.
In relation to serious adverse events reported after mass vaccination campaigns in India
during 2006, no direct causality has been established between the reported illnesses and
the SA14-14-2 JE vaccine.
Nevertheless, GACVS recommended that in future, potential vaccine-related serious
adverse events should be better investigated. Furthermore, more investigations are
required to assess the possible risk of low frequency adverse events (especially
neurological).
Since live JE vaccine is currently used in “catch-up” campaigns on many millions of children
in Asian countries, the opportunity should be taken to examine whether the vaccine safety
profile remains valid in large study populations.
Development of Vero cell-derived inactivated
JE vaccine
Other JE Vaccine Manufacturers
Vaccine
Inactivated
Live
Attenuated
Inactivated
Name of the Vaccine
Mfg.
Strain
Doses
Mouse Brain purified
inactivated JE vaccine
CRI Kasauli
Nakayama
3 (>3yrs– 1ml and
1-3yrs – 0.5 ml)
Mouse Brain purified
inactivated JE vaccine
(JENCEVAC)
Green Cross
– Shantha Nakayama
Biotech
Schedule Route Presentation
0, 7 & 30
SC
Liquid
3 (Adult – 1.0 mL &
0, 7 & 30
Children – 0.5 mL)
SC
Liquid
SC
Lyophilized
Mouse Brain purified
inactivated JE vaccine
(JE-VAX)
Sanofi
Pasteur
Nakayama
3 [Adult – 1.0 mL &
Children (1-3 Yr.)– 0, 7 & 30
0.5 mL]
Vero cell – Inactivated
vaccine (IXIARO)
Intercell
SA-14-14-2
2 (only >17 Yr. - 0.5
mL)
0 & 28
IM
Liquid PFS
Live attenuated JE
Vaccine
China
SA-14-14-2
1 (Adults & children 0.5 mL)
0
SC
Lyophilized
Live attenuated JE
Vaccine (Chimerivax)
Acambis
SA-14-14-2
1 [Adult – 1.0 mL &
Children (9-36
Months.)– 0.5 mL]
0
SC
Lyophilized
Vero- derived Purified
inactivated JE Vaccine
(JENVAC®)
BBIL
Kolar
2 (Adults & children 0.5 mL)
0 & 28
IM
Liquid
Comparison between different JE vaccines
(Mouse brain, Live (PHK) and Vero cell based )
Nakayama, Beijing-1
SA14-14-2
Inactivated
Intercell and Bio E)
IXIARO/ JEEV
SA14-14-2
Mouse brain
Primary hamster kidney
(PHK) cells
Lyophilized
Vero Cells (Monkey Kidney
cells
Liquid
Inactivated
(Biken)
Strain
Substrate
Formulation
Licensed
Lyophilized
1954 – Japan
1993 – US
Worldwide: traveller vaccine
Geographic
SE Asia – childhood
use
Administration Subcutaneous
0.5 mL-children
Dosage
1.0 mL-adults
At one year & every 3 years
Booster
91% – 2 dose
Efficacy
Protection
Safety
Antibody levels > or = 1:10
Rare cases of urticaria,
angioedema, dyspnea, acute
encaphalo-myelitis
*IXIARO
Live attenuated
(Chinese)
1988 – China
China, India
Subcutaneous
0.5 mL-children
1.0 mL-adults
At 6 years
80% – 1 dose
97.5% – 2 dose
Antibody levels > or = 1:10
Serious adverse event
reported
Ixiaro-Licensed in USA,
Australia, Canada & many
other countries
JEEV – Licensed in India
Traveller vaccine
IM
0.25 mL-children
0.5 mL-adults
Studies on going
96 % – 2 dose in adult
95.7% -2 dose in children
Antibody levels > or = 1:10
lower rate of Adverse Events.
PAGE 33
Collaboration with NIV & iOWH
For JE Vaccine Development
has collaborated with
Dr. Milind Gore
National Institute of Virology,
Pune, India,
Dr. Richard Chin, Director
Dr. Raj Shankar Ghosh, Regional Director,
South Asia. (now PATH)
Global Scenario - JE Vaccine
First Generation Vaccines (Mouse Brain Derived):
•BIKEN- Japan has been the largest manufacturer
and international distributor,
but has ceased production.
•JENCEVAC- Manufactured by Green cross, South
Korea.
Other manufacturers are found in
Taiwan, Thailand and Vietnam
Global Scenario - JE Vaccine
Second Generation Vaccines: Vero cell derived, Purified inactivated JE vaccine:
•IXIARO: Manufactured by Intercell AG, Austria. The vaccine was approved for adults.
Phase III clinical trials completed in Indian children (BE collaboration).
•
Manufactured by Bharat Biotech International Limited. The vaccine was
approved for conducting Phase-II/III clinical trial and trials completed in adults &
children.
Innovative aspects of BBIL JE Vaccine
Thermostable strain
Increased stability &
shelf-life of the vaccine
Novel inactivation process - to keep the
Antigenicity increase immunogenicity
NIV-History of JE virus seed
Obtained from
: NIV, Pune, India
Isolation
: JE infected encephalitis patient
Strain
: Thermostable Kolar Strain (JEV 821564 XY)
Passage history
: 17 times in suckling mice
Original Seed titer
: LD50 per mL = 107
Product & Production profile
•
Purified, inactivated Japanese encephalitis protein Not Less Than 5.0µg/0.5mL (Single
Human Dose)
•
Robust manufacturing technology
•
Production facility- Fully validated commercial scale
•
Production capacity- 25 Million doses annually
Pre-clinical study
Pre-clinical toxicity (BBIL)
Systemic toxicity
Group
Dose/Dosage
(Intramuscular)
Type of Sample Injection
Male
Female
4 doses (day 0, 7, 14 &
28)/0.5mL PBS buffer
10
10
4 doses (day 0, 7, 14 &
28)/0.5mL NLT 5µg
10
10
10
10
Group I
(Control)
PBS buffer
Group II
JENVAC
Group III
JENCEVAC
4 doses (day 0, 7, 14 &
28)/ 1mL
Group
Type of Sample Injection
Dose/Dosage
(Intramuscular)
Group I
(Control)
PBS buffer
Group II
JENVAC
Group III
JENCEVAC
®
®
No. of Rats per group
No. of Rabbits per group
Male
Female
4 doses (day 0, 7, 14 &
28)/0.5mL PBS buffer
3
3
4 doses (day 0, 7, 14 &
28)/0.5mL NLT 5µg
3
3
4 doses (day 0, 7, 14 &
28)/ 1mL
3
3
Pre-Clinical studies done as per Schedule-Y
Pre-clinical toxicity (BBIL)
Systemic toxicity
• Dose schedule of the vaccine is a maximum of 2SHDs, but in this study 4SHDs were
given to the rats and rabbits and no impact was found on the animal safety.
• Blood samples for evaluation of serum chemistry and hematology were collected from
all the animals on 0th day & 42nd day.
• A terminal body weight was obtained shortly prior to necropsy and a complete gross
necropsy was conducted on all animals sacrificed during the study.
• There was no treatment related effects on mortality, clinical observations, body weight,
food consumption, water consumption, coagulation, hematology or clinical chemistry
analysis and histopathology in both rats & rabbits.
Conclusion:
Based on the study, Purified Inactivated Japanese Encephalitis Vaccine injection
did not alter any of the above parameters in rats and rabbits in the systemic toxicity
study conducted for a period of 42 days.
Animal Potency study
Animal Potency study (Thailand)
• Project: Study on potency of inactivated Japanese encephalitis vaccines in adult
mice
• Site of Study: Center for Vaccine Development, Mahidol University at Salaya
(WHO approved center for JE vaccines)
• Animal: Female Swiss Albino Inbred strain SPF mice, age 4 weeks
Immunization dose/schedule: Vaccine 1:10 dilution
Day
0
1
1st dose at Day 0, by I.P. route
2
3
4
5
6
7
2nd dose at Day 7, by I.P. route
Animal Potency study (Thailand)
• Vaccines:
Inactivated JE vaccine: Batch-88DP9001, Source: Bharat Biotech, India
Inactivated JE vaccine: Batch-JJ 5210 3, Source: GPO, Thailand
Inactivated JE vaccine: Batch 00410002 Source: Korean Green Cross, S. Korea
(Nakayama),
• Serum collection:
Collected on day 14 post dose 1
• Serologic test:
A validated Plaque Reduction Neutralization Test, 50% end point in continuous LLC-
MK2 cells as per SOP using JE wild type Beijing strain as challenging virus, was used
to evaluate all sera collected during the study period.
Animal Potency study (Thailand)
Result:
•
To evaluate the magnitude of change in circulating neutralizing antibody titers after
immunization, titers were measured in all 10 mice immunized. With 2 doses of the
Bharat Biotech JE vaccine with GMT 153.55 and 100% seroconversion rate.
•
For GPO, GMT of PRNT was found to be 187.22. Seroconversion rate of those 10 mice
being used in the study revealed 90%.
•
For KGC vaccine evaluation, GMT was fount to be 46.21 and 80% seroconversion rate.
Conclusion:
Bharat Biotech JE Vaccine, like GPO JE Vaccine confers higher GMT than the
Korean Green Cross JE Vaccine. For seroconversion rate, the Bharat JE Vaccine
revealed 100% seroconversion rate after 2 doses, while the other 2 vaccines could not.
Phase I Clinical Trial
Phase I Clinical Trial
Protocol Title:
A Phase I, Randomized, Double Blind, Placebo Controlled and Parallel Assignment
Study to Evaluate the Safety, tolerability and immunogenicity of inactivated
Japanese encephalitis Vaccine Produced by BBIL in healthy adult volunteers.
Protocol Number: BBIL/JEV/I/2010
Study Investigator & Centre:
Dr. Murali Mohan, MD-General Medicine, Professor, Dept of Medicine, Vydehi
Institute of Medical Sciences, Bangalore.
Study Population
A total of 60 healthy adult male subjects of age 18 to 50 years were participated in this
study.
Cohort 1: 25 vaccine and 5 placebo = 30 subjects (2 doses, day 0 & 28)*
Cohort 2: 25 vaccine and 5 placebo = 30 subjects (3 doses, day 0, 7 & 28) *
*Dose:
As other commercially available vaccines are either 2 doses or 3 doses,
hence BBIL has selected 2 & 3 dose schedule in Phase I Clinical Trial.
Number of subjects
enrolled
Number of Subjects
completed
Number of subjects
dropped out
60
52
08
Dose and Mode of administration
•
Subjects received either cell culture Inactivated Japanese encephalitis vaccine
containing NLT 5µg protein or placebo by intramuscular route as per
randomization.
•
Liquid 0.5ml of vaccine/placebo is injected as two doses on day 0 and day 28+/-2
(Cohort-1) and three doses on Day 0, Day 7±1 and Day 28±2 (Cohort-2) by
intramuscular route in to the deltoid region
Study Objectives
•
Primary objective:
Evaluate the safety and tolerability in healthy volunteers of 18 to 50 years.
•
Secondary objective:
Immunogenicity in healthy volunteers of 18 to 50 years.
Study Procedure & Plan
Safety Evaluation:
•
Adverse events, vital signs, Physical and clinical evaluation and laboratory tests.
•
Lab investigations for safety evaluation done at baseline and 56±2 days
following administration of either vaccine or placebo.
Immunogenicity Evaluation:
•
Immunological assessment at base line, 28±2 and 56±2 day for 50% plaquereduction neutralization test (PRNT50) antibody titre increase against the JE
virus
Results (Safety)
Adverse events
observed
Test vaccine
(121 doses)*
Placebo
(25 doses)**
Fever
10 (8.26%)
0
Headache
4 (3.35%)
1 (4%)
4 (3.35%)
0
Bodyache
3 (2.48%)
0
Weakness
0 (0.00%)
1 (4%)
Swelling
1 (0.83%)
0
Cold
1 (0.83%)
0
98 (80.90%)
23 (92%)
Pain at Injection
site
No AEs
Results (Safety)
• There was no clinically significant change in any of the vital parameters as well as
haematological and other biochemical lab parameters after two and three doses of
vaccine administration
• Subjects were also followed up till day 90 for safety, none of the enrolled subjects were
withdrawn from study for vaccine related adverse reactions
• There was no significant difference between the vaccine and placebo groups for all the
common adverse reactions (headache, weakness, swelling & cold) and there is a
difference between the groups for fever, pain at injection site & body ache noted.
• Adverse Events observed in the study group are similar/less with other published
clinical studies (Intercell and Sanofi Pasteur).
(Ref: Assessment report for IXIARO - European Medicines Agency, 2009)
Results (Immunogenicity)
The Antibody estimation was carried out by PRNT50 method for the Immunogenicity
evaluation. JE vaccine strain 821564 (homologous virus) is used as a challenge virus.
Comparison of GMT:
Group
Geometric Mean Titre (n)
Day 0
Day 28
Day 56
Vaccine
(2-Doses)
6.75
(25)
148.72
(21)
411.23
(20)
Vaccine
(3-Doses)
6.14
(25)
189.59
(25)
432.47
(25)
Placebo
7.16
(10)
8.08
(10)
8.53
(07)
Note: No statistical difference between 2 and 3 dose group
(p-value >0.05) on 28th and 56th day.
Results (Immunogenicity)
Comparison of % of Seroprotection
Group
% of Seroprotection
(n)
Day 0
Day 28
Day 56
Vaccine
(2-Doses)
23.81
(25)
100
(21)
100
(20)
Vaccine
(3-Doses)
16
(25)
100
(25)
100
(25)
Note: No statistical difference between 2 and 3 dose
group (p-value >0.05) on 28th and 56th day.
Results (Immunogenicity)
Comparison of % of Seroconversion
Group
% of Seroconversion
(n)
Day
0 to 28
Day
0 to 56
Vaccine
(2-Doses)
90.48
(21)
100
(20)
Vaccine
(3-Doses)
96
(25)
100
(25)
Placebo
0
(10)
0
(07)
Note: No statistical difference between 2 and 3 dose
group (p-value >0.05) on 28th and 56th day.
Results (Immunogenicity)
•
There is no statistically significant difference between the Geometric Mean Titres
of the subjects given two and three doses of BBIL’s JE vaccine on day 28 & 56.
•
The percentage of Seroprotection in subjects given two and three doses of BBIL
Japanese encephalitis vaccine is 100% on day 28 or day 56 .
•
The percentage of Seroconversion (≥4-Fold titer rise) with subjects given two
and three doses of BBIL’s Japanese encephalitis vaccine on day 56 was
100%.
Analysis & Cross reactivity study - at NIV
Considering the expertise of NIV, Pune in the field of JE vaccine sera testing, representative set of
blinded samples were sent to NIV, Pune for test validation and cross reactivity evaluation.
Serum samples of the phase I clinical trial were tested for anti-JE neutralizing antibodies against
homologous (821564) and internationally accepted heterologous (057434) JEV strains by Plaque
Reduction Neutralization Test (PRNT) at the National Institute of Virology, Pune.
NIV results
Parameter
Heterologous virus
BBIL results
Homologous virus
Homologous virus
Time period
0 Day
28 Day
56 Day
0 Day
28 Day
56 Day
0 Day
28 Day
56 Day
GMT
6.5
14.8
18.5
8.9
23.0
27.9
8.9
30.4
51.5
Conclusion
•
It can be concluded that BBIL’s Japanese encephalitis vaccine is safe, well
tolerated and immunogenic against homologous (821564) and heterologous
(057434) JE virus strains in healthy volunteers of age 18-50 years.
•
Hence as the immune response is adequate (100% seroconversion) with two
dose vaccination, we wish to carry a large-scale multi-centre Phase III study in
diverse population for evaluation of extended safety and immunogenicity of
Inactivated Japanese encephalitis vaccine.
Phase II/III Clinical Trial
Phase II/III Clinical Trial
Protocol Title:
A Phase II/III, Randomized, Single Blinded, Active
Controlled Study to Evaluate the Immunogenicity and
Safety of inactivated Japanese encephalitis Vaccine in
healthy volunteers.
Protocol Number: BBIL/JEV/II/III/2011
Study Centers:
We have conducted the study in 9 centers in 4
different states stated below across India.
1. Andhra Pradesh
2. West Bengal
3. Karnataka
4. Rajasthan
Service providers
Randomization, Labeling & Decoding
Asian Clinical Trials
Statistical Analysis:
Dr.G.S.R Murthy, Indian Statistical Institute, Hyderabad
Sera Sample Analysis
NIV – Pune
BBIL - Hyderabad
Study Investigators and sites
• Dr. J. Venkateswara Rao, Gandhi Medical College, Secunderabad
• Dr. G. Sampath, Institute of Preventive Medicine, Hyderabad.
• Dr. P. Venugopal, King George Hospital, Visakhapatnam.
• Dr. Mukesh Guptha, Saumya Child Clinic, Jaipur
• Dr. B. Krishnamurthy, Mysore Medical College, Mysore
• Dr. Monjori Mitra, Institute of Child Health, Kolkata
• Dr. Sudhakar, Priya Children’s Hospital, Vijayavada
• Dr. Sri Krishna, Mahavir Hospital, Hyderabad
• Dr. Bhuvaneswar Rao, Sri Sreenivasa Children’s Hospital, Vijayavada
Inclusion Criteria
•
Healthy volunteers of 50 to 1 years.
•
Available for all study related visits and procedures for the entire duration of the
study, without any known exposure to JE prior to the first screening visit based on
previous clinical history.
•
Willing to give signed written Informed Consent.
Exclusion Criteria
•
Subjects with the age less than 1 and above 50 years.
•
Fever of any origin of duration more than 3 days within one month prior to screening or
on the day of screening.
•
History of malaise, head ache, anorexia at the time of screening or during the
administration of the vaccine under study.
•
Past history of JE infection.
•
Life threatening or serious cardiac (NYHA grades III-IV heart failure), respiratory
gastrointestinal, Hepatic, renal, Endocrine, hematological or immune disorders.
•
Past history of / current allergic diseases.
Exclusion Criteria
•
Any confirmed or suspected immunosuppressive or immunodeficient condition
•
Use of any marketed or investigational or herbal medicine or nonregistered drug or vaccine
for JE or other vaccine in the past 2 months.
•
Clinically relevant abnormal hematology or biochemistry values in the opinion of the
investigator.
•
Any criteria, which in the opinion of the investigator, suggests that the subject would not be
compliant with the study protocol.
•
Intention to travel out of the area prior to final or follow-up Visit on day 56±2.
•
Previous history of hypersensitive reaction to vaccine or vaccine component.
Study Population
 The sample size has been calculated on the following assumptions: allocation ratio of 3:1
(test: reference), 90 % power, a non-inferiority margin of 15%, one sided alpha - 97.5% CI.
Based on the above inputs, a total of 600 evaluable subjects are needed (450 in test group
and 150 in the Reference group).
 A total of 644 healthy subjects of age ≤50 to >1 year participated in this study across 9
centers in India
Category
Age in years
Test group
Reference group
1
≤50 to >18
156
56
2
≤18 to > 6
144
57
3
≤6 to ≥1
178
53
478
166
Total
Number of subjects
enrolled
Number of Subjects
completed
Number of subjects
dropped out
644
608
36
Study Endpoints
Primary Endpoint:
• Proportion of participants achieving 4-fold or greater neutralizing antibody titer in
subjects seropositive at baseline (≥1:10) at day 28±2 after a single dose of
vaccination.
• Proportion of participants that are seronegative at baseline (<1:10) will require a
PRNT50 titer of ≥1:10 to meet the criteria for seroconversion at day 28±2 after a
single dose of vaccination.
Study Endpoints
Secondary Endpoint:
• GMT in each group on day 0 and day 28±2.
• Occurrence of solicited and unsolicited local and systemic AEs within 28 days and 56
days of post vaccination on day 0, 28±2 and 56±2.
• Occurrence of vaccine-associated SAEs throughout the course of the study.
• Proportion of participants achieving 4-fold or greater neutralizing antibody titre at day
56 after two doses of vaccination.
Dose and mode of administration
•
Based on the results obtained from Phase I study we have selected the 2 dose
schedule in Phase III study. As per the insert instruction, one dose of
reference
vaccine selected.
•
Test vaccine: Liquid Purified, inactivated Japanese encephalitis protein NLT
5.0µg/0.5mL was injected as two doses on day 0 and day 28±2 by
Intramuscular
route.
•
Reference vaccine: Lyophilized Reference Vaccine (Live attenuated, SA 14-14-2
Chinese vaccine) 0.5mL was injected subcutaneously after reconstitution with the
diluent supplied as one dose on day 0 and Placebo was administered as second dose
on day 28±2.
Study Objectives
•
The primary objective is to compare the immunogenicity of the Test vaccine with
Reference vaccine in terms of seroconversion and Geometric Mean Titers of JEV
neutralizing antibody four weeks after two doses.
•
The Secondary objective is to assess and to evaluate the Safety of the cell cultured
inactivated Japanese encephalitis Vaccine in healthy volunteers of 50 to 1 years.
Trial Profile
Results (Safety)
Distribution of Adverse Events in ≤50 to >1 year age group
Test Vaccine Group
Adverse events
observed
After 1st Dose
(478 doses)
Reference Vaccine Group
After 2nd Dose
(450 doses)
After 1st Dose
(166 doses)
After 2nd Dose
(156 Placebo)
32 (19.3%)
5 (3.0%)
2 (1.3%)
0 (0%)
2 (1.2%)
0 (0%)
General Adverse Events
Fever
93 (19.5%)
6 (1.3%)
Body ache
12 (2.5%)
Vomiting
3 (0.6%)
0 (0%)
0 (0%)
Diarrhoea
3 (0.6%)
0 (0%)
1 (0.6%)
1 (0.6%)
Cold
2 (0.4%)
0 (0%)
2 (1.2%)
0 (0%)
Cough
2 (0.4%)
0 (0%)
0 (0%)
0 (0%)
Myalgia
1 (0.2%)
9 (1.9%)
0 (0%)
2 (1.2%)
0 (0%)
2 (0.4%)
3 (1.8%)
0 (0%)
Pain at Injection site
47 (9.8%)
18 (4%)
22 (13.2%)
6 (3.8%)
Total AEs
172 (36%)
26 (5.8%)
69 (41.6%)
9 (5.8%)
Headache
Local Adverse Events
p-values are given in the next to the graphical presentation slide
Results (Safety)
58.4%
94.2%
94.2%
Results (Safety)
•
There was no significant difference between the Test vaccine and Reference
vaccine groups for adverse reactions noted after first dose of vaccination (p-value
>0.05).
•
Adverse Events were reported significantly lower after second dose, when
compared to after first dose of test vaccination (p-value <0.001).
•
The AEs reported after second dose in Test group were not significant with the AEs
reported after Placebo administration as second dose in Reference group (p-value
>0.05).
Results (Immunogenicity)
•
The Antibody estimation by PRNT50 method for the Immunogenicity.
•
JE vaccine strain 821564 (homologous virus) is used as a challenge virus.
•
Seroprotection: A PRNT50 antibody titre of more than 1:10 generally is accepted as
evidence of protection.
•
Seroconversion: % of subject’s ≥4-fold titer rise from pre to post vaccination titer
called as % of Seroconversion (4-fold).
Note: For subjects with a minimum dilution factor <10 (PRNT50), the titre is set to 5.
Results (Immunogenicity)
Comparison of Seropositive & Seronegative percentages between the vaccine groups (Age
category ≤50 to≥1 year):
Parameter
Test
Vaccine
Referen
ce
Vaccine
Pvalue
% of subjects seronegative
at base line (Day 0)
88.72
82.05
>0.05
% of subjects seropositive
at base line (Day 0)
11.28
17.95
>0.05
% of subjects seropositive
after single dose (Day 28)*
98.50
72.66
<0.001
*Excluding subjects seropositive at base line
Results (Immunogenicity)
Seroprotection & Seroconversion of study Groups in ≤50 to ≥1 years
Response
Time
period
Test
vaccine
Reference
vaccine
p-value
Day 0
11.28
17.95
>0.05
Day 28
98.67
77.56
<0.001
Day 0
to 28
93.14
57.69
<0.001
% of
Seroprotection
% of
Seroconversion
(4-fold)
All the subjects included
Results (Immunogenicity)
Seroprotection & Seroconversion of Test vaccine in different age groups
Age Group
Response
% of
Seroprotection
% of
Seroconversion
(4-fold)
Time
period
≤50->18
years
≤18->6
years
≤6-≥1
years
Pvalue
Day 0
11.11
13.67
9.46
>0.05
Day 28
97.22
99.28
99.41
>0.05
Day 56
99.31
100
100
>0.05
Day 0 to 28
89.58
93.53
95.8
>0.05
Day 0 to 56
93.06
98.56
98.82
>0.05
Results (Immunogenicity)
GMT, Seroprotection & Seroconversion comparison in three different age groups
Group
≤50->18 years
≤18->6 years
≤6-≥1 years
Vaccine Group
Geometric Mean
Titre
% of Sero
prevalence
% of Sero
protection
% of Sero
conversion
Day 0
Day 28
Day 0
Day 28
Day 0 to 28
Test Vaccine
6.02
105.6
11.11
97.22
89.58
Reference
Vaccine
7.09
36.50
25.49
78.43
54.90
Test Vaccine
6.61
134.71
13.67
99.28
93.52
Reference
Vaccine
6.46
29.75
14.81
79.63
59.26
Test Vaccine
5.67
202.0
9.46
99.41
95.85
Reference
Vaccine
6.04
53.63
13.73
74.51
58.82
Results (Immunogenicity)
Comparison of GMT titers
Results (Immunogenicity)
Comparison of % of Seroprevalence & Seroprotection
Results (Immunogenicity)
Comparison of % of Seroconversion
Results (Immunogenicity) of Test Vaccine
1st dose
2nd dose
98.67% Seroprotection
93.14% Seroconversion
99.78% Seroprotection
96.90% Seroconversion
Enrolled
Completed
Day 0
Day 28
Day 56
Results (Immunogenicity)
Seroconversion comparison
Group
% of Seroconversion
(4-Fold)
% of Seroconversion
(Seronegative to
Seropositive)
p-values
Test vaccine
93.14
96.46
>0.05
Reference vaccine
57.69
75
<0.05
Test vaccine
97.25
99.34
>0.05
Reference vaccine
41
55.13
<0.05
Day
Day 28
Day 56
•
When two different seroconversion methods are compared, there is no significant difference
in the test vaccine group, but there is a significant difference observed in the reference
vaccine group.
•
Since there was only one dose of vaccination in reference vaccine group, % of seroconversion
decreased on day 56 by both the methods.
•
Due to the second dose vaccine administration in test vaccine group, % of Seroconversion is
increased slightly but not significantly on day 56 by both the methods.
Results (Immunogenicity)
Batch consistency
Batch
Response
GMT
Sero
protection
4-Fold Rise
Day
88DP10001
(SD)
88DP10002
(SD)
88DP10003
(SD)
88DX10001
(MD)
88DX10002
(MD)
88DX10003
(MD)
0
6.6
6.2
5.7
5.0
5.6
5.0
28
96
183.7
165.8
184.4
102.0
233.6
56
308
547.5
531
387.4
441.2
958.7
0
15.8
13.2
8.1
0.0
8.7
0.0
28
98.5
97.1
100.0
100.0
100.0
100.0
56
100.0
99.3
100.0
100.0
100.0
100.0
0 to 28
91.7
91.9
95.9
93.3
87.0
100.0
0 to 56
97.0
94.9
99.2
93.3
95.7
100.0
SD: Single Dose vial, MD: Multi Dose vial
No significant difference between batches with respect to final Seroconversion (4-fold raise).
Confidence Intervals of all these batches are within the interval (80-120).
Results (Immunogenicity)
Responses of two different vaccine vial presentations of Test Vaccine
Response
Number of Subjects
Geometric
Mean Titre
% of
Seroprotection
% of
Seroconversion
(4-Fold)
Presentation
Single Dose
Multi Dose
392
60
Overall
452
Day 0
6.2
5.2
6.1
Day 28
142.8
160.2
145.0
Day 56
446.0
567.7
460.5
Day 0
12.5
3.3
11.3
Day 28
98.5
100.0
98.7
Day 56
99.7
100.0
99.8
Day 0 To 28
93.1
93.3
93.1
Day 0 To 56
96.9
96.7
96.9
 Test vaccines in two different presentations i.e. single and multi-dose vaccine vials are
bioequivalent with respect to the responses in seroprotection and seroconversion
proportions.
 Confidence Intervals of two different presentations are within the interval (80-120).
Results (Immunogenicity)
Zone wise comparison of the results:
A total of 608 subjects completed the study in 9 centers across India, 6 centers from
Andhra Pradesh (Coastal zone: 3 & Hyderabad zone 3), 1 from Rajasthan, 1 from
West Bengal and 1 from Karnataka. Centers were categorized according to the zones
as below:
Zone
Area
% of Seroprevalence
AP 1
Coastal, Andhra Pradesh
14.18
AP 2
Hyderabad, Andhra Pradesh
11.11
B
Jaipur, Rajasthan
15.38
C
Kolkata, W. Bengal
15.38
D
Mysore, Karnataka
8.82
Results (Immunogenicity)
Interpretations:
From the data it reveals that both one dose and two doses show the significant
immunogenicity.
There is no difference in % of subjects seronegative and seropositive at
baseline, but there is significant difference in % of subjects seropositive after
single dose on day 28 between Test & Reference vaccine groups.
From the data of 2 dose study it shows that single dose of test vaccine is
sufficient to elicit the immune response. As 28th day blood sample, subjects has
received a single dose were 98.67% seroprotected and 93.14% seroconverted
(4 fold) for ≤50- ≥1 years.
Results (Immunogenicity)
 Seroconversion & Seroprotection percentages on 28th and 56th day between
different age groups are statistically not significant (>0.05).
 After second dose of test vaccine GMT titre was increased exponentially from day 28
(145) to day 56 (460.5).
 Seroconversion & Seroprotection percentages on 28th day between Test and Reference
vaccine groups are statistically significant (p-value <0.001).
 There is no significant difference among two presentations i.e. single & multi-dose
vaccine vials and among different centers with respect to final Seroconversion (4-fold
raise) and Seroprotection. Confidence Intervals are within the interval (80-120).
Detailed statistics have done.
Discussion
Comparison with other vaccines
Bharat Biotech has compared the trial results to other commercially available vaccine data such
as IXIARO from Intercell, JEEV from BE and JE-VAX from Sanofi Pasteur (EMEA, 2009).
Geometric Mean Titre (n)
% of Seroconversion (n)
Vaccine
Day 0
Day 56
Day 0 to 56
JENVAC® (Bharat Biotech)
6.06 (452)
460.53 (452)
98.59 (452)
IXIARO (Intercell)
5.0 (365)
243.6 (361)
96.4 (352)
JEEV (Intercell- BE)
9.7 (304)
217.97 (277)
92.42 (277)
JE-VAX (Sanofi Pasteur)
5.0 (370)
102.0 (364)
93.8 (347)
As from the comparative table, BBIL has higher GMTs and % of seroconversion than the other
commercially available vaccines. It shows that BBIL's vaccine is not inferior to the other
commercially available vaccines.
Other Clinical studies with SA 14-14-2
 In a single dose of SA 14-14-2 vaccine study done by NIV, Pune and seroconversion
(>10.0.) was 74.28% after 30 days and 5% after 6 months against internationally
accepted JE virus strain (057434). Titers are in the range of 10.43- 133.03. (Ref:
National Institute of Virology annual report 2007-08)
 Another study in China tested between a two-dose one-month immunization schedule
and three-month immunization schedule. After the first dose, seroconversion rates
varied from 72% (n=53) to 100% (n=56). (Ref: Dr. Robert Siegel, HBIO 115B: The
Vaccine Revolution, June 3, 2000)
 In one early case control study of SA 14-14-2 vaccine it reported 80% vaccine efficacy
in subjects receiving one dose and 98% for two doses (Ref: product insert).
Other Clinical studies with SA 14-14-2
 Post Marketing surveillance studies carried out in India by ICMR show that the
seroconversion is lower (ranging between 35% - 43%) than that reported in other
countries. Independent evaluation of vaccine coverage shows that vaccine coverage
in the programme were very low.
 UNICEF coverage report shows a big difference between reported and evaluated
coverage figures e.g., In Dibrugarh it was 90.5% vs. 35.9% and Gorakhpur 97% vs.
52.3 % for reported and evaluated coverage respectively.
 (Ref: Minutes of the Expert Group meeting on JE Vaccine constituted by Sec. (DHR)
and DG ICMR was held at ICMR Hqs. on 25th Jan.2010.)
 Whereas, results obtained for SA 14-14-2 in our study was 77.56% of seroprotection
on the 28th Day. For the test vaccine (BBIL’s vaccine) 98.67% of seroprotection was
observed on the 28th day.
Summary
 Collaborated with NIV & Institute for OneWorld Health
 Indian Thermo-stable strain
 Well characterised-MVB/WVB & MCB/WCB
 Well equipped Production Facility & Capacity
 Experience in QC testing (Rabies, Polio, H1N1& Rota)
 Vaccine Potency study at Thailand
 Pre-Clinical & Human Clinical studies
 Sera Testing at NIV, Pune
 Comparable with other vaccines
Conclusion
Overall Conclusion
 It can be concluded that the BBIL’s inactivated Japanese encephalitis vaccine is safe, well
tolerated and immunogenic in healthy volunteers in the age group between ≤50 to ≥1,
after one or two doses of vaccination.
 Hence, a single dose schedule can be used for the campaign immunization (~95%
seroprotection and seroconversion after a single dose).
 Two dose schedule can be used for routine immunization (~97% seroprotection and
seroconversion after two doses).
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Vaccine strategy for disaster and outbreak situation
The growing need is being felt to stockpile of vaccines against certain
diseases with potential to cause outbreaks such as Cholera, JE and
H1N1 and other seasonal influenza.
These vaccines are required for an affected target population and the quantity needed for stockpile
should be assessed together with the National Disaster Management Agency (NDMA)
• The manufacturers of these vaccines have to be communicated of
the decision ahead of time for planning production and when the
stock expires or is utilized.
• Adequate budgetary provision for such stockpiles should be
created and adequate cold chain equipment earmarked for storage.
• The NDMA also needs to be intimated about the locations of these
stockpiles and effective communication maintained with the
agency for delivery of these vaccines during an emergency
situation
IAPCOI perspective
Routine vaccinations to be recommended in
high risk zone ???

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