EV71 Vaccine Development

Weining Meng

June 9th , 2016

• Epidemic of EV71-associated HFMD

• Development of Sinovac’s EV71 Vaccine, Inlive

• Phase III Trial Design and Outcome

• Industrialization of EV71 Vaccine

• Summary

Outline

EV71-Hand Food Mouth Disease Epidemic

1998, Taiwan, 129106 cases，including 405 critical

cases and 78 deaths， 91% of deaths are children

aged less than 5 years old.

1975，in Bulgaria, 750 children cases, including 149

cases of acute flaccid paralysis and 44 deaths

1997, Malaysia, 2628 cases，average age of 30

deaths is 1.5 years old.

EV71 Epidemic In China

2007-2015，

In total 14 millions HFMD reported，with more than

3,350 fatal cases

《Hand, foot, and mouth disease in China, 2008–12:An epidemiological study》

EV71 EV71 EV71

Total Serious Death

Mild cases：45% are EV71 Serious cases：80% are EV71 Fatal cases：90% are EV71

Serious HFMD epidemic in China;

EV71 inducing main serious and fatal cases;

Vaccine against EV71 is the answer.

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506 569

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124

0

100

200

300

400

500

600

700

800

900

1000

2007 2008 2009 2010 2011 2012 2013 2014 2015

0

500000

1000000

1500000

2000000

2500000

3000000

发病数 死亡数

HFMD Reported Cases and Fatal Cases 2007-2015

Reported Cases

Fatal Cases

2008 2009 2010 2011 2012 2013 2014 2015

Preclinical Studies Applied

For Clinical Trials

Clinical Trials

PhaseⅠ PhaseⅡ Phase Ⅲ

2011.05●2011.11●

2013.03●

Commercial Plant

Construction

Applied for Approval

★ 2010.12

Clinical Trial Application Approved

★ 2013.05

Applied for Production Approval

★ 2014.11

CFDA Experts Review

★ 2015.12.30 Approval

GM

P

Insp

ect

ion

Development Milestones

Characters of InliveTM

Vero Cell, cell factory cultivation technology;

H07 strain, C4 genotype, isolated by China CDC;

Inactivation with formaldehyde

Al(OH)3 as adjuvant

100 u/200u/400 u, 2 doses/3 doses regimen

Pre-clinical Studies of Sinovac EV71 Vaccine

Safety

Acute toxicity test

Local stimulation test

Allergy test

Repeated doses toxicity study (rat, cynomolgus monkey)

Immunogenicity

Mice (immune dosage, ED50)

Rats (immunization schedule, longevity of serologic responses)

Protection efficacy (neonatal mice)

Animal model was developed by the University of Sydney

Passive protection model

Female mice 0 day 1 week 2 week 3 week 4 week

Mate & prime boost Give birth

New born mice

MP-26M

EV71 vaccine

Challenge new born mice With 5 days old

Clinical seprated human EV71 strain —Unlethal

Mouse adapted strain MP-26M

Continues passage in brains of one-day-old

BALB/c mice Lethal

Establishment of Animal Model-Neonatal Mice

Inoculation for the mother mice with antigen from 50u-800u at day 0 and 14 could

cause 100% protection for the baby mice which were challenged MP-26M virus at 5 days

after birth.

Cross protection to different genotype has been approved in this animal model

Formalin-inactivated vaccine provokes cross-protective immunity in a mouse model of human entervirus 71 infection, Vaccine 29 2011

EV71 Vaccine Clinical Trails

Phase I

• Objective：Safety, Immunogenicity

• Subjects：Babies, children, and Adult

• Dose：100U、200U、400U

Phase II

• Objective：Immunogenicity, safety

• Subjects：6-35 months babies

• Dose：100U、200U、400U

168 subjects

540 subjects

广西

Phase III

• Objective：Protective effective

• Subjects：6-35 months babies

• Dose：400U

Phase III

• Objective：consistency

• Subjective：6 months-5 years children

• Dose：400U

10077 subjects

1400 subjects

江苏

Multi-center, randomized, double-blinded, placebo-controlled

Immunization Schedule: Day 0, 28

Dosage: 400U/dose

Investigator Jiangsu CDC

Lab Tests Technician

Virus isolation, PCR: National Institutes for Viral Disease Control & Prevention, China CDC

Serum Tests: National Institutes for Food and Drug Control (NIFDC)

Statistician The Fourth Military Medical University

Sponsor Sinovac Biotech Co., Ltd.

Data and Safety Monitoring Board (DSMB): 5 members

Phase III-Clinical Trial Design

National & Jiangsu Provincial HFMD Epidemic Surveillance Data

HFMD Epidemiological Data of 6 counties in Jiangsu (2010)

EV71 Incidence of 6-35Months old Infants ranged 400-2000/100,000

Hypothesis 2: Incidence in the placebo group would be 800/100,000

Hypothesis 1: Vaccine Protection Rate would be 80%

Sample Size:

10,000

Experimental Vaccine Group

5000

Placebo (Control) Group

5000

Surveillance Period: 1 Year

Phase III-Hypotheses & Sample Size Calculation

2012 2013 2014

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3

Primary Endpoint Efficacy

Secondary Endpoint Safety

Surveillance (1st Year)

Surveillance (2nd Year)

D0 D56 M8 M14 M26

Secondary Endpoint Immunogenicity Immune Persistency

Blood Sampling

Day0 28

Age Experimental Control Total

6-11 Months 1250 1250 2500

12-23 Months 2500 2500 5000

24-35 Months 1250 1250 2500

Total 5000 5000 10000

Immunogenicity Subgroup

Total: 1200

400 subjects from each of the 3 centers

Phase III-Subjects Grouping & Surveillance Design

Reported by subjects’ parents

Clinical symptoms + PCR results ↓

Preliminary diagnosis

Clinically Suspicious Cases

Collect Throat & Anal Swabs

Fluorescence-based Quantitative PCR within 24 hrs

EV Negative Cases

CA16 Positive Cases

Other EV Positive Cases

EV71 Positive Cases

Follow-up Visit within 48 hrs Collect throat & anal swabs, stool &

blood samples for re-check

DSMB Review Symptoms, duration, PCR

results (Virus isolation,

neutralizing antibody test)

Confirmed Cases

Outpatients Information from

Medical Institution Case

Detected

Sampling & Tests

Phase III-Monitoring & Diagnosis of Cases

Primary

Protection rate against EV71-associated disease (80%)

48 EV71-associated HFMD or Herpangina during 1 year of monitoring period

Secondary

Safety Day 0 – 56: incidences of solicited & unsolicited AE Day 57 – Month 14: incidence of SAE

Immunogenicity (Immunogenicity subgroup) In experimental group & control group at day 56: anti-EV71 neutralizing antibody positive rate, GMT, GMI

Immune persistency (Immunogenicity subgroup) In experimental group & control group at M8 & M14: anti-EV71neutralizing antibody positive rate, GMT, GMI

Exploratory Explore the immunological surrogate of protection

Phase III-Endpoints Design

12446 volunteers been screened

2369 were excluded

10077 enrolled & randomly assigned into experimental or control group

Safety Analysis Set: 5044 5044 received 1st dose 4719 received 2nd dose

Safety Analysis Set: 5033 5033 received 1st dose

4711 received 2nd dose

Surveillance & primary efficacy analysis (intention-to-treat/full analysis set, FAS) 5028

Efficacy analysis: per-protocol Set (PPS) 4587

132 discontinued the study

Surveillance & primary efficacy analysis (intention-to-treat/full analysis set, FAS) 5041

132 discontinued the study

325 did not receive 2nd dose

322 did not receive 2nd dose

5 discontinued

Efficacy analysis: per-protocol Set (PPS) 4578

3 discontinued Experimental Group

Control Group

Phase III-Subjects

EV71 Positive Case

119

EV71-associated

99

Other EV71

Positive Cases

20

PCR

Virus isolation

Neutralizing antibody

DSMB Review &

Confirmation

EV71-associated

herpangina cases

4

EV71-associated

HFMD 95

Total

10077 subjects

EV71-associated hospitalized

HFMD

24

EV71-associated severe HFMD

8

Phase III-Surveillance Results (FAS)

Case Classification

FAS

Case Number Incidence Density (%,95%CI) Protection Rate

(%,95%CI) P-value

Experimental Control Experimental Control

EV71 Positive Cases 13 106 0.261 2.175 88.0

(78.6,93.2) <0.0001

EV71-associated diseases

5 94 0.101 1.929 94.8

(87.2,97.9) <0.0001

EV71-associated HFMD 5 90 0.101 1.847 94.6

(86.6,97.8) <0.0001

EV71-associated hospitalized HFMD

0 24 0.000 0.493 100.0

(83.7,100.0) <0.0001

EV71-associated severe HFMD

0 8 0.000 0.164 100.0

(42.6,100.0) 0.0036

Incidence Density Rate (IDR)=（Case Number/Person-year）×100% Protection Rate = (Control Group IDR – Experimental IDR)/ Control Group IDR ×100%

Person-Year: Experimental: 4973.2 Control: 4873.0

The Protection Efficacy of the vaccine reached the designed primary endpoint（80% for the 1st Year Surveillance）

Phase III-Efficacy Results (FAS) 1st Year

EV71 Vaccine-Efficacy

Protection rate for EV71 infection： 94.8%

Protection for hospitalized cases and serious cases：100.0%

5

94

0

10

20

30

40

50

60

70

80

90

100

疫苗组 对照组

病例数 病例数

Effectiveness for EV71 Infection

0

24

0

10

20

30

40

50

60

70

80

90

100

疫苗组 对照组

Protection rate：100.0%

Effectiveness for hospitalized cases

病例数

Protection rate：94.8%

vaccine Control vaccine Control

Efficacy, Safety, and Immunogenicity of an Enterovirus 71 Vaccine in China, The New England Journal of Medicine, 2014

No. of Cases No. of Cases

EV71 Vaccine-Immunogenicity

56 days after vaccination，Neutralizing antibody positive rate 98.79%、GMT 165.79，

8 months and 14 months after vaccination, high level of antibody

Good immunogenicity and immune persistence.

0

20

40

60

80

100

120

140

160

180

GM

T

对照组

疫苗组

Pre-vaccination

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

阳性率

对照组

疫苗组

Positive R

ate

Control

Vaccine

Control

Vaccine

Pre-vaccination

Efficacy, Safety, and Immunogenicity of an Enterovirus 71 Vaccine in China, The New England Journal of Medicine, 2014

0.00 0.00 0.00 0.00 0.00

2.66

0.24 0.08 0.22 0.10 0.04 0.02 0.06 0.02 0.02 0.00 0.02

2.42 0.40 0.12 0.26 0.16 0.08

0.00 0

3

6

9

12

15

触痛 红斑 硬结 肿胀 瘙痒 发热 腹泻 食欲下降 恶心呕吐 烦躁 疲倦乏力 变态反应

局部不良反应 全身不良反应

试验组 N=5044 安慰剂组 N=5033

Incidence of each Grade 3 AE symptom（%）

Pain Redness Induration Swelling Itching Fever Diarrhea Loss Of Appetite Nausea Irritability Fatigue Allergy

Local AE Systemic AE

Experimental Control

5.5 6.7 5.6 3.2 2.1

34.7

12.6 8.4 8.2 7.4 3.4 1.4 5.3 6.7 5.9 2.9 2.2

35.1

12.4 8.6 7.6 6.9 3.5 1.3

0

20

40

60

80

100

触痛 红斑 硬结 肿胀 瘙痒 发热 腹泻 食欲下降 恶心呕吐 烦躁 疲倦乏力 变态反应

局部不良反应 全身不良反应

试验组 N=5044 安慰剂组 N=5033

Incidence of each AE symptom（%） AE Incidence： Experimental（5044）：51.7% Control（5033）：52.8% not statistically significant (p=0.2905)

Pain Redness Induration Swelling Itching Fever Diarrhea Loss Of Appetite Nausea Irritability Fatigue Allergy Local AE Systemic AE Experimental Control

Phase III-Safety Results

No significant different between vaccine group and placebo group

Objective: to evaluate the lot-to-lot consistency, immunogenicity and safety of this EV71 vaccine candidate

Design: randomized, double-blinded, placebo-controlled

Sample size: 1400 (4 groups with 350 subject per group)

Immunization Schedule: Day0, 28

Immunogenicity indicator: neutralizing antibody level (Day 0, 56)

Safety indicator: systemic AE, local AE, SAE

GMT Logarithmic difference (95% CI)

Criteria Conclusion

Lot 1 vs. Lot 2 0.04 (-0.04～0.12)

-0.176～0.176

Equivalent

Lot 1 vs. Lot 3 0.02(-0.06～0.10) Equivalent

Lot 2 vs. Lot 3 -0.02(-0.10～0.06) Equivalent

Demonstrated Lot-to-lot Consistency

Phase III-Lot to Lot Consistency

Production 19000 m2

4F Ready for use

3F QC Labs

EV71 Bulk 20 million does/year

2F Formulation

Filling & Packaging 100 million doses/year

1F Cold Room 1.8 million vials

Utilities

Others

4000 m2

2F Animal Lab

1F Biobank

Office 9000 m2

Industrialization Total ：29,021 ㎡

Built-up area：32,322 ㎡

Quality Control Center

23

EV71 Workshop

Capacity of 20 million does per year

Large scale cells/virus cultivation

• Completed an integral development process of EV71

vaccine

– Pre-clinical trial (protection animal model)

– Clinical trials (94.8% protection rate)

• Built up vaccine production capacity of >20 million

doses/year

• Believe will play a significant role for HFMD control in

China

• Seek collaboration with other organization for HFMD

control in other countries

• Hope WHO could involve more in HFMD control

Summary