I dati a sostegno dei due vaccini anti-HPV La vaccinazione anti-HPV: nuove conoscenze I dati a sostegno dei due vaccini anti-HPV Giorgio Palù, MD Dipartimento di Medicina Molecolare Università di Padova

Immunogenicity of prophylactic HPV vaccines Investigator-driven studies at University of Padova: Comparison of immunogenicity of bivalent and quandrivalent HPV vaccines in the target population of organized vaccination programs. Immunogenicity of HPV vaccines in different age groups. Long-term immunogenicity of HPV vaccines. Immunogenicity, safety, and tolerability of a bivalent HPV vaccine in adolescents with juvenile idiopathic arthritis.

Indipendent studies on the immunogenicity of prophylactic HPV vaccines Study design Gardasil® (Padova) Cervarix® (Bologna, Milan) 1-6 M after 3rd dose of vaccine 11-13 yrs N = 126 15-26 yrs N = 50 11-13 yrs N = 107 4 Y after 3rd dose of vaccine 11-13 yrs N = 74 15-26 yrs N = 60 15-26 yrs (in progress) Study subjects were vaccinated within organized vaccination programs in Veneto, Emilia Romagna, and Lombardy Regions. Standard 3-doses vaccination schedule.

Neutralizing antibody (ED50) Comparison of immunogenicity of prophylactic HPV vaccines: HPV16 and HPV18 NAb titers induced by HPV vaccines Girls aged 11-13 yrs ** Neutralizing antibody (ED50) Gardasil Cervarix HPV16 HPV18 Significantly higher HPV16 and HPV18 NAb titers after vaccination with Cervarix® than vaccination with Gardasil® Barzon et al. Vaccine 2014 HPV type Gardasil® group (n=126) Cervarix® group (n=107) P value HPV16 Positivity rate GMT (95% CI) 126/126 (100%) 5,092 (4,230; 6,151) 107/107 (100%) 22,136 (18,811; 26,073) NS <0.0001 HPV18 124/126 (98,4%; 96.2-100%) 1,804 (1,574; 2,110) 11,962 (9,536; 14,363)

Neutralizing antibody (ED50) Comparison of immunogenicity of prophylactic HPV vaccines: HPV31 and HPV45 cross-NAb titers induced by HPV vaccines Girls aged 11-13 yrs * Neutralizing antibody (ED50) Gardasil Cervarix HPV31 HPV45 Significantly higher seropositivity rate and HPV31 and HPV45 NAb titers after vaccination with Cervarix® than vaccination with Gardasil® Barzon et al. Vaccine 2014 HPV type Gardasil® group (n=50) Cervarix® group (n=50) P value HPV31 28/50 (56%; 42.2, 69.7%) GMT: 13.0 (6.5; 25.8) 46/50 (92.7%; 84.5, 99.5%) GMT: 157.2 (92; 269) <0.05 <0.0001 HPV45 3/50 (6%; -0.6, 12.6%) GMT: 1.3 (0.3; 3.1) 18/50 (36%; 22.7, 49.3%) GMT: 4.7 (2.1; 10.2) <0.01

Comparison of immunogenicity of prophylactic HPV vaccines: Kinetics of HPV NAb titers Girls aged 11-13 yrs Decrease of NAb titres after vaccination with Gardasil®; stable NAb titres after Cervarix® NAbs in vaccinated subjects at 1-6 months after the third dose of vaccine Barzon et al. Vaccine 2014

Comparison of immunogenicity of prophylactic HPV vaccines: memory B-cell responses (ELISPOT) Girls aged 11-13 yrs Gardasil® Cervarix® HPV16 HPV18 % of Ag-specific memory B-cells p< 0.0001 Significantly higher frequency of HPV16- and HPV18-specific memory B-cells after vaccination with Cervarix® than vaccination with Gardasil® Caputo et al.

Immunogenicity of HPV vaccines in different age groups Comparison of HPV16 and HPV18 NAbs titers in Cervarix® and Gardasil® vaccinees Females aged 11-13 yrs and 15-26 yrs 1 10 100 1000 10000 100000 11-13 yrs 15-26 yrs NAbs (GMT) HPV16 HPV18 Cervarix® Gardasil® * * P<.0001 Cervarix vs. Gardasil Significantly higher HPV16 and HPV18 NAb titers in both adolescents and young women after vaccination with Cervarix® than vaccination with Gardasil® Barzon et al.

B-cell response at 1-6 months after 3rd dose of GARDASIL® Immunogenicity of HPV vaccines in different age groups Females aged 11-13 yrs and 20-26 yrs B-cell response at 1-6 months after 3rd dose of GARDASIL® Gardasil® induces similar HPV-specific frequency of memory B-cells in age-matched cohorts but lower IgG titres in the 20-26 year-aged group than in the 11-13 year-aged group 11-13 yrs (N = 60) 20-26 yrs (N = 45) % of Ag-specific memory B-cells HPV11 HPV16 HPV18 HPV6 *** ** IgG Titre (1/dilution) Mann-Whitney analysis (*) p <0,05 (**) 0,01<p<0,001 (***) p<0,0001. Caputo et al.

Long-term immunogenicity of prophylactic HPV vaccines: Comparison of HPV16 and HPV18 NAb titers at 4 years post vaccination Girls vaccinated at 11-13 yrs Evaluation at 4 yrs after vaccination ** 1 10 100 1000 10000 100000 HPV16 HPV18 NAbs (GMT) Gardasil® Cervarix® Significantly higher seropositivity rate and HPV16 and HPV18 NAb titers after vaccination with Cervarix® than vaccination with Gardasil®: Data at 4 years after vaccination. Barzon et al. HPV type Gardasil® group (n=74) Cervarix® group (n=74) P value HPV16 Positivity rate GMT (95% CI) 73/74 (98.6%; 96.0, 100) 806 (473; 1,140) 74/74 (100%) 4,814 (2,612; 7,017) NS <0.0001 HPV18 61/74 (82.4%; 73.8-91.0%) 102 (<40; 267) 2,265 (770; 3,760)

Long-term immunogenicity of prophylactic HPV vaccines: Comparison of HPV16 and HPV18 NAb titers at 1-6 mo. and 4 yrs post vaccination Girls vaccinated at 11-13 yrs Evaluation at 1-6 mo. and 4 yrs after vaccination ** 1 10 100 1000 10000 100000 Gardasil® Cervarix® NAbs (GMT) HPV16 HPV18 1-6 mo 4 yr ** ** ** ** ** ** ** ** P < .0001 Barzon et al.

Long-term immunogenicity of HPV vaccines Long-term immunogenicity of Gardasil® Gardasil® vaccine Strong reduction of both the frequency of memory B-cells and IgG titres 4 years after vaccination 11-13-y old HPV6 20-26-y old % of Ag-specific memory B-cells HPV11 HPV16 HPV18 IgG Titre (1/dilution) *** 4 Y after vaccine 1-6 M after vaccine Mann-Whitney analysis (***) p<0.0001. Caputo et al.

Study subjects: n=42 females vaccinated with Cervarix®, Immunogenicity of the bivalent HPV vaccine in JIA patients An independent study Immunogenicity, safety, and tolerability of a bivalent HPV vaccine in adolescents with juvenile idiopathic arthritis Study subjects: n=42 females vaccinated with Cervarix®, 3-doses vaccination schedule. Juvenile idiopatic arthritis patients (n = 21) Healthy controls (n = 21) Age range: 12-25yr Clinical and immunological evaluation at month 0, 6, and 7 after the first vaccine dose. Esposito et al. Expert Rev Vaccines 2014

Immunogenicity of a bivalent HPV16/18 vaccine in JIA patients An indipendent study Endpoints of immunogenicity against HPV16 and HPV18 in the JIA patients and healthy controls  Parameter HPV16 NAbs HPV18 NAbs JIA patients (n=21) Healthy controls NAb positivity rate (%)   Before 3rd dose (month 6) 20/21 (95.2) 21/21 (100.0) One month after 3rd dose (month 7) NAb ED50 GMT (fold increase) Baseline <40 Before 3rd dose (month 6) 274.40 (6.9)^ 487.43 (12.2)^ 302.03 (7.6)^ 463 (11.6)^ 6,834.38 (170.9)^*° 12,177.48 (304.4)^* 5,120 (128)^* 6,347.86 (158.7)^* ^p<0.0001 vs baseline; *p<0.0001 vs before the third dose (month 6); °p<0.05 vs healthy controls one month after the third dose (month 7). No other significant between-group difference. Esposito et al. Expert Rev Vaccines 2014

Efficacy of < 3 doses of a bivalent HPV16/18 vaccine: Proof-of-principle from the Costa Rica Vaccine Trial Costa Rica Vaccine trial: women aged 18-25 yrs, randomized to receive a bivalent HPV vaccine or hepatitis A vaccine. Conclusions: two doses of the HPV16/18 vaccine, and maybe even one dose, are as protective as three doses. Kreimer et al. J Natl Cancer Inst 2011

Antibody response after < 3 doses of a bivalent HPV vaccine Post-hoc analysis of the Costa Rica Vaccine Trial HPV16 HPV18 At 4 years, 100% of women in all groups remained HPV16/18 seropositive. HPV16 and HPV18 Ab titers among the extended two-dose group (0 and 6 months) were non-inferior to the three-dose group. Safaeian et al. Cancer Prev Res 2013

Immune response to the bivalent vaccine administered as a 2-dose or 3-dose schedule up to 4 y after vaccination Phase I/II randomized, partially-blind study in girls and young women aged 9 to 25 y. Vaccination with HPV16/18 AS04-adjuvanted vaccine at: 3 doses (20 μg/20 μg) at months 0, 1, and 6 (Group 3D 20/20 M0,1,6; 15-25 y), 2 doses (20 μg/20 μg) at months 0 and 6 (Group 2D 20/20 M0,6; 9-14 y), Comparable HPV16/18 antibody responses to a 2D M0,6 schedule in girls aged 9–14 y to the standard 3D in women aged 15–25 y up to 4 years after first vaccination. Romanowski et al. Hum Vaccine Immunother 2014

Immune response to the bivalent vaccine administered as a 2-dose or 3-dose schedule up to 4 y after vaccination Antibody responses to non-vaccine types HPV31 and HPV45 were similar in girls aged 9–14 y in the 2D 20/20 group and in women aged 15–25 y in the standard 3D group in terms of seroconversion rates and GMTs up to month 48, as measured by ELISA. Romanowski et al. Hum Vaccine Immunother 2014

Non-inferiority of Ab response to the bivalent HPV16/18 vaccine in adolescents vaccinated with 2D vs 3D schedule at 21 months Open-label nonrandomized independent clinical trial in females aged 9-10 and 18-24 y. Vaccination with HPV16/18 AS04-adjuvanted vaccine at: 3 doses (20 μg/20 μg) at months 0, 1, and 6 (9-10 y and 18-24 y), 2 doses (20 μg/20 μg) at months 0 and 6 (9-10 y) (part of an extended 3D schedule 0, 6, 60) Statistical non-inferiority of 2D vs 3D groups. At 21 months, comparing the adolescent 2D vs 3D groups, the GMT ratio and 95% CI were 1.66 (1.55-1.81) and 1.67 (1.51-1.86) for HPV16 and 18, respectively. The 2D regimen was non-inferior when compared to the 3D response in same-age girls and with women aged 18-24 years after 21 months of follow-up. Lazcano-Ponce L et al. Vaccine 2014

Immunogenicity of 2 doses of quadrivalent HPV vaccine in younger adolescents vs 3 doses in young women: A randomized independent study The GMT ratios for girls (2 doses) to women (3 doses) remained noninferior for all genotypes to 36 months. Antibody responses in girls were noninferior after 2 doses vs 3 doses for all 4 vaccine genotypes at month 7, but not for HPV-18 by month 24 or HPV-6 by month 36. Dobson et al. JAMA 2013

Summary and conclusions Using immunological endpoints to infer vaccine efficacy First investigator-driven studies in the target population of organized vaccination programs. High-level HPV16 and HPV18 NAbs are induced by both bivalent and qundrivalent HPV vaccines HPV16 and HPV18 NAbs titres, total IgG,and memory B-cells are significantly higher in Cervarix® vaccinees than in Gardasil® vaccinees. HPV31 and HPV45 cross-NAbs are induced more frequently and at higher level by Cervarix® than by Gardasil® NAb titers are related to age of vaccination. Cervarix® assures an acceptable degree of protection in adolescents and young adults with juvenile idiopathic arthritis. High and sustained immune response allows a reduction of vaccine doses. Evaluation of the immune response to define the duration and the immunological correlates of protection

Acknowledgements Department of Molecular Medicine, University of Padova Luisa Barzon Antonella Caputo Laura Squarzon Serena Masiero Barbara Mantelli Monia Pacenti Silvia Berto Giorgia Marcati Department of Public Health, ULSS16 Padova Lorena Gottardello Department of Specialist, Diagnostic, and Experimental Medicine, University of Bologna Tiziana Lazzarotto Liliana Gabrielli Department of Public Health, Emilia-Romagna Region Maria Grazia Pascucci Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan Susanna Esposito Nicola Principi

Vaccino Quadrivalente RCP – 27 marzo 2014 La schedula di vaccinazione dipende dall’età del soggetto. Individui dai 9 ai 13 anni di età inclusi Gardasil può essere somministrato in accordo ad una schedula a 2 dosi (0,5 ml a 0, 6 mesi) (vedere paragrafo 5.1). Se la seconda dose di vaccino viene somministrata prima di 6 mesi dopo la prima dose, una terza dose deve essere sempre somministrata. Alternativamente Gardasil può essere somministrato in accordo ad una schedula a 3 dosi (0,5 ml a 0, 2, 6 mesi). La seconda dose deve essere somministrata almeno un mese dopo la prima dose e la terza dose almeno 3 mesi dopo la seconda dose. Tutte e tre le dosi devono essere somministrate entro un periodo di 1 anno. Individui di età pari o superiore a 14 anni Gardasil deve essere somministrato in accordo ad una schedula a 3 dosi (0,5 ml a 0, 2, 6 mesi). La seconda dose deve essere somministrata almeno un mese dopo la prima dose e la terza dose deve essere somministrata almeno 3 mesi dopo la seconda dose. Tutte e tre le dosi devono essere somministrate entro il periodo di 1 anno.

Quanto espresso dalle autorità regolatorie L’EMA ha approvato la schedula vaccinale del vaccino bivalente a 2-dosi (M0,6) per le adolescenti di età 9-14 anni ritenendo che sia attesa la stessa efficacia ottenuta con la schedula 3-dosi (M0,1,6) nelle ragazze/giovani donne di età 15-25 anni. La schedula 2-dosi rappresenta l’unica posologia in questa fascia d’età L’EMA ha approvato la modifica della schedula vaccinale del vaccino quadrivalente per la fascia di età compresa tra 9-13 anni aggiungendo la schedula vaccinale 2-dosi (M0,6) come alternativa alla schedula standard 3-dosi (M0,2,6), raccomandando un follow-up delle adolescenti vaccinate con la schedula ridotta e uno studio di effectiveness o di impatto Con una schedula vaccinale più semplice ci si attende una maggiore aderenza al ciclo vaccinale completo e un aumento delle coperture vaccinali, unitamente a vantaggi organizzativi ed economici