EV71 Vaccine Development

Weining Meng
June 9th , 2016
Outline

• Epidemic of EV71-associated HFMD

• Development of Sinovac’s EV71 Vaccine, Inlive
• Phase III Trial Design and Outcome
• Industrialization of EV71 Vaccine
• Summary
 EV71-Hand Food Mouth Disease Epidemic

1975，in Bulgaria, 750 children cases, including 149

cases of acute flaccid paralysis and 44 deaths

1998, Taiwan, 129106 cases，including 405 critical

cases and 78 deaths， 91% of deaths are children
aged less than 5 years old.

1997, Malaysia, 2628 cases，average age of 30

deaths is 1.5 years old.
 EV71 Epidemic In China

HFMD Reported Cases and Fatal Cases 2007-2015

Reported Fatal Total Serious Death

发病数 死亡数
Cases Cases

3000000 2819581 1000

888 900
2500000
2198438 800
2014999
1855547 700
2000000 1795336
1638743 600
569
1500000 506 508 500
1155525
400
1000000 353 EV71
300 EV71 EV71
488955
263
200
500000
83344
126 124100
0 17 0
2007 2008 2009 2010 2011 2012 2013 2014 2015
2007-2015， Mild cases：45% are EV71
Serious HFMD epidemic in China; Serious cases：80% are EV71
In total 14 millions HFMD reported，with more than
Fatal cases：90% are EV71
3,350 fatal cases
EV71 inducing main serious and fatal cases;
Vaccine against EV71 is the answer.

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

Development Milestones

2008 2009 2010 2011 2012 2013 2014 2015

★ ★ ★ ★
2010.12 2013.05 2014.11 2015.12.30
Clinical Trial Applied for CFDA Experts Approval
Application Production Review
Approved Approval

Clinical Trials
Preclinical PhaseⅠ PhaseⅡ Phase Ⅲ
Studies Applied

Inspection
2011.05●2011.11●
For Applied for

GMP
2013.03●
Clinical Approval
Trials

Commercial Plant
Construction
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
 Establishment of Animal Model-Neonatal Mice

Inoculation for the mother mice with antigen from 50u-800u at day 0 and 14 could
Clinical seprated human EV71
cause 100% protection for the baby mice which were challenged MP-26M virus at 5 days
strain —Unlethal

after birth.
Cross protection to different genotype has beenMouse approved
adapted
in this animal model
strain MP-26M

Challenge new born mice

With 5 days old
MP-26M
Continues passage in brains of one-day-old
BALB/c mice Lethal

New born
EV71 vaccine mice
Mate
& prime boost Give birth
Female
0 day 1 week 2 week 3 week 4 week mice

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

• Objective： • Objective：
Protective consistency
effective • Subjective：6
• Subjects：6-35 months-5 years
months babies children
• Dose：400U • Dose：400U

EV71 Vaccine Clinical Trails

Phase I Phase II
10077 1400
subjects subjects
• Objective： • Objective：
江苏
Safety, Immunogenicity,
Immunogenicity safety
• Subjects： • Subjects：6-35
Babies, children, months babies
and Adult • Dose：100U、
• Dose：100U、 200U、400U
200U、400U 广西

168 540
subjects subjects
Phase III-Clinical Trial Design

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

Immunization Schedule: Day 0, 28
Dosage: 400U/dose

Investigator Jiangsu CDC

Virus isolation, PCR: National Institutes for Viral

Lab Tests Disease Control & Prevention, China CDC
Technician 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-Hypotheses & Sample Size Calculation

Hypothesis 1:
Vaccine Protection Rate would be Experimental Vaccine Group
80%
5000

Sample Size:
10,000
Hypothesis 2:
Incidence in the placebo group Placebo (Control) Group
would be 800/100,000 5000

EV71 Incidence of 6-35Months old

Infants ranged 400-2000/100,000
Surveillance Period: 1 Year

National & Jiangsu Provincial HFMD HFMD Epidemiological Data of 6

Epidemic Surveillance Data counties in Jiangsu (2010)
 Phase III-Subjects Grouping & Surveillance Design

Age Experimental Control Total Immunogenicity Subgroup

6-11 Months 1250 1250 2500
Total: 1200
12-23 Months 2500 2500 5000
400 subjects from each of
24-35 Months 1250 1250 2500 the 3 centers
Total 5000 5000 10000

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
Surveillance Surveillance
Secondary (1st Year) (2nd Year)
Endpoint
Safety

Day0 28
Secondary
Endpoint
Immunogenicity Blood Sampling
Immune
Persistency
D0 D56 M8 M14 M26
 Phase III-Monitoring & Diagnosis of Cases
Reported by Outpatients
Case subjects’ Information from
parents Medical Institution
Detected
Clinically Suspicious Cases

Collect Throat & Anal Swabs

Fluorescence-based
Quantitative PCR within 24 hrs

Sampling EV Negative CA16 Positive Other EV Positive EV71 Positive

Cases Cases Cases Cases
& Tests
Follow-up Visit within 48 hrs
Collect throat & anal swabs, stool &
blood samples for re-check

DSMB Review
Symptoms, duration, PCR
Clinical symptoms + PCR results
results Confirmed
↓
(Virus isolation, Cases
Preliminary diagnosis
neutralizing antibody
test)
Phase III-Endpoints Design

Protection rate against EV71-associated disease

(80%)
Primary 48 EV71-associated HFMD or Herpangina
during 1 year of monitoring period

Safety
Day 0 – 56: incidences of solicited & unsolicited AE
Day 57 – Month 14: incidence of SAE
Immunogenicity (Immunogenicity subgroup)
Secondary 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-Subjects
12446 volunteers been screened

2369 were excluded

10077 enrolled & randomly assigned into experimental or

control group

Safety Analysis Set: 5044 Safety Analysis Set: 5033 322 did not receive
325 did not receive 5044 received 1st dose 5033 received 1st dose
2nd dose 2nd dose
4719 received 2nd dose 4711 received 2nd dose

3 discontinued
5 discontinued
Surveillance & Surveillance &
Experimental primary efficacy primary efficacy Control
analysis (intention-to- analysis (intention-to-
Group treat/full analysis set, treat/full analysis set, Group
FAS) FAS)
5041 5028
132 discontinued the 132 discontinued the
study study

Efficacy analysis: per- Efficacy analysis: per-

protocol Set (PPS) protocol Set (PPS)
4587 4578
 Phase III-Surveillance Results (FAS)

Total
10077 subjects

EV71 Positive Case

119
PCR
Virus isolation
Neutralizing EV71-associated
antibody EV71-associated EV71-associated
EV71-associated hospitalized
DSMB Review severe HFMD
& 99 HFMD 95 HFMD
8
Confirmation 24

Other EV71 EV71-associated

Positive Cases herpangina cases
20 4
 Phase III-Efficacy Results (FAS) 1st Year
Person-Year:
Experimental: 4973.2 Incidence Density Rate (IDR)=（Case Number/Person-year）×100%
Control: 4873.0 Protection Rate = (Control Group IDR – Experimental IDR)/ Control Group IDR ×100%

FAS
Case Classification Case Number Incidence Density (%,95%CI) Protection
Rate P-value
Experimental Control Experimental Control (%,95%CI)
88.0
EV71 Positive Cases 13 106 0.261 2.175 <0.0001
(78.6,93.2)

EV71-associated 94.8
5 94 0.101 1.929 <0.0001
diseases (87.2,97.9)

94.6
EV71-associated HFMD 5 90 0.101 1.847 <0.0001
(86.6,97.8)

EV71-associated 100.0
0 24 0.000 0.493 <0.0001
hospitalized HFMD (83.7,100.0)

EV71-associated severe 100.0

0 8 0.000 0.164 0.0036
HFMD (42.6,100.0)

The Protection Efficacy of the vaccine reached the designed

primary endpoint（80% for the 1st Year Surveillance）
 EV71 Vaccine-Efficacy

No. of Cases No. of Cases

病例数
病例数
100
100
90
Protection rate：94.8% 90 Protection rate：100.0%
80
80
70
70
60
60
50
94 50
40
40
30
30
20
20
10 24
10
0 5
0 0
疫苗组 对照组
vaccine Control 疫苗组 对照组
vaccine Control
Effectiveness for EV71 Infection Effectiveness for hospitalized cases

Protection rate for EV71 infection： 94.8%

Protection for hospitalized cases and serious cases：100.0%

Efficacy, Safety, and Immunogenicity of an Enterovirus 71 Vaccine in China, The New England Journal of Medicine, 2014
 EV71 Vaccine-Immunogenicity

180 100.00%

Positive Rate
160 90.00%

140 80.00%

70.00%
120
60.00%
100

阳性率
GMT

Control 50.00% Control

80 对照组 对照组
40.00%
疫苗组 疫苗组
60 Vaccine 30.00% Vaccine
40 20.00%
20 10.00%

0 0.00%

Pre-vaccination Pre-vaccination

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.

Efficacy, Safety, and Immunogenicity of an Enterovirus 71 Vaccine in China, The New England Journal of Medicine, 2014
 Phase III-Safety Results
Incidence of each AE symptom（%） AE Incidence：
Experimental（5044）：51.7%
100 Control（5033）：52.8%
not statistically significant (p=0.2905)
80

60

40 34.735.1

20 12.6 8.4 8.6 8.2 7.6

5.5 5.3 6.7 6.7 5.6 5.9 3.2 2.9 12.4 7.4 6.9 3.4 3.5
2.1 2.2 1.4 1.3
0
Pain Redness Induration Swelling Itching Fever Diarrhea Loss Of Appetite Nausea Irritability Fatigue Allergy
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
Local AE Systemic AE
局部不良反应 全身不良反应
Experimental Control
试验组 N=5044 安慰剂组 N=5033

Incidence of each Grade 3 AE symptom（%）

15

12
No significant different between vaccine group and placebo group
9

6
2.66
3 2.42
0.06 0.40 0.12 0.26 0.16 0.08 0.02
0.02 0.02 0.00 0.02
0.00 0.00 0.00 0.00 0.00 0.24 0.08 0.22 0.10 0.04 0.00
0
Pain Redness Induration Swelling Itching Fever Diarrhea Loss Of Appetite Nausea Irritability Fatigue Allergy
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
Local AE Systemic AE
局部不良反应 全身不良反应
Experimental Control
试验组 N=5044 安慰剂组 N=5033
Phase III-Lot to Lot Consistency

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
Criteria Conclusion
difference (95% CI)

Lot 1 vs. Lot 2 0.04 (-0.04～0.12) Equivalent

Lot 1 vs. Lot 3 0.02(-0.06～0.10) -0.176～0.176 Equivalent

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

Demonstrated Lot-to-lot Consistency

 Total ：29,021 ㎡
Built-up area：32,322 ㎡
Industrialization
Others
4000 m2

Production
19000 m2
2F Animal Lab

Office
4F
Ready for use 1F Biobank
9000 m2

QC Labs
3F EV71 Bulk
20 million does/year

Formulation
2F Filling & Packaging
100 million doses/year

Cold Room
1F 1.8 million vials

Utilities
Quality Control Center

23
EV71 Workshop

Capacity of 20 million does per year

Large scale cells/virus cultivation
Summary

• 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