Safety, tolerability, and immunogenicity of influenza vaccination with a high-density microarray patch: Results from a randomized, controlled phase I clinical trial


Autoři: Angus H. Forster aff001;  Katey Witham aff001;  Alexandra C. I. Depelsenaire aff001;  Margaret Veitch aff002;  James W. Wells aff002;  Adam Wheatley aff003;  Melinda Pryor aff004;  Jason D. Lickliter aff005;  Barbara Francis aff006;  Steve Rockman aff003;  Jesse Bodle aff007;  Peter Treasure aff008;  Julian Hickling aff009;  Germain J. P. Fernando aff001
Působiště autorů: Vaxxas Pty Ltd, Brisbane, Queensland, Australia aff001;  The University of Queensland Diamantina Institute, Faculty of Medicine, The University of Queensland, TRI, Brisbane, Queensland, Australia aff002;  Department of Microbiology and Immunology, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia aff003;  360biolabs, Melbourne, Victoria, Australia aff004;  Nucleus Network Pty Ltd, Melbourne, Victoria, Australia aff005;  Avance Clinical Pty Ltd, Thebarton, South Australia, Australia aff006;  Seqirus Pty Ltd, Parkville, Victoria, Australia aff007;  Peter Treasure Statistical Services Ltd, Kings Lynn, United Kingdom aff008;  Working in Tandem Ltd, Cambridge, United Kingdom aff009;  The University of Queensland, School of Chemistry & Molecular Biosciences, Faculty of Science, Brisbane, Queensland, Australia aff010
Vyšlo v časopise: Safety, tolerability, and immunogenicity of influenza vaccination with a high-density microarray patch: Results from a randomized, controlled phase I clinical trial. PLoS Med 17(3): e1003024. doi:10.1371/journal.pmed.1003024
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003024

Souhrn

Background

The Vaxxas high-density microarray patch (HD-MAP) consists of a high density of microprojections coated with vaccine for delivery into the skin. Microarray patches (MAPs) offer the possibility of improved vaccine thermostability as well as the potential to be safer, more acceptable, easier to use, and more cost-effective for the administration of vaccines than injection by needle and syringe (N&S). Here, we report a phase I trial using the Vaxxas HD-MAP to deliver a monovalent influenza vaccine that was to the best of our knowledge the first clinical trial to evaluate the safety, tolerability, and immunogenicity of lower doses of influenza vaccine delivered by MAPs.

Methods and findings

HD-MAPs were coated with a monovalent, split inactivated influenza virus vaccine containing A/Singapore/GP1908/2015 H1N1 haemagglutinin (HA). Between February 2018 and March 2018, 60 healthy adults (age 18–35 years) in Melbourne, Australia were enrolled into part A of the study and vaccinated with either: HD-MAPs delivering 15 μg of A/Singapore/GP1908/2015 H1N1 HA antigen (A-Sing) to the volar forearm (FA); uncoated HD-MAPs; intramuscular (IM) injection of commercially available quadrivalent influenza vaccine (QIV) containing A/Singapore/GP1908/2015 H1N1 HA (15 μg/dose); or IM injection of H1N1 HA antigen (15 μg/dose). After 22 days’ follow-up and assessment of the safety data, a further 150 healthy adults were enrolled and randomly assigned to 1 of 9 treatment groups. Participants (20 per group) were vaccinated with HD-MAPs delivering doses of 15, 10, 5, 2.5, or 0 μg of HA to the FA or 15 μg HA to the upper arm (UA), or IM injection of QIV. The primary objectives of the study were safety and tolerability. Secondary objectives were to assess the immunogenicity of the influenza vaccine delivered by HD-MAP. Primary and secondary objectives were assessed for up to 60 days post-vaccination. Clinical staff and participants were blind as to which HD-MAP treatment was administered and to administration of IM-QIV-15 or IM-A/Sing-15. All laboratory investigators were blind to treatment and participant allocation. Two further groups in part B (5 participants per group), not included in the main safety and immunological analysis, received HD-MAPs delivering 15 μg HA or uncoated HD-MAPs applied to the forearm. Biopsies were taken on days 1 and 4 for analysis of the cellular composition from the HD-MAP application sites.

The vaccine coated onto HD-MAPs was antigenically stable when stored at 40°C for at least 12 months. HD-MAP vaccination was safe and well tolerated; any systemic or local adverse events (AEs) were mild or moderate. Observed systemic AEs were mostly headache or myalgia, and local AEs were application-site reactions, usually erythema. HD-MAP administration of 2.5 μg HA induced haemagglutination inhibition (HAI) and microneutralisation (MN) titres that were not significantly different to those induced by 15 μg HA injected IM (IM-QIV-15). HD-MAP delivery resulted in enhanced humoral responses compared with IM injection with higher HAI geometric mean titres (GMTs) at day 8 in the MAP-UA-15 (GMT 242.5, 95% CI 133.2–441.5), MAP-FA-15 (GMT 218.6, 95% CI 111.9–427.0), and MAP-FA-10 (GMT 437.1, 95% CI 254.3–751.3) groups compared with IM-QIV-15 (GMT 82.8, 95% CI 42.4–161.8), p = 0.02, p = 0.04, p < 0.001 for MAP-UA-15, MAP-FA-15, and MAP-FA-10, respectively. Higher titres were also observed at day 22 in the MAP-FA-10 (GMT 485.0, 95% CI 301.5–780.2, p = 0.001) and MAP-UA-15 (367.6, 95% CI 197.9–682.7, p = 0.02) groups compared with the IM-QIV-15 group (GMT 139.3, 95% CI 79.3–244.5). Results from a panel of exploratory immunoassays (antibody-dependent cellular cytotoxicity, CD4+ T-cell cytokine production, memory B cell (MBC) activation, and recognition of non-vaccine strains) indicated that, overall, Vaxxas HD-MAP delivery induced immune responses that were similar to, or higher than, those induced by IM injection of QIV. The small group sizes and use of a monovalent influenza vaccine were limitations of the study.

Conclusions

Influenza vaccine coated onto the HD-MAP was stable stored at temperatures up to 40°C. Vaccination using the HD-MAP was safe and well tolerated and resulted in immune responses that were similar to or significantly enhanced compared with IM injection. Using the HD-MAP, a 2.5 μg dose (1/6 of the standard dose) induced HAI and MN titres similar to those induced by 15 μg HA injected IM.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR.org.au), trial ID 108 ACTRN12618000112268/U1111-1207-3550.

Klíčová slova:

Antigens – Forearms – H1N1 – Immune response – Influenza – Microarrays – Vaccination and immunization – Vaccines


Zdroje

1. DeMuth PC, Min Y, Irvine DJ, Hammond PT. Implantable silk composite microneedles for programmable vaccine release kinetics and enhanced immunogenicity in transcutaneous immunization. Adv Healthc Mater. 2014 Jan;3(1):47–58. doi: 10.1002/adhm.201300139 23847143

2. Fernando GJP, Hickling J, Jayashi Flores CM, Griffin P, Anderson CD, Skinner SR, et al. Safety, tolerability, acceptability and immunogenicity of an influenza vaccine delivered to human skin by a novel high-density microprojection array patch (NanopatchTM). Vaccine. 2018 18;36(26):3779–88. doi: 10.1016/j.vaccine.2018.05.053 29779922

3. Hirobe S, Azukizawa H, Hanafusa T, Matsuo K, Quan Y-S, Kamiyama F, et al. Clinical study and stability assessment of a novel transcutaneous influenza vaccination using a dissolving microneedle patch. Biomaterials. 2015 Jul;57:50–8. doi: 10.1016/j.biomaterials.2015.04.007 25913250

4. McGrath MG, Vucen S, Vrdoljak A, Kelly A, O’Mahony C, Crean AM, et al. Production of dissolvable microneedles using an atomised spray process: effect of microneedle composition on skin penetration. Eur J Pharm Biopharm. 2014 Feb;86(2):200–11. doi: 10.1016/j.ejpb.2013.04.023 23727511

5. Poirier D, Renaud F, Dewar V, Strodiot L, Wauters F, Janimak J, et al. Hepatitis B surface antigen incorporated in dissolvable microneedle array patch is antigenic and thermostable. Biomaterials. 2017 Nov;145:256–65.

6. Courtenay AJ, Rodgers AM, McCrudden MTC, McCarthy HO, Donnelly RF. Novel Hydrogel-Forming Microneedle Array for Intradermal Vaccination in Mice Using Ovalbumin as a Model Protein Antigen. Mol Pharm. 2019 07;16(1):118–27. doi: 10.1021/acs.molpharmaceut.8b00895 30452868

7. Rouphael NG, Paine M, Mosley R, Henry S, McAllister DV, Kalluri H, et al. The safety, immunogenicity, and acceptability of inactivated influenza vaccine delivered by microneedle patch (TIV-MNP 2015): a randomised, partly blinded, placebo-controlled, phase 1 trial. Lancet. 2017 12;390(10095):649–58. doi: 10.1016/S0140-6736(17)30575-5 28666680

8. Arya J, Prausnitz MR. Microneedle patches for vaccination in developing countries. J Control Release. 2016 Oct 28;240:135–41. doi: 10.1016/j.jconrel.2015.11.019 26603347

9. Marshall S, Sahm LJ, Moore AC. The success of microneedle-mediated vaccine delivery into skin. Hum Vaccin Immunother. 2016 Nov;12(11):2975–83. doi: 10.1080/21645515.2016.1171440 27050528

10. Depelsenaire ACI, Meliga SC, McNeilly CL, Pearson FE, Coffey JW, Haigh OL, et al. Colocalization of cell death with antigen deposition in skin enhances vaccine immunogenicity. J Invest Dermatol. 2014 Sep;134(9):2361–70. doi: 10.1038/jid.2014.174 24714201

11. Esser ES, Pulit-Penaloza JA, Kalluri H, McAllister D, Vassilieva EV, Littauer EQ, et al. Microneedle patch delivery of influenza vaccine during pregnancy enhances maternal immune responses promoting survival and long-lasting passive immunity to offspring. Sci Rep. 2017 Jul 18;7(1):5705. doi: 10.1038/s41598-017-05940-7 28720851

12. Fernando GJP, Zhang J, Ng H-I, Haigh OL, Yukiko SR, Kendall MAF. Influenza nucleoprotein DNA vaccination by a skin targeted, dry coated, densely packed microprojection array (Nanopatch) induces potent antibody and CD8(+) T cell responses. J Control Release. 2016 Sep 10;237:35–41. doi: 10.1016/j.jconrel.2016.06.045 27381247

13. Fernando GJP, Chen X, Prow TW, Crichton ML, Fairmaid EJ, Roberts MS, et al. Potent immunity to low doses of influenza vaccine by probabilistic guided micro-targeted skin delivery in a mouse model. PLoS ONE. 2010 Apr 21;5(4):e10266. doi: 10.1371/journal.pone.0010266 20422002

14. Moon S, Wang Y, Edens C, Gentsch JR, Prausnitz MR, Jiang B. Dose sparing and enhanced immunogenicity of inactivated rotavirus vaccine administered by skin vaccination using a microneedle patch. Vaccine. 2013 Jul 25;31(34):3396–402. doi: 10.1016/j.vaccine.2012.11.027 23174199

15. Muller DA, Fernando GJP, Owens NS, Agyei-Yeboah C, Wei JCJ, Depelsenaire ACI, et al. High-density microprojection array delivery to rat skin of low doses of trivalent inactivated poliovirus vaccine elicits potent neutralising antibody responses. Sci Rep. 2017 Oct 3;7(1):12644. doi: 10.1038/s41598-017-13011-0 28974777

16. Quan F-S, Kim Y-C, Compans RW, Prausnitz MR, Kang S-M. Dose sparing enabled by skin immunization with influenza virus-like particle vaccine using microneedles. J Control Release. 2010 Nov 1;147(3):326–32. doi: 10.1016/j.jconrel.2010.07.125 20692307

17. Resch TK, Wang Y, Moon S-S, Joyce J, Li S, Prausnitz M, et al. Inactivated rotavirus vaccine by parenteral administration induces mucosal immunity in mice. Sci Rep. 2018 Jan 12;8(1):561. doi: 10.1038/s41598-017-18973-9 29330512

18. Wan Y, Hickey JM, Bird C, Witham K, Fahey P, Forster A, et al. Development of Stabilizing Formulations of a Trivalent Inactivated Poliovirus Vaccine in a Dried State for Delivery in the NanopatchTM Microprojection Array. J Pharm Sci. 2018 Jun;107(6):1540–51. doi: 10.1016/j.xphs.2018.01.027 29421219

19. Griffin P, Elliott S, Krauer K, Davies C, Rachel Skinner S, Anderson CD, et al. Safety, acceptability and tolerability of uncoated and excipient-coated high density silicon micro-projection array patches in human subjects. Vaccine. 2017 Dec 4;35(48 Pt B):6676–84.

20. Wagner R, Göpfert C, Hammann J, Neumann B, Wood J, Newman R, et al. Enhancing the reproducibility of serological methods used to evaluate immunogenicity of pandemic H1N1 influenza vaccines-an effective EU regulatory approach. Vaccine. 2012 Jun 8;30(27):4113–22. doi: 10.1016/j.vaccine.2012.02.077 22446639

21. Wines BD, Vanderven HA, Esparon SE, Kristensen AB, Kent SJ, Hogarth PM. Dimeric FcγR Ectodomains as Probes of the Fc Receptor Function of Anti-Influenza Virus IgG. J Immunol. 2016 15;197(4):1507–16. doi: 10.4049/jimmunol.1502551 27385782

22. Whittle JRR, Wheatley AK, Wu L, Lingwood D, Kanekiyo M, Ma SS, et al. Flow cytometry reveals that H5N1 vaccination elicits cross-reactive stem-directed antibodies from multiple Ig heavy-chain lineages. J Virol. 2014 Apr;88(8):4047–57. doi: 10.1128/JVI.03422-13 24501410

23. Landry N, Pillet S, Favre D, Poulin J-F, Trépanier S, Yassine-Diab B, et al. Influenza virus-like particle vaccines made in Nicotiana benthamiana elicit durable, poly-functional and cross-reactive T cell responses to influenza HA antigens. Clin Immunol. 2014 Oct;154(2):164–77. doi: 10.1016/j.clim.2014.08.003 25128897

24. Bodle J, Verity EE, Ong C, Vandenberg K, Shaw R, Barr IG, et al. Development of an enzyme-linked immunoassay for the quantitation of influenza haemagglutinin: an alternative method to single radial immunodiffusion. Influenza Other Respir Viruses. 2013 Mar;7(2):191–200. doi: 10.1111/j.1750-2659.2012.00375.x 22583601

25. Wijnans L, Voordouw B. A review of the changes to the licensing of influenza vaccines in Europe. Influenza Other Respir Viruses. 2016 Jan;10(1):2–8. doi: 10.1111/irv.12351 26439108

26. Wheatley AK, Kristensen AB, Lay WN, Kent SJ. HIV-dependent depletion of influenza-specific memory B cells impacts B cell responsiveness to seasonal influenza immunisation. Sci Rep. 2016 May 25;6:26478. doi: 10.1038/srep26478 27220898

27. Marra F, Young F, Richardson K, Marra CA. A meta-analysis of intradermal versus intramuscular influenza vaccines: immunogenicity and adverse events. Influenza Other Respir Viruses. 2013 Jul;7(4):584–603. doi: 10.1111/irv.12000 22974174

28. Norman JJ, Arya JM, McClain MA, Frew PM, Meltzer MI, Prausnitz MR. Microneedle patches: usability and acceptability for self-vaccination against influenza. Vaccine. 2014 Apr 1;32(16):1856–62. doi: 10.1016/j.vaccine.2014.01.076 24530146

29. Arnou R, Icardi G, De Decker M, Ambrozaitis A, Kazek M-P, Weber F, et al. Intradermal influenza vaccine for older adults: a randomised controlled multicenter phase III study. Vaccine. 2009 Dec 9;27(52):7304–12. doi: 10.1016/j.vaccine.2009.10.033 19849996

30. Kenney RT, Frech SA, Muenz LR, Villar CP, Glenn GM. Dose sparing with intradermal injection of influenza vaccine. N Engl J Med. 2004 Nov 25;351(22):2295–301. doi: 10.1056/NEJMoa043540 15525714

31. Leroux-Roels I, Vets E, Freese R, Seiberling M, Weber F, Salamand C, et al. Seasonal influenza vaccine delivered by intradermal microinjection: A randomised controlled safety and immunogenicity trial in adults. Vaccine. 2008 Dec 2;26(51):6614–9. doi: 10.1016/j.vaccine.2008.09.078 18930093

32. Levin Y, Kochba E, Hung I, Kenney R. Intradermal vaccination using the novel microneedle device MicronJet600: Past, present, and future. Hum Vaccin Immunother. 2015;11(4):991–7. doi: 10.1080/21645515.2015.1010871 25745830

33. Van Damme P, Oosterhuis-Kafeja F, Van der Wielen M, Almagor Y, Sharon O, Levin Y. Safety and efficacy of a novel microneedle device for dose sparing intradermal influenza vaccination in healthy adults. Vaccine. 2009 Jan 14;27(3):454–9. doi: 10.1016/j.vaccine.2008.10.077 19022318

34. Hung IF-N, Zhang AJ, To KK-W, Chan JF-W, Li P, Wong T-L, et al. Topical imiquimod before intradermal trivalent influenza vaccine for protection against heterologous non-vaccine and antigenically drifted viruses: a single-centre, double-blind, randomised, controlled phase 2b/3 trial. Lancet Infect Dis. 2016 Feb;16(2):209–18. doi: 10.1016/S1473-3099(15)00354-0 26559482

35. Erbelding EJ, Post DJ, Stemmy EJ, Roberts PC, Augustine AD, Ferguson S, et al. A Universal Influenza Vaccine: The Strategic Plan for the National Institute of Allergy and Infectious Diseases. J Infect Dis. 2018 Jul 2;218(3):347–54. doi: 10.1093/infdis/jiy103 29506129

36. Ortiz JR, Hickling J, Jones R, Donabedian A, Engelhardt OG, Katz JM, et al. Report on eighth WHO meeting on development of influenza vaccines that induce broadly protective and long-lasting immune responses: Chicago, USA, 23–24 August 2016. Vaccine. 2018 08;36(7):932–8. doi: 10.1016/j.vaccine.2017.11.061 29221895

37. Jegaskanda S, Luke C, Hickman HD, Sangster MY, Wieland-Alter WF, McBride JM, et al. Generation and Protective Ability of Influenza Virus-Specific Antibody-Dependent Cellular Cytotoxicity in Humans Elicited by Vaccination, Natural Infection, and Experimental Challenge. J Infect Dis. 2016 Sep 15;214(6):945–52. doi: 10.1093/infdis/jiw262 27354365

38. Vanderven HA, Jegaskanda S, Wheatley AK, Kent SJ. Antibody-dependent cellular cytotoxicity and influenza virus. Curr Opin Virol. 2017;22:89–96. doi: 10.1016/j.coviro.2016.12.002 28088123

39. DiPiazza A, Richards KA, Knowlden ZAG, Nayak JL, Sant AJ. The Role of CD4 T Cell Memory in Generating Protective Immunity to Novel and Potentially Pandemic Strains of Influenza. Front Immunol. 2016;7:10. doi: 10.3389/fimmu.2016.00010 26834750

40. WHO. The immunological basis for immunization series: influenza vaccines [Internet]. WHO. Available from: http://www.who.int/immunization/documents/WHO_IVB_ISBN9789241513050/en/. [cited 2019 Jan 9].

41. Le Luduec J-B, Debeer S, Piras F, Andréoni C, Boudet F, Laurent P, et al. Intradermal vaccination with un-adjuvanted subunit vaccines triggers skin innate immunity and confers protective respiratory immunity in domestic swine. Vaccine. 2016 Feb 10;34(7):914–22. doi: 10.1016/j.vaccine.2015.12.058 26768129

42. Norton EB, Bauer DL, Weldon WC, Oberste MS, Lawson LB, Clements JD. The novel adjuvant dmLT promotes dose sparing, mucosal immunity and longevity of antibody responses to the inactivated polio vaccine in a murine model. Vaccine. 2015 Apr 15;33(16):1909–15. doi: 10.1016/j.vaccine.2015.02.069 25765967

43. Weldon WC, Martin MP, Zarnitsyn V, Wang B, Koutsonanos D, Skountzou I, et al. Microneedle vaccination with stabilized recombinant influenza virus hemagglutinin induces improved protective immunity. Clin Vaccine Immunol. 2011 Apr;18(4):647–54. doi: 10.1128/CVI.00435-10 21288996

44. Nougarede N, Bisceglia H, Rozières A, Goujon C, Boudet F, Laurent P, et al. Nine μg intradermal influenza vaccine and 15 μg intramuscular influenza vaccine induce similar cellular and humoral immune responses in adults. Hum Vaccin Immunother. 2014;10(9):2713–20. doi: 10.4161/hv.29695 25483667

45. Etchart N, Hennino A, Friede M, Dahel K, Dupouy M, Goujon-Henry C, et al. Safety and efficacy of transcutaneous vaccination using a patch with the live-attenuated measles vaccine in humans. Vaccine. 2007 Sep 28;25(39–40):6891–9. doi: 10.1016/j.vaccine.2007.07.014 17764789

46. Beran J, Ambrozaitis A, Laiskonis A, Mickuviene N, Bacart P, Calozet Y, et al. Intradermal influenza vaccination of healthy adults using a new microinjection system: a 3-year randomised controlled safety and immunogenicity trial. BMC Med. 2009 Apr 2;7:13. doi: 10.1186/1741-7015-7-13 19341446

47. Guillermet E, Alfa DA, Phuong Mai LT, Subedi M, Demolis R, Giersing B, et al. End-user acceptability study of the nanopatchTM; a microarray patch (MAP) for child immunization in low and middle-income countries. Vaccine. 2019 Jul 26;37(32):4435–43. doi: 10.1016/j.vaccine.2019.02.079 30890383

48. Whitaker JA, von Itzstein MS, Poland GA. Strategies to maximize influenza vaccine impact in older adults. Vaccine. 2018 25;36(40):5940–8. doi: 10.1016/j.vaccine.2018.08.040 30153995

49. Ng TWY, Cowling BJ, Gao HZ, Thompson MG. Comparative Immunogenicity of Enhanced Seasonal Influenza Vaccines in Older Adults: A Systematic Review and Meta-analysis. J Infect Dis. 2019 Apr 19;219(10):1525–35. doi: 10.1093/infdis/jiy720 30551178

50. Patois E, Capelle M a. H, Gurny R, Arvinte T. Stability of seasonal influenza vaccines investigated by spectroscopy and microscopy methods. Vaccine. 2011 Oct 6;29(43):7404–13. doi: 10.1016/j.vaccine.2011.07.067 21803109

51. McLean KA, Goldin S, Nannei C, Sparrow E, Torelli G. The 2015 global production capacity of seasonal and pandemic influenza vaccine. Vaccine. 2016 Oct 26;34(45):5410–3. doi: 10.1016/j.vaccine.2016.08.019 27531411

52. Monath TP, Woodall JP, Gubler DJ, Yuill TM, Mackenzie JS, Martins RM, et al. Yellow fever vaccine supply: a possible solution. Lancet. 2016 Apr 16;387(10028):1599–600. doi: 10.1016/S0140-6736(16)30195-7 27116054

53. Okayasu H, Sein C, Chang Blanc D, Gonzalez AR, Zehrung D, Jarrahian C, et al. Intradermal Administration of Fractional Doses of Inactivated Poliovirus Vaccine: A Dose-Sparing Option for Polio Immunization. J Infect Dis. 2017 Jul 1;216(suppl_1):S161–7. doi: 10.1093/infdis/jix038 28838185

54. Wu JT, Peak CM, Leung GM, Lipsitch M. Fractional dosing of yellow fever vaccine to extend supply: a modelling study. Lancet. 2016 10;388(10062):2904–11. doi: 10.1016/S0140-6736(16)31838-4 27837923

55. Tarantola A, Tejiokem MC, Briggs DJ. Evaluating new rabies post-exposure prophylaxis (PEP) regimens or vaccines. Vaccine. 2019 Oct 3;37 Suppl 1:A88–93.


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