Presentation on theme: "Japanese Encephalitis Vaccine"— Presentation transcript:
1 Japanese Encephalitis Vaccine Dr Monjori MitraAssociate ProfessorInstitute of Child Health Kolkata
2 Issues to Consider Epidemiological status Currently Available Vaccines New Vaccination ModalitiesThe Clinical Trial Currently Underway
3 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 deathsInitially called Japanese type B encephalitis to differentiate from epidemic encephalitis lethargica, type A encephalitisVirus first isolated from the brain of a fatal case in 1935Isolated from Culex tritaeneorhinchus in 1938Now known to be the principal mosquito vector in most of the geographic distribution of the disease
4 Epidemiology Primarily a disease of rural Asia Vector mosquitoes proliferate in close association with birds and pigsBirds and pigs are the major amplifying hostsMany other mammals and reptiles infected as well, long term viremia documented in bats, othersCulex tritaeniorhynchus the principal vector but many other mosquitoes are competent and can transmitC. pipiensC. quinquefasciatusSpecies of Aedes, AnophelesVirus overwinters in mosquitoes as well as vertical transmissionTraditional seasonal spread (spring/summer) heavily impacted by rice paddy flooding
5 Cattle May Serve to Modulate JE Activity Photo by George Risi
6 Incidence and Prevalence Commonest cause of encephalitis in AsiaIn hyperendemic areas half of all cases occur in children under 4 years of age, nearly all before age 10Nearly 100% seroprevalence by adulthood in heavily infected areasEpidemic and endemic forms20,000 cases and 6,000 deaths annually a gross underestimateMathematical modeling predicts 175,000 annual cases, 43,750 fatalities, 78,750 with disability
7 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 outbreakRatio 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
8 Epidemiology Geographic range expanding; new areas infected by Viremic migratory birds- Guam, SaipanWindblown mosquitoes- Torres strait of Australia
9 EpidemiologyUttar PradeshBiharJuly 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
11 EpidemiologyJapanese 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: - hyrcanus, subpictusCulex species: - tritaeniorhynchus, vishnuiMansonia species:- annulifera, indianaPigs & birds are primary reservoirs wherein the virus is maintained & amplified30- 50,000 overt JE cases and 10,000 deaths reported annually worldwide (likely underreported).30% of survivors suffer from lasting damage to central nervous systemIn India JE has shown increasing trend in occurrence and expansion of disease to non- endemic areas in IndiaIn JEV endemic areas, JE is primarily a pediatric disease
12 JEVirus –Transmission, Prevalence, Risk Military deployed to endemic areasExpatriates in rural areasTravelersKey risk groupsResidents of rural areas in endemic locations
13 JE Vaccination Program – Overview JE campaign States & districts 1Andhra Pradesh102Kerala3Uttar Pradesh34+14Goa5Assam116Bihar7Haryana8Karnataka7+19Tamil Nadu9+1MaharashtraWest Bengal12Manipur13Nagaland14Arunachal Pradesh15UttarakhandTotal112Map showing 112 JE vaccination campaign districts
14 The JE Mass vaccination Drives ( Campaigns ) Coverage S.No.YearNo. of States coveredNo. of Districts coveredTarget population yearsTotal JE vaccination campaign coverageJE vaccination campaign coverage %1200641188.392200792784.71320082284.242009103066.615201081981.762010*re- campaigns97.85Total11880.67* Based on the emergence of new cases JE/ AES and low coverage asper CES report in 9 districts 2 states , it was decided to conduct re-campaigns
15 JE vaccination campaigns - Year coverage 2006 - 2011
21 Japanese Encephalitis Disease Incubation 6-16 days. Spectrum from mild febrile headache to severe encephalitisHeadache, fever, nausea, vomiting, drowsiness. Abdominal pain and diarrhea common in childrenProgression over several days to severe diseaseDull, mask-like faciesMuscular rigidityCranial nerve palsiesTremulous eye and extremity muscle movementsGeneralized and localized paresis, incoordination, pathologic reflexesSeizures frequent in children, <10% of adultsAssociated Press
22 Clinical Manifestations Death in 5-40%Some deaths after acute fulminant course, others from cardiopulmonary complications with prolonged comaChildren under 10 more likely to die or have residual neurological defectsPoor prognosis associated withRespiratory dysfunctionBabinsky’s signFrequent or prolonged seizuresProlonged feverAlbuminuriaHigh viral replication in the brainSource: Reuters News Agency
25 Type of vaccine: 1) Live attenuated vaccine (SA strain) 2) Inactivated, Vero cell-derived, alum-adjuvanted vaccine (SA 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).
26 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 reactionsBefore departure: The immunization series should be completed at least 1 week before potential exposure to JEV.
27 Japanese Encephalitis Vaccine A new live attenuated, JE–yellow fever chimeric vaccine has recently been licensed in Australia and Thailand , and will be commercialized from 2012.This vaccine requires a single dose for primary immunization; the possible need for booster doses remains to be determined.
28 Efficacy of the SA 14-14-2 Vaccine against Japanese Encephalitis. Effectiveness of One Dose of SA Vaccine against Japanese EncephalitisN Engl J Med 2009; 360: April 2, 2009Kumar R et al. N Engl J Med 2009;360:
29 Immunogenicity and efficacy of Live Attenuated SA 14-14-2 Several studies have demonstrated an excellent immune response after a single dose of SA 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%.
30 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 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 SA 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.
31 Development of Vero cell-derived inactivated JE vaccine
32 Other JE Vaccine Manufacturers Name of the VaccineMfg.StrainDosesScheduleRoutePresentationInactivatedMouse Brain purified inactivated JE vaccineCRI KasauliNakayama3 (>3yrs– 1ml and1-3yrs – 0.5 ml)0, 7 & 30SCLiquidMouse Brain purified inactivated JE vaccine (JENCEVAC)Green Cross – Shantha Biotech3 (Adult – 1.0 mL & Children – 0.5 mL)Mouse Brain purified inactivated JE vaccine (JE-VAX)Sanofi Pasteur3 [Adult – 1.0 mL & Children (1-3 Yr.)– 0.5 mL]LyophilizedVero cell – Inactivated vaccine (IXIARO)IntercellSA2 (only >17 Yr mL)0 & 28IMLiquid PFSLive AttenuatedLive attenuated JE VaccineChina1 (Adults & children mL)Live attenuated JE Vaccine (Chimerivax)Acambis1 [Adult – 1.0 mL & Children (9-36 Months.)– 0.5 mL]Vero- derived Purified inactivated JE Vaccine(JENVAC®)BBILKolar2 (Adults & children mL)
33 Comparison between different JE vaccines (Mouse brain, Live (PHK) and Vero cell based )Inactivated(Biken)Live attenuated(Chinese)Intercell and Bio E)IXIARO/ JEEVStrainNakayama, Beijing-1SASubstrateMouse brainPrimary hamster kidney (PHK) cellsVero Cells (Monkey Kidney cellsFormulationLyophilizedLiquidLicensed1954 – Japan1993 – US1988 – ChinaIxiaro-Licensed in USA, Australia, Canada & many other countriesJEEV – Licensed in IndiaGeographic useWorldwide: traveller vaccineSE Asia – childhoodChina, IndiaTraveller vaccineAdministrationSubcutaneousIMDosage0.5 mL-children1.0 mL-adults0.25 mL-children0.5 mL-adultsBoosterAt one year & every 3 yearsAt 6 yearsStudies on goingEfficacy91% – 2 dose80% – 1 dose97.5% – 2 dose96 % – 2 dose in adult95.7% -2 dose in childrenProtectionAntibody levels > or = 1:10SafetyRare cases of urticaria, angioedema, dyspnea, acute encaphalo-myelitisSerious adverse event reportedlower rate of Adverse Events.*IXIAROPage 33
34 Collaboration with NIV & iOWH For JE Vaccine Developmenthas collaborated withDr. Milind GoreNational Institute of Virology,Pune, India,Dr. Richard Chin, DirectorDr. Raj Shankar Ghosh, Regional Director, South Asia. (now PATH)
35 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 Vietnam35
36 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.36
37 Innovative aspects of BBIL JE Vaccine Novel inactivation process - to keep theAntigenicity increase immunogenicityIncreased stability &shelf-life of the vaccineThermo-stable strain
38 NIV-History of JE virus seed Obtained from : NIV, Pune, IndiaIsolation : JE infected encephalitis patientStrain : Thermostable Kolar Strain (JEV XY)Passage history : 17 times in suckling miceOriginal Seed titer : LD50 per mL = 1073838
39 Product & Production profile Purified, inactivated Japanese encephalitis protein Not Less Than 5.0µg/0.5mL (Single Human Dose)Robust manufacturing technologyProduction facility- Fully validated commercial scaleProduction capacity- 25 Million doses annually
41 Type of Sample Injection Type of Sample Injection Pre-clinical toxicity (BBIL) Systemic toxicityGroupType of Sample InjectionDose/Dosage(Intramuscular)No. of Rats per groupMaleFemaleGroup I(Control)PBS buffer4 doses (day 0, 7, 14 & 28)/0.5mL PBS buffer10Group IIJENVAC®4 doses (day 0, 7, 14 & 28)/0.5mL NLT 5µgGroup IIIJENCEVAC4 doses (day 0, 7, 14 & 28)/ 1mLGroupType of Sample InjectionDose/Dosage(Intramuscular)No. of Rabbits per groupMaleFemaleGroup I(Control)PBS buffer4 doses (day 0, 7, 14 & 28)/0.5mL PBS buffer3Group IIJENVAC®4 doses (day 0, 7, 14 & 28)/0.5mL NLT 5µgGroup IIIJENCEVAC4 doses (day 0, 7, 14 & 28)/ 1mLPre-Clinical studies done as per Schedule-Y41
42 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 injectiondid not alter any of the above parameters in rats and rabbits in the systemic toxicitystudy conducted for a period of 42 days.42
44 Animal Potency study (Thailand) Project: Study on potency of inactivated Japanese encephalitis vaccines in adult miceSite 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 weeksImmunization dose/schedule: Vaccine 1:10 dilution1234567Day1st dose at Day 0, by I.P. route2nd dose at Day 7, by I.P. route
45 Animal Potency study (Thailand) Vaccines:Inactivated JE vaccine: Batch-88DP9001, Source: Bharat Biotech, IndiaInactivated JE vaccine: Batch-JJ , Source: GPO, ThailandInactivated JE vaccine: Batch Source: Korean Green Cross, S. Korea (Nakayama),Serum collection:Collected on day 14 post dose 1Serologic 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.
46 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 and 100% seroconversion rate.For GPO, GMT of PRNT was found to be Seroconversion rate of those 10 mice being used in the study revealed 90%.For KGC vaccine evaluation, GMT was fount to be and 80% seroconversion rate.Conclusion:Bharat Biotech JE Vaccine, like GPO JE Vaccine confers higher GMT than theKorean Green Cross JE Vaccine. For seroconversion rate, the Bharat JE Vaccinerevealed 100% seroconversion rate after 2 doses, while the other 2 vaccines could not.
48 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/2010Study Investigator & Centre:Dr. Murali Mohan, MD-General Medicine, Professor, Dept of Medicine, Vydehi Institute of Medical Sciences, Bangalore.
49 Study Population 52 08 Number of subjects enrolled 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 enrolledNumber of Subjects completedNumber of subjects dropped out605208
50 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
51 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.
52 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% plaque- reduction neutralization test (PRNT50) antibody titre increase against the JE virus
54 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 administrationSubjects were also followed up till day 90 for safety, none of the enrolled subjects were withdrawn from study for vaccine related adverse reactionsThere 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)
55 Geometric Mean Titre (n) Results (Immunogenicity)The Antibody estimation was carried out by PRNT50 method for the Immunogenicity evaluation. JE vaccine strain (homologous virus) is used as a challenge virus.Comparison of GMT:GroupGeometric Mean Titre (n)Day 0Day 28Day 56Vaccine (2-Doses)6.75(25)148.72(21)411.23(20)Vaccine (3-Doses)6.14189.59432.47Placebo7.16(10)8.088.53(07)Note: No statistical difference between 2 and 3 dose group (p-value >0.05) on 28th and 56th day.
56 Results (Immunogenicity) Comparison of % of SeroprotectionGroup% of Seroprotection(n)Day 0Day 28Day 56Vaccine (2-Doses)23.81(25)100(21)(20)Vaccine (3-Doses)16Note: No statistical difference between 2 and 3 dose group (p-value >0.05) on 28th and 56th day.
57 Results (Immunogenicity) Comparison of % of SeroconversionGroup% of Seroconversion(n)Day0 to 280 to 56Vaccine (2-Doses)90.48(21)100(20)Vaccine (3-Doses)96(25)Placebo(10)(07)Note: No statistical difference between 2 and 3 dose group (p-value >0.05) on 28th and 56th day.
58 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%.
59 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 resultsBBIL resultsParameterHeterologous virusHomologous virusTime period0 Day28 Day56 DayGMT6.514.818.58.923.027.930.451.5
60 ConclusionIt 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 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.
62 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/2011Study Centers:We have conducted the study in 9 centers in 4different states stated below across India.1. Andhra Pradesh2. West Bengal3. Karnataka4. Rajasthan
63 Service providers Randomization, Labeling & Decoding Asian Clinical TrialsStatistical Analysis:Dr.G.S.R Murthy, Indian Statistical Institute, HyderabadSera Sample AnalysisNIV – PuneBBIL - Hyderabad
64 Study Investigators and sites Dr. J. Venkateswara Rao, Gandhi Medical College, SecunderabadDr. G. Sampath, Institute of Preventive Medicine, Hyderabad.Dr. P. Venugopal, King George Hospital, Visakhapatnam.Dr. Mukesh Guptha, Saumya Child Clinic, JaipurDr. B. Krishnamurthy, Mysore Medical College, MysoreDr. Monjori Mitra, Institute of Child Health, KolkataDr. Sudhakar, Priya Children’s Hospital, VijayavadaDr. Sri Krishna, Mahavir Hospital, HyderabadDr. Bhuvaneswar Rao, Sri Sreenivasa Children’s Hospital, Vijayavada
65 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.
66 Exclusion CriteriaSubjects 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.
67 Exclusion CriteriaAny confirmed or suspected immunosuppressive or immunodeficient conditionUse 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.
68 Study PopulationThe 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 % 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 IndiaCategoryAge in yearsTest groupReference group1≤50 to >18156562≤18 to > 6144573≤6 to ≥117853Total478166Number of subjects enrolledNumber of Subjects completedNumber of subjects dropped out64460836
69 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.
70 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.
71 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 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.
72 Study ObjectivesThe 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.
76 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).
77 Results (Immunogenicity) The Antibody estimation by PRNT50 method for the Immunogenicity.JE vaccine strain (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.
78 Results (Immunogenicity) Comparison of Seropositive & Seronegative percentages between the vaccine groups (Age category ≤50 to≥1 year):ParameterTest VaccineReference VaccineP-value% of subjects seronegativeat base line (Day 0)88.7282.05>0.05% of subjects seropositive11.2817.95after single dose (Day 28)*98.5072.66<0.001*Excluding subjects seropositive at base line
79 Results (Immunogenicity) Seroprotection & Seroconversion of study Groups in ≤50 to ≥1 yearsResponseTime periodTest vaccine Reference vaccinep-value% of SeroprotectionDay 011.2817.95>0.05Day 2898.6777.56<0.001% of Seroconversion(4-fold)Day 0 to 2893.1457.69All the subjects included
80 Results (Immunogenicity) Seroprotection & Seroconversion of Test vaccine in different age groupsResponseTime periodAge Group≤50->18 years≤18->6 years≤6-≥1 yearsP-value% of SeroprotectionDay 011.1113.679.46>0.05Day 2897.2299.2899.41Day 5699.31100% of Seroconversion(4-fold)Day 0 to 2889.5893.5395.8Day 0 to 5693.0698.5698.82
81 Results (Immunogenicity) GMT, Seroprotection & Seroconversion comparison in three different age groupsGroupVaccine GroupGeometric Mean Titre% of SeroprevalenceprotectionconversionDay 0Day 28Day 0 to 28≤50->18 yearsTest Vaccine6.02105.611.1197.2289.58Reference Vaccine7.0936.5025.4978.4354.90≤18->6 years6.61134.7113.6799.2893.526.4629.7514.8179.6359.26≤6-≥1 years5.67202.09.4699.4195.856.0453.6313.7374.5158.82
82 Results (Immunogenicity) Comparison of GMT titers
83 Results (Immunogenicity) Comparison of % of Seroprevalence & Seroprotection
84 Results (Immunogenicity) Comparison of % of Seroconversion
85 Results (Immunogenicity) of Test Vaccine 1st dose2nd dose98.67% Seroprotection93.14% Seroconversion99.78% Seroprotection96.90% SeroconversionEnrolledCompletedDay 0Day 28Day 568585
86 % of Seroconversion (Seronegative to Seropositive) Results (Immunogenicity)Seroconversion comparisonDayGroup% of Seroconversion(4-Fold)% of Seroconversion (Seronegative to Seropositive)p-valuesDay 28Test vaccine93.1496.46>0.05Reference vaccine57.6975<0.05Day 5697.2599.344155.13When 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.
87 Results (Immunogenicity) Batch consistencyResponseDayBatch88DP10001(SD)88DP1000288DP1000388DX10001(MD)88DX1000288DX10003GMT126.96.36.199.05.62896183.7165.8184.4102.0233.656308547.5531387.4441.2958.7Seroprotection15.813.28.10.08.798.597.1100.099.34-Fold Rise0 to 2891.791.995.993.387.00 to 5697.094.999.295.7SD: Single Dose vial, MD: Multi Dose vialNo significant difference between batches with respect to final Seroconversion (4-fold raise). Confidence Intervals of all these batches are within the interval (80-120).
88 Results (Immunogenicity) Responses of two different vaccine vial presentations of Test VaccineResponsePresentationOverallSingle DoseMulti DoseNumber of Subjects39260452Geometric Mean TitreDay 06.25.26.1Day 28142.8160.2145.0Day 56446.0567.7460.5% of Seroprotection12.53.311.398.5100.098.799.799.8% of Seroconversion(4-Fold)Day 0 To 2893.193.3Day 0 To 5696.996.7Test 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).
89 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:ZoneArea% of SeroprevalenceAP 1Coastal, Andhra Pradesh14.18AP 2Hyderabad, Andhra Pradesh11.11BJaipur, Rajasthan15.38CKolkata, W. BengalDMysore, Karnataka8.82
90 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.
91 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.
93 Geometric Mean Titre (n) % of Seroconversion (n) Comparison with other vaccinesBharat 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).VaccineGeometric Mean Titre (n)% of Seroconversion (n)Day 0Day 56Day 0 to 56JENVAC® (Bharat Biotech)6.06 (452)(452)98.59 (452)IXIARO (Intercell)5.0 (365)243.6 (361)96.4 (352)JEEV (Intercell- BE)9.7 (304)(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.
94 Other Clinical studies with SA 14-14-2 In a single dose of SA 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 (Ref: National Institute of Virology annual report )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 vaccine it reported 80% vaccine efficacy in subjects receiving one dose and 98% for two doses (Ref: product insert).
95 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 % 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 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.
96 Summary Collaborated with NIV & Institute for OneWorld Health Indian Thermo-stable strainWell characterised-MVB/WVB & MCB/WCBWell equipped Production Facility & CapacityExperience in QC testing (Rabies, Polio, H1N1& Rota)Vaccine Potency study at ThailandPre-Clinical & Human Clinical studiesSera Testing at NIV, PuneComparable with other vaccines
98 Overall ConclusionIt 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).
99 KOLKATA40 yrs on, Japanese encephalitis claims life in KolkataOctober 11, 2008 | Prithvijit Mitra & Saikat Ray , TNNKOLKATA: Japanese encephalitis - which kills one in every three persons it infects - is back in the city. On Thursday, 34-year-old Behala resident Pralay Choudhury died from the disease after being under treatment for over three months. This is the first death in Kolkata due to Japanese encephalitis in over four decades. It sparked panic in Pralay's locality in ward 126, with residents accusing KMC of doing nothing to stop mosquitoes from breeding. Pralay's neighbour, a...DELHITwo more in grip of Japanese EncephalitisNovember 1, 2011 | TNNNEW DELHI: Two more people have been confirmed positive for Japanese Encephalitis in the city, taking the total number of patients suffering from the mosquito-borne disease to 14. According to Dr V K Monga, the MCD health committee chairman, they have not found the source of the infection yet. "The blood samples collected from pigs in the affected areas and the ones being slaughtered have tested negative. Now, we are going to expand the screening...CHANDIGARHHaryana ready to combat vector-borne diseasesOctober 14, 2003 | TNNCHANDIGARH: The Haryana health department has geared up to combat the spread of vector borne diseases such as dengue, malaria and Japanese Encephalitis in Faridabad, Sonepat, Karnal, Jhajjar, Rohtak, Ambala and Panchkula districts and is taking all necessary preventive and curative measures to control the spread of these diseases. Haryana director general of health services Dr B S Dahiya said that regular monitoring and evaluation was being carried out and the situation was well...INDIAEncephalitis claims 3 more in UP, 180 dead since JanAugust 25, 2009 | PTIGORAKHPUR: Three more children have succumbed to Japanese Encephalitis here, taking the toll in the viral infection since January to 180. The children belonging to Kushinagar, Siddharthanagar and Mahrajganj districts died in the last two days at the BRD Medical College here, additional director health L P Rawat said here on Tuesday. Twenty people suspected to be suffering from the viral fever have been admitted to the hospital during the same period. ...SCIENCEBeware! New viruses are hereOctober 29, 2004 | TNNNEW DELHI: Scientists are investigating the possibility of new and lesser known viruses emerging in the country even as a brain fever in Baghpat and Saharanpur in UP has claimed 60 lives. With new killer bugs having emerged in several parts of the country in the recent past, Japanese Encephalitis is not the only bug that is being tested. In Baghpat, at least, experts have ruled out Japanese Encephalitis as the cause of the death of 13 children. A lethal bug, spread...GUWAHATIEncephalitis claims 3 more in Dibrugarh, toll 32August 3, 2012 | TNNDibrugarh/GUWAHATI: Three more people have died of encephalitis in Dibrugarh district over the past two days. With this, 32 people have so far lost their lives after contracting the vector-borne disease in the district. Confirming the deaths, joint director of health services (Dibrugarh) DN Bangthai on Thursday said 11 deaths have occurred due to Japanese Encephalitis (JE), while 21 died of Acute Encephalitis Syndrome (AES). "As of now, we've 49 other people, who have been found JE...ALLAHABAD79% kids administered many essential vaccinesJuly 31, 2012 | TNNALLAHABAD: When it comes to carrying out special immunization campaign in low performing areas including urban slums, migrant and mobile populations and marginalised population, the district health department on Monday claimed to have covered 79% children of set target who were administered with BCG, measles, DPT, Polio and other essential vaccines during four days special drive in the district. District immunization officer Dr Ashutosh Kumar told TOI that 3,705 children were administered...Spurt in encephalitis cases before onset of the seasonJuly 16, 2012 | Shailvee Sharda , TNNGORAKHPUR: A short spell of rain has provided a breeding ground for culex, the encephalitis causing mosquito, just outside a hospital ward. Water in choked drains along the passage leading to the epidemic ward too is home to mosquitoes. Add to these the poor management of hospital waste. These factors are accompanied by the sight of helpless parents who crowd the hospital corridors. Welcome to Baba Raghav Das (BRD) Medical College, Gorakhpur -- the infamous encephalitis capital of...NAGPURChandipura virus claims 14 childrenJuly 13, 2012 | TNNNAGPUREPUNE: Scanty rains have once again activated the sand fly, known to transmit the Chandipura virus. The virus has killed 14 children since June 15 in six districts of Nagpur circle. The figures are scary as the deaths have occurred in a short duration. The virus in monsoon is generally known to claim children over a period of 3-4 months. This year, the toll has already reached 14 in less than 30 days. The Pune-based National Institute of Virology (NIV) has...Centre’s largesse for UP governmentJuly 12, 2012 | Swati Mathur , TNNLUCKNOW: Call it prudent politics ahead of Lok Sabha elections 2014 or the fruits of persistent letter writing, either way it paid off for Uttar Pradesh on Tuesday, when the state walked away with a bag full of goodies from the Centre. In a three-and-a-half-hour meeting with PM Manmohan Singh and senior bureaucrats in New Delhi, UP chief secretary Jawed Usmani along with the state's senior bureaucrats managed to extract promises of funds for nearly all pending projects proposed by the state...
100 Vaccine strategy for disaster and outbreak situation The growing need is being felt to stockpile of vaccines against certaindiseases with potential to cause outbreaks such as Cholera, JE andH1N1 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 ofthe decision ahead of time for planning production and when thestock expires or is utilized.• Adequate budgetary provision for such stockpiles should becreated and adequate cold chain equipment earmarked for storage.The NDMA also needs to be intimated about the locations of thesestockpiles and effective communication maintained with theagency for delivery of these vaccines during an emergencysituation
101 IAPCOI perspectiveRoutine vaccinations to be recommended in high risk zone ???