Immunogenicity and safety of primary and booster vaccination with 2 investigational formulations of diphtheria, tetanus and Haemophilus influenzae type b antigens in a hexavalent DTPa-HBV-IPV/Hib combination vaccine in comparison with the licensed Infanrix hexa

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=khvi20 Download by: [Tampere University] Date: 07 August 2017, At: 22:46 Human Vaccines & Immunotherapeutics ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20 Immunogenicity and safety of primary and booster vaccination with 2 investigational formulations of diphtheria, tetanus and Haemophilus influenzae type b antigens in a hexavalent DTPa-HBV-IPV/Hib combination vaccine in comparison with the licensed Infanrix hexa Timo Vesikari, Luis Rivera, Tiina Korhonen, Anitta Ahonen, Brigitte Cheuvart, Marjan Hezareh, Winnie Janssens & Narcisa Mesaros To cite this article: Timo Vesikari, Luis Rivera, Tiina Korhonen, Anitta Ahonen, Brigitte Cheuvart, Marjan Hezareh, Winnie Janssens & Narcisa Mesaros (2017) Immunogenicity and safety of primary and booster vaccination with 2 investigational formulations of diphtheria, tetanus and Haemophilus influenzae type b antigens in a hexavalent DTPa-HBV-IPV/Hib combination vaccine in comparison with the licensed Infanrix hexa, Human Vaccines & Immunotherapeutics, 13:7, 1505-1515, DOI: 10.1080/21645515.2017.1294294 To link to this article: http://dx.doi.org/10.1080/21645515.2017.1294294 © 2017 The Author(s). Published with license by Taylor & Francis© Timo Vesikari, Luis Rivera, Tiina Korhonen, Anitta Ahonen, Brigitte Cheuvart, Marjan Hezareh, Winnie Janssens, and Narcisa Mesaros Published online: 24 Mar 2017. Submit your article to this journal Article views: 453 View related articles View Crossmark data RESEARCH PAPER Immunogenicity and safety of primary and booster vaccination with 2 investigational formulations of diphtheria, tetanus and Haemophilus influenzae type b antigens in a hexavalent DTPa-HBV-IPV/Hib combination vaccine in comparison with the licensed Infanrix hexa Timo Vesikari a , y , Luis Rivera b , y , Tiina Korhonen c , Anitta Ahonen d , Brigitte Cheuvart e , Marjan Hezareh f , Winnie Janssens g , and Narcisa Mesaros g a Vaccine Research Center, University of Tampere, Tampere, Finland; b Hospital Maternidad Nuestra Se~ nora de la Altagracia Santo Domingo, Santo Domingo, Dominican Republic; c University of Tampere, Tampere Vaccine Research Clinic, Tampere, Finland; d Vaccine Research Center, University of Tampere, J€ arvenp€ a€ a Vaccine Clinic, J€ arvenp€ a€ a, Finland; e GSK, Wavre, Belgium; f Chiltern International c/o GSK, Wavre, Belgium; g GSK, Wavre, Belgium ARTICLE HISTORY Received 15 December 2016 Revised 2 February 2017 Accepted 8 February 2017 ABSTRACT Safety and immunogenicity of 2 investigational formulations of diphtheria, tetanus and Haemophilus influenzae type b antigens of the combined diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliomyelitis-Hib vaccine (DTPa-HBV-IPV/Hib) were evaluated in a Primary (NCT01248884) and a Booster vaccination (NCT01453998) study. In the Primary study, 721 healthy infants (randomized1:1:1)received3dosesofDTPa-HBV-IPV/Hib formulation A (D A T A Pa-HBV-IPV/Hib), or B (D B T B Pa-HBV-IPV/Hib) or the licensed DTPa-HBV-IPV/Hib vaccine (Infanrix hexa, GSK; control group) at 2, 3, 4 months of age. Infants were planned to receive a booster dose at 12–15 months of age with the same formulation received in the Primary study; however, following high incidence of fever associated with the investigational formulations in the Primary study, the Booster study protocol was amended and all infants yet to receive a booster dose (N D385) received the licensed vaccine. In the Primary study, non-inferiority of 3-dose vaccination with investigational formulations compared with the licensed vaccine was not demonstrated due to anti-pertactin failing to meet the non-inferiority criterion. Post-primary vaccination, most infants had seroprotective levels of anti-diphtheria (100% of infants), anti-tetanus antigens (100%), against hepatitis B (97.5% across groups), polyribosyl-ribitolphosphate (88.0%) and poliovirus types 1–3(90.5%). Seropositivity rates for each pertussis antigen were 100% in all groups. Higher incidence of fever (>38C) was reported in infants receiving the investigational formulations (Primary study: 75.0% [A] and 72.1% [B] vs 58.8% [control]; Booster study, before amendment: 49.4% and 46.6% vs 37.4%, respectively). The development of the investigational formulations was not further pursued. KEYWORDS acellular pertussis; DTPaHBV-IPV/Hib; diphtheria; hepatitis B; Haemophilus influenzae type b; immunogenicity; infants; poliovirus; safety; tetanus Introduction Combining multiple antigens into a single vaccine has several potential advantages including simplified administration, higher vaccine coverage, reduction in vaccination costs and number of visits, and minimized risk of administration errors and missed doses. 1,2 A combined hexavalent diphtheria (D), tetanus (T), acellular pertussis (Pa), hepatitis B (HBV), inactivated poliomyelitis (IPV), and Haemophilus influenzae type b (Hib) vaccine (DTPa-HBV-IPV/Hib; Infanrix hexa,GSK)wasfirst authorized for use in 2000. 3 DTPa-HBV-IPV/Hib is indicated for primary vaccination as a 2or 3-dose primary vaccination course in infants, followed by a booster vaccination with an interval of at least 6 months between the last dose of primary vaccination and the booster dose. The currently licensed formulation of DTPa-HBV-IPV/ Hib contains D and T antigens from Novartis Vaccines and Diagnostics, while the other antigens are manufactured inhouse. In response to an increasing demand for DTPabased vaccines and to increase supply flexibility, alternative formulations of diphtheria and tetanus antigens for use in DTPa combination vaccines have been developed and tested in pre-clinical settings and were proposed to progress in clinical evaluation. The historical manufacturing facilities could potentially not be able to face the increasing requirements for DTPa combination vaccines. Increasing the manufacturing capability would overcome this rising demand and help controlling the whole manufacturing process. Two DTPa-HBV-IPV/Hib formulations containing new diphtheria and tetanus antigens (D A T A Pa-HBV-IPV/ CONTACT Timo Vesikari timo.vesikari@uta.fiVaccine Research Center, University of Tampere, Biokatu 10, FI-33014 Tampere, Finland. y Authors with equal contribution. © 2017 Timo Vesikari, Luis Rivera, Tiina Korhonen, Anitta Ahonen, Brigitte Cheuvart, Marjan Hezareh, Winnie Janssens, and Narcisa Mesaros. Published with license by Taylor & Francis. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The moral rights of the named author(s) have been asserted. HUMAN VACCINES & IMMUNOTHERAPEUTICS 2017, VOL. 13, NO. 7, 1505–1515 https://doi.org/10.1080/21645515.2017.1294294 Downloaded by [Tampere University] at 22:46 07 August 2017 Hib and D B T B Pa-HBV-IPV/Hib, formulations A and B, respectively), detoxified and adsorbed on aluminum hydroxide used as an adjuvant following 2 different processes (A and B), were chosen for clinical development. Additionally, in both investigational formulations, the Hib antigen was conjugated to the investigational tetanus toxoid (TT). We aimed to evaluate the immunogenicity and safety of the 2 new formulations administered as a primary 3-dose vaccination to infants at 2, 3 and 4 months of age (Primary vaccination study) and as a booster dose at 12–15 months of age (Booster study). All infants were co-administered with a 13-valent pneumococcal conjugate vaccine (PCV13; Prevenar 13TM,Pfizer Inc.). The licensed formulation of DTPaHBV-IPV/Hib vaccine was used as a benchmark to investigate non-inferiority of the immune response to all vaccine antigens. Results Study participants In the Primary study, a total of 721 infants, 456 infants from Finland and 265 infants from Dominican Republic, were enrolled and included in the total vaccinated cohort (TVC) (240 received formulation A [group A], 242 received formulation B [group B] and 239 received the licensed vaccine [control group]); of those, 651 (215 in group A, 217 in group B and 219 in the control group) were included in the according-to-protocol (ATP) cohort for immunogenicity (ATP-I) (Fig. 1). Screen failures were not recorded for the primary study. In total, 657 infants (409 from Finland and 248 from Dominican Republic) were enrolled in the Booster study. The remaining 64 screened participants were not enrolled in the study due to withdrawal of consent (31), nonPrimary TVC N=240 Booster TVC pre*: N=85; post*: N=131 Enrolled (N=721) Group B Group A Control 2 Withdrawn: Consent withdrawal (1); Death (1) Completed N=238 25 Excluded: Administration of vaccine(s) forbidden in the protocol (3); Study vaccine dose not administered according to protocol (1); Non-compliance with vaccination schedule (11); Non-compliance with blood sampling schedule (2); Essential serological data missing (8) ATP cohort for immunogenicity N=215 Primary TVC N=242 Primary TVC N=239 3 Withdrawn: Consent withdrawal (3) Completed N=239 1 Withdrawn: Consent withdrawal (1) Completed N=238 25 Excluded: Administration of vaccine(s) forbidden in the protocol (1); Administration of any medication forbidden by the protocol (1); Non-compliance with vaccination schedule (9); Non-compliance with blood sampling schedule (2); Essential serological data missing (12) ATP cohort for immunogenicity N=217 20 Excluded: Administration of vaccine(s) forbidden in the protocol (2); Non-compliance with vaccination schedule (8); Non-compliance with blood sampling schedule (6); Essential serological data missing (4) ATP cohort for immunogenicity N=219 Booster TVC pre*: N=88; post*: N=130 Booster TVC pre*: N=99; post*: N=124 4 Excluded pre: Vaccine temperature deviation (1); Protocol violation (2); Non-compliance with blood sampling schedule (1) 8 Excluded post: Protocol violation (5); Noncompliance with blood sampling schedule (2); Essential serological data missing (1) Booster ATP immunogenicity cohort pre*: N=81; post*: N=123 6 Excluded pre: Administration of vaccine(s) forbidden in the protocol (1); Protocol violation (2); Non-compliance with blood sampling schedule (1); Essential serological data missing (2) 8 Excluded post: Protocol violation (4); Noncompliance with blood sampling schedule (2); Essential serological data missing (2) Booster ATP immunogenicity cohort pre*: N=82; post*: N=122 9 Excluded pre: Administration of vaccine(s) forbidden in the protocol (2); Protocol violation (3); Non-compliance with blood sampling schedule (1); Essential serological data missing (3) 6 Excluded post: Administration of vaccine(s) forbidden in the protocol (1); Study vaccine dose not administered according to protocol (1); Protocol violation (4); Booster ATP immunogenicity cohort pre*: N=90; post*: N=118 Primary vaccination study Booster vaccination study 0 Withdrawn pre 1 Withdrawn post: Consent withdrawal Completed pre*: N=85; post*: N=130 0 Withdrawn pre & post Completed pre*: N=88; post*: N=130 0 Withdrawn pre & post Completed pre*: N=99; post*: N=124 Figure 1. Flow of participants in the Primary and Booster vaccination studies. N, number of participants, TVC, total vaccinated cohort; ATP, according to protocol; group A/ group B, infants who received the new formulations A or B of DTPa-HBV-IPV/Hib CPCV13 as a primary vaccination at 2, 3, 4 months of age and a booster dose with the same vaccine at 12–15 months of age (after protocol amendment, both groups received the licensed DTPa-HBV-IPV/Hib and PCV13 as booster); Control, infants who received the licensed DTPa-HBV-IPV/Hib CPCV13 as a primary vaccination at 2, 3, 4 months of age and a booster dose at 12–15 months of age; pre  , before protocol amendment; post  , after protocol amendment. 1506 T. VESIKARI ET AL. Downloaded by [Tampere University] at 22:46 07 August 2017 eligibility (14), lost to follow up (8), moving from the study area (7) or non-willingness for blood sampling (1). One infant had died (serious adverse event [SAE] described in Safety –Primary study section)and2didnotparticipate because of an adverse event (AE; acute disease at enrolment and foot erythema). Initially, 85, 88 and 99 infants were enrolled in groups A, B and control, respectively, to receive a booster of the formulation as in the primary study; of these, 81 (group A), 82 (group B) and 90 (control group) were included in the ATP-I. Following a high incidence of fever observed in infants who received the investigational formulations in the Primary study (see Safety section of the Results), the study protocol was amended and all infants (N D385) who were still to receive the booster dose, received the licensed formulation as booster. After the protocol amendment, 131, 130 and 124 infants were included in groups A, B and control, respectively; of these, 123 (group A), 122 (group B) and 118 (control group) were included in ATP-I (Table 1). Immunogenicity Primary study The non-inferiority of the immunogenicity of the investigational DTPa-HBV-IPV/Hib formulations compared with the licensed vaccine was assessed in terms of seroprotection rates to diphtheria and tetanus antigens, hepatitis B surface antigens (HBsAg), and polyribosyl-ribitol-phosphate antigens (PRP, a polysaccharide component of Haemophilus influenzae bacterium capsule associated with virulence), and in terms of antibody geometric mean concentrations (GMCs) for pertussis antigens one month after the third vaccine dose. The non-inferiority of the investigational D A T A Pa-HBV-IPV/Hib and D B T B Pa-HBV-IPV/Hib formulations to the licensed vaccine was not demonstrated as the upper limits (ULs) of the 97.5% confidence intervals (CIs) of anti-pertactin (PRN) GMC ratio (control group/investigational formulation) exceeded the predefined limit of 1.5 for both formulations (A: 1.54 and B: 1.84); of note, the non-inferiority criteria were met for all other antigens (Table 2). One month post-dose 3, seroprotective/seropositive concentrations of antibodies against diphtheria, tetanus and all pertussis antigens were observed in all infants in the 3 groups, and at least 97.5% of infants in all groups had seroprotective levels of anti-HBs antibodies, at least 88.0% of infants had anti-PRP antibody concentrations 0.15 mg/mL, and at least 97.4%, 90.5% and 97.9% of infants had seroprotective titers of antibodies against poliovirus types 1, 2 and 3 across the 3 groups, respectively (Table 3). Seropositivity rates for each pertussis antigen were 100% in all groups. Vaccine response to PT, FHA and PRN was mounted in at least 97.1%, 96.9% and 91.0% of infants, respectively (Table 4). Booster study The percentage of infants with anti-D, anti-T, anti-HBs, anti-PRP and anti-poliovirus types 1–3 antibody concentrations above the seroprotective cut-offs one month after booster vaccination was at least 97.3% before the protocol amendment, and at least 98.3% after the amendment. With respect to pertussis, higher GMCs were observed when the licensed vaccine was administered in the primary phase (Table 3). Table 1. Summary of demographic characteristics (total vaccinated cohorts). TVC Group A (N D240) Group B (N D242) Control group (N D239) Primary study Age at dose 1 (we) Mean 9.7 9.8 9.7 Range (min–max) 8–12 8–12 8–12 Female/male, % 49.6/50.4 57.0/43.0 41.4/58.6 Ancestry, n (%) White Caucasian 144 (60.0) 148 (61.2) 140 (58.6) Other 96 (40.0) 94 (38.8) 99 (41.4) Booster study (Before protocol amendment) Group A (N D85) Group B (N D88) Control group (N D99) Age at booster dose (mo) Mean 12.9 13.0 13.0 Range (min–max) 12–15 12–15 12–15 Female/male, % 55.3/44.7 55.7/44.3 38.4/61.6 Ancestry, n (%) White Caucasian 79 (92.9) 83 (94.3) 91 (91.9) Other 6 (7.1) 5 (5.7) 8 (8.1) Booster study (After protocol amendment) Group A (N D131) Group B (N D130) Control group (N D124) Age at booster dose (mo) Mean 14.1 13.9 14.0 Range (min-–max) 12–16 12–15 12–15 Female/male, % 46.6/53.4 58.5/41.5 42.7/57.3 Ancestry, n (%) White Caucasian 49 (37.4) 46 (35.4) 39 (31.5) Other 82 (62.6) 84 (64.6) 85 (68.5) N, number of participants; n (%), number (percentage) of participants in a given category; TVC, total vaccinated cohort; we, weeks; mo, months; min, minimum; max, maximum. In the Primary and Booster studies (before protocol amendment) groups A and B received the investigational formulations A and B of DTPa-HBV-IPV/Hib CPCV13 at 2, 3 and 4 months of age and as a booster dose at 12–15 months of age; the control group received the licensed DTPa-HBV-IPV/Hib CPCV13 vaccines at 12–15 months of age. After protocol amendment of the Booster study, all 3 groups received the licensed DTPa-HBV-IPV/Hib CPCV13 vaccines. HUMAN VACCINES & IMMUNOTHERAPEUTICS 1507 Downloaded by [Tampere University] at 22:46 07 August 2017 Safety Primary study Injection site pain was the most frequently reported solicited local symptom in the 3 groups, reported in 79.2%, 70.4% and 65.1% of infants in groups A, B and control, respectively; the most common grade 3 solicited local symptom was swelling, reported in 15.4% of infants in group A, 15.0% of infants in group B, and 16.4% of infants in the control group (Fig. 2A). Irritability was the most common solicited general symptom in all 3 groups (group A: 82.1%, group B: 85.4%, control: 80.3%), and was also the most common grade 3 symptom (group A: 14.2%, group B: 17.1%, control: 10.5%) (Fig. 2B). The incidence of fever reported in infants who received the investigational formulations appeared higher compared with control (group A: 75.0%, group B: 72.1%, control: 58.8%). The incidence of fever was in majority considered by the investigators to be related to vaccination and causally related fever incidence was 74.6% in group A, 70.0% in group B and 58.0% in the control group. Grade 3 fever (>39.0C axillary temperature) was reported for 1.7% of infants in group A and the control group, and for 2.1% of infants in group B (Fig. 2B). During the 31-day post-vaccination period, at least one unsolicited adverse event was reported for 63.8%, 68.2%, and 66.5% of infants in groups A, B, and control, respectively; grade 3 unsolicited AEs were reported for 7.1%, 8.7% and 6.7% of infants and unsolicited AEs with a causal relationship to vaccination, for 21.7%, 21.1% and 23.0% of infants in these groups, respectively. Twenty-one SAEs were reported for 18 infants (9, 5, and 4 infants in groups A, B and control, respectively). During the entire study period, one fatal SAE was reported in the Dominican Republic in group A 17 d post-dose 1, the reason being asphyxia and interstitial lung disease. None of the SAEs were considered by the investigator to be potentially related to vaccination. Booster study Before protocol amendment The most common solicited local symptom was injection site pain, reported for 65.9%, 76.1% and 63.6% of infants in groups A, B, and control, respectively; the most common grade 3 solicited local symptom was swelling, reported in 20.0% of infants in group A, 11.4% of infants in group B, and 19.2% of infants in the control group (Fig. 2A). The incidence of solicited general symptoms ranged from 49.4%–81.2% in group A, from 46.6%–83.0% in group B, and from 37.4%–74.7% in the control group. Irritability was the most common solicited general symptom in all 3 groups (group A: 81.2%, group B: 83.0%, control: 74.7%), and was also the most common grade 3 symptom (group A: 5.9%, group B: 4.5%, control: 2.0%) (Fig. 2B). The incidence of fever appeared higher in groups A (49.4%) and B (46.6%) compared to control (37.4%); grade 3 fever (>39.0Caxillary temperature) was not reported (Fig. 2B). The incidence of fever was in majority considered by the investigators to be related to vaccination and causally related incidence was 49.4% in group A, 45.5% in group B and 36.4% in the control group. The incidence of unsolicited AEs reported up to day 31 following vaccination was similar in infants who received the investigational formulations or the licensed vaccine as booster (group A: 49.4%, group B: 44.3%, control: 50.5%). No SAEs were reported before protocol amendment. After protocol amendment The most common solicited local symptom in all groups was injection site pain (58.0% in group A, 50.8% in group B and 51.6% in control group). The most common grade 3 solicited local symptoms were redness (group A: 6.1%, group B: 6.2%, control: 6.5%) and swelling (group A: 6.1%, group B: 7.7%, control: 4.8%). The most common general symptom in all groups was irritability reported in 50.4%, 44.6% and 50.0% of infants from Table 2. Group differences in seroprotection/seropositivity rates and adjusted GMC ratio one month post-dose 3 in the Primary vaccination study (ATP cohort for immunogenicity). Control Group A Difference in percentage (control group minus group A) Group B Difference in percentage (control group minus group B) Antibody n (%) n (%) % (97.5% CI) n (%) % (97.5% CI) Anti-D (0.1 IU/mL) 219 (100) 214 (100) 0.00 (¡2.25–2.30) 217 (100) 0.00 (¡2.25–2.27) Anti-T (0.1 IU/mL) 219 (100) 214 (100) 0.00 (¡2.25–2.30) 217 (100) 0.00 (¡2.25–2.27) AntiHBs 10 mIU/mL, in-house ELISA 205 (98.1) 197 (97.5) 0.56 (¡3.27–4.63) 203 (99.0) ¡0.94 (¡4.57–2.36) 10 mIU/mL, CLIA adjusted 203 (97.1) 197 (97.5) ¡0.40 (¡4.62–3.80) 201 (98.0) ¡0.92 (¡5.07–3.02) Anti-PRP (0.15 mg/mL) 193 (88.5) 197 (92.1) ¡3.52 (¡10.19–3.00) 190 (88.0) 0.57 (¡6.53–7.70) Adjusted GMC Adjusted GMC ratio (control group/group A) Adjusted GMC Adjusted GMC ratio (control group/group B) Pertussis antigens Control Group A Value (97.5% CI) Group B Value (97.5% C) Anti-PT (EU/mL) 73.9 58.5 1.26 (1.11–1.44) 59.0 1.25 (1.10–1.43) Anti-FHA (EU/mL) 207.6 193.0 1.08 (0.94–1.23) 166.6 1.25 (1.09–1.42) Anti-PRN (EU/mL) 105.6 79.5 1.33 (1.14–1.54) 66.7 1.58 (1.37–1.84) ATP, according-to-protocol; n (%), number (percentage) of participants with antibody concentration above the specified cut-off; CI, confidence interval; D, diphtheria; T, tetanus; PRP, polyribosyl-ribitol phosphate; HBs, hepatitis B; PT, pertussis toxoid; FHA, filamentous hemagglutinin; PRN, pertactin; CLIA, ChemiLuminescence ImmunoAssay; ELISA, enzyme-linked immunosorbent assay; EU/ml, ELISA units per milliliter; IU/ml, international units per milliliter. Adjusted GMC ratio, geometric mean antibody concentration adjusted for baseline concentration. In the Primary study, groups A and B received the investigational formulations A and B of DTPa-HBV-IPV/Hib CPCV13 at 2, 3 and 4 months of age; control group received the licensed DTPa-HBV-IPV/HibCPCV13 vaccine at 2, 3 and 4 months of age. 1508 T. VESIKARI ET AL. Downloaded by [Tampere University] at 22:46 07 August 2017 Table 3. Seroprotection/seropositivity rates and GMCs/GMTs before and one month post-dose 3 in the Primary and Booster vaccination studies (ATP-I cohorts). Primary Vaccination Booster Vaccination before amendment Booster Vaccination after amendment Antibody Groups Time point %SP 95% CI GMC/GMT 95% CI %SP 95% CI GMC/GMT 95% CI %SP 95% CI GMC/GMT 95% CI Anti-D A Pre 77.0 70.5–82.6 0.292 0.247–0.347 96.3 89.6–99.2 0.357 0.305–0.419 87.0 79.7–92.4 0.247 0.213–0.287 (0.1 IU/mL) Post 100 98.3–100 1.499 1.367–1.644 100 95.5–100 5.652 4.985–6.408 100 97.0–100 6.327 5.698–7.025 B Pre 78.6 72.4–83.9 0.281 0.238–0.332 97.6 91.5–99.7 0.445 0.381–0.520 94.2 88.4–97.6 0.278 0.244–0.317 Post 100 98.3–100 1.704 1.564–1.856 100 95.6–100 5.494 4.891–6.171 100 97.0–100 5.452 4.956–5.998 Control Pre 75.8 69.5–81.4 0.290 0.245–0.343 94.4 87.4–98.2 0.401 0.343–0.468 88.9 81.7–93.9 0.304 0.258–0.360 Post 100 98.3–100 1.839 1.686–2.005 100 96.0–100 6.772 5.897–7.777 100 96.9–100 7.192 6.419–8.059 Anti-T A Pre 98.5 95.7–99.7 0.936 0.832–1.053 93.8 86.2–98.0 0.358 0.301–0.427 94.3 88.6–97.7 0.364 0.313–0.422 (0.1 IU/mL) Post 100 98.3–100 1.761 1.624–1.910 100 95.5–100 5.015 4.341–5.794 100 97.0–100 5.986 5.204–6.885 B Pre 98.1 95.2–99.5 0.920 0.822–1.029 95.1 88.0–98.7 0.362 0.306–0.428 94.2 88.4–97.6 0.332 0.289–0.380 Post 100 98.3–100 1.726 1.597–1.865 100 95.6–100 5.034 4.366–5.803 100 97.0–100 5.316 4.716–5.992 Control Pre 99.1 96.6–99.9 0.907 0.812–1.013 95.5 88.9–98.8 0.394 0.337–0.459 94.9 89.2–98.1 0.331 0.285–0.383 Post 100 98.3–100 1.947 1.818–2.085 100 96.0–100 5.571 4.869–6.374 100 96.9–100 5.993 5.222–6.878 Anti-PRP A Pre 50.6 39.3–61.9 0.173 0.138–0.216 74.8 66.2–82.2 0.328 0.262–0.409 (0.15 mg/mL) Post 92.1 87.6–95.3 0.951 0.793–1.142 100 95.5–100 12.765 9.300–17.520 99.2 95.6–100 21.462 16.65–27.664 B Pre 54.9 43.5–65.9 0.175 0.142–0.216 64.5 55.2–73 0.288 0.227–0.365 Post 88.0 82.9–92.0 0.730 0.606–0.880 100 95.6–100 15.904 11.723–21.576 100 97.0–100 15.903 12.132–20.848 Control Pre 58.4 47.5–68.8 0.236 0.182–0.307 69.2 60.0–77.4 0.334 0.254–0.439 Post 88.5 83.5–92.4 1.082 0.884–1.324 100 96–100 17.099 12.966–22.55 99.2 95.4–100 17.429 13.429–22.620 Anti-PT A Pre 16.6 11.7–22.5 3.3 3.0–3.6 85.0 75.3–92.0 10.5 8.8–12.6 77.2 68.8–84.3 8.3 7.2–9.7 (5 EU/mL) Post 100 98.3–100 57.7 52.9–62.9 100 95.4–100 76.1 66.1–87.6 100 96.9–100 92.4 80.6–106 B Pre 18.1 13.1–24 3.4 3.1–3.7 81.3 71.0–89.1 9.5 7.9–11.4 77.7 69.2–84.8 7.9 6.8–9.1 Post 100 98.3–100 57.5 53.1–62.4 100 95.5–100 74.3 62.6–88.1 100 97.0–100 93.6 83.1–105.5 Control Pre 14.8 10.3–20.3 3.1 2.9–3.4 89.7 81.3–95.2 12.7 10.8–15.0 82.9 74.8–89.2 9.9 8.5–11.5 Post 100 98.3–100 73.2 67.7–79.2 100 95.9–100 96.0 83.5–110.3 100 96.9–100 132.6 114.9–153.0 Anti-FHA A Pre 80.6 74.4–85.9 10.6 9.3–12.2 100 95.5–100 41.7 35.4–49.2 99.2 95.6–100 37.6 32.5–43.4 (5 EU/mL) Post 100 98.3–100 192.4 175–211.4 100 95.5–100 393.7 346.4–447.6 100 97.0–100 467.3 417.3–523.3 B Pre 76.7 70.4–82.2 9.7 8.5–11.1 98.8 93.4–100 36.9 31.5–43.3 99.2 95.4–100 34.0 28.7–40.4 Post 100 98.3–100 165.5 151.5–180.7 100 95.6–100 372.4 332.7–416.7 100 97.0–100 446.2 402.3–494.9 Control Pre 75.0 68.5–80.7 9.1 8.0–10.4 100 95.9–100 47.1 40.3–55.1 100 96.9–100 45.7 38.8–53.9 Post 100 98.3–100 210.6 194.1–228.6 100 96.0–100 423.0 368.1–485.9 100 96.9–100 582.9 517.1–657.1 Anti-PRN A Pre 42.0 35.1–49.2 5.1 4.5–5.9 84.0 74.1–91.2 12.8 10.4–15.7 79.7 71.5–86.4 11.6 9.7–13.9 (5 EU/mL) Post 100 98.3–100 76.6 68.1–86.3 100 95.5–100 213.0 178.1–254.7 100 97.0–100 253.2 216.9–295.6 B Pre 42.4 35.6–49.4 4.9 4.3–5.5 85.2 75.6–92.1 10.8 8.9–13.1 76.0 67.4–83.3 9.7 8.1–11.7 Post 100 98.3–100 65.7 58.9–73.3 100 95.5–100 180.0 154.2–210.1 100 97.0–100 181.0 154.8–211.7 Control Pre 36.2 29.7–43.1 4.9 4.3–5.7 93.3 85.9–97.5 18.2 15.0–22.1 89.7 82.8–94.6 15.6 13.0–18.7 Post 100 98.3–100 106.6 96.6–117.8 100 95.9–100 372.9 309.3–449.5 100 96.9–100 401.1 342.2–470.0 Anti-HBs A Pre 91.9 83.2–97.0 130.3 91.2–186.0 90.0 83.2–94.7 94.9 72.2–124.8 (10 mIU/mL) Post 97.5 94.3–99.2 639.5 523.6–781.2 98.7 93.1–100 2233.3 1479.7–3370.8 98.4 94.2–99.8 2229.3 1625.5–3057.5 B Pre 93.7 85.8–97.9 124.4 89.5–173.0 84.0 76.2–90.1 61.8 45.7–83.5 Post 99.0 96.5–99.9 602.6 492.1–737.9 98.7 93.1–100 2026.3 1389.4–2955.2 98.3 93.9–99.8 1729.8 1240.6–2411.9 Control Pre 92.9 85.1–97.3 166.4 112.8–245.5 92.2 85.7–96.4 125.9 94.6–167.7 Post 98.1 95.2–99.5 799.0 662.2–964.0 100 95.7–100 2685.7 1868.8–3859.7 99.1 95.3–100 3711.4 2729.7–5046.1 Anti-poliovirus type 1 (8ED 50 ) A Pre 63.9 56.7–70.7 13.5 11.5–16.0 72.5 60.4–82.5 18.2 13.7–24.1 89.6 82.2–94.7 53.5 39.6–72.4 Post 97.4 94.1–99.2 110.0 88.6–136.5 98.7 93.0–100 572.9 435.5–753.6 100 96.7–100 1121.0 904.2–1389.8 B Pre 67.0 60.1–73.4 13.3 11.4–15.5 73.0 61.4–82.6 17.8 13.5–23.5 86.7 78.6–92.5 50.7 37.2–69.2 Post 97.5 94.2–99.2 94.6 77.2–116.0 100 95.0–100 558.3 422–738.8 100 96.6–100 1099.6 905.2–1335.8 Control Pre 58.4 51.3–65.3 13.2 11.1–15.8 78.9 67.6–87.7 22.4 16.8–29.9 92.9 86.0–97.1 70.8 52.4–95.8 (Continued on next page) HUMAN VACCINES & IMMUNOTHERAPEUTICS 1509 Downloaded by [Tampere University] at 22:46 07 August 2017 Table 3. (Continued ) Primary Vaccination Booster Vaccination before amendment Booster Vaccination after amendment Antibody Groups Time point %SP 95% CI GMC/GMT 95% CI %SP 95% CI GMC/GMT 95% CI %SP 95% CI GMC/GMT 95% CI Post 97.5 94.4–99.2 143.8 117.7–175.7 100 95.8–100 902.1 698.4–1165.0 99.0 94.7–100 1386.2 1091.8–1760.0 Anti-poliovirus type 2 (8ED 50 ) A Pre 67.0 59.6–73.9 16.0 13.3–19.3 55.1 42.6–67.1 12.7 9.5–16.9 86.7 77.9–92.9 76.6 50.3–116.7 Post 90.5 85.4–94.3 72.0 57.3–90.4 100 94.2–100 629.7 452.6–876.1 100 96.2–100 1485.3 1182.4–1865.8 B Pre 71.9 64.8–78.2 18.4 15.2–22.2 61.1 48.9–72.4 17.1 12.3–23.8 87.1 78.5–93.2 55.0 38.2–79.3 Post 94.8 90.6–97.5 68.5 55.3–84.9 98.4 91.2–100 668.7 489.9–912.7 99.0 94.4–100 1215.6 973.8–1517.4 Control Pre 70.4 63.3–76.8 18.8 15.5–22.8 63.8 51.3–75.0 16.6 12.0–22.8 87.1 78.0–93.4 82.7 55.6–122.9 Post 93.4 89.0–96.4 81.0 65.1–101.0 100 95.3–100 1184.9 901.1–1558.1 100 95.8–100 1537.2 1191.0–1984.1 Anti-poliovirus type 3 (8ED 50 ) A Pre 51.8 44.5–59.0 13.0 10.7–15.8 69.9 58.0–80.1 24.7 17.1–35.8 88.9 81.4–¡4.1 67.8 47.3–97.2 Post 97.9 94.8–99.4 179.4 141.2–227.9 100 94.4–100 1147.5 846.2–1556.0 100 96.8–100 1851.2 1473.2–2326.1 B Pre 51.2 44.2–58.2 12.5 10.4–15.0 58.9 46.8–70.3 16.8 12.0–23.5 90.8 83.8–95.5 73.8 52.2–104.2 Post 97.9 94.8–99.4 159.6 126.9–200.8 100 94.3–100 614.0 453.9–830.6 100 96.5–100 1960.4 1574.0–2441.5 Control Pre 53.2 46.1–60.2 12.6 10.5–15.1 76.3 65.4–85.1 26.6 19.2–36.9 87.5 79.6–93.2 93.9 64.4–136.8 Post 98.9 96.2–99.9 221.7 176.1–279.2 97.3 90.5–99.7 1120.7 793.0–1583.9 100 96.3–100 2376.4 1874.2–3013.2 ATP-I, according-to-protocol (cohort for) immunogenicity; %SP, percentage of seroprotected/seropositive infants; GMC/GMT, geometric mean antibody concentration/titer; 95% CI, 95% confidence interval; Pre, pre-primary/booster vaccination; Post, post-dose 3/booster vaccination; D, diphtheria; T, tetanus; PRP, polyribosyl-ribitol phosphate; PT, pertussis toxoid; FHA, filamentous hemagglutinin; PRN, pertactin, HBs, hepatitis B; EU/ml, ELISA units per milliliter; IU/ml, international units per milliliter; ED 50 , median effective dose. In the Primary and Booster studies (before protocol amendment), groups A and B received the investigational formulations A and B of DTPa-HBV-IPV/Hib CPCV13 at 2, 3 and 4 months of age and as a booster dose at 12–15 months of age; the control group received the licensed DTPa-HBV-IPV/Hib CPCV13 vaccines at 12–15 months of age. After protocol amendment of the Booster study, all 3 groups received the licensed DTPa-HBV-IPV/Hib CPCV13 vaccines. All samples with antiHBs antibody concentrations between 10–100 mIU/mL at one month after the primary vaccination by the in-house ELISA (considered overestimated), were retested with the commercial ChemiLuminescence ImmunoAssay (CLIA) with a cut-off defining seropositivity of 6.2 mIU/mL. Anti-HBs seroprotection was redefined as in-house ELISA concentration above 100 mIU/mL (considered valid) or CLIA concentration above 10 mIU/mL. CLIA was also used for the Booster study. 1510 T. VESIKARI ET AL. Downloaded by [Tampere University] at 22:46 07 August 2017 group A, group B and control, respectively, and was also the most common grade 3 general symptom (group A: 4.6%, group B: 1.5%, control: 1.6%). The incidence of fever was always considered by the investigators to be related to vaccination and appeared similar in all groups (group A: 44.3%, group B: 38.5%, control: 41.9%, respectively); grade 3 fever was not reported (Fig. 2B). Three SAEs were reported after the amendment, 2 cases of pneumonia and a case of dehydration (all in group B); none were considered by the investigator to be related to vaccination and all recovered before the study end. Table 4. Vaccine response rate to anti-PT, anti-FHA and anti-PRN antibodies one month post-primary vaccination (ATP cohort for immunogenicity). % Vaccine response (95% CI) Antibody Group A (N D181) Group B (N D194) Control (N D198) Anti-PT 98.0 (94.9–99.4) 97.1 (93.9–98.9) 99.0 (96.6–99.9) Anti-FHA 96.9 (93.5–98.9) 97.6 (94.5–99.2) 98.1 (95.1–99.5) Anti-PRN 91.0 (86.1–94.6) 93.3 (89.0–96.3) 94.3 (90.2–97.0) ATP, according-to-protocol; %, percentage of infants with vaccine response; CI, confidence interval; PT, pertussis toxoid; FHA, filamentous hemagglutinin; PRN, pertactin; N, minimum number of infants with available results. Groups A and B received the investigational formulations A and B of DTPa-HBV-IPV/Hib CPCV13 at 2, 3 and 4 months of age. Control group received the licensed DTPa-HBV-IPV/Hib CPCV13 vaccines at 2, 3 and 4 months of age. Vaccine response was defined as a post-dose 3 antibody concentration 5 ELISA units/mL (EU/mL) for initially seronegative infants, or an antibody concentration 1fold the pre-vaccination antibody concentration for initially seropositive infants. Infants with antibody concentration <5 EU/mL before vaccination were considered seronegative; infants with antibody concentration 5 EU/mL before vaccination were considered seropositive. Figure 2. Incidence of solicited local (A) and general symptoms (B) in Primary (day 0–7) and Booster study (day 0–4) (total vaccinated cohorts). Group A/Group B, infants who received the new formulations A or B of DTPa-HBV-IPV/Hib CPCV13 as a primary vaccination at 2, 3, 4 months of age and a booster dose with the same vaccine at 12–15 months of age (after protocol amendment, both groups received the licensed DTPa-HBV-IPV/Hib CPCV13 as booster); Control, infants who received the licensed DTPa-HBV-IPV/Hib CPCV13 as a primary vaccination at 2, 3, 4 months of age and a booster dose at 12–15 months of age; Pri, primary vaccination; Pre, booster vaccination before protocol amendment; Post, booster vaccination after protocol amendment. The error bars indicate 95% confidence intervals. HUMAN VACCINES & IMMUNOTHERAPEUTICS 1511 Downloaded by [Tampere University] at 22:46 07 August 2017 Discussion The immunogenicity of the investigational DTPa-HBV-IPV/ Hib formulations administered to infants as a 3-dose primary vaccination was inferior to the licensed DTPa-HBV-IPV/Hib vaccine and the reactogenicity was higher. In the Primary vaccination study reported in this manuscript, the incidence of fever following 3 doses of the investigational DTPa-HBV-IPV/Hib formulations was much higher (group A: 75.0%, group B: 72.1%), and was likely either due to the new formulations of the diphtheria and tetanus antigens or to the PRP that was conjugated to the investigational tetanus antigen. Nevertheless, the incidence of grade 3 fever reported for the investigational vaccine formulation post-primaryvaccinationwaslow(1.7%–2.1% across the groups), similar to previously reported for the investigational DTaP5-IPV-Hib-HepB formulation (2%). 4 Altogether, the results of the Primary and Booster vaccination studies presented in this manuscript indicate that the DTPa-HBV-IPV/Hib vaccine formulations containing investigational diphtheria and tetanus antigens are associated with a lower immunogenicity and a higher reactogenicity compared to the licensed DTPa-HBV-IPV/Hib vaccine. The incidence of SAEs was low, consistent with the results of previous studies with the DTPa-HBV-IPV/Hib vaccine. 5,6 This finding emphasizes the need to carry out head-to-head comparisons for any new compositions of hexavalent vaccine. This experience suggests that the formulation of a hexavalent vaccine is sensitive to changes in the vaccine components and new experimental combinations may be less immunogenic than the licensed Infanrix hexa. In the light of waning immunity following vaccination with acellular pertussis vaccines, the need for a new generation of pertussis vaccines is recognized. Alternative formulations might be improved with the addition of more or improved antigens to the multicomponent vaccines, removal of antigens or adjuvant improvement, or use of DNA or attenuated, live bacterial vaccines. 7 The studies had the following strengths: (1) enrolment from different settings (Finland and Dominican Republic) allowed assessing whether the observed effects were country specific; (2) the short vaccination schedule provided a worst case scenario for assessing seroprotection by the different vaccine formulations; (3) the drop-out rate was reasonably low for this type of study as approximately 85% of the infants completed both primary and booster studies. Another advantage of the study design was the availability of blood samples pre-vaccination, allowing anti-pertussis geometric mean titer (GMT) group comparisons while accounting for the pre-vaccination immunogenicity. Potential limitations of the studies include the fact that inferential analysis linked to the primary objective in the Booster study could not be performed due to failure of the primary non-inferiority objective in the Primary vaccination study and due to the protocol amendment. As the investigational formulations of the DTPa-HBV-IPV/ Hib failed to demonstrate non-inferiority of the vaccine immunogenicity to the licensed formulation, and because of a higher incidence of fever associated with the investigational formulations compared to the licensed vaccine, the development of the investigational formulations was not further pursued. Patients and Methods Study design The Primary vaccination study was a phase I/II double-blind, randomized, multicenter study conducted in 2 centers in the Dominican Republic and 14 centers in Finland between December 2010 and January 2012. Healthy infants were randomized (1:1:1) to receive 3 doses of 2 investigational DTPaHBV-IPV/Hib formulations (A or B; group A and B, respectively) or the licensed DTPa-HBV-IPV/Hib formulation (control group) at 2, 3, 4 months of age; in addition, all infants received concomitant injections of PCV13. Infants who received 3 doses of either formulation of DTPa-HBV-IPV/Hib vaccine (A, B or control [licensed vaccine]) in the Primary study were invited to participate in a follow-up, phase II, randomized, double-blind Booster vaccination study (October 2011–November 2012) to evaluate the response to the booster vaccination with DTPa-HBVIPV/Hib received between 12 and 15 months of age. Infants participating in the Booster study retained the group allocation to which they were randomized in the Primary study. In addition, all infants received a concomitant booster dose of PCV13. Initially, infants received a booster dose with the same vaccine formulations as in the Primary study; following a protocol amendment (see Results section), infants in all 3 groups received the licensed DTPa-HBV-IPV/Hib formulation as booster dose. The double-blinding regarding the vaccine received during the Primary study was maintained until the end of the Booster study. Written informed consent was obtained for each infant from the parent or the legally acceptable representative (LAR). The study was conducted according to the Declaration of Helsinki, Good Clinical Practice, International Conference on Harmonisation (ICH) Harmonised Tripartite Guideline for clinical investigation of medicinal products in the pediatric population (ICH E11), and the Finnish and Dominican laws and regulations. The study protocol, the amendments, the informed consent, and all documents requiring pre-approval were reviewed and approved by an Institutional Review Board or an Independent Ethics Committee. The studies are registered at www.clinicaltrials.gov (NCT01248884 and NCT01453998). A summary of each study protocol is available at http://www.gsk-clinicalstudyregister. com (GSK study ID: 113948 and 114843). Study objectives Primary vaccination study The primary objective of the study was to demonstrate noninferiority of at least one of the 2 investigational DTPa-HBVIPV/Hib formulations compared with the licensed formulation in terms of seroprotection rates to diphtheria, tetanus, HBsAg and PRP antigens, and in terms of antibody GMCs for pertussis antigens one month after the third dose. The secondary objectives included the assessment of the immune response to the study vaccines in terms of: seroprotection/seropositivity and antibody concentrations or titers, one month after the third dose; immunological status toward 1512 T. VESIKARI ET AL. Downloaded by [Tampere University] at 22:46 07 August 2017