EP1963522A2 - Multivalent meningococcal derivatized polysaccharide-protein conjugates and vaccine - Google Patents

Abstract

The present invention describes derivatized polysaccharide-protein conjugates, a composition comprising one or more of such derivatized polysaccharide-protein conjugates and methods of immunizing human patients with the same. The derivatized polysaccharide-protein conjugates are purified capsular polysaccharides from Neisseria meningitidis serogroups A, C, W-135, and/or Y, derivatized chemically activated and selectively attached to a carrier protein by means of a covalent chemical bond, forming polysaccharide-protein conjugates capable of eliciting long-lasting immunity to a variety of N. meningitidis strains.

Description

MULTIVALENT MENINGOCOCCAL DERIVATIZED POLYSACCHARIDE-PROTEIN CONJUGATES AND VACCINE

Field of the Invention

The present invention relates to the field of medicine generally, and more specifically to microbiology, immunology, vaccines and the prevention of infection by a bacterial pathogen by immunization.

Background of the Invention

Neisseria meningitidis is a leading cause of bacterial meningitis and sepsis throughout the world. The incidence of endemic meningococcal disease during the last thirty years ranges from 1 to 5 per 100,000 in the developed world, and from 10 to 25 per 100,000 in developing countries (Reido, F. X., et al, J. Ped. Infect. Dis., U, pp. 643-657 [1995]). During epidemics the incidence of meningococcal disease approaches 1000 per 1000,000. There are approximately 2,600 cases of bacterial meningitis per year in the United States, and on average 330,000 cases in developing countries. The case fatality rate ranges between 10 and 20%.

Pathogenic meningococci are enveloped by a polysaccharide capsule that is attached to the outer membrane surface of the organism. Thirteen different serogroups of meningococci have been identified on the basis of the immunological specificity of the capsular polysaccharide (Frasch, C. E., et al., Rev. Infect. Dis., 7, pp. 504-510 [1985]). Of these thirteen serogroups, five cause the majority of meningococcal disease; these include serogroups A, B, C, Wl 35, and Y. Serogroup A is responsible for most epidemic disease. Serogroups B, C, and Y cause the majority of endemic disease and localized outbreaks.

The human naso-oropharyngeal mucosa is the only known natural reservoir of Neisseria meningitidis. Colonization takes place both at the exterior surface of the mucosal cell and the subepithelial tissue of the nasopharynx. Carriage of meningococci can last for months. Spreading of meningococci occurs by direct contact or via air droplets. Meningococci become invasive by passing through the mucosal epithelium via phagocytic vacuoles as a result of endocytosis. Host defense of invasive meningococci is dependent upon complement-mediated bacteriolysis. The serum antibodies that are responsible for complement-mediated bacteriolysis are directed in large part against the outer capsular polysaccharide.

Vaccines based on meningococcal polysaccharide have been described which elicit an immune response against the capsular polysaccharide. These antibodies are capable of complement-mediated bacteriolysis of the serogroup specific meningococci. The meningococcal polysaccharide vaccines are shown to be efficacious in children and adults (Peltola, H., et al, New Engl. J. Med., 291, pp. 686-691 [1997]; and Artenstein, M. S., et al, New Engl. J. Med., 282, pp. 417-420 [1970]), but the efficacy is limited in infants and young children (Reingold, A. L., et al, Lancet, 2,pp. 114-118 [1985]). Subsequent doses of the polysaccharide in younger populations elicited a weak or no booster response (Goldschneider, L, et al, J. Infect. Diseases, 128, pp. 769-776 [1973] and Gold, R., et al, J. Infect. Diseases, 136, S31-S35 [1977]). The duration of protection elicited by the meningococcal polysaccharide vaccines is not long lasting, and has been estimated to be between 3 to 5 years in adults and children above four years of age (Brandt, B.L. and Artenstein, M.S., J. Infect. Diseases, 131, pp. S69-S72 [1975], Kyhty, H., et al, J. Infect. Diseases,_. 142, pp. 861-868 [1980], and Cessey, S.J., et al, J. Infect. Diseases, 161, pp. 1212-1216 [1993]). For children from one to four years old the duration of protection is less than three years (Reingold, A.L., et al, Lancet, 2, pp. 114- 118 [1985]).

Polysaccharides are incapable of binding to the major histocompatibility complex molecules, a prerequisite for antigen presentation to and stimulation of T-helper lymphocytes, i.e., they are T-cell independent antigens. Polysaccharides are able to stimulate B lymphocytes for antibody production without the help of T-helper lymphocytes. As a result of the T-independent stimulation of the B lymphocytes, there is a lack of memory induction following immunization by these antigens. The polysaccharide antigens are capable of eliciting very effective T-independent responses in adults, but these T-independent responses are weak in the immature immune system of infants and young children.

T-independent polysaccharide antigens can be converted to T-dependent antigens by covalent attachment of the polysaccharides to protein molecules ("carriers" or "carrier proteins"). B cells that bind the polysaccharide component of the conjugate vaccine can be activated by helper T cells specific for peptides that are a part of the conjugated carrier protein. The T-helper response to the carrier protein serves to augment the antibody production to the polysaccharide.

The serogroup B polysaccharide has been shown to be poorly to non- immunogenic in the human population (WyIe, F. A., et al, J. Infect. Diseases, 126, pp. 514-522 [1972]). Chemical attachment of this serogroup polysaccharide to proteins has not significantly altered the immune response in laboratory animals (Jennings, H.J. and Lugowski, C.J., Immunol, 127,/?/?. 1011-1018 [1981]). The reason for the lack of immune response to this serogroup polysaccharide is thought to arise from structural similarities between the serogroup B polysaccharide and polysialylated host glycoproteins, such as the neural cell adhesion molecules.

A meningococcal conjugate vaccine based on serogroup C polysaccharide has been described. This monovalent vaccine elicits a strong functional antibody response to the capsular polysaccharide present on strains of N. meningitidis corresponding to serogroup C. Such a vaccine is only capable of protecting against disease caused by serogroup C bacteria.

Existing vaccines based on meningococcal polysaccharide are of limited use in young children and do not provide long-lasting protection in adults. The only meningococcal vaccine which as been shown to be capable of eliciting long-lasting protection in all groups, including children, at risk for meningococcal infection is based on a polysaccharide from a single serogroup of N. meningitidis and provides no protection against infection by other serogroups. Thus, a need exists for a meningococcal conjugate vaccine capable of conferring broad, long-lived protection against meningococcal disease in children and adults at risk for meningococcal infection. The multivalent meningococcal polysaccharides of the present invention solve this need by providing vaccine formulations in which immunogenic polysaccharides from the major pathogenic serogroups of N. meningitidis have been converted to T-dependent antigens through conjugations to carrier proteins.

FDA licensure of vaccines for meningococcal polysaccharides has been based on bactericidal assays with baby rabbit complement (SBA-BR) performed on blood samples of those immunized with the licensed vaccine. A number of government and expert panels have published current requirements and recommendations for assessing meningococcal polysaccharide vaccines on such assays.

Licensure is granted because human immunity to meningococcal disease has been shown to correlate well with the level of complement-mediated bactericidal antibody detected by the Serum Bactericidal Assay (SBA) (Goldschneider, L, et al, J. Exp. Med., 129:1307-1326 [1969] and Goldschneider, L, et al, J. Exp. Med., 129:1327-1348 [1969]). A surrogate level of a 1:4 SBA titer against serogroup C has been established using a human complement in the assay (SBA-H). However, licensing requirements for meningococcal polysaccharide vaccines are based on the induction of serum bactericidal responses using baby rabbit complement (SBA-BR) as the source of complement in the assay (World Health Organization. 1976. Requirements for meningococcal polysaccharide vaccine. World Health Organization technical report series, no. 594. World Health Organization, Geneva, Switzerland (WHO 1976). According to this recommendation, the antibody titers of the sera from at least 90% of subjects vaccinated with meningococcal polysaccharide vaccine should show a 4-fold or greater rise 2-4 weeks after immunization when tested against the following target strains or equivalent strains: Al for serogroup A, Cl 1 for serogroup C, S- 1975 for serogroup Y, and S-4383 for serogroup W-135 (WHO 1976, WHO 1981, Bureau of Biologies, Food and Drug Administration July 17, 1985). The Bureau of Biologies adopted the WHO recommendation and the meningococcal polysaccharide vaccines, groups A and C combined and groups A, C, Y, and W-135 combined, are licensed in the United States based upon this requirement, hi order to facilitate interlaboratory comparisons of the bactericidal activity induced by meningococcal vaccines, a standardized SBA using baby rabbit complement (SBA-BR) is established through a multilaboratory study (Maslanka S.E., et al, Clin. Diagn. Lab. Immunol., 4:156-167 (1997).

As data from meningococcal conjugate C vaccines started to become available, concerns began to emerge that the use of rabbit complement in the assay may lead to falsely high SBA titers. Following a March 1999 meeting to clarify and resolve issues relating to the laboratory assay for the analysis of human serum for meningococcal serogroups A and C specific antibodies, the WHO Expert Committee on Biological Standardization recommended that the SBA with baby rabbit complement be used for measuring antibody responses to serogroup C (The World Health Organization.1999. Standardization and validation of serological assays for the evaluation of immune responses to Neisseria meningitidis serogroup A/C vaccines. Geneva, WHO/V&B/99.19 (WHO 1999)). In an effort to avoid overestimating protection using baby rabbit complement, the WHO recommended that a study be undertaken to correlate the threshold titers measured by the SBA assay using baby rabbit complement relative to SBA titers measured using human complement. A follow-up meeting is held and results presented to support a general conclusion that a SBA titer of < 1:8 using baby rabbit complement correlates with an absence of protection against serogroup C and that an SBA titer of >=1 : 128 using baby rabbit complement correlates well to the protective SBA titer of 1 :4 using human complement. No information is provided for corresponding correlate SBA-BR titers for other meningococcal serogroups, such as A, Y or W- 135 or for polysaccharide conjugates.

SBA titers between 1 :8 and 1 :64 using baby rabbit complement do not necessarily correlate well with the protective SBA titer of 1 :4 using human complement (Jodar, L., et al, Biologicals, 30:323-329 [2002]). The WHO Expert Committee recommended that post vaccination SBA-BR titers of 1 :8, 1:16, 1 :32 and 1 :64 be reassessed using human complement. Other measures to resolve the uncertainties of the SBA-BR titers of 1 :8, 1 :16, 1:32, and 1 :64 included the assessment of four-fold rise in antibody SBA titers between pre- and post- vaccination. Demonstration of memory as a correlate of protection is also offered, however the Expert Committee recognized that the available data for these surrogates are either inadequate or limited.

An SBA-BR titer higher than 1 :8 is a better indicia of human immunity to meningococcal disease, as is a four-fold rise or higher, of SBA-BR titer from pre- immunization to post-immunization period of about 15 to about 45 days after immunization.

In one embodiment, the present invention provides a method of immunizing a human patient with a multivalent meningococcal polysaccharide conjugate composition, wherein the human patient has a serum SBA-BR titer of 1 : 16 or higher, preferably, of 1 :32 or higher, and more preferably, 1 : 64 or higher, and even more preferably, 1 : 128 or higher. In still further embodiments, the present invention provides a method of immunizing a human patient with a meningococcal polysaccharide conjugate composition, wherein the human patient has four-fold rise, or higher, in antibody SBA titers between pre- and post- vaccination.

In still another embodiment, the present invention provides a method of providing immunity to a human patient against multiple serogroups of N. meningococcal by immunizing the human patient with a multivalent meningococcal polysaccharide conjugate composition, wherein the composition comprises two or more polysaccharides selected from N. meningococcal serogroups A and W- 135; Y and W-135; C and Y; C and W-135; A, C and Y; A,C and W-135; C₅Y and W-135; A,Y and W-135; and A,C,Y and W-135.

In still further embodiments, the present invention provides a method of providing immunity to a human patient against multiple serogroups of N. meningococcal and by immunizing the human patient with a multivalent meningococcal (purified) polysaccharide conjugate composition, wherein the polysaccharide is derivatized to less than 100,000 Daltons. In one embodiment of the invention, the purified polysaccharide is depolymerized to an average polysaccharide size of about 5,000 to about 75,000 Daltons; preferably, to an average polysaccharide size of about 7,000 to about 50,000 Daltons; more preferably, to an average polysaccharide size of about 8,000 to about 35,000 Daltons; even more preferably, to an average polysaccharide size of about 12,000 to about 25,000 Daltons. In one embodiment of the invention, the average polysaccharide size in the composition is about 15,000 to about 22,000 Daltons.

SUMMARY OF THE INVENTION

The present invention provides a method of providing human immunity to meningococcal disease caused by pathogenic Neisseria meningitidis by administration of immunological compositions of meningococcal polysaccharide-protein conjugates. In one embodiment of the invention, the immunological composition comprises two or more protein-polysaccharide conjugates, wherein each of the conjugates comprises a capsular polysaccharide from N. meningitidis conjugated to a carrier protein. In a preferred embodiment, the immunological composition comprises two or more distinct protein-polysaccharide conjugates, wherein each of the conjugates comprises a capsular polysaccharide from a different serogroup of N. meningitidis conjugated to a carrier protein.

The present invention provides a method of providing human immunity to meningococcal disease caused by pathogenic Neisseria meningitidis comprising administration of an immunological composition comprising two or more distinct protein-polysaccharide conjugates, wherein each of the conjugates comprises a capsular polysaccharide from a different serogroup of N. meningitidis conjugated to a carrier protein.

The present invention provides a method of providing human immunity to meningococcal disease caused by pathogenic Neisseria meningitidis comprising administration of meningococcal polysaccharide-protein conjugates. The present invention provides multivalent meningococcal vaccines comprised of immunologically effective amounts of from two to four distinct protein-polysaccharide conjugates, wherein each of the conjugates contains a different capsular polysaccharide conjugated to a carrier protein, and wherein each capsular polysaccharide is selected from the group consisting of capsular polysaccharide from sero groups A, C, W-135 and Y. The present invention further provides a method of inducing an immunological response to capsular polysaccharide of N. meningitidis comprising administering an immunologically effective amount of the immunological composition of the invention to a human. In one embodiment, the multivalent meningococcal vaccine comprises immunologically effective amounts of two distinct protein-polysaccharide conjugates, wherein each of the conjugates contains a different capsular polysaccharide conjugated to a carrier protein, and wherein each capsular polysaccharide is selected from the group consisting of capsular polysaccharide from serogroups A, C, W- 135 and Y, more preferably, comprises capsular polysaccharides A and W-135, A and Y, C and W- 135, C and Y, and W-135 and Y. In one embodiment, the multivalent meningococcal vaccine comprises immunologically effective amounts of three distinct protein-polysaccharide conjugates, wherein each of the conjugates contains a different capsular polysaccharide conjugated to a carrier protein, and wherein each capsular polysaccharide is selected from the group consisting of capsular polysaccharide from serogroups A, C, W- 135 and Y, more preferably, comprises capsular polysaccharides A, C and W- 135, A, C and Y, C, Y and W-135, C, W-135 and Y, and A, W-135 and Y. In another embodiment, the multivalent meningococcal vaccine comprises immunologically effective amounts of four distinct protein-polysaccharide conjugates, wherein each of the conjugates contains a different capsular polysaccharide conjugated to a carrier protein, and wherein each capsular polysaccharide is selected from the group consisting of capsular polysaccharide from sero groups A, C, W-135 and Y.

The present invention further provides a method of inducing an immunological response to capsular polysaccharide of JV. meningitidis comprising administering an immunologically effective amount of the immunological composition of the invention to a human or animal.

The present invention provides a multivalent meningococcal vaccine comprised of immunologically effective amounts of from two to four distinct protein-polysaccharide conjugates, wherein each of the conjugates contains a different capsular polysaccharide conjugated to a carrier protein, and wherein each capsular polysaccharide is selected from the group consisting of capsular polysaccharide from serogroups A, C, W-135 and Y.

The present invention provides a method of protecting a human or animal susceptible to infection from JV. meningitidis comprising administering an immunologically effective dose of the vaccine of the invention to the human or animal.

In still further embodiments, the present invention provides methods of boosting the response elicited following a first, second, third, etc., dose of a meningococcal vaccine or immunogenic composition. In some of these embodiments, the first (or more) dose of the meningococcal vaccine or immunogenic composition comprises capsular polysaccharides from one or more serogroups of JV. meningitidis (serogroups A, B, C, Y, W-135, etc.). In some other of embodiments, the first (or more) dose of the meningococcal vaccine or immunogenic composition comprises capsular polysaccharides from one or more serogroups of JV. meningitidis (e.g., serogroups A, B, C, Y, W-135, etc.) conjugated to one or more carriers (e.g., carrier proteins). In preferred embodiments, the carrier proteins are immunogenic and/or provide additional therapeutic or other benefits. In some preferred embodiments, a primary response in a subject (e.g., a human) elicited after one or more doses of a meningococcal vaccine or immunogenic composition is boosted by one or more subsequent doses of a vaccine or immunogenic composition comprising capsular polysaccharides from 1, 2, 3, 4, or more, different serogroups of N. meningitidis. The present invention is not limited however to administration of one or more priming doses of a vaccine or immunogenic composition comprising non-conjugated capsular polysaccharides, nor is the present invention intended to be limited to the administration of one or more boosting doses comprising conjugated capsular polysaccharide-carrier protein immunogenic compositions or vaccines. Likewise, the present invention is not intended to be limited by the temporal spacing of the priming or boosting doses.

In some embodiments, the present example provides methods of administering the disclosed tetravalent (A, C, Y, and W-135) meningococcal diphtheria toxoid conjugate composition (formulated as for example a human vaccine) in subjects who had previously received one or more does of a monovalent meningococcal conjugate vaccine composition (e.g., serotype A, B, C, Y, and/or W-135). The present methods are not intended to be limited, by the subject's age at the time they received either the monovalent meningococcal conjugate vaccine or one or more subsequent doses of the disclosed tetravalent immunological composition. For example, in certain embodiments, suitable subjects for the present administration methods and regimes include, but are not limited to, infants, toddlers, children, adolescents, teenagers, and adults. In some preferred embodiments, suitable subjects include from about 1 month to 55 year olds, or from about 12 month to 20 year olds. In particularly preferred embodiments, suitable subjects include 24 month to 5 year olds.

The present invention provides, in some preferred embodiments, methods for administering an immunogenic composition to a subject comprising, providing: a subject, wherein said subject has been vaccinated with a dose of a monovalent meningococcal conjugate vaccine; a tetravalent meningococcal polysaccharide protein conjugate composition; and administering said tetravalent meningococcal polysaccharide protein conjugate composition to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

In additional embodiments, the present invention provides methods for administering an immunogenic composition to a subject comprising, providing: a subject, wherein said subject has been vaccinated with a dose of a monovalent meningococcal conjugate vaccine; a tetravalent meningococcal polysaccharide protein conjugate vaccine; and administering said tetravalent meningococcal polysaccharide protein conjugate vaccine to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

Still additional embodiments provide methods for administering an immunogenic composition to a subject comprising, providing: a subject, wherein said subject has been vaccinated with a protective antigen against N. meningitidis serogroup C; a tetravalent meningococcal polysaccharide protein conjugate vaccine; and administering said tetravalent meningococcal polysaccharide protein conjugate vaccine to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

Other embodiments of the present invention provide methods for administering an immunogenic composition to a subject comprising, providing: a subject, wherein said subject has been vaccinated with a monovalent JV. meningitidis serogroup C meningococcal vaccine; a tetravalent meningococcal polysaccharide protein conjugate composition; and administering said tetravalent meningococcal polysaccharide protein conjugate vaccine to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

Yet another embodiment provides a method of preventing meningococcal disease in a subject comprising administering to said subject a therapeutically effective dose of a tetravalent meningococcal conjugate vaccine about twelve months after said subject has been vaccinated with a monovalent meningococcal conjugate vaccine.

In addition to the compositions and methods already described, the present invention further provides a method of preventing meningococcal disease in a subject comprising administering to said subject a therapeutically effective dose of a tetravalent meningococcal conjugate vaccine from about 1 to 120 months after said subject has been vaccinated with monovalent N. meningitidis serogroup C meningococcal vaccine.

Still further embodiments of the present invention provide methods of stimulating and/or inducing an immunologic response in a subject comprising administering to said subject a therapeutically effective dose of a tetravalent meningococcal conjugate vaccine at least twelve months after said subject has been vaccinated with at least one dose of a monovalent meningococcal conjugate vaccine (e.g., one or more of serogroups A, C, B, Y, and/or W-135). In some embodiments, a suitable subject (e.g., preferably a mammal, and more preferably a human) has received concomitant administrations of one or more monovalent polysaccharide-protein conjugated vaccines or polysaccharide non- conjugated vaccines comprises a protective antigen against N. meningitidis bacteria or a disease caused by N. meningitidis.

In certain embodiments, the compositions of the present invention comprise tetravalent meningococcal conjugate vaccines formulated as sterile 0.5ml liquid doses in an acceptable administration device such as a syringes (e.g., single use), nasal injections, aerosolizers, nebulizers, transdermal devices, and the like.

Various embodiments of the present invention provide compositions of from about 0.5ml of a multivalent (e.g., tetravalent) meningococcal conjugate vaccine comprising from about 0.01 μg to about 10 μg of purified capsular polysaccharides from one or more serogroups N. meningitidis (e.g., purified capsular polysaccharides from one or more of the serogroups A, C, Y, or W-135)

Additional embodiments of the present invention provide combination vaccine compositions comprising one, two, three, or four distinct meningococcal protein- polysaccharide conjugates and one or more antigens or immunogenic components from other vaccine compositions (e.g., licensed vaccines). In still other embodiments, the present invention provides immunogenic compositions comprising one, two, three, or four distinct protein-polysaccharide conjugates and one or more antigens or antigenic components from vaccine (e.g., licensed vaccines) compositions. The present invention contemplates, but is not limited to, combinations of from one to four distinct N. meningitidis protein-polysaccharide conjugates and immunogenic components (e.g., antigens) from vaccines directed to preventing or ameliorating the effects of diseases not caused by N. meningitidis. For example, in some embodiments, the present invention provides immunogenic compositions comprising one, two, three, or four distinct protein- polysaccharide conjugates and one or more components from a licensed vaccine typically administered to travelers including, but not limited to, vaccines against typhoid (e.g., Typhim Vi^®), yellow fever (e.g., YF- VAX^®), polio vaccine, and the like. For example, in still other embodiments, the present invention provides combinations of from one to four distinct N. meningitidis protein-polysaccharide conjugates and immunogenic compositions from vaccines directed to preventing or ameliorating the effects of hepatitis (e.g., A, B, C, D, or E), small pox and vaccinia, AIDS, tuberculosis, diphtheria, haemophilus influenzae, measles, mumps, pertussis, pneumococcal diseases, polio, rubella, tetanus, varicella, adenovirus diseases, anthrax, cholera, encephalitis (e.g., Japanese, tick-borne, etc.), plague, rabies, typhoid, herpes, malaria, parasitic diseases, poxvirus diseases, respiratory syncytial virus diseases, rotavirus, alpha virus infections (e.g., Venezuelan, Western, or Eastern equine encephalitis, Chikungunya virus disease, Ross River virus disease, etc.), Bunyavirus diseases (e.g., Rift Valley fever, Hantavirus disease), Arenavirus diseases (e.g., Junin virus disease), rickettsial diseases (e.g., Q fever), tularemia diseases, brucellosis diseases, pseudomonas diseases, botulism, West Nile disease, and staphylococcus infections, among other viral, bacteria, and parasitic based diseases. In preferred embodiments, the non-N. meningitidis immunogenic compositions administered in conjunction (e.g., concomitantly) with the distinct N. meningitidis protein-polysaccharide conjugates of the present invention are derived from licensed vaccines.

The present invention is not limited to any particular concomitant combination of vaccines or immunogenic compositions, nor to methods of using any such concomitant combinations. Indeed, the present invention also provides combinations of from one to four distinct N. meningitidis protein-polysaccharide conjugates and immunogenic components from unlicensed (e.g., experimental) non-N. meningitidis vaccines or immunogenic compositions.

Administration of combinations of one to four distinct N. meningitidis protein- polysaccharide conjugates and immunogenic components from non-N. meningitidis vaccines or immunogenic compositions can be concomitant. In some embodiments, the concomitant administration of from one to four distinct N. meningitidis protein- polysaccharide conjugates and immunogenic components non-N. meningitidis vaccines or immunogenic compositions is accomplished at two or more sites using similar or dissimilar administration methods. In still some other of these embodiments, concomitant administration of from one to four distinct N. meningitidis protein- polysaccharide conjugates and immunogenic components from non-N. meningitidis vaccines or immunogenic compositions is accomplished by physically combining two or more compositions into a single aggregate composition which is then administered in one or more sites using or more administration routes.

Administration of a combination of from one to four distinct N. meningitidis protein-polysaccharide conjugates and immunogenic components from non-N. meningitidis vaccines or immunogenic compositions can be carried out at two different times temporally separated by seconds, minutes, hours, days, etc. The present invention is not intended to be limited by the routes and/or timing of administration events.

In still other embodiments, the present invention provides methods of administering to a subject (e.g., a human) one or more immunological compositions (e.g., a human vaccine), such that the first immunological composition primes subject for a booster effect following administration of a second (or more) immunological composition. In certain of these embodiments, the first, second, third, or more, immunological compositions comprises a protein. Suitable protein carriers include, but are not limited to, diphtheria toxin, diphtheria toxoid, CRM₁₉₇, tetanus toxoid, pertussis toxoid, E. coli LT, E. coli ST, exotoxin A, outer membrane complex c (OMPC), porin, transferrin binding protein, pneumolysis, pneumococcal surface protein A (PspA), pneumococcal adhesin protein (PsaA), ovalbumin, keyhole limpit hemocyanin (KLH), bovine serum albumin (BSA) or purified protein derivative of tuberculin (PPD), and the like. In a preferred embodiment, the carrier protein comprises a diphtheria toxin, diphtheria toxoid, CRM₁₉₇, tetanus toxoid, exotoxin A, or outer membrane complex c (OMPC). In a particularly preferred embodiment, the carrier protein comprises a diphtheria toxin or diphtheria toxoid.

Additional embodiments provide for the use of at least one of the compositions contemplated by the present invention in the treatment, prevention, or attenuation of a disease state in a mammal. In certain of these embodiments, the disease state is caused by a bacterial infection, for example, an infection caused by one or more serogroups of Neisseria meningitidis.

Still further embodiments provide for the use of at least one of the compositions contemplated by the present invention for the manufacture of a medicament for a the therapeutic application such as the treatment, prevention, or attenuation of a disease state in a mammal caused by bacterial infection of the mammal by one or more sero groups of Neisseria meningitidis.

In still other embodiments, the compositions of the present invention are provided in a kit {e.g., a commercial package) with instructions for administration and/or storage of the contents of the kit (e.g., ampoules, syringes, vials, patches, suppositories, salves, etc. comprising meningococcal vaccine or meningococcal vaccine components). As used herein, the term "instructions for administering said immunologic composition (or a human vaccine) to a subject" includes instructions for using the compositions contained in a kit for prophylaxis of meningococcal infection of a disease caused by N. meningitidis. In some embodiments, the instructions further comprise a statement of the recommended or usual dosages of the compositions contained within the kit pursuant to 21 C.F.R. §201 et seq., and/or those of other applicable U.S. or international regulatory agencies. Additional information concerning labeling and instruction requirements applicable to the methods and compositions of the present are available at the Internet web page of the U.S.F.D.A.

As used herein, the term "third party" refers to any entity engaged in selling, warehousing, distributing, or offering for sale the compositions or methods of the present invention.

All patents, patent applications, and other publications recited herein are hereby incorporated by reference in their entirety except where they are in conflict with the disclosed invention.

DESCRIPTION OF THE FIGURES

Figures 1-8 show certain embodiments of the present invention.

DETAILED DESCRIPTION OF THE INVENTION

The present invention comprises an immunological composition of two or more distinct protein-polysaccharide conjugates, wherein each of the conjugates comprises a capsular polysaccharide conjugated to a carrier protein. Thus, the present invention includes compositions that comprise two or more different derivatized capsular polysaccharides conjugated to one or more carrier protein(s). Capsular polysaccharides can be prepared by standard techniques known to those of skill in the art. hi the present invention capsular polysaccharides prepared from serogroups A, C, W-135 and Y of N. meningitidis are preferred.

In a preferred embodiment, these meningococcal serogroup conjugates are prepared by separate processes and formulated into a single dosage formulation. For example, capsular polysaccharides from serogroups A, C, W-135 and Y of N. meningitidis are separately purified.

In a preferred embodiment of the present invention the purified polysaccharide is depolymerized and activated prior to conjugation to a carrier protein. In a preferred embodiment of the present invention capsular polysaccharides of serogroups A, C, W- 135, and Y from N. meningitidis are partially depolymerized using mild oxidative conditions.

Native meningococcal polysaccharide is about 500,000 to 1,500,000 daltons. The present invention is directed to meningococcal polysaccharides of a smaller size. When purifying native polysaccharides, a certain percentage of the polysaccharides will be of a smaller size. However, to obtain a better yield, it is generally preferred to depolymerize, or derivatize the native meningococcal polysaccharide to a preferred size range, preferably less than 100,000 daltons. hi one embodiment of the invention, the purified polysaccharide is depolymerized to an average polysaccharide size of about 5,000 to about 75,000 daltons; preferably, to an average polysaccharide size of about 7,000 to about 50,000 daltons; more preferably, to an average polysaccharide size of about 8,000 to about 35,000 daltons; even more preferably, to an average polysaccharide size of about 12,000 to about 25,000 daltons. hi one embodiment of the invention, the average polysaccharide size in the composition is about 15,000 to about 22,000 daltons.

The depolymerization or partial depolymerization of the polysaccharides may then be followed by an activation step. By "activation" is meant chemical treatment of the polysaccharide to provide chemical groups capable of reacting with the carrier protein. A preferred activation method involves treatment with adipic acid dihyrazide in physiological saline at pH 5.0.+-.0.1 for approximately two hours at 15 to 30 deg. C. One process for activation is described in U.S. Pat. No. 5,965,714. Once activated, the capsular polysaccharides may then be conjugated to one or more carrier proteins. In a preferred embodiment of the present invention each capsular polysaccharide is separately conjugated to a single carrier protein species. In a preferred embodiment, the capsular polysaccharides from serogroups A, C, W-135 and Y of N. meningitidis are each separately conjugated to the same carrier protein species.

Carrier proteins may include bacterial toxins such as diphtheria toxin, inactivated bacterial toxins such as diphtheria toxoid, CRM₁Q₇, tetanus toxoid, pertussis toxoid, E. coli LT, E. coli ST, and exotoxin A from Pseudomonas aeruginosa. Bacterial outer membrane proteins such as, outer membrane complex c (OMPC), porins, transferrin binding proteins, pneumolysis, pneumococcal surface protein A (PspA), or pneumococcal adhesin protein (PsaA), could also be used. Other proteins, such as ovalbumin, keyhole limpit hemocyanin (KLH), bovine serum albumin (BSA) or purified protein derivative of tuberculin (PPD) may also be used as carrier proteins. Carrier proteins are preferably proteins that are non-toxic and non-reactogenic and obtainable in sufficient amount and purity. Carrier proteins should be amenable to standard conjugation procedures. In a preferred embodiment of the present invention diphtheria toxin purified from cultures of Corynebacteria diphtheriae and chemically detoxified using formaldehyde is used as the carrier protein. An alternative carrier protein is Protein D which is an outer membrane surface exposed protein of H. influenza.

In one embodiment of the invention, the average ratio of each derivatized polysaccharide to carrier protein is about 1 : 1 to about 1 :20 (w/w). In a preferred embodiment of the invention, the average ratio of total derivatized polysaccharide to carrier protein is about 1 :2 to about 1:10 (w/w), and an even more preferred average ratio of each derivatized polysaccharide to carrier protein is about 1 :2 to about 1 :6 (w/w). In a more preferred embodiment of the invention, the average ratio of total derivatized polysaccharide to carrier protein is about 1 :(4±1); more preferably, 1 :(4±0.5), even more preferably, l:(4±0.25) (w/w).

After conjugation of the capsular polysaccharide to the carrier protein, the polysaccharide-protein conjugates may be purified (enriched with respect to the amount of polysaccharide-protein conjugate) by a variety of techniques. One goal of the purification step is to remove the unbound polysaccharide from the polysaccharide- protein conjugate. One method for purification, involving ultrafiltration in the presence of ammonium sulfate, is described in U.S. Pat. No. 6,146,902. Alternatively, conjugates can be purified away from unreacted protein and polysaccharide by any number of standard techniques including, inter alia, size exclusion chromatography, density gradient centrifugation, hydrophobic interaction chromatography or ammonium sulfate fractionation. See, e.g., P. W. Anderson, et. al. (1986). J. Immunol. 137: 1181-1186. See also H. J. Jennings and C. Lugowski (1981) J. Immunol. 127: 1011-1018.

After conjugation of the polysaccharide and carrier protein the immunological compositions of the present invention are made by combining the various derivatized polysaccharide-protein conjugates. The immunological compositions of the present invention comprise two or more different capsular polysaccharides conjugated to one or more carrier protein(s). A preferred embodiment of the present invention is a bivalent immunological composition comprising derivatized capsular polysaccharides from serogroups A and C of N. meningitidis separately conjugated to diptheria toxin or toxoid. More preferably the present invention is a tetravalent immunological composition comprising capsular polysaccharides from serogroups A, C, W-135 and Y of N. meningitidis separately conjugated to diptheria toxin or toxoid.

The present invention is directed, in part, to a composition of multicomponent, derivatized polysaccharide conjugates where each derivatized polysaccharide is present in about 0.5 to about 15 μg per dose. Thus, the composition may comprise a total derivatized polysaccharide μg of 1 μg to 60 μg. In a preferred embodiment, the relative amount of each derivatized polysaccharide in the composition is about equal within ± 50%; more preferably, within ± 30%; even more preferably, within ± 20%. Preparation and use of carrier proteins, and a variety of potential conjugation procedures, are well known to those skilled in the art. Conjugates of the present invention can be prepared by such skilled persons using the teachings contained in the present invention as well as information readily available in the general literature. Guidance can also be obtained from any one or all of the following U.S. patents, the teachings of which are hereby incorporated in their entirety by reference: U.S. Pat. Nos. 4,356,170; 4,619,828; 5,153,312; 5,422,427 and 5,445,817. Alternatively, the immunological compositions may be made by either culturing two or more N. meningitidis serogroups together and copurifying, depolymerizing, activating and conjugating the polysaccharides, or by culturing purifying the N. meningitidis serogroups separately and combining two or more purified polysaccharides before or after any of the steps of depolymerizing, activating and conjugating the polysaccharides.

The immunological compositions of the present invention are made by separately preparing polysaccharide-protein conjugates from different meningococcal serogroups and then combining the conjugates. The immunological compositions of the present invention can be used as vaccines. Formulation of the vaccines of the present invention can be accomplished using art recognized methods. The vaccine compositions of the present invention may also contain one or more adjuvants. Adjuvants include, by way of example and not limitation, aluminum adjuvants (e.g., aluminum salts such as aluminum hydroxide, aluminum phosphate, aluminum sulfate or combinations thereof), Freund's Adjuvant (Complete or Incomplete), BAY, DC-chol, pcpp, monophoshoryl lipid A, CpG, QS-21, cholera toxin and formyl methionyl peptide. See, e.g., Vaccine Design, the Subunit and Adjuvant Approach, 1995 (M. F. Powell and M. J. Newman, eds., Plenum Press, N. Y.). The adjuvant is preferably an aluminum adjuvant, such as aluminum hydroxide or aluminum phosphate.

Alternative adjuvants include oil-in-water emulsion formulations for example MF59 as described in PCT Publ. No. WO 90/14837), SAF, containing 10% Squalane, 0.4% Tween 80, 5% pluronic-blocked polymer Ll 21, and thr-MDP, RibiTM adjuvant system (PvAS), (Ribi Immunochem, Hamilton, MT) containing 2% Squalene, 0.2% Tween 80, and one or more bacterial cell wall components from the group consisting of monophosphorylipid A (MPL), trehalose dimycolate (TDM), and cell wall skeleton (CWS), preferably MPL+CWS (DetoxTM); saponin adjuvants, such as StimulonTM (Cambridge Bioscience, Worcester, Mass.) may be used or particles generated there from such as ISCOMs (immunostimulating complexes); cytokines, such as interleukins (e.g., IL-I, IL-2, IL-4, IL-5, IL-6, IL-7, IL- 12, etc.), interferons (e.g., gamma interferon), macrophage colony stimulating factor (M-CSF), tumor necrosis factor (TNF). In one embodiment of the invention, the protein-polysaccharide conjugates have an average glycosylation ratio (polysaccharide to protein ratio) of about 0.05 to about 2; more preferably, an average ratio of about 0.08 to about 1.25; and even more preferably, an average ratio of about 0.1 to about 0.9. In one preferred embodiment, the protein- polysaccharide conjugates have an average glycosylation ratio polysaccharide to protein ratio of about 0.2 to about 0.8; more preferably, an average ratio of about 0.2 to about 0.6, and even more preferred embodiment, an average ratio of about 0.3 to about 0.5.

As demonstrated below, the vaccines and immunological compositions according to the invention elicit a T-dependent-like immune response in various animal models, whereas the polysaccharide vaccine elicits a T-independent-like immune response. Thus, the compositions of the invention are also useful research tools for studying the biological pathways and processes involved in T-dependent-like immune responses to N. meningitidis antigens.

The amount of vaccine of the invention to be administered a human or animal and the regime of administration can be determined in accordance with standard techniques well known to those of ordinary skill in the pharmaceutical and veterinary arts taking into consideration such factors as the particular antigen, the adjuvant (if present), the age, sex, weight, species and condition of the particular animal or patient, and the route of administration, m the present invention, the amount of polysaccharide-protein carrier to provide an efficacious dose for vaccination against N. meningitidis can be from between about 0.02 μg to about 5 μg per kg body weight. In a preferred composition and method of the present invention the dosage is between about 0.1 μg to 3 μg per kg of body weight. For example, an efficacious dosage will require less antibody if the postinfection time elapsed is less since there is less time for the bacteria to proliferate. In like manner an efficacious dosage will depend on the bacterial load at the time of diagnosis. Multiple injections administered over a period of days could be considered for therapeutic usage.

The multivalent conjugates of the present invention can be administered as a single dose or in a series (i.e., with a "booster" or "boosters"). For example, a child could receive a single dose early in life, then be administered a booster dose up to ten years later, as is currently recommended for other vaccines to prevent childhood diseases. The booster dose will generate antibodies from primed B-cells, i.e., an anamnestic response. That is, the multivalent conjugate vaccine elicits a high primary (i.e., following a single administration of vaccine) functional antibody response in younger populations when compared to the licensed polysaccharide vaccine, and is capable of eliciting an anamnestic response (i.e., following a booster administration), demonstrating that the protective immune response elicited by the multivalent conjugate vaccine of the present invention is long-lived.

Compositions of the invention can include liquid preparations for orifice, e.g., oral, nasal, anal, vaginal, peroral, intragastric, mucosal (e.g. , perlinqual, alveolar, gingival, olfactory or respiratory mucosa) etc., administration such as suspensions, syrups or elixirs; and, preparations for parenteral, subcutaneous, intradermal, intramuscular, intraperitoneal or intravenous administration (e.g., injectable administration), such as sterile suspensions or emulsions. Intravenous and parenteral administration are preferred. Such compositions may be in admixture with a suitable carrier, diluent, or excipient such as sterile water, physiological saline, glucose or the like. The compositions can also be lyophilized. The compositions can contain auxiliary substances such as wetting or emulsifying agents, pH buffering agents, gelling or viscosity enhancing additives, preservatives, flavoring agents, colors, and the like, depending upon the route of administration and the preparation desired. Standard texts, such as "REMINGTON'S PHARMACEUTICAL SCIENCE", 1985, or later additions, incorporated herein by reference, may be consulted to prepare suitable preparations, without undue experimentation.

In one embodiment of the invention, a preferred route of administration is intramuscular or subcutaneous, with intramuscular route preferred. Administration may be by injection or by an alternative delivery device.

Compositions of the invention are conveniently provided as liquid preparations, e.g., isotonic aqueous solutions, suspensions, emulsions or viscous compositions that may be buffered to a selected pH. If digestive tract absorption is preferred, compositions of the invention can be in the "solid" form of pills, tablets, capsules, caplets and the like, including "solid" preparations which are time-released or which have a liquid filling, e.g., gelatin covered liquid, whereby the gelatin is dissolved in the stomach for delivery to the gut. If nasal or respiratory (mucosal) administration is desired, compositions may be in a form and dispensed by a squeeze spray dispenser, pump dispenser or aerosol dispenser. Aerosols are usually under pressure by means of a hydrocarbon. Pump dispensers can preferably dispense a metered dose or a dose having a particular particle size.

Liquid preparations are normally easier to prepare than gels, other viscous compositions, and solid compositions. Additionally, liquid compositions are somewhat more convenient to administer, especially by injection or orally, to animals, children, particularly small children, and others who may have difficulty swallowing a pill, tablet, capsule or the like, or in multi-dose situations. Viscous compositions, on the other hand, can be formulated within the appropriate viscosity range to provide longer contact periods with mucosa, such as the lining of the stomach or nasal mucosa.

In a preferred embodiment of the invention, the vaccine composition is formulated as a sterile liquid, pyrogen-free, phosphate-buffered physiological saline, with or without a preservative. In one preferred embodiment, the formula per dose, comprises about 0.3 to about 1.0 mg sodium phosphate and about 3.5 to about 6.0 mg sodium chloride and up to 1.5 mL water, hi one preferred embodiment, the formula per dose, comprises about 0.6 ± 0.2 mg sodium phosphate and 4.4 ± 0.2 mg sodium chloride and up to about 0.5 ± 0.2 mL water.

Obviously, the choice of suitable carriers and other additives will depend on the exact route of administration and the nature of the particular dosage form, e.g., liquid dosage for (e.g., whether the composition is to be formulated into a solution, a suspension, gel or another liquid form), or solid dosage form (e.g., whether the composition is to be formulated into a pill, tablet, capsule, caplet, time release form or liquid-filled form).

Solutions, suspensions and gels, normally contain a major amount of water (preferably purified water) in addition to the active ingredient. Minor amounts of other ingredients such as pH adjusters (e.g., a base such as NaOH), emulsifiers or dispersing agents, buffering agents, preservatives, wetting agents, jelling agents, (e.g., methylcellulose), colors and/or flavors may also be present. The compositions can be isotonic, i.e., it can have the same osmotic pressure as blood and lacrimal fluid. The desired isotonicity of the compositions of this invention maybe accomplished using sodium tartrate, propylene glycol or other inorganic or organic solutes. In one embodiment, the preferred isotonicity of the composition is obtained from sodium phosphate or sodium chloride, or mixtures thereof. Sodium chloride is preferred particularly for buffers containing sodium ions.

Viscosity of the compositions may be maintained at the selected level using a pharmaceutically acceptable thickening agent. Methylcellulose is preferred because it is readily and economically available and is easy to work with. Other suitable thickening agents include, for example, xanthan gum, carboxymethyl cellulose, hydroxypropyl cellulose, carbomer, and the like. The preferred concentration of the thickener will depend upon the agent selected. The important point is to use an amount that will achieve the selected viscosity. Viscous compositions are normally prepared from solutions by the addition of such thickening agents.

A pharmaceutically acceptable preservative can be employed to increase the shelf life of the compositions. Benzyl alcohol may be suitable, although a variety of preservatives including, for example, parabens, thimerosal, chlorobutanol, or benzalkonium chloride may also be employed. A suitable concentration of the preservative will be from 0.02% to 2% based on the total weight although there may be appreciable variation depending upon the agent selected.

Those skilled in the art will recognize that the components of the compositions must be selected to be chemically inert with respect to the N. meningitidis polysaccharide-protein carrier conjugates.

The invention will be further described by reference to the following illustrative, non-limiting examples setting forth in detail several preferred embodiments of the inventive concept. Other examples of this invention will be apparent to those skilled in the art without departing from the spirit of the invention.

The following abbreviations and Trademarks are: ACIP, Advisory Committee on Immunization Practices; AE, Adverse Event; Cetavalon¹ , cetyltrimethylammonium bromide, CTAB; CFR, Code of Federal Regulations; CRF, Case Report Form; DTP, Diphtheria Tetanus Pertussis; ELISA, Enzyme Linked Immunosorbent Assay; FDA, Food and Drug Administration; GCP, Good Clinical Practice; GMC, Geometric Mean Concentration; GMT, Geometric Mean Titer; IgG, Immunoglobulin G; IgGl, Immunoglobulin G subclass 1 ; IgG2, Immunoglobulin G subclass 2; IgM, Immunoglobulin M; ICH, International Conference on Harmonization; IND, Investigational New Drug; IRB, Institutional Review Board; MenA/C-Dt Bivalent (A and C) Meningococcal Polysaccharide Diphtheria Conjugate Vaccine; MenPS, Meningococcal group specific polysaccharide; mL milliliter; Menomune™, licensed Meningococcal A,C Y and W-135 polysaccharide vaccine; OD, Optical Density; PBS, Phosphate Buffered Saline; SAE, Serious Adverse Event; SBA, Serum bactericidal activity; SBA-BR, Serum bactericidal activity assay performed using baby rabbit complement; SBA-HC, Serum bactericidal activity assay performed using human complement; SIDS, Sudden Infant Death Syndrome; TetraMenD, Tetravalent (A, C, Y, and W-135) Meningococcal Polysaccharide Diphtheria Conjugate Vaccine; Td, Tetanus and Diphtheria vaccine; UAE, Unexpected Adverse Experience; URI, Upper Respiratory Infection; μg, Micrograms.

EXAMPLES

Example 1 Preparation of Neisseria meningitidis Serogroups A, C, W-135, and Y Purified Capsular Polysaccharides Powders

Crude Paste Preparation

Separately, Neisseria meningitidis serogroup A, C, W-135, and Y wet frozen seed cultures are thawed and recovered with the aid of liquid Watson Scherp medium and planted in Blake bottles containing Mueller Hinton agar medium. The Blake are incubated at 35 to 37 deg. C. in a CO₂ atmosphere for 15 to 19 hours. Following the incubation period, the growth from the Blake bottles are dislodged and added to 4 L flasks containing Watson Scherp medium. The flasks are incubated at 35 to 37 deg. C. for 3 to 7 hours on a platform shaker. The contents of the 4 L flasks are transferred to a fermenter vessel containing Watson Scherp medium. The fermenter vessel is incubated at 35 to 37 deg. C. for 7 to 12 hours controlling dissolved oxygen content and pH with supplement feed and antifoam additions. After the incubation period, the contents of the fermentor vessel are transferred to a 500 L tank, Cetavlon™ is added, and the material mixed for 1 hours. The Cetavlon treated growth is centrifuged at approximately 15,000 to 17,000 x g at a flow rate of approximately 30 to 70 liters per hours. The crude polysaccharide is precipitated from the supernatant with a second Cetavlon™ precipitation. Cetavlon™ is added to the supernatant and the material mixed for at least 1 hour at room temperature. The material is stored at 1 to 5 deg. C. for 8 to 12 hours. The precipitated polysaccharide is collected centrifogation at approximately 45,000 to 50,000 x g at a flow rate of 300 to 400 ml per minute. The collected paste is stored at -60 deg. C. or lower until further processed.

Purified Polysaccharide Powder Preparation

The inactivated paste is thawed and transferred to a blender. The paste is blended with 0.9 M calcium chloride to yield a homogeneous suspension. The suspension is centrifuged at approximately 10,000 x g for 15 minutes. The supernatant is decanted through a lint free pad into a container as the first extract. A second volume of 0.9 M calcium chloride is added to the paste, and blended to yield a homogeneous suspension. The suspension is centrifuged as above, and the supernatant combined with the supernatant from the first extraction. A total of four extractions are performed, and the supernatants pooled. The pooled extracts are concentrated by ultrafiltration using 10-30 kDa MWCO spiral would ultrafiltration units.

Magnesium chloride is added to the concentrated, and the pH adjusted to 7.2 to 7.5 using sodium hydroxide. DNase and RNase are added to the concentrate, and incubated at 25 to 28 deg. C. with mixing for 4 hours. Ethanol is added to a concentration of 30 to 50%. Precipitated nucleic acid and protein are removed by centrifugation at 10,000 x g for 2 hours. The supernatant is recovered and the polysaccharide precipitated by adding ethanol to 80% and allowing it to stand overnight at 1 to 5 deg. C. The alcohol is siphoned off, and the precipitated polysaccharide is centrifuged for 5 minutes at 10,000 x g. The precipitated polysaccharide is washed with alcohol. The polysaccharide is washed with acetone, centrifuged at 15 to 20 minutes at 10,000 x g. The polysaccharide is dried under vacuum. The initial polysaccharide powder is dissolved into sodium acetate solution. Magnesium chloride is added and the pH adjusted to 7.2 to 7.5 using sodium hydroxide solution. DNase and RNase are added to the solution and incubated at 25 to 28 deg. C. with mixing for 4 hours to remove residual nucleic acids. After incubation with these enzymes, an equal volume of sodium acetate-phenol solution is added to the polysaccharide-enzyme mixture, and placed on a platform shaker at 1 to 5 deg. C. for approximately 30 minutes. The mixture is centrifuged at 10,000 x g for 15 to 20 minutes. The upper aqueous layer is recovered and saved. An equal volume of sodium acetate- phenol solution is added to the aqueous layer, and extracted as above. A total of four extractions are performed to remove protein and endotoxin from the polysaccharide solution. The combined aqueous extracts are diluted up to ten fold with water for injection, and diafiltered against 10 volumes of water for injection. Calcium chloride is added to the diafiltered polysaccharide. The polysaccharide is precipitated overnight at 1 to 5 deg. C. by adding ethanol to 80%. The alcohol supernatant is withdrawn, and the polysaccharide collected by centrifugation at 10,000 x g for 15 minutes. The purified polysaccharide is washed two times with ethanol, and once with acetone. The washed powder is dried under vacuum in a desiccator. The dried powder is stored at -30 deg. C. or lower until processed onto conjugate.

Example 2 Depolymerization of Neisseria meningitidis serogroups A₅C, W135, and Y Purified Capsular Polysaccharide Powder

Materials used in the preparation include purified capsular polysaccharide powders from Neisseria meningitidis serogroups A, C, W-135, and Y (prepared in accordance with Example 1), sterile 50 mM sodium acetate buffer, pH 6.0, sterile IN hydrocholoric acid, sterile IN sodium hydroxide, 30% hydrogen peroxide, and sterile physiological saline (0.85% sodium chloride).

Each serogroup polysaccharide is depolymerized in a separate reaction. A stainless steel tank is charged with up to 60 g of purified capsular polysaccharide powder. Sterile 50 mM sodium acetate buffer, pH 6.0 is added to the polysaccharide to yield a concentration of 2.5 g polysaccharide per liter. The polysaccharide solution is allowed to mix at 1 to 5 deg. C. for 12 to 24 hours to effect solution. The reaction tank is connected to a heat exchanger unit. Additional 50 mM sodium acetate buffer, pH 6.0, is added to dilute the polysaccharide to reaction concentration of 1.25 g per liter. The polysaccharide solution is heated to 55 deg. C..+-.0.1. An aliquot of 30% hydrogen peroxide is added to the reaction mixture to yield a reaction concentration of 1% hydrogen peroxide.

The course of the reaction is monitored by following the change in the molecular size of the polysaccharide over time. Every 15 to 20 minutes, aliquots are removed from the reaction mixture and injected onto a HPSEC column to measure the molecular size of the polysaccharide. When the molecular size of the polysaccharide reached the targeted molecular size, the heating unit is turned off and the polysaccharide solution rapidly cooled to 5 deg. C. by circulation through an ice water bath. The depolymerized polysaccharide solution is concentrated to 15 g per liters by connecting the reaction tank to an ultrafiltration unit equipped with 3000 MWCO regenerated cellulose cartridges. The concentrated depolymerized polysaccharide solution is diafiltered against 10 volumes of sterile physiological saline (0.85% sodium chloride). The depolymerized polysaccharide is stored at 1 to 5 deg. C. until the next process step.

The molecular size of the depolymerized polysaccharide is determined by passage through a gel filtration chromatography column sold under the tradename "Ultahydrogel.TM.250" that is calibrated using Dextran molecular size standards and by multi-angle laser light scattering. The quantity of polysaccharide is determined by phosphorus content for serogroup A using the method of Bartlet, G. R. J. (1959) Journal of Biological Chemistry, 234, pp-466-468, and by the sialic acid content for serogroups C, Wl 35 and Y using the method of Svennerholm, L. (1955) Biochimica Biophysica Acta 24, pp604-611. The O-acetyl content is determined by the method of Hesterin, S. (1949) Journal of Biological Chemistry 180, p249. Reducing activity is determined by the method of Park, J. T. and Johnson, M. J. (1949 Journal of Biological Chemistry 181, pp 149-151. The structural integrity of the depolymerized polysaccharide is determined by protein .sup.lH and .sup.l3C NMR. The purity of the depolymerized polysaccharide is determined by measuring the LAL (endotoxin) content and the residual hydrogen peroxide content.

Example 3 Derivatization of Neisseria meningitidis Serogroups A, C, W- 135, and Y Depolymerized Polysaccharide Materials used in this preparation include hydrogen peroxide depolymerized capsular polysaccharide sero groups A, C, W- 135, and Y from Neisseria meningitidis (prepared in accordance with Example 2), adipic acid dihydrazide, l-ethyl-3-(3- dimethylaminopropyl) carbodiimide (EDAC) for serogroup A only, sodium cyanborohydride, sterile IN hydrocholoric acid, sterile IN sodium hydroxide, sterile 1 M sodium chloride, and sterile physiological saline (0.85% sodium chloride).

Each serogroup polysaccharide is derivatized in a separate reaction. A stainless steel tank is charged with the purified depolymerized polysaccharide, and diluted with sterile 0.85% physiological saline to achieve a final reaction concentration of 6 g polysaccharide per liter. To this solution is added a concentrated aliquot of adipic acid dihydrazide dissolved in sterile 0.85% physiological saline, in order to achieve a reaction concentration of Ig per liter. For serogroup A only, EDAC is added as a concentrated aliquot dissolved in sterile 0.85% physiological saline, to achieve a reaction concentration of Ig per liter. The pH is adjusted to 5.0.+-.0.1, and this pH is maintained for 2 hours using sterile IN hydrochloric acid and sterile IN sodium hydroxide at room temperature (15 to 30 deg. C). After two hours, a concentrated aliquot of sodium cyanoborohydride, dissolved in 0.85% physiological saline, is added to the reaction mixture to achieve a reaction concentration of 2 g per liter. The reaction is stirred at room temperature (15 to 30 deg. C) for 44 hours.+-.4 hours while maintaining the pH at 5.5.+- .0.5. Following this reaction period, the pH is adjusted to 6.0.+-.0.1, and the derivatized polysaccharide is concentrated to 12 g polysaccharide per liter by connecting the reaction tank to a ultrafiltration unit equipped with a 3000 MWCO regenerated cellulose cartridges. The concentrated derivatized polysaccharide is diafiltered against 30 volumes of 1 M sodium chloride, followed by 10 volumes of 0.15 M sodium chloride. The tank is disconnected from the ultrafiltration unit and stored at 1 to 5 deg. C. for 7 days. The tank is reconnected to an ultrafiltration unit equipped with 3000 MWCO regenerated cellulose cartridges, and diafiltered against 30 volumes of 1 M sodium chloride, followed by 10 volumes of 0.15 M sodium chloride.

The molecular size of the derivatized polysaccharide, the quantity of polysaccharide, and the O-acetyl content are measured by the same methods used on the depolymerized polysaccharide. The hydrazide content is measured by the 2,4,6- trinitrobenzensulfonic acid method of Snyder, S. L. and Sobocinski, P. Z. (1975) Analytical Biochemistry 64, pp282-288. The structural integrity of the derivatized polysaccharide is determined by proton ¹H and ¹³C NMR. The purity of the derivatized polysaccharide is determined by measuring the level of unbound hydrazide, the LAL (endotoxin) content, and the residual cyanoborohydride content.

Example 4 Preparation of Carrier Protein

Preparation of Crude Diphtheria Toxoid Protein

Lyophilized seed cultures are reconstituted and incubated for 16 to 18 hours. An aliquot from the culture is transferred to a 0.5-liter flask containing growth medium, and the culture flask is incubated at 34.5 to 36.5 deg. C. on a rotary shaker for 7 to 9 hours. An aliquot from the culture flask is transferred to a 4-liter flask containing growth medium, and the culture flask is incubated at 34.5 to 36.5 deg. C. on a rotary shaker for 14 to 22 hours. The cultures from the 4-liter flask are used to inoculate a fermenter containing growth media. The fermenter is incubated at 34.5 to 36.5 deg. C. for 70 to 144 hours. The contents of the fermenter are filtered through depth filters into a collection vessel. An aliquot of formaldehyde solution, 37% is added to the harvest to achieve a concentration of 0.2%. The pH is adjusted to 7.4 to 7.6. The harvest is filtered through a 0.2 micron filter cartridge into sterile 20 liter bottles. The bottles are incubated at 34.5 to 36.5 deg. C. for 7 days. An aliquot of formaldehyde solution, 37%, is added to each 20 liter bottle to achieve a concentration of 0.4%. The pH of the mixtures is adjusted to 7.4 to 7.6. The bottles are incubated at 34.5 to 36.5 deg. C. for 7 days on a shaker. An aliquot of formaldehyde solution, 37%, is added to each 20 liter bottle to achieve a concentration of 0.5%. The pH of the mixtures is adjusted to 7.4 to 7.6. The bottles are incubated at 34.5 to 36.5 deg. C. for 8 weeks. The crude toxoid is tested for detoxification. The bottles are stored at 1 to 5 deg. C. during the testing period.

Purification of the Crude Diphtheria Toxoid Protein

The crude toxoid is allowed to warm to room temperature, and the contents of the 20-liter bottles are combined into a purification tank. The pH of the toxoid is adjusted to 7.2 to 7.4, and charcoal is added to the crude toxoid and mixed for 2 minutes. The charcoal toxoid mixture is allowed to stand for 1 hours, and is then filtered through a depth filter cartridge into a second purification tank. Solid ammonium sulfate is added to the filtrate to achieve 70% of saturation. The pH is adjusted to 6.8 to 7.2, and the solution is allowed to stand for 16 hours. The precipitated protein is collected by filtration and washed with 70% of saturation ammonium sulfate solution, pH 7.0. The precipitate is dissolved into sterile distilled water, and the protein solution is filtered into a stainless steel collection vessel. The pH is adjusted to 6.8 to 7.2, and ammonium sulfate is added to 40% of saturation. The pH of the solution is adjusted to 7.0 to 7.2, and the solution is allowed to stand for 16 hours. The precipitate is removed by filtration and discarded. Ammonium sulfate is added to the filtrate to 60% of saturation, and the pH adjusted to 7.0 to 7.2. The mixture is allowed to stand for 16 hours, and the precipitated protein is collected by filtration. The precipitate is dissolved into sterile distilled water, filtered to remove undissolved protein, and diafiltered against 0.85% physiological saline.

Concentration and Sterile Filtration of the Purified Diphtheria Toxoid Protein

The protein solution is concentrated to 15 g per liter and diafiltered against 10 volumes of 0.85% physiological saline suing a 10,000 MWCO regenerated cellulose filter cartridge. The concentrated protein solution is sterilized by filtration through a 0.2 micron membrane. The protein solution is stored at 1 to 5 deg. C. until processed onto conjugate.

The protein concentration is determined by the method of Lowry, O. H. et. al (1951) Journal of Biological Chemistry 193, p265-275. The purity of the protein is measured by sterility, LAL (endotoxin) content, and residual formaldehyde content.

Example 5 Preparation of Monovalent Conjugates of Neisseria meningitidis Serogroups A, C, W-135, and Y Polysaccharide to Diphtheria Toxoid Protein

Materials used in this preparation include adipic acid derivatized polysaccharide from Neisseria meningitidis serogroups A, C, W-135, and Y (prepared in accordance with Example 3), sterile diphtheria toxoid protein (prepared in accordance with Example 4), EDAC, ammonium sulfate, sterile IN hydrochloric acid, sterile IN sodium hydroxide, and sterile physiological saline (0.85%).

Each serogroup polysaccharide conjugate is prepared by a separate reaction. All four conjugates are prepared by the following process. A stainless steel tank is charged with the purified adipic acid derivatized polysaccharide at a reaction concentration of 700 to 1000 .mu.moles of reactive hydrazide per liter and purified diphtheria toxoid protein at a reaction concentration of 3.8 to 4.0 g protein per liter. Physiological saline 0.85%, is used to dilute the starting materials to the target reaction concentrations and the pH is adjusted to 5.0.+-.0.1. An aliquot of EDAC is added to the polysaccharide protein mixture to achieve a reaction concentration of 2.28 to 2.4 g per liter. The pH of the reaction is kept at 5.0.+-.0.1 for 2 hours at 15 to 30 deg. C. After two hours, the pH is adjusted to 7.0.+-.0.1 using sterile IN sodium hydroxide, and the reaction is stored at 1 to 5 deg. C. for 16 to 20 hours.

The reaction mixture is allowed to warm to 15 to 30 deg. C. and the reaction vessel is connected to an ultrafiltration unit equipped with a 30,000 MWCO regenerated cellulose cartridge. Solid ammonium sulfate is added to 60% of saturation (for serogroups A, W-135 and Y) and 50% of saturation (for serogroup C). The conjugate reaction mixture is diafiltered against 20 volumes of 60% of saturated ammonium sulfate solution (for serogroups A, W-135 and Y) and 50% of saturated ammonium sulfate solution (for serogroup C), followed by 20 volumes of physiological saline, 0.85%. The diafiltered conjugate is first filtered through a filter capsule containing a 1.2 micron and a 0.45 micron filter, and then through a second filter capsule containing a 0.22 micron filter.

The quantity of polysaccharide and O-acetyl content are measured by the same methods used on the depolymerized and derivatized polysaccharide. The quantity of protein is determined by the Lo wry method. The molecular size of the conjugate is determined by passage through a gel filtration chromatography column sold under the tradename "TSK6000PW" that used DNA as the void volume marker, ATP as the total volume marker, and bovine thyroglobulin as a reference marker. In addition, the molecular size of the conjugate eluted from the TKS6000PW column is measured by multi-angle laser light scattering. The antigenic character of the conjugate is measured by binding to anti-polysaccharide serogroup specific antibody using double-sandwich ELISA method. The purity of the conjugates is determined by measuring the amount of unbound (unconjugated) polysaccharide by elution though a hydrophobic interaction chromatography column, unconjugated protein by capillary electrophoresis, sterility, LAL (endotoxin) content, residual EDAC content, and residual ammonium ion content.

Example 6 Formulation of a Multivalent Meningococcal A, C, W-135, and Y Polysaccharide Diphtheria Toxoid Conjugate Vaccine

Materials used in this preparation include, serogroups A, C, W-135, and Y polysaccharide-diphtheria toxoid conjugates that are prepared in accordance with Example 5, sterile 100 mM sodium phosphate buffered physiological saline (0.85% sodium chloride).

An aliquot of sterile 100-500 mM sodium phosphate buffered physiological saline is added to physiological saline (0.85%) in a stainless steel bulking tank to yield a final vaccine concentration of 10 mM sodium phosphate. An aliquot of each of from two to four of the sterile monovalent meningococcal polysaccharide-diphtheria toxoid conjugates is added to the bulking tank containing 10 mM sterile sodium phosphate physiological saline to yield a final concentration of 8 μg of each serogroup polysaccharide per milliliter of buffer. The formulated tetravalent conjugate is mixed and filtered through a 0.2 .mu.m filter into a second bulking tank.

The quantity of each serogroup polysaccharide present in the multivalent formulation is determined by component saccharide analysis using high pH anion- exchange chromatography with pulsed amperometric detection. The quantity of protein is measured by the method of Lo wry. Th pH of the vaccine is measured using a combination electrode connected to a pH meter. The antigenic character of the multivalent conjugate vaccine is measured by binding to anti-polysaccharide serogroup specific antibody using a double-sandwich ELISA method. Immunogenicity of the multivalent conjugate vaccine is measured the ability of each conjugate present in the vaccine to elicit both a primary and booster anti-polysaccharide IgG immune response in an animal model. The purity of the multivalent conjugate vaccine is determined by measuring the amount of unbound (unconjugated) polysaccharide using high pH anion- exchange chromatography with pulsed amperometric detection, sterility, LAL (endotoxin) content, pyrogenic content, and general safety.

Example 7 Preparation of Aluminum-hydroxide Adjuvanted Multivalent Meningococcal Polysaccharide Diphtheria Toxoid Protein Conjugate

Preparation of conjugate adsorbed to aluminum hydroxide. Materials used in this preparation include sero groups A, C, W-135, and Y polysaccharide-diphtheria toxoid conjugates that are prepared in accordance with Example 5, sterile physiological saline (0.85% sodium chloride), and sterile aluminum hydroxide in physiological saline (0.85% sodium chloride).

An aliquot of each of the sterile monovalent meningococcal polysaccharide diphtheria toxoid conjugates is added to the bulking tank containing physiological saline to yield a final concentration of 8 μg of each serogroup polysaccharide per milliliter of buffer. An aliquot of sterile aluminum hydroxide in physiological saline (0.85% sodium chloride) is added to the multivalent conjugate vaccine to achieve a final concentration of 0.44 mg aluminum ion per milliliter vaccine.

Example 8 Preparation of Aluminum Phosphate-adjuvanted Conjugate

Materials used in this preparation include serogroups A, C, W-135, and Y polysaccharide-diphtheria toxoid conjugates that are prepared according to Example 5, sterile physiological saline (0.85% sodium chloride), and sterile aluminum phosphate in physiological saline (0.85% sodium chloride).

An aliquot of each of the sterile monovalent meningococcal polysaccharide-diphtheria toxoid conjugates is added to the bulking tank containing physiological saline to yield a final concentration of 8 μg of each serogroup polysaccharide per milliliter of buffer. An aliquot of sterile aluminum phosphate in physiological saline (0.85% sodium chloride) is added to th© multivalent conjugate vaccine to achieve a final concentration of 0.44 mg aluminum ion per milliliter vaccine.

Example 9 General Description of Materials and Methods Used in Human Clinical Studies Immunogenicity of a Tetravalent Derivatized Conjugate Vaccine

The conjugate vaccine is studied for its ability to elicit an immune response in humans under a number of different clinical protocols. The following studies summarize the results. The materials and methods used in each of the following studies, unless indicated otherwise, are:

TetraMenD

TetraMenD vaccine comprises four meningococcal capsular polysaccharides of serogroups A, C, Y, and W-135, 4 μg of each polysaccharide, covalently attached to a total of 48 μg diphtheria toxoid protein. The vaccine is formulated in sterile, pyrogen- free, phosphate-buffered physiological saline, with no preservative. The formula comprises 0.6 mg sodium phosphate, 4.4 mg sodium chloride and up to 0.5 mL water.

Menomune^®

Menomune^® is licensed in the United States and elsewhere for use among persons aged 2 years and older. Menomune is a freeze-dried preparation, each dose of vaccine containing 50 μg of each A, C, Y and W-135 polysaccharide as antigens, reconstituted with a diluent of isotonic sodium chloride solution preserved with thimerosal and given subcutaneously as a 0.5 mL dose. Each 0.5 mL dose of vaccine contains 2.5 mg to 5 mg of lactose as a stabilizer. Menomune^® - A/C/Y/W-135, Meningococcal Polysaccharide Vaccine, Groups A, C, Y, and W-135 Combined, for subcutaneous use, is a freeze-dried preparation of the group-specific polysaccharide antigens from Neisseria meningitidis, Group A, Group C, Group Y, and Group W-135. The diluent is sterile, pyrogen-free, distilled water. After reconstitution of the lyophilized product with diluent as indicated on the label, each 0.5 mL dose is formulated to contain 50 μg of "isolated product" from each of the serogroups A, C, Y, and W-135 in isotonic sodium chloride solution.

Tetanus and Diphtheria Toxoids Adsorbed for Adult Use^® (referred to subsequently as Td) Is a sterile suspension of alum precipitated toxoid in an isotonic sodium chloride solution containing sodium phosphate buffer to control pH. The vaccine is for intramuscular injection. Each 0.5mL dose is formulated to contain 5Lf of tetanus toxoid, 2Lf of diphtheria toxoid and not more than 0.28 mg of aluminum by assay. Tetanus and diphtheria toxoids induce at least 2 units and 0.5 units of antitoxin per mL respectively in the guinea pig potency test. At visit 1, Td is administered to all participants as a single 0.5mL dose by intramuscular injection using a one inch 25 gauge needle into the deltoid of the left arm. Each 0.5mL dose contains 5Lf of tetanus toxoid and 2Lf of diphtheria toxoid.

Sera Samples

Blood specimens are drawn on the Days indicated after the baseline. For example, if the protocol indicates three time points, DO, D28 and 6 Month, then blood specimens are drawn on Day 0 prior to vaccination (baseline), at Day 28 post- vaccination (to assess primary immune response, and at 6 month post- vaccination (to assess the longevity of the immune response). Approximately 5 mL of whole blood is collected from each subject at each time point. The whole blood is centrifuged within four hours of collection. The serum is removed and stored at -20 deg. C. A 'Day 28' blood sample is taken at least 28 days but not yet 57 days after the Day 0 injection. A "6 month" blood sample is taken at 6 months plus or minus 28 days after the Day 0 injection. Thus, a Day 28 sera represents a sera is drawn between day 28 to day 56 after DO; and a 6 month sera represents a sera is drawn between day 149 to day 217 after DO.

Assay Techniques

The present studies utilize a number of standard immunological assays. The following descriptions summarize the methodologies used herein. However, other similar assays, including variations of those presented herein, are well known by those in the art and may be utilized. Anti-Meningococcal Antibody Determination by a Serum Bactericidal Assay using Baby Rabbit Complement (SBA-BR)

Functional antibody activity for anti-meningococcal antibody to serogroups A, C, Y, and W-135 is measured using a serum bactericidal assay. Two-fold dilutions of test sera are prepared in sterile 96-well microtiter plates. Serogroup specific meningococcal bacteria along with baby rabbit complement are added to the serum dilutions and allowed to incubate. After this incubation period, an agar overlay medium is added to the serum/complement/bacteria mixture, allowed to harden, and then incubated overnight at 37°C with 5% CO₂. Bacterial colonies present in the wells are counted. The endpoint titer is determined by the reciprocal serum dilution yielding > 50% killing as compared to the mean of the complement control wells. The limit of detection for this assay, using rabbit complement, is a titer of 8.

IgG Anti-Meningococcal Antibody Determination

IgG antibody activity for anti-meningococcal antibody to serogroups A, C, Y, and W-135 is measured using an indirect ELISA. This procedure involves reacting antibody in sera with excess meningococcal group specific polysaccharide (MenPs) antigen adsorbed to plastic microtiter wells by methylated human serum albumin. The amount of bound antibody is determined by a reaction with peroxidase-labeled mouse anti-human IgG specific monoclonal antibody. A subsequent reaction using peroxidase substrate generates a chromogenic product that is measured spectrophotometrically. The resulting optical density (OD) correlates with the amount of IgG antibody in the serum that is bound to the meningococcal polysaccharide on the microtiter plate. The amount of IgG antibody is then calculated by comparison to a reference (Lot CDC 1992 or equivalent) with an assigned value using a 4-parameter logistic curve method.

IgM Anti-Meningococcal Antibody Determination

IgM antibody activity for anti-meningococcal antibody to serogroups A, C, Y, and W-135 is measured using an indirect ELISA. This procedure involves reacting antibody in sera with excess MenPs antigen adsorbed to plastic microtiter wells by methylated human serum albumin. The amount of bound antibody is determined by a reaction with peroxidase-labeled mouse anti-human IgM specific monoclonal antibody. A subsequent reaction using peroxidase substrate generates a chromogenic product that is measured spectrophotometrically. The resulting OD correlates with the amount of IgM antibody in the serum that is bound to the meningococcal polysaccharide on the microtiter plate. The amount of IgM antibody is then calculated by comparison to a reference (Lot CDC 1992 or equivalent) with an assigned value using a 4-parameter logistic curve.

High Avidity Anti-Meningococcal IgG Antibody Determination

High avidity IgG antibody activity for anti-meningococcal antibody to serogroups A, C, Y, and W- 135 will be measured at Aventis Pasteur Inc. using a modified ELISA. This assay is currently under development at Aventis Pasteur Inc. and will be qualified prior to testing of clinical specimens. Briefly, 96 well microtiter plates are coated with MenPs antigen. After aspirating and ishing the coated plates, serial dilutions of clinical sera are prepared directly in the plates, using phosphate buffered saline (PBS) serum diluting buffer containing 75 mM ammonium thiocyanate, and allowed to incubate overnight. The amount of bound antibody is determined by a reaction with peroxidase- labeled mouse anti-human IgG specific monoclonal antibody. A subsequent reaction using peroxidase substrate generates a chromogenic product that is measured spectrophotometrically. The resulting OD correlates with the amount of high avidity IgG antibody in the serum that is bound to the meningococcal polysaccharide on the microtiter plate. The amount of high avidity IgG antibody is then calculated by comparison to a reference (Lot CDC 1992 or equivalent) using a 4-parameter logistic curve.

IgGl and IgG2 Subclass Meningococcal Antibody Determination

IgGl and IgG2 subclass antibody distribution for anti-meningococcal antibody to serogroups A, C, Y and W-135 is measured using an ELISA. Antibody present in serial dilutions of sera is reacted with MenPs antigen adsorbed to the wells of microtiter plates. The amount of bound antibody will be determined using anti-human IgGl Fc or IgG2 Fc specific reagents. A subsequent reaction with enzyme substrate generates a chromogenic product that is measured spectrophotometrically. The resulting OD correlates with the amount of IgGl or IgG2 antibody in the serum that is bound to the meningococcal polysaccharide on the microtiter plate. The amount of antibody will be reported as the IgGl :IgG2 ratio in the serum specimen or as the concentration of IgGl or IgG2 in the specimen if a suitable reference is available.

Anti-Diphtheria Antibody Determination By Metabolic Inhibition of VERO Cells

Anti-diphtheria antibody responses are measured by the ability of the test sera to protect VERO cells from a diphtheria toxin challenge. Using sterile 96-well microtiter plates, two-fold dilutions of test sera, beginning with a 1:4 dilution, are challenged with diphtheria toxin and allowed to incubate. VERO cells are then added, the wells sealed with sterile mineral oil and incubated for six to eight days. Antibody levels are then determined by observing a color change of the pH indicator in the media resulting from the byproducts of cell metabolism. Results are reported as International Units/mL by comparison to a calibrated WHO reference serum and determined by the highest serum dilution that allows cell metabolism in the presence of the challenge dose of diphtheria toxin. The lower limit of detection is determined by the minimum detectable antitoxin level of the reference serum, and the starting dilution of the test sera, and is typically 0.005 IU/mL.

Anti-Tetanus Antibody Determination By Elisa

Anti-Tetanus antibody levels are determined by an indirect Enzyme Linked Immunosorbent Assay (ELISA). The method involves reacting antibody in test sera with tetanus toxoid adsorbed to plastic microtiter wells. The amount of bound antibody is determined by a reaction with Goat Anti-Human IgG-specific antibody conjugated to alkaline phosphatase. A subsequent reaction with alkaline phosphatase substrate generates a chromogenic product that is measured spectrophotometrically. The OD (optical density) correlates with the amount of antibody in the serum dilution that binds to the antigen coated microtiter plate. The antibody concentration is calculated by comparison to an international human reference (WHO Lot TE-3) with assigned unitage by a Parallel Line Analysis method. Results are reported as International Units per milliliter (IU/mL). The minimum level of quantitation for the anti-tetanus IgG ELISA is 0.01 IU/mL, with samples resulting in values lower than this level reported as < 0.01 IU/mL.

Adverse Event (AE) is defined as "any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and that does not necessarily have a causal relationship with this treatment. An adverse event can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product." (ICH guidelines, GCP (E6) § 1.2).

Serious Adverse Experience (SAE) is "any adverse drug experience occurring at any dose that results in any of the following outcomes: death, a life-threatening adverse drug experience, inpatient hospitalization or prolongation of existing hospitalization, a persistent or significant disability/incapacity, or a congenital anomaly/birth defect. Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgement, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. Examples of such medical events include allergic bronchospasm requiring intensive treatment in an emergency room or at home, blood dyscrasias or convulsions that do not result in inpatient hospitalization, or the development of drug dependency or drug abuse." (21 CFR Ch. I, §312.32(a)).

Unexpected Adverse Experience (UAE) is "any adverse drug experience, the specificity or severity of which is not consistent with the current investigator's brochure; or, if an investigator brochure is not required or available, the specificity or severity of which is not consistent with the risk information described in the general investigational plan or elsewhere in the current application, as amended." (21 CFR Ch. I, §312.32(a)). The studies conducted in accordance with standard clinical practice, and the criteria for enrollment or exclusion of patients in the studies are:

Inclusion criteria for patients:

1. Participant is healthy, as determined by medical history and physical examination. 2. Participant is at least 11 years of age but not yet 19 years of age at the time of vaccination.

3. Parent/guardian or participant has signed Institutional Review Board (IRB) approved informed consent form where applicable.

4. Participant has signed Institutional Review Board (IRB) approved assent form where applicable

Exclusion criteria for patients:

1. Serious chronic disease (i.e. cardiac, renal, neurologic, metabolic, rheumatologic, etc.).

2. Known or suspected impairment of immunologic function.

3. Acute medical illness with or without fever within the last 72 hours or an oral temperature > 38⁰C (100.4⁰F) at the time of inclusion.

4. History of documented invasive meningococcal disease or previous meningococcal vaccination.

5. Administration of immune globulin, other blood products within the last 3 months, or oral or injected corticosteroids or other immunomodulatory therapy within 6 weeks of the study vaccine. Individuals on a tapering dose schedule of oral steroids lasting < 7 days may be enrolled in the trial as long as they have not received more that one course within a two week period prior to enrollment.

6. Antibiotic therapy within the 72 hours prior to vaccination

7. Received any vaccine in the 28-day period prior to enrollment, or scheduled to receive any vaccination in the 28-day period after enrollment, except where the study notes additional vaccinations.

8. Suspected or known hypersensitivity to any of the vaccine components.

9. Unavailable for the entire study period or unable to attend the scheduled visits or to comply with the study procedures.

10. Enrolled in another clinical trial.

11. Any condition which, in the opinion of the investigator, would pose a health risk to the participant or interfere with the evaluation of the vaccine. 12. In females, a positive or equivocal urine pregnancy test at the time of vaccination.

Example 10 Study A -Dosage Study

Study A is an unblinded, open-label, dose-escalation trial of three dosage levels of TetraMenD vaccine, administered to participants in three age groups. Ninety healthy adults (18 to 55 years of age) are enrolled in Stage I and received a single injection of TetraMenD vaccine. Thirty healthy children (12 to 22 months of age) are enrolled in Stage II and received 2 injections of a single dosage level of TetraMenD vaccine. Ninety healthy infants (6 to 12 weeks of age) are enrolled in Stage III and received 3 injections of a single dosage level of TetraMenD vaccine.

Stage IDosage Study in Adults 18 to 55 Years

This clinical trial is an unblinded, open-label, dose-escalation trial of three dosage levels of TetraMenD vaccine, which is administered to participants in three age groups. In Stage 1, ninety healthy adults (18 to 55 years of age) receive a single injection of TetraMenD vaccine.

For adult participants, serum specimens for serologic analysis are obtained at baseline (day 0) prior to TetraMenD administration, and at day 28 after TetraMenD administration. All available specimens are analyzed for SBA against meningococcal polysaccharide serogroups A, C, Y, and W-135, and by ELISA for IgG antibody against these same serogroups. The SBA and IgG ELISA findings for all serogroups are summarized below.

One key immunogenicity endpoint is the proportion of participants with a >4-fold rise from baseline. To determine what effect the baseline SBA titer had on the proportion with a >4-fold rise in SBA, a subgroup analysis is performed for adults whose baseline titer for each particular antigen is less than 1 :64, and adults whose baseline titer for that particular antigen is at least 1 :64.

The safety profile of TetraMenD is comparable to that of Menomune^®. The results of this Study are summarized in the following Tables.

Table A-3: Stage I (Adults) - Proportions Achieving SBA Thresholds at Baseline and at Day 28 Post-Injection, By TetraMenD Dosage Level (Per-Protocol Po ulation

N: number of evaluable participants at each time point (day 0; day 28)

Table A-4: Stage I (Adults) - SBA and IgG ELISA Results at Baseline and at Day 28 Post-Injection, by TetraMenD Dosage Level (Per-Protocol Population)

Table A-4: Stage I (Adults) - SBA and IgG ELISA Results at Baseline and at Day 28 Post-Injection, by TetraMenD Dosage Level (Per-Protocol Population)

Table A-4: Stage I (Adults) - SBA and IgG ELISA Results at Baseline and at Day 28 Post-Injection, by TetraMenD Dosage Level (Per-Protocol Population)

Day 0: Baseline blood sample drawn prior to vaccination.

Day 28: Blood sample drawn 28 days following vaccination.

% > 4-fold rise: the percent of adults who had a > 4-fold rise in GMT at day 28 in comparison to day 0.

N: number of evaluable participants

*GMTs are computed for the SBA data; GMCs are computed for the IgG ELISA data.

Table A-5 presents the GMT by dose, patient age and serogroup.

Stage II Dosage Study in Toddlers Aged 12 Months to 22 Months

This clinical trial is an unblinded, open-label, dose-escalation trial of three dosage levels of TetraMenD vaccine, which is administered to participants in three age groups. In Stage II, thirty healthy children (12 to 22 months of age) receive two injections of a single dosage level of TetraMenD vaccine.

For toddler participants, serum specimens for serologic analysis are obtained at three timepoints: at baseline (day 0) prior to TetraMenD injection #1, at day 60 after enrollment (60 days after injection #1 and immediately prior to TetraMenD injection #2), and at day 90 after enrollment (30 days after injection #2). All available specimens are analyzed for SBA against meningococcal polysaccharide serogroups A, C, Y, and W- 135, and by ELISA for IgG antibody against these same serogroups. The SBA and IgG ELISA findings for all serogroups are summarized below. The results are summarized in the following Tables.

Table A-IO: Stage II (Toddlers) - SBA and IgG ELISA Results Among Toddlers by TetraMenD Dosage Level At Baseline, 60 Days Post-Injection #1, and 30

Table A-IO: Stage II (Toddlers) - SBA and IgG ELISA Results Among Toddlers by TetraMenD Dosage Level At Baseline, 60 Days Post-Injection #1, and 30 Da s Post-Injection #2 Per-Protocol Po ulation)

Day 0: Baseline blood sample drawn prior to injection #1.

Day 60: Blood sample drawn 60 days following injection #1 and prior to injection #2.

Day 90: Blood sample drawn 30 days following injection #2.

% > 4-fold rise: Post-Inj #1 : the percentage of toddlers which had a > 4-fold rise in GMT at day 60 in comparison to day 0; Post-Inj #2: the percentage of toddlers which had a

> 4-fold rise in GMT at day 90 in comparison to day 0.

N: number of evaluable participants

*GMTs are computed for the SBA data; GMCs are computed for the IgG ELISA data.

Table A-Il summarizes the GMT by Dose, Patient Age and Serogroup

Stage III Dosage Study in Infants

This clinical trial is an unblinded, open-label, dose-escalation trial of three dosage levels of TetraMenD vaccine, which is administered to participants in three age groups. In Stage III, ninety healthy infants (6 to 12 weeks of age) receive three injections of a single dosage level of TetraMenD vaccine.

Infant participants received TetraMenD injections at age 2 months (injection #1), at age 4 months (injection #2), and at age 6 months (injection #3). Serum specimens for serologic analysis are obtained at two time points: at age 6 months (2 months following injection #2), and at age 7 months (one month after injection #3). All available specimens are analyzed for SBA against meningococcal polysaccharide serogroups A, C, Y, and W-135, and by ELISA for IgG antibody against these same serogroups. The SBA and IgG ELISA findings for all serogroups are summarized below. The results are summarized in the following Tables.

Table A-14: Stage III (Infants) - Proportions Achieving SBA Thresholds at

Age 6 months (pre 3^rd dose) and at Age 7 months (post 3^rd dose) by TetraMenD Dosage Level (Per-Protocol Population)

N: number of evaluable participants at each time point (6 months of age; 7 months of age)

Table A-15: Stage III (Infants) - SBA and IgG ELISA Results Among Infants At Age 6 months (pre 3^rd dose) and at Age 7 months (post 3^rd dose), by TetraMenD Dosage Level (Per-Protocol Population)

Table A-15: Stage III (Infants) - SBA and IgG ELISA Results Among Infants At Age 6 months (pre 3^rd dose) and at Age 7 months (post 3^rd dose), by TetraMenD Dosage Level (Per-Protocol Population)

Table A-15: Stage III (Infants) - SBA and IgG ELISA Results Among Infants At Age 6 months (pre 3^rd dose) and at Age 7 months (post 3^rd dose), by TetraMenD Dosage Level (Per-Protocol Population)

N: number of evaluable participants

*GMTs are computed for the SBA data; GMCs are computed for the IgG

ELISA data.

Table A- 16 presents a summary of GMT by patient age and serogroup

Pediatric Vaccines Administered Concomitantly with TetraMenD in Infants

Infants currently receive routine pediatric vaccinations per current ACIP recommendation and local practice. In this study, infants receive TetraMenD with pediatric vaccinations. DTacP (Tripedia^®) and Hib (ActHIB^®) are administered at ages 2, 4, and 6 months. Either IPV or OPV may be given; IPV is administered with the first and second injections of TetraMenD (at ages 2 and 4 months). Hepatitis B vaccine is given per local practice; hepatitis B vaccine is administered at age 2 months to some participants, but not administered to any participant at ages 4 months or 6 months. During the conduct of the infant stage of this trial, RotaShield® became licensed and received an ACIP recommendation for routine use. A single participant received RotaShield® at ages 4 months and 6 months in the context of this trial. Antibody responses to routinely administered pediatric vaccine antigens are assessed at age 6 months and 7 months. The results are summarized in separate Tables.

Infants participating in this trial received DTacP and PRP vaccines at 2, 4, and 6 months of age; the 7-month blood draw occurred one month after the third injection of these vaccines. For each of these vaccine antigens (diphtheria, tetanus, pertussis FHA, pertussis PT, and PRP), the observed antibody levels do not demonstrate a statistically significant difference among the 3 TetraMenD dosage groups (all p-values >0.05). (See Table A-17).

In the context of this trial, IPV is administered at 2 months and at 4 months of age. The 7-month blood draw occurs three months after the second injection of IPV. For polio type 1 and polio type 2, the observed GMTs, proportions with NA >1:4, and proportions with NA >1 :8 do not demonstrate a statistically significant difference among the 3 TetraMenD dosage groups (all p-values >0.05). At least 95.0% of all 3 TetraMenD dosage groups demonstrate protection against polio types 1 and 2 by proportion with NA >1:8. For polio type 3, the GMTs in the 1 μg, 4 μg, and 10 μg groups are 562.7, 164.0, and 113.3, respectively. The difference among the groups in the polio type 3 GMTs is statistically significant (p=0.001, ANOVA). However, all three TetraMenD dosage groups demonstrate protection against polio type 3 by proportion with NA >1 :8 (100.0% [22/22], 100.0% [21/21], and 94.1% [16/17], respectively). These proportions are not statistically different (p=0.283, Fisher's exact test). Moreover, the observed GMTs for the three polio serotypes are well within published ranges following two doses of IPV at 2 and 4 months of age, the IPV vaccination schedule utilized in this trial.

The 7-month blood draw occurs at a minimum of 5 months after the most recent hepatitis B vaccination. The observed levels of hepatitis B surface antibody by GMT and proportion >10 mIU/mL do not demonstrate a statistically significant difference among the 3 TetraMenD dosage groups (both p- values >0.649). Notably, no infants in this trial received hepatitis B vaccine at the 6-month visit, which is the earliest recommended age for the third dose of this vaccine. This may explain why the proportions of 7-month-old infants with hepatitis B surface antibody titers >10 mIU/mL are consistent with published ranges for detectable antibody following the initial doses of the vaccine, but lower than would have been expected for protective antibody levels following the complete three- vaccination series. The results of this Study are summarized in the following Tables.

Table A-17: Stage III (Infants) - Immunogenicity of Concomitant Vaccines Among Infants At Age 7 Months, by TetraMenD Dosage Level (Per-Protocol Population)

Table A-17: Stage III (Infants) - Immunogenicity of Concomitant Vaccines Among Infants At Age 7 Months, by TetraMenD Dosage Level (Per-Protocol Population)

Table A-17: Stage III (Infants) - Immunogenicity of Concomitant Vaccines Among Infants At Age 7 Months, by TetraMenD Dosage Level (Per-Protocol Population)

* GMT comparisons use the F-test. Comparisons of percentages use the Fisher's exact test.

⁺ p-value < 0.05

Example 11 Study B One and Six Month Study in Children Aged 2 to 10

This is a randomized, active-controlled sutyd of healthy children between the ages of 2 and 10, comparing a single dose of TetraMenD with a single dose of Menomune. Blood specimens are drawn on DO, before vaccination, D28 and at 6-months post DO. The overall safety of TetraMenD compared with Menomune is comparable. The results of this study are summarized in the following Tables.

Distribution of SBA-BR Antibody Titers

Table B-I shows the frequency distribution of baseline, Day 28 and Month 6 SBA-BR antibody titers for each serogroup.

Table B-2 summarizes of Geometric Mean Titer (GMT) by Subject Age and Serogroup for TetraMenD

Table B-3 shows the numbers and proportions of participants with a >4-fold rise in SBA-BR titer from baseline to Day 28 for the serogroups A, C, Y, and W-135. For each serogroup, these percentages are higher in the TetraMenD group than in the Menomune^® group. The differences in the proportions are: -0.0397, -0.0452, -0.1092 and -0.0562, for serogroups A, C, Y, and W-135, respectively.

Table B-3: Summary of Primary Hypothesis Testing for the Per-Protocol Population

n: number of participants with a > 4-fold rise from baseline titer. N: total number of participants in the used population.

P_t and P_1n: proportions of participants with a >4-fold rise in SBA post- vaccination titer from the TetraMenD and Menomune^® groups, respectively.

The proportion of participants with SBA antibody titers > 32 at Day 28 after vaccination is summarized in Table B-3.

%: n/N. n: number of participants with titer>32 at Day 28 post- vaccination. * N: total number of participants with valid blood sample at Day 28 in this group.

The proportion of participants with SBA antibody titers > 128 at Day 28 after vaccination is summarized in Table B-4.

Table B-4: Percentage and Number of Participants with an SBA-BR Antibody Titer > 128 at Day 28 Post- Vaccination (Per-Protocol Population)

Table B-4: Percentage and Number of Participants with an SBA-BR Antibody Titer > 128 at Day 28 Post- Vaccination (Per-Protocol Population)

%: n/N.

* n: number of participants with titer>128 at Day 28 post-vaccination.

* N: total number of participants with valid blood sample at Day 28 in this group.

Proportion of Participants with at least a 4-fold rise in SBA-BR Antibody Titers

Table B-5 shows the proportion of participants with a >4-fold rise in Day 28 and Month 6 SBA antibody titers from baseline. Twenty-eight to 56 days after receiving TetraMenD, the majority of participants experienced a > 4-fold rise in the SBA-BR antibody titer for each of the serogroups contained in the vaccine.

Table B-5: Percentage and Number of Participants with a >4-Fold Rise in Day 28 and Month 6 SBA-BR Antibody Titers From Baseline (Per-Protocol Population)

TetraMenD Menomune^®

Test Date

Test Type

,« ^{(95% CI} > (nW) <^{95% CI} >

Day 28 87.7 ( 84.9, 83.8 ( 80.7, 86.5)

Serogroup A (558/636) 90.2) (547/653)

SBA Month 6 79.1 ( 75.6, 56.9 ( 52.9, 60.8) (480/607) 82.2) (354/622)

Day 28 73.4 ( 69.8, 68.9 ( 65.2, 72.4)

Serogroup C (466/635) 76.8) (449/652)

SBA Month 6 55.7 ( 51.6, 43.7 ( 39.8, 47.7) (338/607) 59.7) (272/622)

Serogroup Y Day 28 56.6 ( 52.7, 45.7 ( 41.8, 49.6) SBA (359/634) 60.5) (298/652) Table B-5: Percentage and Number of Participants with a >4-FoId Rise in Day 28 and Month 6 SBA-BR Antibody Titers From Baseline (Per-Protocol Population)

TetraMenD Menomune^®

Test Date

Test Type (»W, ^{(95% CI ) (95% CI)}

Month 6 57.3 ( 53.3, 39.2 ( 35.3, 43.2) (348/607) 61.3) (243/620)

Day 28 91.0 ( 88.5, 85.4 ( 82.5, 88.0)

Serogroup W- (578/635) 93.1) (556/651)

135 SBA Month 6 82.7 ( 79.5, 69.5 ( 65.7, 73.1) (502/607) 85.6) (432/622)

%: n/N. ^f n: number of participants with > 4-fold rise from baseline titer. * N: total number of participants in the used population.

Proportion of Participants with Undetectable Titers (<8) at Day 0 Achieving a >4- FoId Rise in Day 28 SBA-BR Antibody Titers

In both treatment groups and for all vaccine serogroups, most participants with an undetectable (<8) SBA-BR titer at baseline achieved a >4-fold rise in Day 28 SBA titers. (Table B-6) The proportions of participants with an SBA titer <8 at Day 0 who had a >4- fold rise from baseline to Day 28 ranged from 86.21% to 98.57% in the TetraMenD group; and from 75.00 to 94.64 in the Menomune^® group.

Table B-6: Number and Percentage of Participants with Undetectable Titers (<8) at Day 0 Achieving a >4-Fold Rise in Day 28 SBA-BR Antibody Titers.

*n = The number of participants with titers < 8 at Day 0 and titers > 32 at Day 28 within each serogroup

N = The number of participants with titers < 8 at Day 0 within each serogroup Exact 95% confidence interval for the percentage

SBA-BR Antibody GMTs and mean fold rises

Table B-7 shows the SBA GMTs at baseline and on Day 28 and Month 6 after vaccination and the fold rises in SBA GMTs.

Table B-7: SBA-BR Serology Results at Baseline, Day 28, and Month 6 After Vaccination (Per-Protocol Population)

TetraMenD Menomune^®

Test Type Parameter Bleed Geometric Geometric

N^f (95% CI) (95% CI) Mean Mean

Serogroup Titer 638 35.44 ( 29.77, 655 32.72 ( 27.71,

Day O A SBA 42.20) 38.63)

Day 637 1700.27 (1512.07, 654 892.20 ( 789.97,

28 1911.89) 1007.66)

Mont 607 1053.65 ( 912.93, 623 214.97 ( 179.84, h 6 1216.07) 256.97)

Fold rise 638 1.00 ( 1.00, 655 1.00 ( 1.00,

Day O 1.00) 1.00) Table B-7: SBA-BR Serology Results at Baseline, Day 28, and Month 6 After Vaccination (Per-Protocol Population)

Table B-7: SBA-BR Serology Results at Baseline, Day 28, and Month 6 After Vaccination (Per-Protocol Population)

TetraMenD Menomune^®

Test Type Parameter^* Bleed Geometric Geometric

N^f Mean ^v Mean ^v '

Day 635 40.24 ( 34.30, 651 22.98 ( 19.73,

28 47.21) 26.76)

Month 607 19.19 ( 16.31, 622 7.42 ( 6.33, 6 22.56) 8.69)

^* Titer or fold rise, where fold rise = titer at Day 28/titer at Day 0 *N: total number of participants used in the calculation. ELISA IgG for serogroups A, C, W-135, and Y

Table B-8 shows the IgG GMCs at baseline and on Day 28 and Month 6 after vaccination and the fold rises in IgG GMCs.

Table B-8: IgG Serology Results at Baseline, Day 28, and Month 6 After Vaccination (Per-Protocol Population)

Table B-8: IgG Serology Results at Baseline, Day 28, and Month 6 After Vaccination (Per-Protocol Population)

Titer or fold rise, where fold rise = titer at Day 28/titer at Day 0 ^N: total number of participants used in the calculation. Twenty-eight to 56 days after receiving the study vaccination, TetraMenD, the majority of participants experience a > 4-fold rise in the SBA-BR antibody titer for each of the sero groups contained in the vaccine. Overall, 77% of TetraMenD recipients experience a 4-fold rise in antibody titer across all serogroups. Higher pre- vaccination antibody levels are observed for sero group Y than for C or W-135. This may be related to the fact that natural exposure to serogroup Y at this age may be more common than previously thought. Higher circulating antibody levels reflect recent natural exposure and may reduce the proportion of vaccine recipients exhibiting 4-fold or higher antibody responses. This clearly appears to be the case for serogroup Y responses when compared to other serogroups. The 4-fold rise for serogroup Y is 56.6% compared with 73.4% for serogroup C, 87.7% for serogroup A, and 91.0% for serogroup W-135. High pre- vaccination antibody levels are also observed for serogroup A. This may be the result of intermittent exposure over a prolonged period of time to several naturally occurring cross-reacting antigens.

To further evaluate the impact of pre-existing titers and to investigate the rate of seroconversion (as defined by the proportion of vaccine recipients who achieve a 4-fold rise in antibody titer when the pre- vaccination titer for any serogroup is < 1 :8), a separate analysis is performed on participants who had pre- vaccination antibody titers of <1 :8 to any one of the 4 serogroups contained in the vaccine. A titer of < 1 :8 by the SBA assay using baby rabbit as the complement source is considered to represent an undetectable level of circulating antibody. When participants are evaluated using this criterion, it is observed that there is a 98.6% seroconversion rate for serogroup A, 87.9% for serogroup C, 96.0% for serogroup W-135, and 86.2% for serogroup Y after vaccination with TetraMenD.

Based on observations in military recruits, Goldschneider proposed that a minimum titer of > 1 :4 using an SBA assay with a human complement source correlated with protection from invasive disease against Serogroup C. However, because of the need for standardization of the assay and the lack of a reliable source of human complement, baby rabbit complement is suggested as an alternative source. Meningococci appear to be more sensitive to the baby rabbit complement than human complement, resulting in higher measured antibody titers. Several authors have suggested that titers > 1 : 128 using the rabbit complement assay are predictive of protection while titers of < 1:8 are predictive of susceptibility at least for serogroup C. Although this level may be appropriate when evaluating polysaccharide vaccines, it may not be applicable for conjugate vaccines. Borrow suggested that, in subjects receiving a monovalent C conjugate vaccine who demonstrated post vaccination SBA titers between 8 and 64, the demonstration of a memory response using a reduced dose (10 μg) of a meningococcal polysaccharide vaccine given several months later showed that these individuals are also protected, having achieved an antibody level >1 :128. The results for subjects who received the TetraMenD vaccine with SBA-BR titers >1 : 128 for each serogroup are presented the Tables. When these criteria are applied to each of the serogroups contained in the vaccine, overall, 96.2% of participants who received TetraMenD achieved a post- vaccination SBA-BR titer of > 1 :32 and 90.5% achieved a titer > 1:128. A subset of sera from this clinical study is also used to evaluate the correlation between the SBA assay using baby rabbit complement and human complement and the results are provided in a subsequent Study.

Total IgG responses are significantly higher for serogroups C, Y, and W-135 in the Menomune^® group than in the group receiving TetraMenD. However, the post- vaccination SBA GMT levels for serogroups A, C, Y, and W-135, are significantly higher in the TetraMenD group. Table B-9 provides a comparison of GMC versus GMT titers by serogroup.

The observation that the lower levels of IgG produced by the conjugate generated a higher level of bactericidal activity than the polysaccharide vaccine strongly suggests that the quality and affinity of the antibody response to the conjugate vaccine is superior to that generated by unconjugated polysaccharide vaccine. High affinity antibody is associated with functional activity and memory response. This effect has also been observed in several published studies. These data demonstrate that TetraMenD is highly immunogenic in children aged 2 to 10 years, the observed GMTs in the TetraMenD group are superior to those observed in the Menomune group for each of the four serogroups, and the titers achieved are predictive of protection. Finally, it appears that TetraMenD generates higher affinity antibody responses for each serogroup contained in the vaccine.

Safety is monitored at 4 specific time points during the trial: Immediate reactions (within 30 minutes of vaccination), solicited local and systemic reactions within the first 7 days post-vaccination, all adverse events in the 28-day period after vaccination and continuing AEs (from Days 0-28) and serious adverse events from Day 0 to 6 months post-vaccination are reported.

For all participants, most local solicited reactions for both treatment groups are reported as mild and resolved within 3 days of vaccination. The frequency of local reactions is similar for each treatment group. In the group receiving TetraMenD 58.8% reported at least one local reaction while the group receiving Menomune^® 58.3% reported the same. In addition, experience with the monovalent C CRM ₁₉-₇ conjugate vaccine given intramuscularly to adolescents shows that the rate of local reactions is very similar to that observed for TetraMenD in this study.

The majority of reported AEs are not serious, reversible, and unrelated to vaccination. There are no reports in this study of new onset bronchial asthma, diabetes mellitus, or autoimmune disease.

Example 12 Study C One Month Study in Children Aged 11 to 18

Study C is a randomized, active-controlled study of healthy children aged 11 to 18 years as of DO of a single dose of TetraMenD versus a single dose of Menomune^®. Blood serum is drawn on DO, prior to vaccination and D28 and analyzed, and a subset of sera from patients is further evaluated as described in the results.

For all participants, most local solicited reactions for both treatment groups are reported as mild and resolved within 2 days of vaccination. The frequency of local reactions is more common in the group receiving TetraMenD (72.4%) than in the group receiving Menomune^® (34.7%). This result is probably due to the nature of the conjugate vaccine (diphtheria carrier protein) rather than the route of administration (intramuscular). The results of this Study are summarized in the following Tables.

Table C-I shows the frequency distribution of baseline and Day 28 SBA-BR antibody titers for each serogroup.

6886

Table C-2 summarizes GMT levels by Subject Age and Serogroup for TetraMenD

Table C-3 shows the numbers and percentages of participants with a >4-fold rise in SBA-BR titer from baseline to Day 28 for the serogroups A, C, Y, and W-135. For each serogroup, these percentages are higher in the TetraMenD group than in the Menomune^® group.

Table C-3: Numbers and Percentages of participants with a >4-fold rise in SBA- BR titer from Baseline to Day 28

Frequency of SBA-BR Antibody Titers > 32

The proportion of participants with SBA antibody titers > 32 at Day 28 after vaccination is summarized in Table C-4.

Table C-4: Percentage and Number of Participants with an SBA Antibody Titer > 32 at Day 28 Post- Vaccination (Per-Protocol Population)

%: n/N.

* n: number of participants with titer>32 at Day 28 post-vaccination.

* N: total number of participants with valid blood sample at Day 28 in this group.

Frequency of SBA-BR Antibody Titers > 128

The proportion of participants with SBA antibody titers > 128 at Day 28 after vaccination is summarized in Table C-5.

Table C-5: Percentage and Number of Participants with an SBA Antibody Titer > 128 at Day 28 Post- Vaccination (Per-Protocol Population)

%: n/N expressed as a percentage.

' n: number of participants with titer>128 at Day 28 post-vaccination. * N: total number of participants with valid blood sample at Day 28 in this group.

Percentage of Participants with > 4-fold Rise in SBA-BR Antibody Titers

Table C-6 shows the proportion of participants with a >4-fold rise in Day 28 SBA antibody titers from baseline.

Table C-6: Percentage and Number of Participants with a >4-Fold Rise in Day 28 SBA Antibody Titers From Baseline

%: n/N expressed as a percentage..

* n: number of participants with > 4-fold rise from baseline titer.

* N: total number of participants in the used population.

Percentage of Participants with Undetectable Titers (<8) at Day 0 achieving a >4- FoId Rise in Day 28 SBA-BR Antibody Titers

In both treatment groups and for all vaccine serogroups, most participants with an undetectable (< 8) SBA titer at baseline achieve a >4-fold rise in Day 28 SBA titers. The proportions of participants with an SBA titer <8 at Day 0 who had a >4-fold rise from baseline to Day 28 range from 98.17% to 100.0% (Table C-7).

Table C-7: Number and Percentage of Participants with Undetectable Titers (<8) at Day 0 Achieving a >4-Fold Rise in Day 28 SBA-BR Antibody Titers.

*n = The number of participants with titers < 8 at Day 0 and titers > 32 at Day 28 within each serogroup N = The number of participants with titers < 8 at Day 0 within each serogroup t Exact 95% confidence interval for the percentage

SBA-BR Antibody GMTs and Mean Fold Rises

Table C-8 shows the SBA GMTs at baseline and on Day 28 after vaccination and the fold rises in SBA GMTs.

Table C-8: SBA Serology Results at Baseline and at Day 28 After Vaccination (Per- Protocol Population)

Titer or fold rise, where fold rise = titer at Day 28/titer at Day 0 ⁺N: total number of participants used in the calculation.

ELISA IgG for serogroups A, C, W-135, and Y

Table C-9 shows the IgG GMCs (in μg/mL) at baseline and on Day 28 after vaccination and the fold rises in IgG GMCs. Table C-9: IgG Serology Results at Baseline and at Day 28 After Vaccination (Per-Protocol Population)

Titer or fold rise, where fold rise = titer at Day 28/titer at Day 0 ^{1^}N: total number of participants used in the calculation.

ELISA IgM for serogroups A, C, Y, and W-135

Table C-10 shows the IgM GMCs at baseline and on Day 28 after vaccination and the fold rises in IgM GMCs. Table C-10: IgM Serology Results at Baseline and at Day 28 After Vaccination (Per-Protocol Population)

Table C-IO shows the IgM GMCs at baseline and on Day 28 after vaccination and the fold rises in IgM GMCs. Table C-IO: IgM Serology Results at Baseline and at Day 28 After Vaccination (Per-Protocol Population)

Titer or fold rise, where fold rise = titer at Day 28/titer at Day 0 N: total number of participants used in the calculation.

Twenty-eight to 56 days after receiving the study vaccination, TetraMenD, the majority of participants experience a > 4-fold rise in the SBA-BR antibody titer for each of the serogroups contained in the vaccine. Overall, 90.7% of TetraMenD recipients experience a 4-fold rise in antibody titer across all serogroups. Higher pre- vaccination antibody levels are observed for serogroup Y than for C or W-135. This may be related to the fact that serogroup Y is currently the most common serogroup associated with invasive meningococcal disease in this age group in the U.S. and that natural exposure to this serogroup may be more common. Higher circulating antibody levels reflect recent natural exposure and may reduce the proportion of vaccine recipients exhibiting 4-fold or higher antibody responses. This appears to be the case for serogroup Y responses when compared to other serogroups. The 4-fold rise for serogroup Y is 81.8% compared with 91.7% for serogroup C and 96.7% for serogroup W-135. High pre-vaccination antibody levels are also observed for serogroup A. This may be the result of intermittent exposure over a prolonged time to several naturally occurring cross-reacting antigens.

To further evaluate the impact of pre-existing titers and to investigate the rate of seroconversion (as defined by the proportion of vaccine recipients who achieve a 4- fold rise in antibody titer when the pre-vaccination titer for any serogroup is< 1 :8), a separate analysis is performed on participants who had pre-vaccination antibody titers of <1:8 to any one of the 4 serogroups contained in the vaccine. A titer of < 1 :8 by the SBA assay using baby rabbit as the complement source is considered to represent an undetectable level of circulating antibody. When participants are evaluated using this criterion, it is observed that there is a 100% seroconversion rate for serogroup A, 98.1% for serogroup C, 98.1% for serogroup W-135, and 98.3% for serogroup Y after yaccination with TetraMenD.

As previously discussed in another Study, Goldschneider proposed that a minimum titer of > 1 :4 using an SBA assay with a human complement source correlated with protection from invasive disease against Serogroup C based on observations in military recruits. However, because of the need for standardization of the assay and the lack of a reliable source of human complement, baby rabbit complement is suggested as an alternative source. Meningococci appear to be more sensitive to the baby rabbit complement than human complement, resulting in higher measured antibody titers. Several authors have suggested that titers > 1:128 using the rabbit complement assay are predictive of protection while titers of < 1 :8 are predictive of susceptibility at least for serogroup C. Although this level may be appropriate when evaluating polysaccharide vaccines, it may not be applicable for conjugate vaccines. Borrow suggested that, in subjects receiving a monovalent C conjugate vaccine who demonstrated post vaccination SBA titers between 8 and 64, the demonstration of a memory response using a reduced dose (lOμg) of a meningococcal polysaccharide vaccine given several months later showed that these individuals are also protected, having achieved an antibody level >1 : 128. The results for subjects who received the TetraMenD vaccine with SBA-BR titers > 1 :128 for each serogroup is presented in the Tables. When these criteria are applied to each of the serogroups contained in the vaccine, overall, 99.2% of participants who received TetraMenD achieved a post- vaccination SBA-BR titer of > 1 :128.

IgG and IgM responses are evaluated in a subset of participants using a standard ELISA assay. Post- vaccination, the mean level of IgG antibody in the TetraMenD recipients is > 2μg for each serogroup. IgM responses are very similar for each serogroup in both treatment arms. The IgG responses are generally higher for serogroups C, Y, and W- 135 in the Menomune^® group than in the group receiving TetraMenD. The post- vaccination SBA GMT levels for serogroups C, Y, and W- 135, however, are very similar in each treatment group, Table C-I l.

Table C-Il: Relative Contribution of IgG and IgM to Total Bactericidal Activity

* GMC units are μg/mL

The observation that the lower levels of IgG produced by the conjugate generated a similar level of bactericidal activity as the polysaccharide vaccine strongly suggests that the quality and affinity of the antibody response to the conjugate vaccine is superior to that generated by the polysaccharide. It is the high affinity antibody that is associated with functional activity and memory response. This effect has also been observed in several published studies.

These data demonstrate that TetraMenD is highly immunogenic in the adolescent population. The GMTs are essentially equivalent for each of the four sero groups for both vaccines, and the titers achieved are predictive of protection, and it appears that TetraMenD generates higher affinity antibody responses for each serogroup contained in the vaccine.

Study D

This study is a randomized, active-controlled study of healthy adults aged 18 to 55 years as of DO of a single dose of TetraMenD versus a single dose of Menomune^®. Blood serum is drawn on DO, prior to vaccination and D28 and analyzed.

Generally, the safety profile of TetraMenD is comparable to Menomune, specifically, the percentages reported for Solicited Local Reactions (Days 0-7), Solicited Systemic Reactions (Days 0-) Unsolicited Adverse Events (Days 0-28) Unsolicited Significant Adverse Events and SAEs (Day 29-Month 6) Serious Adverse Events (Day 0- Month 6) are all within 2-3% of the percentages reported for Menomune. The results of the Study are provided in the following Tables.

Distribution of SBA-BR Antibody Titers

Table D-I shows the frequency distribution of baseline and Day 28 SBA-BR antibody titers for each serogroup.

Table D-2 provides a summary of the Geometric Mean Titer (GMT) by Subject Age and Serogroup for TetraMenD.

Table D-3 shows the numbers and percentages of participants with a >4-fold rise in SBA-BR titer from baseline to Day 28 for the serogroups A, C, Y, and W-135. The numbers and percentages for the serogroups A, 1028/1278 (80.4%); C, 1131/1278 (88.5%); Y, 941/1278 (73.6%); and W-135, 1142/1278 (89.4%) in the TetraMenD group are comparable to those in the Menomune^® group, with serogroups A, 929/1099 (84.5%); C, 985/1099 (89.6%); Y, 872/1099 (79.3%); and W-135, 1036/1099 (94.3%).

Ill Table D-3: Number and Percentage of participants with a > 4-Fold Rise from Baseline in SBA-BR Titer by Serogroup^*

* Testing the null hypothesis H₀: PMenomune® - PϊetraMenD ≥O.IO VerSUS H_a: PMenomune® - PτetraMenD ^< 0.10

^ n/N: n = number of participants with a >4-fold rise from baseline titer / N = total number of participants in the per-protocol population.

* Pτ_etraM_enD: percentages of participants with a >4-fold rise from baseline in SBA-BR post- vaccination titer from the TetraMenD group.

^§ PMenom_une^®: percentages of participants with a >4-fold rise from baseline in SBA-BR post- vaccination titer from the Menomune^® group.

Frequency of SBA-BR Antibody Titers > 32

The proportion of participants with SBA-BR antibody titers > 32 at Day 28 after vaccination is summarized in Table D-4.

Table D-4: Percentage and Number of Participants with an SBA Antibody Titer > 32 at Day 28 Post-Vaccination (Per-protocol Population)

%: = n/N n: number of participants with a titer > 32 at Day 28 post-vaccination / N: total number of participants with a valid blood sample at Day 28 in this group.

Frequency of SBA-BR Antibody Titers > 128

The proportion of participants with SBA-BR antibody titers > 128 at Day 28 after vaccination is summarized in Table D-5.

Table D-5: Percentage and Number of Participants with an SBA Antibody Titer > 128 at Day 28 Post- Vaccination (Per-protocol Population)

%: n/N.

* n: number of participants with a titer > 128 at Day 28 post-vaccination.

* N: total number of participants with a valid blood sample at Day 28 in this group.

Table D-6 Analysis of Treatment Effect on GMTs Adjusted by Baseline Covariate: Response of Titer Difference from Day 0 to Day 28 (Per-protocol Population)*

Proportion of Participants with at least a 4-fold rise in SBA-BR Antibody Titers

Table D-7 shows the proportion of participants with a > 4-fold rise from baseline in Day 28 SBA antibody titers.

Table D-7: Number and Percentage of Participants with a > 4-Fold Rise in Day 28 SBA Antibody Titers From Baseline

^* %: n/N.

^ n: number of participants with > 4-fold rise from baseline titer.

* N: number of participants with blood draws within each serogroup.

Proportion of Participants with Undetectable Titers (< 8) at Day 0 Achieving a > 4- FoId Rise in Day 28 SBA-BR Antibody Titers

Table D-8 shows the proportion of participants with undetectable titers (< 8) at Day 0 Achieving a > 4-Fold Rise in Day 28 SBA-BR Antibody Titers. In both treatment groups and for all vaccine serogroups, most participants with an undetectable (< 8) SBA titer at baseline achieved a > 4-fold rise in Day 28 SBA titers. The proportions of participants with an SBA titer < 8 at Day 0 who had a > 4-fold rise from baseline to Day 28 ranged from 90.7% to 100.0% in the TetraMenD group and from 96.9% to 99.3% in the Menomune^® group.

Table D-8: Proportion of Participants with Undetectable Titers (<8) at Day 0 Achieving a >4-Fold Rise in Day 28 SBA-BR Antibody Titers

%: n/N. t n: number of participants with titers < 1 :8 at Day 0 and titers > 1 :32 at Day 28 within each serogroup *N: number of participants with titers < 1:8 at Day 0 within each serogroup.

Table D-9 shows the SBA GMTs at baseline and on Day 28 after vaccination and the fold rises in SBA GMTs.

Table D-9 : Summary of Geometric Mean of Antibody Titers (GMT) and Fold Rise of GMT by Serogroup (Per-protocol Population)

Titer or fold-rise, where fold rise = titer at Day 28 / Titer at Day 0 ^ N: number of participants with blood draws within each serogroup. Note: One

Participant did not have a second blood sample done

* 95% CI for the GMT is calculated based on an approximation to the normal distribution.

Twenty-eight to 56 days after receiving the study vaccination, TetraMenD, the majority of participants experience a > 4-fold rise in the SBA-BR antibody titer for each of the serogroups contained in the vaccine. The percentages of TetraMenD recipients obtaining a 4-fold rise in antibody titer are 80.4%, 88.5%, 73.6 %, and 89.4% for serogroups A, C, Y, and W-135, respectively. Higher pre- vaccination antibody levels are observed for serogroup Y than for C or W-135. This may be related to the fact that serogroup Y is currently the most common serogroup associated with invasive meningococcal disease in this age group in the U.S. and that natural exposure to this serogroup may be more common. Higher circulating antibody levels reflect recent natural exposure and may reduce the proportion of vaccine recipients exhibiting 4- fold or higher antibody responses. This appears to be the case for serogroup Y responses when compared to other serogroups. The 4-fold rise for serogroup Y is 73.6% compared with 88.5% for serogroup C and 89.4% for serogroup W-135. High pre-vaccination antibody levels are also observed for serogroup A. This may be the result of intermittent exposure over a prolonged period of time to several naturally occurring cross-reacting antigens.

To further evaluate the impact of pre-existing titers and to investigate the rate of seroconversion (as defined by the proportion of vaccine recipients who achieve a 4-fold rise in antibody titer when the pre-vaccination titer for any serogroup is< 1 :8), a separate analysis is performed on participants who had pre-vaccination antibody titers of < 1 :8 to any one of the 4 serogroups contained in the vaccine. A titer of < 1 :8 by the SBA assay using baby rabbit as the complement source is considered to represent an undetectable level of circulating antibody. When participants are evaluated using this criterion, it is observed that there is a 100% seroconversion rate for serogroup A, 99.4% for serogroup C, 96.5% for serogroup W-135, and 90.7% for serogroup Y after vaccination with TetraMenD.

As previously discussed in another Study herein, based on observations in military recruits, Goldschneider proposed that a minimum titer of ≥ 1 :4 using an SBA assay with a human complement source correlated with protection from invasive disease against Serogroup C. Baby rabbit complement is suggested as an alternative source, but meningococci appear to be more sensitive to the baby rabbit complement than human complement, resulting in higher measured antibody titers. Several authors have suggested that titers ≥ 1:128 using the baby rabbit complement assay are predictive of protection while titers of < 1 :8 are predictive of susceptibility at least for serogroup C. Although this level may be appropriate when evaluating polysaccharide vaccines, it may not be applicable for conjugate vaccines. Borrow suggested that, in subjects receiving a monovalent C conjugate vaccine who demonstrated post vaccination SBA titers between 8 and 64, the demonstration of a memory response using a reduced dose (lOμg) of a meningococcal polysaccharide vaccine given several months later showed that these individuals are also protected, having achieved an antibody level >1:128. When this criterion is applied to all the serogroups contained in the vaccine, the percentages of participants receiving TetraMenD who achieve a post- vaccination SBA-BR titer > 1:128 are 99.8%, 98.7%, 96.9%, and 97.1% for serogroups A, C, Y, and W-135, respectively.

Example 13 Study E Td Booster Study in Children Aged 10 to 18

This study compares the tetanus and diphtheria toxoid (Td) booster response in the group receiving the experimental tetravalent Meningococcal Diphtheria Conjugate vaccine, TetraMenD, concomitantly with Td to the response in the group receiving Td with placebo, as measured by the proportion of participants who have an acceptable response in their respective tetanus and diphtheria titers. An acceptable response is defined as, 28 days following vaccination, at least a 4-fold rise from baseline in participants with a predefined low pre- vaccination titer and at least a 2-fold rise from baseline in participants with a predefined high pre- vaccination titer.

To compare the antibody response for serogroups A, C, Y, and W-135 in TetraMenD when administrated concomitantly with Td to the response when TetraMenD is administrated 28 days following Td vaccine, as measured by the proportion of participants with at least a 4-fold rise in titer to each serogroup.

This is a randomized, modified double-blind, active-control multi-center trial, with a total of 1024 participants randomized to one of two treatment groups: A and B.

The age range of 11 to 17 years is chosen to capture those individuals who would normally receive Td vaccine as part of the routine childhood immunization schedule. In addition, this age range has been identified as high risk for development of invasive meningococcal disease and would most likely be candidates for vaccination with the meningococcal conjugate vaccine once licensed. In order to properly evaluate safety, a modified double-blind design using a placebo control is utilized. For the first visit, the vaccination nurse is unblinded and administered the vaccines in each arm according to protocol; TetraMenD (IM) or placebo in the right arm and Td in the left. For the second visit, each treatment group received the vaccine in the left arm. The evaluation nurse is blinded monitored local and systemic reactions and adverse events.

The age range of 11 to 17 years is chosen to capture those individuals who would normally receive Td vaccine as part of the routine childhood immunization schedule. In addition, this age range has been identified as high risk for development of invasive meningococcal disease and would most likely be candidates for vaccination with the meningococcal conjugate vaccine once licensed.

Blood specimens (at least 5 mL whole blood) for serologic testing are drawn on Day 0 prior to vaccination (baseline) and at Day 28 post- vaccination 1. There is a third blood draw for participants 28 days after visit 2. At each of these time points, sera are assayed for meningococcal serogroups A, C, Y, and W-135, anti-diphtheria antibody and anti-tetanus antibody.

To evaluate antibody function in recipients of TetraMenD, all available specimens are assayed for SBA using baby rabbit complement (SBA-BR) against each vaccine serogroup. One immunologic endpoint is the proportion of participants in each treatment group with a >4-fold rise in SBA-BR titer. Anti-diphtheria antibody levels are measured by the ability of the test sera to protect Vera cells from a diphtheria toxin challenge. Anti-tetanus antibody levels are measured by an indirect Enzyme Linked Immunosorbent Assay (ELISA).

This study compares the antibody responses to TetraMenD for serogroups A, C, Y, and W-135 as measured by the GMTs in participants from an earlier study, Study C, who receive one dose of TetraMenD to the responses in participants who receive TetraMenD administered concomitantly with Td and 28 days following Td vaccination. Serum specimens for serologic analysis are obtained at baseline (Day 0) prior to vaccination and at Day 28 (window: +28 days) and 6 months after vaccination. Antibody titers to tetanus toxoid and diphtheria toxoid (Td) vaccine are measured pre- and 28 days post vaccination.

SBA-BR antibody titers foriV. meningitidis serogroups A, C, Y, and W-135 are measured for all available serum specimens pre- and 28 days post vaccination. Overall, the safety profile of Group A and Group B are comparable. The results of this Study are summarized in the following Tables.

Table E-2 shows the numbers and proportions of participants with at least a 4-fold or 2- fold rise in tetanus and diphtheria antibody on Day 28.

Tetanus and Diphtheria Antibody Titers and SBA Antibody Titers for Serogroups A, C, Y, and W-135

Table E-2 shows the numbers and proportions of participants with at least a 4- fold or 2-fold rise in tetanus and diphtheria antibody on Day 28. The differences in the proportions are: 2.78 and -2.73 for tetanus and diptheria, respectively.

Table E-3 shows the numbers and proportions of participants with at least a 4-fold rise in antibody titer to serogroups A, C, Y, and W-135 on Day 28.

Table E-4 shows the number of participants with high diphtheria and tetanus titers at baseline and the number and proportion of participants with a 2-fold rise on Day 28.

Table E-5 shows the number of participants with low diphtheria and tetanus titers at baseline and the number and proportion of participants with a 4-fold rise on Day 28.

Table E-6 shows the number and proportion of participants with a titer >1.0 IU/ml in tetanus and diphtheria antibody on Day 28 following tetanus and diphtheria vaccination given concomitantly with TetraMenD or Placebo.

Table E-7 shows the geometric mean antibody titers(GMTs) for tetanus and diphtheria on Day 28 following tetanus and diphtheria vaccination (given concomitantly with TetraMenD or Placebo).

Table E-8 shows the geometric mean antibody titers(GMTs) for SBA-BR for serogroups A, C, Y, and W-135 on Day 28 post TetraMenD vaccination. The GMT ratios are 0.92, 0.42, 0.39, and 0.32 for serogroups A, C, Y, and W-135, respectively.

Table E-9 shows the geometric mean antibody titers(GMTs) for SBA-BR for serogroups A, C, Y, and W-135 on Day 28 post TetraMenD vaccination in the Td + TetraMenD, Placebo group and the corresponding results from study MTA02. The GMT ratios are 0.48, 0.38, 0.34, and 0.39 for serogroups A, C, Y, and W-135, respectively.

Table E- 10 shows the geometric mean antibody titers (GMTs) for SBA-BR for serogroups A, C, Y, and W-135 on Day 28 post TetraMenD vaccination in the Td + Placebo, TetraMenD group and the corresponding results from study MTA02. The GMT ratios are 0.53, 0.90, 0.99, and 1.05 for serogroups A, C, Y, and W- 135, respectively.

Table E-I l shows the distribution of SBA-BR antibody titers on Day 0 and Day 28 after the TetraMenD Vaccination by serogroup for the Per-Protocol Population (SBA- BR Titers <8 to 1024). While, Table E-12 shows the distribution of SBA-BR antibody titers on Day 0 and Day 28 after the TetraMenD Vaccination by serogroup for the Per- Protocol Population (SBA-BR Titers 2048 to 524288). Table E-13 provides additional data.

Related studies were conducted to access the safety and immunogenicity of MCV-4 vaccine concomitantly administered with licensed Td vaccine in healthy 10 -17 year old adolescents. Briefly, in a multicenter randomized trial healthy 10-17 year olds (mean age 12.9 years) received TetraMenD (MCV-4) + Td either concomitantly (n = 509), or at separate visits one month apart (n = 512). Safety assessments for the two vaccines, given separately and concomitantly, were collected on days 8 and 28 post-vaccination. Immune responses were assessed prior to and 4 weeks post- vaccination by antibody titers to diphtheria and tetanus, and serum bactericidal activity (SBA) to the meningococcal serogroups. The safety profile for subjects given Td alone was similar to that in subjects given Td + TetraMenD. Concomitant administration of Td + TetraMenD did not interfere with the immune response to either tetanus or diphtheria toxoids. SBA responses to the four sero groups are summarized in Table E- 14 shown below.

Table E-14: SBA response to the four serogroups

This study shows that the co-administration of Td and TetraMenD was safe and well tolerated in the test subjects. Concomitant administration of TetraMenD + Td does not adversely affect immune responses to tetanus and diphtheria toxoids. The immune responses to serogroups C, Y, and Wl 35 polysaccharide were enhanced when MCV-4 was co-administered with Td. The enhanced immune response observed in this study was surprising and unexpected.

Example 14 Comparison of Serum Bactericidal Assay with Baby Rabbit Complement and with Human Complement for N. Meningococcal Serogroups C, W-135 and Y

A subset of serum samples from Study A, Stage III, is used in this study to compare the results obtained with SBA-BR titers with SBA-HC titers for Serogroups C, W-135 and Y. Subjects enrolled into this trial are at least 2 years of age but not yet 11 years of age and each is randomly assigned to one of the two vaccine groups. Approximately 5 mL of whole blood is collected from each subject at baseline (prior to vaccination) and on Day 28 post-vaccination. Blood specimens from subjects are centrifuged within 4 hours of collection. The serum is taken off the clot, transferred into labeled cryotubes and stored in a temperature-monitored freezer at -20⁰C or colder. All samples that are used in the analysis in this report are from paired sera obtained from the first subjects enrolled in the clinical study and that are of sufficient serum volume to complete all planned testing. All samples are from 2 year old and 3 year old subjects with the exception of a single 4 year old. There are 2 subjects in the intent-to-treat category. One of these is from the TetraMenD vaccine group (Day 28 post- vaccination sample is collected on Day 24) and one is from the Menomune® vaccine group (Day 28 post-vaccination is collected on Day 9).

Baby rabbit complement (Pel-Freez^®, Clinical Systems LLC₅ Brown Deer, WI, product code 31038) is pre-screened for suitability in each of the serogroup specific assays. The criteria for suitability included an agreement with SBA-BR test results for a defined set of serum samples (within a 2-fold dilution) using a previously qualified lot of rabbit complement. Criteria for meeting predetermined titers for a reference serum and control samples are also used. Aliquots of 2.5 ml of the rabbit complement are stored at - 70°C or colder until ready for use. Aliquots are thawed once and used or discarded.

Serum from subjects enrolled is screened for anti-meningococcal polysaccharide IgG and IgM levels by ELISA and tested in the SBA-BR for functional antibodies to identify potential sources of complement for use in the SBA-H. Criteria established for selection of a human source of complement are the following; (1) lack of detectable antibody when assayed in the SBA-BR assay, (2) lack of intrinsic bactericidal activity when used as the complement source in the assay, (3) acceptable performance when used as a complement source with a panel of negative control, using sera with previous negative test results determined at an independent outside lab by Dr. Ray Borrow, and (4) acceptable reproducibility performance with a panel of 24 samples. Exogenous complement sources used in each of the serogroup specific assays are from different subjects. No complement sources are found to work for more than one serogroup. Also, the three complement sources used in the SBA assays are from a single donor per serogroup.

Serogroup C

Serum from several subjects with acceptably low ELISA values (less than 0.5 μ g/ml for both IgG and IgM) demonstrated bactericidal activity. Serogroup Y

The complement source for the serogroup Y SBA-H is selected from the subjects enrolled in the collection protocol. Serum from the source of complement displayed low- level serogroup Y IgG and IgM antibodies by ELISA and is negative in the SBA-BR assay. Serum from the source showed no intrinsic bactericidal activity when used in the SBA.

Serogroup W-135

The complement source for the serogroup W-135 SBA-H is selected from the subjects enrolled in the collection protocol. Serum from the source of complement displayed low-level serogroup W-135 IgG and IgM antibodies by ELISA and is negative in the SBA-BR assay. Serum from the source showed no intrinsic bactericidal activity when used in the SBA.

Serum Bactericidal Assays

Briefly, meningococcal sero groups C, Y, and W-135 strains are obtained from the Centers for Disease Control, Atlanta, GA (CDC). Target strains of bacteria are prepared for use in the assays from freshly thawed working seed lot vials of serogroups C, Y and W-135. Each vial is used to streak a Thayer Martin plate that is incubated overnight at 37°C ± 0.5⁰C in 5% CO₂. The following day, isolated colonies are harvested with a sterile swab and used to inoculate the entire surface of fresh Thayer Martin plates that had been warmed to ambient temperature. Plates are incubated for 4 h at 37°C ± 0.5°C in 5% CO₂ to obtain a light veil of confluent bacterial growth that is harvested with sterile swabs and suspended in Dulbecco's PBS + 0.1% Dextrose Buffer to a prescribed optical density (absorbance at 600 nm). A working solution with a prescribed concentration of bacteria is prepared in Dulbecco's PBS + 0.1% Dextrose Buffer, maintained at ambient temperature and used within 30 minutes of preparation.

Test samples are heat-treated at 56°C for 30 minutes to inactivate endogenous complement. To all wells of a 96-well microtiter plate, Dulbecco's PBS + 0.1% Dextrose Buffer is added, then test serum samples are dispensed in 2-fold serial dilutions across the plate leaving the final two columns of wells for complement and serum control wells. Columns on every plate included a complement column ([column 11] - serunV+complement) and a serum control column ([column 12] +serum/-complement).

Freshly thawed complement is mixed with the working concentration of bacteria and the mixture is dispensed into all but the serum control wells of the microtiter plates. Bacteria without added complement are dispensed into the serum control wells. The plates are covered and placed on a plate-shaker for 1 minute then removed to a 37°C ± 0.5°C CO₂ incubator. Incubation times are 90 minutes for the serogroup A assay plates and 60 minutes for the serogroups C₅ Y, and W-135 assay plates. After incubation, 100 μl of agarose overlay medium at 50°C ± 1 °C is carefully added to all wells avoiding air bubble formation. After a 10 minute period at ambient temperature with the microtiter plate lids ajar to avoid moisture formation, the plates are covered and removed to a dry (no added humidity) 5% CO₂ incubator at 37⁰C ± 0.5⁰C for 20 ± 4 h. After this incubation, the number of bacterial colonies per well is counted. The average number of colonies per well for the complement controls wells is calculated and divided in half to obtain the 50% survival at T₀.

The bactericidal titer of each unknown serum is expressed as the final reciprocal serum dilution yielding > 50% killing compared with the 50% survival value at To. The starting dilution for samples in the SBA-BR is a 1 :8 dilution. For the SBA-H, the starting dilution is lowered to a 1 :4 dilution as described in the original assays.

A comparison of the SBA-BR procedure for the serogroup A assay described herein with the Standardized SBA procedure (CDC) and with the SBA procedure as performed at the Manchester Public Health Laboratory Services, Meningococcal Reference Unit, Manchester, UK (PHLS) is provided as Table 14-1.

Table 14-1: Serum Bactericidal Assay Methods Comparison

A reference serum is obtained from Dr. George Carlone, CDC (CDC donor-R21654- 3430107) as lyophilized powder in vials, which are stored at 2°C to 8⁰C until used. When needed, vials are each rehydrated with 0.5 ml sterile water and stored at -8O⁰C to -4O⁰C as 100 μl working aliquots. The titer of the reference serum when reconstituted under these conditions is 1 :256 + 1 two-fold dilution in the standardized SBA-BR for serogroups A, C, Y, and W-135. Reference serum samples are run twice on different plates of the daily set of plates.

Group-specific rabbit antisera for serogroups A, C, Y, and W-135 are purchased from Difco as lyophilized powder in vials, that are stored at 2° to 8⁰C until used. When needed, each vial is rehydrated with 1 ml sterile water and stored at -8O⁰C to -4O⁰C as 50 μl aliquots for use as quality control samples in the SBA.

The results of the Serum Bactericidal Assay using baby rabbit complement (SBA- BR) provided herein for the determination of complement-mediated anti-polysaccharide bactericidal activity to Neisseria meningitidis serogroups C, Y, and W-135 in clinical serum samples is fully validated for precision, dilutability (linearity), specificity and limit of detection. The SBA-H assay (for Serogroup C) is repeated on five consecutive days with an identical set of serum samples to establish the precision of the assay.

Calculation of sensitivity and specificity of the SBA-BR

Titers obtained in the SBA-BR are classified as true positive (TP) (and false positive [FP]) and true negative (TN) (and false negative [FN]) using the SBA-H benchmark titers of 1 :4 and 1:8. Sensitivity is calculated as TP/(TP + FN) and specificity is calculated as TN/(TN + FP). The results of these calculations are expressed as percentages.

SBA Titer Distribution Comparison of SBA-BR versus SBA-H

The pre- and twenty-eight day post-immunization SBA titers are shown in Tables 1 and 4 for serogroup C, Tables 2 and 5 for serogroup Y, and Tables 3 and 6 for serogroup W- 135. Summarized in the following subsections is an analysis of the pre- and post-immunization SBA titers comparing the results obtained for the two sources of complement (BR versus H).

Serogroup C SBA Titer Distribution

Of the 101 pre-immunization serum samples, 63 are negative as defined by having a SBA-H titer of < 1 :4 and a SBA-BR titer < 1 :8. Twenty-seven of the pre- immunization samples are negative by SBA-H (< 1 :4) but are positive by SBA-BR (>= 1:8). The false positive rate using a SBA-BR cut off titer of < 1:8 is 30%. The false positive rate decreases at higher SBA-BR cut off titers to less than 20% at a cut off titer of 1 :128, and to less than 10% at a cut off titer of 1:512. Seven of the samples that are positive by SBA-H (>= 1 :4) are negative by SBA-BR (< 1 :8).

In the post-immunization sera, 48 samples are negative by SBA-H, and only 11 are negative by SBA-BR. Of the 11 samples that are negative by SBA-BR, 3 are positive by SBA-H. Seventeen of 51 post-immunization samples (32%) in the conjugate group are negative by SBA-H, but positive by SBA-BR (>= 1:8). For the polysaccharide group, 23 of 50 post-immunization samples (46%) are negative by SBA-H, but positive by SBA- BR titer (>= 1 :8). In terms of positive responses in the post-immunization sera, 90 of 101 US2005/046886

(89%) of samples are positive by SBA-BR (>= 1:8) but only 53 of 101 (52%) are positive by SBA-H (>= 1 :4). There is a notable difference in the positive response rates when comparing the SBA titers (BR versus H) obtained for the two vaccine groups. For the 51 post-immunization samples in the conjugate group, 33 of 51 (65%) are positive by SBA- H (>= 1 :4) and by SBA-BR (>= 1 :8). Agreement between the SBA titers (BR versus H) improves at a SBA-BR threshold titer of >= 1 :64 and higher. Of the 50 post- immunization samples in the polysaccharide group, 17 of 50 (34%) are positive by SBA- H (>= 1 :4) and by SBA-BR (>= 1 :8). Agreement between the SBA titers (BR versus H) improves at SBA-BR threshold titer >= 1 :512 and higher.

Serogroup Y SBA Titer Distribution

Unlike the serogroup C pre-immunization sera, only 9 of the serogroup Y pre- immunization samples are negative as defined by having an SBA-H titer < 1 :4 and a SBA-BR titer < 1 :8. Fifty-two of 61 pre-immunization samples are negative by SBA-H (< 1 :4) but positive by SBA-BR (>= 1:8). The false positive rate using a SBA-BR cut off titer of < 1 :8 is 85%. The false positive rate decreases at higher SBA-BR cut off titers to less than 15% at a cut off titer of 1 :256, and less than 2% at 1 :512. Two samples are positive by SBA-H (>= 1 :4) but negative by SBA-BR (< 1 :8).

There are no post-immunization serum samples that had a SBA-H titer < 1:4 and a SBA-BR titer that is < 1:8. Nineteen samples that are negative by SBA-H (< 1 :4) are positive by SBA-BR (>= 1 :8). As noted for serogroup C, there is a difference in the proportion of false negative results. In the conjugate group, 5 of 48 samples (9%) are negative by SBA-H (< 1 :4), but positive by SBA-BR. In the polysaccharide group, 14 of 52 samples (27%) are negative by SBA-H (< 1:4), but positive by SBA-BR.

There is good agreement between the two SBA titers (BR versus H) for positive responses in the post-immunization sera for serogroup Y. For the total set of 100 samples, all 100 post-immunization samples had SBA-BR titers >= 1:8, and 81 of 100 had SBA-H titers of >= 1 :4. As noted for the SBA responses for serogroup C, there is better correlation between the SBA titers (BR versus H) in the conjugate group compared to the SBA titers (BR versus H) obtained for the polysaccharide group. Of the 48 post- immunization samples in the conjugate group, 43 (90%) are positive by SBA-H (>= 1 :4) and by SBA-BR (>=1 :8). Only 1 of 48 samples had a SBA-BR titer less than 1 :32, and that sample is positive by SBA-H (>= 1:4). The agreement between the SBA titers (BR versus H) is not as good in the polysaccharide group. Only 38 of 52 (73%) had post- immunization SBA-H titers >= 1 :4 and a SBA-BR titer >=1 :8. Agreement between the SBA titers (BR versus H) in the post-immunization sera for the polysaccharide group improves at a SBA-BR titers of >= 1:128.

Serogroup W-135 SBA Titer Distribution

For serogroup W-135, 54 of 100 (54%) are negative where both the SBA-H titer is < 1 :4 and the SBA-BR titer is < 1 :8. Of the pre-immunization samples, 27 of 81 are negative by SBA-H (<' 1 :4) but positive by SBA-BR (>= 1 :8). The false positive rate using a SBA-BR cut off titer of < 1 :8 is 33%. The false positive rate decreases as higher SBA-BR cut off titers to less than 15% at a cut off titer of 1:128, and to less than 5% at a cut off titer of 1 :256. Eleven samples are positive by SBA-H (>— 1 :4) but are negative by SBA-BR (< 1:8).

Three post-immunization samples are negative by SBA-H (< 1 :4) and negative by SBA-BR (< 1:8). Thirty-nine post-immunization samples are negative by SBA-H (< 1 :4) but are positive by SBA-BR titer (>= 1:8). In the conjugate group, 11 of 47 samples (23%) are negative by SBA-H but positive by SBA-BR. In the polysaccharide group, 28 of 53 samples (53%) are negative by SBA-H but positive by SBA-BR.

The agreement between the post-immunization SBA-BR and SBA-H titers is comparable to serogroup C, but not as good compared to serogroup Y. As with both serogroup C and serogroup Y, there is a notable difference in the agreement between the two SBA titers (BR versus H) when comparing the two vaccine groups. The agreement between the two SBA titers (BR versus H) is better for the conjugate group compared to the polysaccharide group. In the post-immunization SBA titers for the conjugate group, 36 of 47 (77%) had an SBA-H titer of >= 1 :4 and all are positive by SBA-BR (>= 1:8). AU samples from the conjugate group had post vaccination SBA-BR titers >= 1 :32. For the post-immunization titers for the polysaccharide group, the correlation between the two titers is not as good, only 22 of 53 (42%) had an SBA-H titer >= 1:4 and 50 of 53 (94%) had a SBA-BR titer >= 1 :8. Table 1. Comparison of the SBA-BR titer in sera positive and negative by SBA-H for serogroup C

Table 2. Comparison of the SBA-BR titer in sera positive and negative by SBA-H for serogroup Y

Table 3. Comparison of the SBA-BR titer in sera positive and negative by SBA-H for serogroup W-135

Table 4. Summary of distribution of serogroup C titers measured by the SBA-BR and the SBA-H

Table 5. Summary of distribution of serogroup Y titers measured by the SBA-BR and the SBA-H

Total number of samples is 100.

Table 6. Summary of distribution of serogroup W-135 titers measured by the SBA- BR and the SBA-H

Total number of samples is 100.

Sensitivity and Specificity Comparison of the SBA-BR and SBA-H Titers SBA-BR titers are compared to the SBA-H protective titers of 1 :4 and 1 :8 in performing sensitivity and specificity assessments between the two sets of titers. Both pre- and post- immunization sera are used in this analysis. Using the SBA-H benchmark titers of 1 :4 and 1:8, specificity and sensitivity are calculated for all three serogroups and are summarized in Tables 7, 9 and 10. The analysis of sensitivity and specificity are discussed in turn for each serogroup. For serogroup C, the sensitivity is greater than 80% for SBA-BR threshold titers of 1:8, 1:16, and 1:32 relative to both a 1:4 and 1:8 SBA-H titer. However, the specificity at these SBA-BR titers is less than 60%. Specificity increased above 60% at a SBA-BR titer of 1 :64, and above 70% at a SBA-BR titer of 1 : 128. For these latter two SBA-BR titers, the specificity begins to drop off. At a SBA-BR threshold titer of 1 :64, the sensitivity is between 75 and 78%, but at a SBA-BR titer 1:128, sensitivity falls to between 62 and 65%. Specificity continues to improve at SBA-BR titers > 1 :64 ranging from 73% up to 83% for 1:128 and 1:256, respectively. However, sensitivity falls from 43% to less than 20%. The SBA-BR titer for serogroup C with the best balance between sensitivity and specificity falls in a range of SBA-BR titers between 1:32 and 1:128. The sensitivity and specificity results for serogroup C are found to be quite comparable to the results obtained by Santos GF, et al, 2001. Clin. Diagn. Lab. Immunol. 8:616-623, obtained by different set of serum samples and reagents (Table 8). With respect to Santos's results, the best balance of sensitivity and specificity is observed between the SBA-BR titers of 1:64 and 1:128 versus both the SBA-H titers of 1:4 and 1:8.

Table 7. Sensitivity and Specificity of the SBA-BR at Protective Titers in the SBA-H for Serogroup C

Table 8. Sensitivity and Specificity of the SBA-BR at Protective Titers in the SBA-H for Serogroup C as reported by Santos et al 2001. Clin. Diagn. Lab. Immunol. 8:616-623.

For serogroup Y, sensitivity is highest for SBA-BR threshold titers ranging from 1 :8 to 1 :64, but, as expected, drops off at higher SBA-BR threshold titers. Specificity results for serogroup Y start out much lower compared to the results for serogroup C, and do not reach a level of greater than 50% until a threshold SBA-BR titer of 1 :128. The SBA-BR titer that is best balanced for sensitivity and specificity for serogroup Y falls in a range between 1 :64 and 1 :256. At 1 :256, the sensitivity drops off to approximately 55%, but specificity increases from the mid-30% region to approximately 82-83%.

Table 9. Sensitivity and Specificity of the SBA-BR at Protective Titers in the SBA-H for Serogroup Y

For serogroup Wl 35, the values for sensitivity follow more closely to the values obtained for serogroup C, but the overall pattern is the same for all three serogroups. Sensitivity starts out high at a SBA-BR threshold titer of 1 :8 and drops off at titers >= 1 :128. Likewise, specificity starts out low at a SBA-BR titer of 1 :8 begins to level out at a titer of 1 :256. As observed for serogroup Y, the SBA-BR with the best balance between sensitivity and specificity for serogroup Wl 35 falls in a range between 1 :64 and 1 :256. 46886

Table 10. Sensitivity and Specificity of the SBA-BR at Protective Titers in the SBA- H for Serogroup W-135

Table 11 summarizes the proportion of four- fold rise in SBA titers using both baby rabbit complement or human complement for serogroups C, Y, and Wl 35 relative to the post-immunization SBA-BR titer. This analysis is performed separately on the conjugate group, TetraMenD, and the polysaccharide group, Menomune®, and both sets of analysis are included in Table 11. There are some observable differences in the four- four rise patterns comparing the bactericidal responses induced to the three serogroups and for the two vaccine groups. The response patterns are discussed in turn for each serogroup and for both vaccine groups.

Table 11. Stratified Comparative Ratios to a 4-Fold Rise in Meningococcal Polysaccharide Titers Determined by SBA-BR and SBA-H

The Table shows as a ratio (and percentage) the 4-fold rise in SBA titer as determined in each assay (from paired samples pre-immunization and 28-day post-immunization) stratified by SBA-BR titer, vaccine and serogroup.

For serogroup C, there is close agreement in the four-fold rise between SBA-BR versus SBA-H for the conjugate group. Within this vaccine group, there appears to be a trend that at low post-immunization titers, e.g. 1:32 — 1 : 128, the SBA-H four-fold rise is lagging behind the four-fold rise in SBA-BR. But, at post-immunization SBA-BR titers >= 1 :256, the number of subjects achieving a four-fold rise by SBA-H appears to be greater than the number of subjects achieving a four-fold rise by SBA-BR. This difference in the fold rises comparing the two complement sources is small, and may be due to higher pre-immunization SBA-BR titers that alter the percentage of achieving a four-fold rise by SBA-BR. For the polysaccharide group, the agreement between the four-fold rise between SBA-BR versus SBA-H is not as close as it is for the conjugate group. Also, there is no notable trend that the four-fold rise by SBA-H becomes more sensitive at higher post-immunization SBA-BR titers than is observed for the conjugate group.

For serogroup Y, the agreement between the four-fold rise by SBA-H and SBA- BR is very close for both vaccine groups. There are very few post-immunization SBA- BR titers less than 1:32 for either vaccine group compared to the post-immunization SBA-BR titers for serogroup C. For this reason, the proportion of subjects achieving a four-fold rise in both SBA-BR and SBA-H for serogroup Y occurs at a higher post- immunization SBA-BR titer compared to serogroup C. For serogroup Y, the proportion of four- fold rise increases to >= 50% at a post-immunization SBA-BR titer of 1 : 128 for the conjugate group, whereas for serogroup C the threshold SBA-BR titer is 1 :32 for the conjugate group.

The agreement between four-fold rise by SBA-H and SBA-BR for serogroup W135 is not as close compared to the other two serogroups. As observed for serogroup Y, there are a limited number of subjects with post-immunization SBA-BR titers less than 1:32 for either vaccine group. The agreement between the four-fold rise in SBA titers (BR versus H) occurs at SBA-BR titers >= 1:256. As noted for serogroup C, there is a difference in the proportion of four-fold rises (BR versus H) between the two vaccine groups that is less evident for serogroup Y. The agreement between the four-fold rise in the serogroup W135 SBA titers (BR versus H) is poorest in the polysaccharide group compared to the four-fold rise in SBA titers (BR versus H) by the polysaccharide vaccine for the two other serogroups.

The Serum Bactericidal Assay with baby rabbit complement (SBA-BR) is compared to the corresponding SBA using human complement (SBA-H) for measuring titers in serum samples from 2 to 3 year old subjects vaccinated with either the licensed quadrivalent meningococcal polysaccharide vaccine (Menomune®) or an experimental quadrivalent meningococcal polysaccharide conjugate vaccine (TetraMenD). Human complement sources for serogroups C, Y, and Wl 35 are identified and used to support this comparison in the SBA. The SBA results from this comparative study are analyzed by two approaches. In one approach the SBA-BR and SBA-H data obtained by measuring the pre- and post-immunization titers for both vaccine groups are pooled for analysis. In the second approach, the pre- and post-immunization titers from the two vaccine groups are analyzed separately. One of the goals of this study is to describe the SBA-BR serum titer that best correlates to a negative SBA-H serum titer. A second goal is to determine the titer using baby rabbit complement that best correlated with a positive titer using human complement in the assay as a correlate of protection for serogroup C and to extrapolate to the protective bactericidal titers for serogroups Y and Wl 35. Other laboratories have published results attempting to establish a protective threshold correlate for the SBA-BR for serogroup C. The results of this study will be compared to those published results. Lastly, the four-fold rise in SBA titers measured in pre- and post- immunization sera are compared for the two complement sources.

A correlation of a SBA titer to protection against disease has only been established for serogroup C. The SBA correlate of protection for serogroup C is determined using human complement in the SBA assay. For the other serogroups an assumption will be made that the SBA-H correlate of protection for serogroup C (SBA titer of 1 :4) applies for the other serogroups. Defining a SBA-BR titer(s) that correlates to the SBA titer of 1 :4 for serogroup C may differ between serogroups. In terms of defining a SBA-BR titer that best correlates to a negative SBA-H serum titer, a SBA-BR titer of <1 :8 is compared to SBA-H titer of <1 :4 in the pre- and post-immunization sera. The SBA-BR titer of < 1 :8 is used based in part on the results from the WHO/CDC study for comparing serogroup C SBA titers (BR versus H) and on the recent finding that a SBA-BR titer of < 1 :4 is linked to susceptibility to serogroup C disease in a University Outbreak in the United Kingdom (Jones, G.R., et al., J. Infect. Dis., 181:1172-1175 [2000]).

Based upon the SBA titers (BR versus H) generated in this study, the false positive rate for serogroup C using a SBA-BR cut off titer of < 1 :8 is 30%. Using higher SBA-BR cut off titers improves the false positive rate as follows: at >=1 : 16 the false positive rate decreases to 26%, at >= 1:32 the false positive rate decreases to 24%, at >= 1 :64, the false positive rate decreases to 22%, at >= 1:128 the false positive rate decreases to 18%, at >= 1 :256 the false positive rate decreases to 14%, and at >= 1 :512 the false positive rate decreases to 2%. Increasing the SBA-BR cut off titer does serve to improve the accuracy of defining a negative titer that corresponds to a SBA-H titer of < 1 :4, however the sensitivity in discriminating between a positive response and a negative response is much lower when using higher SBA-BR cut off titers. The data in this report showed that sensitivity of the SBA-BR is highest (81-84%) at cut off titers of 1 :8, 1 :16, or 1 :32. At SBA-BR titers greater than 1 :32, the sensitivity drops below 80%. However, specificity of the assay at cut off titers of 1:8, 1:16, and 1:32 is at aminimum, ranging from 51 to 58%. A balance is made between sensitivity, specificity and false positive rates in selecting a cut off titer that correlates to a negative titer in the human complement assay. The assignment of 1 :32 as the cut off titer for the SBA-BR would result in unnecessarily rejecting true positive responders. The results of this study indicate that a SBA-BR titer of >= 1:16 may be a more appropriate cut off titer. It is minimally 2- dilutions above the titer deemed protective based upon both the WHO/CDC study analysis (< 1 :8) and the U.K. University Outbreak analysis (< 1 :4).

Identification of the protective cut off titer in the assays for serogroups Wl 35 and Y are derived by assuming that bactericidal antibody protection is analogous with serogroup C disease and the bactericidal titers that correspond to a negative titer in the human complement assay. For serogroup Y, the false positive rate using a SBA-BR cut off titer of < 1 :8 is quite high at 85% compared to 30% for serogroup C. However, as with serogroup C, increasing the SBA-BR cut off titer lowers the false positive rate. At a SBA-BR cut off titer of 1:16 the false positive rate decreases to 84%, at 1:32 the false positive rate is 75%, at 1:64 the false positive rate is 61%, at 1:128 the false positive rate is 38%, at 1 :256 the false positive rate is 13%, and at 1 :512 the false positive rate is 2%. Even though the false positive rate for serogroup Y starts out much higher compared to serogroup C, at cut off titers of >= 1:128, the false positive rates for the two serogroup assays become quite comparable. Such high cut off titers, hoarer, may overstate the threshold titers for a positive response. Based upon the sensitivity and specificity analysis, sensitivity is maximized at SBA-BR cut off titers of 1 :8 to 1 :32, where sensitivity ranged from 95 to 98%. However, as with serogroup C, specificity at these SBA-BR titers is correspondingly low, ranging from 11 to 18%. At the next highest SBA-BR titer, 1:64, sensitivity decreases from 95% to 88%, but the specificity sharply increases to 35%. A cut off titer of < 1:64 in the serogroup Y assay appears to best correspond to a negative titer in the human complement assay.

For serogroup W135, the false positive rate at a SBA-BR cut off titer of < 1 :8 is 33%, which is similar to serogroup C. As noted for both serogroups C and Y at higher SBA-BR cut off titers, the false positive rate decreases to lower levels. At a SBA-BR cut off titer of 1:16 the false positive rate decreases to 32%, at 1:32 the false positive rate decreases to 28%, at 1 :64 the false positive rate decreases to 26%, at 1 : 128 the false positive rate decreases to 12%, at 1 :256 the false positive rate decreases to 4%, and at 1:512 the false positive rate is minimized at 0%. Sensitivity is highest at SBA-BR titers ranging from 1:8 to 1:64 (86% to 81%). Specificity, as expected, is lowest (46% to 52%) at this range of SBA-BR titers. Even though the false positive rates for serogroup Wl 35 start out much lower compared to serogroup Y, the cut off titer that best corresponds to a negative titer in the human complement assay is < 1 :64.

Having identified titers for the three serogroups that correspond to negative titers in the human complement assay, SBA-BR titers above these levels are analyzed for a threshold titer for consideration of a positive response. For serogroup C the threshold titer for a positive response is >= 1:16, for serogroup Y the threshold titer for a positive response is >= 1 :64, and for serogroup W135 the threshold titer for a positive response is >= 1 :64. It appears that a threshold SBA-BR titers of >= 1:128 for serogroup C provides good assurance that a protective titer is achieved, relative to either a SBA-H titer of 1 :4 or 1 :8 and correlates of efficacy SBA-H titer of 1 :4 for serogroup C. This threshold titer compares well with the analysis made on the WHO/CDC data set for serogroup C, and to the data set of Santos. As noted in both of these studies, titers >= 1 : 128 are highly predictive of protection, but SBA-BR titers less than 1:128 may also be protective. For the WHO/CDC and the Santos data set, SBA-BR titers of 1:8, 1:16, 1:32, 1:64 are referred to as the equivocal titers. Since SBA-BR titers less than 1:16 for the data set presented herein for serogroup C are regarded as negative, the equivocal titers for this analysis is 1 :16 to 1 :64, which is a subset of the other two studies. In all of these analyses, SBA-BR titers are being compared to SBA-H titers (1 :4 or 1 :8) that correlate to natural protection data that is collected in the 1960's.

More recently, efforts have been made to correlate the United Kingdom efficacy data for the monovalent C conjugates directly to a SBA-BR titer (Miller E, et al, 2002, Vaccine 20:S58-S67). In this analysis both SBA-BR titers of >= 1:8 and >= 1:128 are found to correlate well with the efficacy data that has been collected thus far for 15 to 17 year old subjects vaccinated with one dose of the monovalent C conjugates. However, when Miller and colleagues performed the same analysis for the toddler age group (12 to 30 months of age) they found very good agreement between SBA-BR titers of >= 1 :8 with efficacy, but at SBA-BR titers of >= 1 : 128 the agreement is not as close. Miller presented additional data at the 13^th International Pathogenic Neisseria Conference, September 1-6, 2002 in Oslo, Norway where the predicted efficacy of subjects achieving a SBA-BR titers >= 1 :64, one-month post vaccination, are outside the 95% confidence interval of the observed efficacy for this age group. These data help support the notion that SBA-BR titers in the equivocal region of 1 :8 to 1 :64 may lend assurance of protection. Based upon the analysis for this study, SBA-BR titers of 1 : 16 to 1 :64 may likewise lend assurance of protection against serogroup C.

The serogroup Y assay at a SBA-BR titer of 1:64 has a specificity of only 35%, but as the cut off titer is increased to 1:128 and 1:256, specificity increases to 59% and 84%, respectively. A threshold titer of >= 1 :256 provides good assurance of a protective titer in the human complement assay of 1 :4 and 1:8. However, sensitivity and specificity are better balanced at a threshold titer of 1 : 128 for serogroup Y. The range of SBA-BR titers of 1 :64 to 1 : 128 for serogroup Y represent the equivocal range of titers compared to the corresponding range of SBA-BR titers of 1 : 16 to 1 : 64 for serogroup C that have been correlated to the SBA-H protective titer.

The serogroup W- 135 assay at a SBA-BR titer of 1:64, has a specificity of 52%, but as the titer is increased to 1:128 and 1:256, specificity increases to 64 and 77%, respectively. As with serogroup Y, a threshold titer of >= 1 :256 provides good assurance of a protective titer in the human complement assay of 1 :4 and 1:8. Like serogroup Y, sensitivity and specificity are better balanced at a threshold titer of 1 : 128 for serogroup W135. The range of SBA-BR titers of 1 :64 to 1 : 128 for serogroup W135 represent the equivocal range compared to the range of SBA-BR titers of 1 : 16 to 1 : 64 for serogroup C that are correlated to the SBA-H protective titer in this study.

The four- fold rise in bactericidal titers are calculated for each serogroup and separately analyzed by vaccine group using both assays. In general, there is an indication that a higher four-fold rise in SBA titer (BR and H) is detected at higher post- immunization SBA-BR titers for all three serogroups. There are differences in the fourfold rises in SBA titers (BR vs. H) both by serogroup and by vaccine group. For serogroup C, four-fold rises in the assay with human complement appeared lower compared to titers in the assay with baby rabbit complement at low post-immunization SBA-BR titers. However at higher post-immunization SBA-BR titers, the four-fold rise in titer appeared higher in the assay with human complement. This pattern seems to suggest that at low post-immunization SBA-BR titers, the assay is less sensitive with human complement than it is with baby rabbit complement, but at high post- immunization SBA-BR titers, the opposite is true, that is, the assay with human complement becomes more sensitive. This pattern is not apparent when assaying samples from the polysaccharide vaccine group. In those samples the four-fold rise in titer appeared lower when using human complement in the assay. Although no explanation for this observation between sample type is apparent, it does suggest that the assay performed with human complement lacks sensitivity with serum samples containing low titers of bactericidal activity.

For serogroup Y, there is good agreement in the four-fold rises in SBA titers in comparing the two complement sources. The four-fold rises in SBA titers (BR and H) are slightly higher for the conjugate group compared to the polysaccharide group, but the difference is not as large as noted for serogroup C.

For serogroup Wl 35, the agreement between four-fold rise in SBA titers using human complement or baby rabbit complement in the assay for either vaccine group is not as good as compared to the results with the other two serogroup assays. The fourfold rise by SBA-BR titer is very good for both vaccine groups, but the proportion of four-fold rise titers by SBA-H is lower compared to the other two serogroups. The fourfold rise by SBA-H in the polysaccharide groups is quite low, and comparatively lower in the four-fold rise in SBA-H titers for the other two serogroups.

Four- fold rise in SBA titer using BR complement has been the benchmark for registration of the meningococcal polysaccharide vaccines. More recently, an effort has been made to link four-fold rise in SBA-BR titers to clinical efficacy from the post- registration surveillance data on the monovalent C conjugates in the United Kingdom (Borrow R, et al, 2001, Infect. Immun. 69:1568-1573). Based on this analysis the efficacy of the monovalent C conjugates in toddlers, ranging in age from 12 to 30 months, has been estimated at 88% (69 to 95%) within 16 months of the first dose. For this age group, the proportion of subjects achieving a four-fold rise in SBA-BR titer ranges from 89 to 100% following one dose of the monovalent C conjugate vaccines.

The SBA-BR provided herein provides bactericidal titer values that are comparable to the values obtained using human complement as the source of complement in the assay for serogroup C. Therefore, these SBA-BR titers are relevant to the original studies that established the surrogate for protective immunity to serogroup C meningococcal disease and support the extrapolation of the clinical results provided herein to protection, and the SBA-BR titers for serogroup C at are comparable to those reported from other laboratories. Performance of the SBA using human complement in the determination of the serogroup specific response to serogroup Y and serogroup W- 135 capsular polysaccharides, by analogy to the serogroup C model, support the relevance of the SBA-BR for determining bactericidal titers to sero groups Y and W-135.

Example 15 Concomitant administration of TetraMenD (Menomune™) and Typhim Vi^® in Adults

This example describes the results obtained in a phase 2b modified double- blinded, safety and immunogenicity study of TetraMenD (Menactra™) given alone or concomitantly with the licensed Typhim Vi^® vaccine in healthy 18 to 55 year olds in the US.

Typhim Vi^® is commercially available in the United States. Each 0.5ml dose of Typhim Vi^® contains 25 μg of purified Vi polysaccharide, isotonic phosphate buffered saline, and 0.25% phenol, which is added as a preservative. The Typhim Vi^® vaccine also contains residual polydimethylsiloxane or fatty acid ester antifoam. There were a total of 945 participants enrolled in this study. Briefly, study participants were randomized to either one of two treatment groups; Group A received Menactra™ and Typhim Vi^® concomitantly at Visit 1 and a saline placebo 28 days later at Visit 2; Group B received Typhim Vi^® and placebo at Visit 1 and Menactra™ 28 days later at Visit 2. A total of 469 participants were enrolled in Group A and 476 in Group B.

There were two primary immunogenicity objectives in this study. The first objective was to describe and compare the antibody responses after one dose of Typhim Vi^® in each of the study groups 28 days post- vaccination. Antibody responses to Typhim Vi^® in participants from Group A would be considered similar to the antibody responses to Typhim Vi^® from Group B if the difference in the proportion of recipients achieving an antibody level of > 1.0 mg/mL from Group B minus the proportion from Group A was less than 10%. A level of > l.Oug/mL of anti Vi antibodies was chosen as the primary serologic endpoint as this antibody level is considered protective. The second of the two primary objectives was to describe and compare the SBA antibody responses to each of the four serogroups in Menactra™ recipients 28 days post- vaccination. Participants were evenly distributed by age, sex and race between the two study groups. Sixty nine percent of participants were female with a median age of all subjects being 31 years. In Group A, 432 (92.1%) met the criteria for inclusion in the per protocol population and 439 (92.2%) for Group B.

1. Immunogenicity results

Twenty-eight days post- vaccination with Typhim Vi^® vaccine 81.6% of participants from Group A and 78.5% of participants from Group B achieved antibody levels > 1.0 ug/mL. A summary of results are shown in Table 1 below.

Table 1 Percent of Participants with Typhoid Vi Antibody Titer > 1.0 μg/mL on Day 28

Following Typhim Vi Vaccination (Per-Protocol Population)

The antibody response to Typhim Vi^® when administered concomitantly with Menactra™ is similar to the corresponding response when Typhim Vi^® is given alone, using two-sided Type I error rate α = 0.05 and a margin of 10% (Figure 1). These results were consistent with expectations based on the seroconversion rates reported in the literature when Typhim Vi^® is given alone or together with other common traveler vaccines including polysaccharide meningococcal and Hepatitis A vaccines. Figure 1 shows the results from these studies: testing with Typhim Vi Antibody Titer > 1.0 μg/mL on day 28 in adults, 95% CI of % difference (% Typhim Vi + Placebo, Menactra - % Typhim Vi + Menactra, Placebo).

Figure 2 shows the proportion of participants achieving a 4-fold rise in SBA antibody titer from Group A, when Menactra is given concomitantly with Typhim Vi^® vaccine, was comparable to that demonstrated in Group B, when Menactra was administered one month after a Typhim Vi vaccination (Per Protocol Population). The antibody response to Menactra™ when administered concomitantly with Typhim Vi^® is similar to the corresponding response when Menactra™ is given alone, using two-sided Type I error rate α = 0.05 and a margin of 10% (Figure 3).

2. GMTs

An observational objective was added to compare the GMT of the responses to Menactra™ in participants who were enrolled in a separate safety and immunogenicity trial in healthy adults to the GMT of Menactra recipients from both study groups in the present trial. The same criteria used in the secondary immunogenicity hypothesis were applied to this comparison. In each case, the GMT for each serogroup in safety and immunogenicity study (MT A09) participants compared favorably with that of Menactra™ recipients from either Group A or B in this trial. In no case did the upper 97.5% confidence limit (which is equivalent to the upper two-sided 95% confidence limit) of the ratio of the GMT exceed 2 for any serogroup In addition, over 95% of participants in both study groups demonstrate antibody titers above the level of protection for all 4 serogroups (Figure 4).

Study participants were monitored for immediate reactions for 30 minutes after vaccination, and for local and systemic reactogenicity during the 7 days following vaccination. Pre-specified adverse events include localized reactions (e.g., erythema, swelling, induration, and pain) and systemic symptoms (e.g., fever measured by oral temperature, headache, fatigue, chills, arthralgia, anorexia, vomiting, diarrhea, seizures, malaise, and rash), which were assessed after each vaccination. These events were recorded daily on a diary card, and also collected by study personnel through telephonic interview eight days after each vaccination. If rash was reported, the investigator was prompted to record additional details on a separate case report form. Other non-serious, unexpected adverse events were obtained by telephonic interview eight and twenty days after each vaccination. Serious adverse events were reported and recorded during the entire study duration. Studies show that the contaminant administration of Menactra™ with other vaccines, such as Typhim Vi^®, is safe and does not cause significantly increased rates of serious adverse reactions. These data demonstrate that Menactra™ is highly immunogenic in the adult population when given alone or concomitantly with the travel vaccine Typhim Vi^®. When these data are applied to the primary hypothesis, all criteria are met.

Example 16 Diphtheria Toxoid Conjugate Vaccine Versus a Nonrineningococcal Control Vaccine in Children Previously vaccinated With a Monovalent Meningococcal C Conjugate Vaccine

The present example describes a randomized, modified double-blind trial to evaluate the antibody responses to TetraMenD (Menactra), a tetravalent (A, C, Y, and W- 135) meningococcal diphtheria toxoid conjugate vaccine, in children 2 to < 5 years of age who had received a monovalent meningococcal C conjugate vaccine at least one year before enrollment into the trial. More particularly, the present examples describes a comparison of the SBA antibody response for serogroups C in subjects receiving TetraMenD to the sero group C antibody response in a control group of participants receiving a licensed Hib conjugate vaccine (Hiberix^®), as measured by the proportion of participants with at least a 4-fold rise in serogroup C titers 28 days following vaccination. All participants had previously received at least one dose of a monovalent meningococcal C conjugate vaccine at least one year before enrollment in the trial. The control group received a Hib conjugate vaccine rather than placebo in order to establish clinical benefit for these participants.

1. Inclusion and Exclusion Criteria

A participant had to meet all of the following criteria to be enrolled in the trial: 1) participant was healthy, as determined by medical history and physical examination; 2) participant was 2 years to < 5 years of age at the time of vaccination; 3) at least one year from primary vaccination with a monovalent meningococcal C conjugate vaccine had elapsed; and 4) parent/guardian had signed an Ethics Committee-approved informed consent form. Potential participants were excluded from the trial for any of the following reasons: 1) had a serious chronic disease (e.g., cardiac, renal, neurologic, metabolic, rheumatologic, etc.); 2) known or suspected impairment of immunologic function; 3) acute medical illness with or without fever within the last 72 hours or an axillary temperature > 37.5°C at the time of inclusion; 4) history of documented invasive meningococcal disease; 5) administration of immune globulin or other blood products within the last three months, or injected or oral corticosteroids or other immunomodulatory therapy within six weeks of the study vaccine (individuals on a tapering dose schedule of oral steroids lasting < 7 days could be included in the trial as long as they had not received more than one course within the last two weeks prior to enrollment); 6) antibiotic therapy within the 72 hours prior to vaccination or 72 hours prior to drawing any blood sample; 7) received any vaccine in the 28-day period prior to enrollment, or scheduled to receive any vaccine during enrollment in the trial; 8) received a meningococcal C conjugate vaccine within one year prior to enrollment; 9) suspected or known hypersensitivity to any of the vaccine components; 10) unable to attend all of the scheduled visits or comply with the study procedures; 11) enrolled in another clinical trial; and 12) any condition which, in the opinion of the investigator, would have posed a health risk to the participant or interfered with the evaluation of the vaccine.

Prior to vaccination, antipyretics or analgesics (e.g., acetaminophen, ibuprofen, etc.) were not to be given routinely. Analgesic/antipyretic use on the day of and/or prior to vaccination was documented. During the 8-day observation period following vaccination, if a participant experienced an elevated temperature or complained of pain or discomfort, a standardized dose of an antipyretic/analgesic was permitted. The concomitant use during the 8-day observation period of any other medications was documented.

2. Administered Compositions A. TetraMenD

The TetraMenD composition administered in this trial is composed of four distinct meningococcal capsular polysaccharides, serogroups A, C, Y, and W 135, which are covalently attached to diphtheria toxoid protein. The vaccine was formulated in sterile, pyrogen-free, phosphate-buffered physiological saline, with no preservative. The vaccine was prepared as a clear to slightly turbid liquid in single dose (0.5 mL) pre filled syringes. The purified meningococcal capsular polysaccharide used to prepare TetraMenD was the same material used to manufacture the licensed polysaccharide vaccine, Menomune^®- A/C/Y/W 135 at Aventis Pasteur Inc., Swiftwater, Pennsylvania, USA. The diphtheria toxoid protein used was a thimerosal-free intermediate taken from the U.S. -licensed process for preparing the intermediate of other licensed diphtheria toxoid-containing vaccines at Aventis Pasteur Inc., Swiftwater, Pennsylvania, U.S.A. Each 0.5 mL dose of TetraMenD contains 16 μg of meningococcal polysaccharide antigen (4 μg of each group specific polysaccharide antigen [A, C, Y, and W 135]), conjugated to 48 μg of diphtheria toxoid protein. Inactive ingredients in each 0.5 mL dose of TetraMenD include 0.6 mg sodium phosphate, 4.4 mg sodium chloride, and sterile pyrogen-free water for injection.

B. Conjugated Hib Vaccine (Hiberix^®)

Hiberix^® is provided as a lyophilized vaccine product. After reconstitution with diluent, each 0.5 mL dose of Hiberix^® consists of 10 μg of purified polyribosyl-ribitol- phosphate (PRP) capsular polysaccharide of Hib covalently bound to approximately 30 μg of tetanus toxoid. Hiberix^® diluent contains sodium chloride and water for injections (as sterile saline solution [0.9%]). The Hiberix^® vaccine was prepared and reconstituted prior to administration according to the manufacture's instructions.

3. Trial Design and Dose Administration

A total of 103 participants were actually enrolled in this study: 52 participants received TetraMenD, and 51 received the Hiberix^® conjugate vaccine. Eligible participants were randomized to receive a single injection of either TetraMenD or the Hib conjugate vaccine. No concomitant vaccinations were administered in this trial.

Briefly, at visit 1, TetraMenD was administered as a single 0.5 mL dose intramuscularly into the deltoid of the arm of choice using a pre-filled syringe with a 25 mm, 25-gauge needle. Alternatively, at visit 1, Hiberix^® vaccine was administered as a single 0.5 mL dose intramuscularly into the deltoid of the arm of choice using a syringe with a 25 mm, 25-gauge needle. The site of injection was cleansed with an appropriate antiseptic prior to injection. Only the specified dose (0.5 mL) was given. Care was taken to avoid administering the injection into or near blood vessels and nerves. After aspiration, if blood or any suspicious discoloration appeared in the syringe, the vaccine was discarded, and the procedures were repeated using a new dose of vaccine administered at a different site.

Several safety parameters were assessed during the trial. During the 30-minute period following vaccination, each participant was monitored for immediate reactions. On the evening of vaccination and for each of the 7 subsequent days, parents/legal guardians recorded the presence and severity of solicited local and systemic reactions and any other unsolicited adverse events that according to the parent/legal guardian represented a change in the health status of the participant. During the 28-day period following vaccination, all unsolicited adverse events and serious adverse events were identified (by interview and chart review) and recorded.

Blood specimens (5 mL whole blood) for serologic testing were drawn from each participant on Day 0 prior to vaccination (baseline) and on Day 28 post- vaccination. At the Day 0 and Day 28 time points, sera were collected and assayed for serum bactericidal activity and IgG antibodies against meningococcal sero groups A, C, Y, and W 135, as described herein.

Each blood specimen was centrifuged within 4 hours of collection. The serum was then separated into 3 cryotubes and labeled with the protocol number, participant number and initials, and sample number (V-I or V-2). The primary sample had to have at least 1.0 mL of serum. The remaining serum in some cases was split between other retention aliquots. If there was less than 1.0 mL of serum, then all of the serum was placed in the primary tube, and not split among the three cryotubes. The serum specimens were stored in a non-frost-free, temperature-monitored freezer maintained at 20°C or less.

The following Table presents a summary of participant disposition by administered composition.

Table 1 Participant Disposition (All Participants)

Percentages are based on the number of participants in the safety population in each vaccine group.

Study populations are defined in Section Error! Reference source not found.. ITT: intent-to-treat; PP: per-protocol.

Protocol violators are counted only once according to their first violation.

Table 2, presented below, summarizes the demographic characteristics of the participants. The baseline distributions of participants by sex, age, and race were not statistically different between the 2 administration groups (p-values: 0.326, 0.696, and 0.720, respectively). Participants ranged in age from 24 to 57 months (mean age: 37.3 months). There were 51.5% males and 48.5% females. The majority of participants were either Caucasian (46.6%) or Asian (41.7%).

Table 2 Participant Demographics (All Participants)

Table 2 Participant Demographics (All Participants)

* p-values were calculated using Fisher's Exact Test for sex and race, and an F-test in an ANOVA for age. ^t n: number of participants in the vaccine group satisfying the condition. The denominator for the percentage is the total number of randomized participants in each vaccine group.

4. Immunologic Laboratory Methods

The first criterion for evaluating immunogenicity was the SBA-BR antibody responses for sero groups A, C, Y, and W- 135 at baseline (pre- vaccination) and at Day 28 after vaccination. This criteria included: 1) the proportion of participants with a > 4 fold rise in SBA-BR titer from baseline to Day 28 (serogroups A, Y, and W- 135); 2) the distribution of titers pre- vaccination and 28 days post- vaccination (all four serogroups); 3) the reverse cumulative distribution curves pre- and 28 days post-vaccination (all four serogroups); and 4) the GMTs pre- and 28 days post-vaccination and the geometric mean fold rises from baseline to Day 28 (all four serogroups). The second criterion for evaluating immunogenicity was the total IgG antibody responses for serogroups A, C, Y, and W-135 at baseline (pre- vaccination) and at Day 28 after vaccination (e.g., measured using an indirect IgG ELISA). This included the GMCs pre- vaccination and 28 days post-vaccination and the geometric mean fold rises from baseline to Day 28. All immunologic evaluations were conducted for each serogroups (e.g., A, C, Y, and W-135) separately.

The proportions of participants with a > 4 fold rise in SBA-BR titers from baseline to Day 28 were calculated, as well as the 95% CI (using normal approximation) (Agresti A., Chap. 3.4 Large-Sample Confidence Intervals. In: Categorical Data Analysis. New York: John Wiley & Sons; 1990. pp. 54-59) of these proportions. When computing the fold rises, baseline pre- vaccination values reported as < 8 were translated to 8, while post-vaccination values reported as < 8 were translated to 4 for analysis purposes.

Reverse cumulative distribution curves were plotted at Days 0 and 28 for each vaccine group and serogroup. The reverse cumulative distribution curves show the percentage of participants with a titer greater than or equal to the given titer on the x-axis.

SBA-BR GMTs at Days 0 and 28 and the 95% CIs for the GMTs were calculated as log base 2 titers assuming that the titers follow the lognormal distribution (Smith W., Mean. In: Armitage P, Colton T, editors. Encyclopedia of Biostatistics, Vol. 3., Chichester, UK: John Wiley & Sons; 1998./>p. 2487-2488; and Ratnaparkhi M., Lognormal Distribution. In: Armitage P, Colton T, eds. Encyclopedia of Biostatistics, Vol. 3., Chichester (UK): John Wiley & Sons; 1998. pp. 2349-2351). When computing GMTs, any value reported as < 8 was converted to 4 for analysis purposes. The geometric means of the fold rises in SBA-BR titers from Day 0 to Day 28 and the 95% CIs for the geometric means were calculated.

IgG GMCs at Days 0 and 28 and the 95% CIs for the GMCs were calculated as log base 2 concentrations assuming that the concentrations follow the lognormal distribution.

A. Anti-Meningococcal Antibody Determination by a Serum Bactericidal Assay Using Baby Rabbit Complement

The SBA-BR is an in vitro method using baby rabbit (BR) complement that measures the antibody-mediated, complement-dependent killing of target bacteria for the purpose of measuring the immunological response to the capsular polysaccharides of N. meningitidis sero groups A, C, Y, or W- 135.

Functional antibody to meningococcal sero groups A, C, Y, and W- 135 was measured by the Clinical Immunology Platform, Swiftwater, PA, USA, with a serum bactericidal assay using BR complement. Briefly, serogroup specific bacterial seeds were streaked onto Thayer-Martin plates and incubated overnight. Isolated colonies from the overnight plates were harvested and the bacteria were swabbed onto Thayer-Martin plates. These plates were then incubated to obtain a light veil of confluent bacterial growth. Sera were heat-treated according to inactivate endogenous complement.

Dulbecco's phosphate-buffered saline (PBS) was dispensed into the wells of a 96- well microtiter plate. Heat-inactivated serum samples, reference antisera, or serogroup- specific antibodies (as controls), were then dispensed and diluted twofold across the plate. There was also a serum control and complement control associated with each sample. The serogroup-specific meningococcal bacteria along with baby rabbit complement and the serum dilutions were allowed to incubate.

Bacterial cells were harvested from the Thayer-Martin plate and suspended in buffer. A working dilution of bacterial cells was prepared and mixed with an equal volume of complement. This bacterial suspension was then dispensed into the 96-well microtiter plates, covered, and placed on a plate shaker for 1 min. The plates were removed to a 37°C CO₂ incubator and incubated for 90 min for serogroup A and 60 min for serogroups C, Y, and W- 135.

After incubation, an agar overlay was added to each well. The plates were covered and incubated overnight at 37°C with 5% CO₂. The next day the bacterial colonies in the wells were counted. The bactericidal titer of each unknown serum was expressed as the final reciprocal serum dilution yielding > 50% killing compared with the TO colony-forming units (cfu) of the mean of the complement control wells. The serogroup-specific antibody controls were used to identify the serogroup being tested. The limit of detection for this assay was a titer of eight.

The reference serum was obtained from the CDC (donor R21654-3430107) and was stored at -70⁰C. Commercially available serogroup-specific antibodies for A, C, Y, and W-135 were used as quality controls. The serogroup-specific antibodies were received refrigerated at 5⁰C and were rehydrated with ImL sterile water, aliquoted, and stored at -70°C.

B. Anti-Meningococcal IgG Antibody Determination

In general, the ELISA method uses specific serum antibodies to bind a target antigen attached to a solid substrate. A secondary antibody, raised against human IgG, is added to complete the antigen-antibody-antibody complex. This secondary antibody is conjugated to an enzyme that catalyses a chromogenic reaction after addition of an appropriate substrate. The ELISA reader's software plots the optical density (OD) and constructs a standard curve for the reference serum from which the test serum antibody titer can be calculated, with assigned unitage using a 4-parameter logistic curve (4PL) method.

Total IgG antibody activity for anti-meningococcal antibody to serogroups A, C, Y, and W-135 was measured by Clinical Immunology Platform, Swiftwater, PA, USA, using an indirect ELISA. In brief, clinical, control, or reference sera were incubated on microtiter plates precoated with excess serogroup-specific antigen (coating adsorption was enhanced with methylated human serum albumin). The plates were then incubated at room temperature with a peroxidase-labeled mouse anti-human IgG specific antibody. Tetramethylbenzidine (TMB) was added to generate a chromogenic product. Plates were monitored at 650 run until the top reference wells reached an OD in the range between 0.6 and 0.7. Once the range was attained, sulfuric acid stopping solution was added to each well. The resulting OD was read on an ELISA plate reader. The anti- meningococcal polysaccharide IgG level of the test sera was calculated through comparison to reference sera (Lot CDC 1992) with an assigned value using a 4-parameter logistic (4PL) curve method. Results were reported in mg/ml.

The primary reference serum was a commercially available pooled human antiserum: CDC Lot 1992 (current NIBSC code 99/706). The primary reference, received in lyophilized state, was stored at 2°C to 8⁰C upon receipt.

The serum used for quality control serum was Aventis Pasteur human serum pool AvP Lot 10OB 189 A. Vials were stored at -8O⁰C to -40⁰C. Working aliquots were stored at -30⁰C to -1O⁰C.

5. Statistical Analysis

The statistical analysis was performed with SAS^® software version 8.2. In general, all data collected are presented in summary tables and/or data listings. Categorical variables were presented by frequency distributions (number and proportion [with its 95% CI] of participants in each category). Continuous variables were presented by summary statistics (number of observations [n], mean, standard deviation [SD], median, and minimum and maximum values). The trial had at least an 85% power to reject the hypothesis that the true difference between the proportions of participants with a > 4 fold rise in serogroup C antibody titer in the TetraMenD group and in the Hib conjugate vaccine group is < 50%. The calculation was based on a one-sided test with a type I error rate of 0.05 and on the assumption that the true proportion is at least 85% in the TetraMenD group and less than 10% in the Hib conjugate vaccine group.

The primary endpoint is the proportion of participants with at least a 4-fold rise in antibody titers to serogroup C from baseline to Day 28 after vaccination in the TetraMenD group compared to the corresponding proportion in the control group. In support of the primary hypothesis, a one-sided 95% confidence interval was constructed around the observed proportion in the TetraMenD group minus the corresponding proportion in the control group. The primary hypothesis was to be supported by the data if the lower limit of the one-sided 95% confidence interval of the difference was > 0.50. This was equivalent to testing the null hypothesis that the proportion of participants with a > 4 fold rise in antibody titers to serogroup C in the TetraMenD group minus the corresponding proportion in the control group was < 0.50 (Ho". ^T_etraM_enD -/Ηi_be_πx ≤ 0.50), versus the alternative hypothesis that the difference is > 0.50 (H₁: /?τetraMenD -/Ηiberix > 0.50), using a one-sided test with a type I error rate of 0.05. If the primary null hypothesis was rejected, it would be concluded that the proportion of participants with a > 4 fold rise in antibody titers to serogroup C in the TetraMenD group was more than 50% higher than the proportion in the control group.

A participant was eligible for the per-protocol population for immunogenicity if the participant: 1) met the above-mentioned criteria for inclusion in the trial; 2) received the assigned vaccine; and 3) had Blood Sample 1 drawn on Day 0 (before vaccination) and Blood Sample 2 at least 28 but not more than 35 days after vaccination.

However, for analysis purposes, participants without any valid serology results were excluded from the per-protocol analyses. In this context, "valid" refers to the evaluability of the sera and/or results. Participants excluded from the per-protocol immunogenicity analyses include those for whom sera was lost or for whom an insufficient quantity of serum was available for analysis. Participants with protocol violations that did not impact their immunologic response or their evaluability for immunogenicity were included in the per-protocol population. The per-protocol population was used for all immunogenicity analyses.

The intent-to-treat population for immunogenicity consisted of all participants who received one injection of either TetraMenD or the Hib conjugate vaccine, and had at least one valid serology result needed for analysis. The same immunogenicity analyses were performed on the per-protocol and intent-to-treat populations.

The safety population consisted of all participants who received one injection of either TetraMenD or the Hib conjugate vaccine and had any safety information available. The safety analysis was performed using the safety population. If the safety data were not available from any given participant, the data from that particular participant's reaction were reported as missing.

6. Immunogenicity Results

Summary Table 3 shows the number and percentage of participants with a > 4 fold rise in SBA BR antibody titers from baseline to Day 28 for serogroups A, C, Y, and W 135. Twenty-eight days after vaccination, the majority of TetraMenD recipients experienced a > 4 fold rise in SBA BR antibody titers from baseline, while a minority of Hiberix^® recipients achieved this result.

Table 3 Number and Percentage of Participants with a > 4-Fold Rise in SBA-BR Antibody Titers From Baseline to Day 28 (Per-Protocol Population)

TetraMenD Hiberix^® serogroup n/N* %⁺ 95% CI n/N* %^f 95% CI

A 43/44 97.73 87.98, 99.94 11/36 30.56 16.35, 48.11

C 41/44 93.18 81.34, 98.57 2/36 5.56 0.68, 18.66

Y 35/44 79.55 64.70, 90.20 1/36 2.78 0.07, 14.53

W-135 43/44 97.73 87.98, 99.94 8/36 22.22 10.12, 39.15

* n: number of participants with a > 4-fold rise from baseline titer. N: number of participants with valid serology data.

⁺ %: n/N expressed as a percentage.

Table 4 shows the number and percentage of participants with a > 4 fold rise in SBA-BR antibody titers from baseline to Day 28 for serogroup C. This percentage is much higher in the TetraMenD group (93.18%) than in the Hiberix® group (5.56%). The difference in percentages (pτet_πιMenD -puibeήx®) is 87.63%, and the lower limit of the onesided 95% confidence interval of the difference is 78.77%, which is above 50%. Based on these results, it can be concluded that the percentage of per-protocol participants in the TetraMenD group with a > 4 fold rise in SBA BR titers for serogroup C minus the corresponding percentage in the Hiberix^® group is greater than 50%, using a one-sided test with a type I error rate of 0.05.

Table 4 Number and Percentage of Participants with a > 4-Fold Rise in Serogroup C SBA-BR Antibody Titers from Baseline to Day 28, Testing of the Primary Hypothesis (Per-protocol Population)

* n: number of participants with a > 4-fold rise in serogroup C SBA-BR titer from baseline to Day 28. N: total number of participants with valid serology data for serogroup C.

* P_\. percentage of participants with a > 4-fold rise in serogroup C SBA-BR titer from baseline to Day 28 in the TetraMenD group.

* p₂- percentage of participants with a > 4-fold rise in serogroup C SBA-BR titer from baseline to Day 28 in the Hiberix^® group.

Table 5 shows the SBA-BR GMTs at baseline and on Day 28 after vaccination, as well as the geometric mean fold rises in SBA BR titers from baseline to Day 28. In the TetraMenD group, there was a significant increase in SBA-BR antibody titers between Day 0 and Day 28; the geometric mean fold rises in SBA-BR titers were 70.34 for serogroup A, 136.33 for serogroup C, 16.51 for serogroup Y, and 159.59 for serogroup W 135. In the Hiberix^® group, there was no or little increase in SBA-BR antibody titers between Day 0 and Day 28. Table 5 SBA-BR Geometric Mean Titers at Baseline and Day 28, and Geometric Mean Fold Rises in SBA-BR Titers from Baseline to Day 28 (Per-Protocol Population)

* N: number of participants with valid serology data. ^f Geometric mean fold rise = = geometric mean of [titer at Day 28/Titer at Day 0]

Table 6 shows the frequency distribution of baseline and Day 28 SBA-BR antibody titers for each serogroup.

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O

* N_f number of TetraMenD recipients with valid serology data at the indicated timepomts, N_H number of Hibeπx recipients with valid serology data at the indicated timepomts n number oi participants with the indicated titer, % n/N expressed as a percentage

Figures 5, 6, 7, and 8, respectively, present the Day 0 and Day 28 reverse cumulative Lstribution curves of SBA BR antibody titers for serogroups A, C, Y, and W 135.

Table 7 shows the IgG GMCs at baseline and on Day 28 after vaccination as well as the eometric mean fold rises in IgG concentrations from baseline to Day 28. In the TetraMenD roup, there was an increase in IgG antibody titers between Day 0 and Day 28; the geometric lean fold rises in IgG titers were 26.74 for serogroup A, 15.86 for serogroup C, 12.13 for erogroup Y, and 22.00 for serogroup W-135. In the Hiberix^® group, there was no or little icrease in IgG antibody titers between Day 0 and Day 28.

Table 7 IgG Geometric Mean Concentrations at Baseline and Day 28, and Geometric Mean Fold Rises in IgG Concentrations from Baseline to Day 28 (Per-Protocol Population)

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* N: number of participants with valid serology data. The quantity of serum remaining from the sample provided by Participant 355 (Hiberix group) at Visit 2 was not sufficient to perform the Day 28 IgG testing. ^f Geometric mean fold rise = geometric mean of [(concentration at Day 28)/(concentration at Day O)]

Immunogenicity Summary

Prior to vaccination, the SBA and IgG antibody levels were similar in both the TetraMenD and the Hib conjugate vaccine groups. Twenty-eight days after TetraMenD administration, there was a marked increase in SBA and IgG antibody levels for all the serogroups contained in the composition (Tables 5 and 7). In particular, the serogroup C responses were consistent with a memory response to that antigen. For each serogroup, the proportion of TetraMenD recipients achieving a > 4 fold rise in antibody titers (Table 3) was similar to that reported in a large trial in 2- to 10-year-olds who received a single dose of the investigational vaccine. (Pichichero M. E., et al, A Comparative Trial of the Safety and Immunogenicity of Quadrivalent (A, C, Y, W- 135) Meningococcal Diphtheria Conjugate Vaccine (MCV-4) Versus Quadrivalent Polysaccharide Vaccine (Menomune^®, PS) in Children 2-10 Years of Age. Abstracts of the 43rd Annual ICAAC, Chicago, Illinois. American Society for Microbiology, p. 286). This proportion was 79.6% for serogroup Y, compared with 97.7% for serogroup A, 93.2% for serogroup C, and 97.7% for serogroup W-135 (Table 3). The highest pre-vaccination antibody levels were observed for serogroup Y (Table 5). This may be due to natural exposure to this serogroup, which maybe more common than previously believed. Higher circulating antibody levels reflect recent natural exposure and may reduce the proportion of vaccine recipients achieving a > 4-fold rise in antibody levels. Higher pre- vaccination antibody levels were also observed for serogroup A, compared to serogroups C or W-135. This is probably the result of intermittent exposure over a prolonged period of time to several naturally occurring cross-reacting antigens.

There was no significant difference between the pre- and post-meningococcal antibody responses in the control group who received the Hib vaccine. The difference between the TetraMenD and Hib vaccine groups in the proportion of participants with a > 4 fold rise in SBA-BR titers was > 50% for each of the four serogroups (Table 4). In the control group, the proportion of participants achieving a > 4-fold rise in SBA-BR titers was higher for serogroups A and W-135 than for serogroup C or Y. This may have resulted from natural exposure to serogroup-specific antigens circulating in this population during the conduct of the study. A large proportion of the participants were recruited from the Muslim community in London, where clinical cases of serogroup W-135 meningococcal disease have been identified. This increased risk has been associated with pilgrimage to the Hajj. Although assay results are known to differ between laboratories, a similar trend was observed in the SBA and IgG antibody responses following the administration of a booster dose of a serogroup C meningococcal conjugate vaccine in children who were primed in infancy with a monovalent conjugate vaccine. (McVernon J., et al, Safety and immunogenicity of meningococcus serogroup C conjugate vaccine administered as a primary or booster vaccination to healthy four-year-old children, Ped. Infect. Dis. J., 21(8):747-753 [2002]).

In the TetraMenD group, the magnitude of the post- vaccination GMTs to all four serogroups (Table 5) demonstrates that the vaccine is highly immunogenic in this population. All TetraMenD recipients achieved levels of antibody consistent with protection. (Balmer P. and Borrow R., Serologic correlates of protection for evaluating the response to meningococcal vaccines, Expert Rev. Vaccines. 3(l):77-87 [2004]).

7. Overall Safety Profile

Table 8 presents an overall summary of participants with immediate reactions within 30 minutes, solicited local and systemic reactions within 7 days after vaccination, and unsolicited adverse events and serious adverse events during the entire study period (Days 0-28 after vaccination).

Table 8 Overall Participant Safety Profile (Safety Population)

TetraMenD Hiberix^®

Type of Adverse Events n/N* % n/N* %

Immediate Reactions (within 30 minutes) 0/52 0.0 0/50 0.0

Solicited Local Reactions (Days 0-7) 27/51 52.9 24/49 49.0

Solicited Systemic Reactions (Days 0-7) 35/52 67.3 25/49 51.0

Unsolicited Adverse Events (Days 0-28) 29/51 56.9 31/47 66.0

Serious Adverse Events (Days 0-28) 1/52 1.9 0/50 0.0

* n: number of participants reporting at least one event in this category; N: total number of participants who submitted safety information at each of these time points.

Safety Summary

The following safety data were reported during the trial: immediate reactions within 30 minutes of vaccination, solicited local and systemic reactions within the first 7 days post- vaccination, and all unsolicited adverse events in the 28-day period after vaccination. No immediate reactions were observed within 30 minutes after vaccination. The frequency of solicited local reactions was similar in both vaccine groups. In both vaccine groups, most solicited local reactions were reported as mild and resolved within 3 days (median duration). Irritability and drowsiness were the most common systemic complaints. One TetraMenD recipient experienced a febrile convulsion within 24 hours of receiving the vaccine. He also was noted to have cough with upper respiratory symptoms. This participant had a history of febrile convulsions associated with respiratory infections. This event was reported as an SAE possibly related to vaccination. No other SAEs were reported during the study period.

Unsolicited adverse events were common and their frequency similar in both vaccine groups. Most of them were common medical complaints and conditions that were reported as unrelated to vaccination. Overall, TetraMenD was well tolerated and had a safety profile similar to that of the licensed Hib conjugate vaccine used as a control.

Claims

"We claim:

1. A method for administering an immunogenic composition to a subject comprising, a) providing: i) a subject, wherein said subject has been vaccinated with a dose of a monovalent meningococcal conjugate vaccine; ii) a tetravalent meningococcal polysaccharide protein conjugate composition; and b) administering said tetravalent meningococcal polysaccharide protein conjugate composition to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

2. A method for administering an immunogenic composition to a subject comprising, a) providing: i) a subject, wherein said subject has been vaccinated with a dose of a monovalent meningococcal conjugate vaccine; ii) a tetravalent meningococcal polysaccharide protein conjugate vaccine; and b) administering said tetravalent meningococcal polysaccharide protein conjugate vaccine to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

3. A method for administering an immunogenic composition to a subject comprising, a) providing: i) a subject, wherein said subject has been vaccinated with a protective antigen against N. meningitidis serogroup C; ii) a tetravalent meningococcal polysaccharide protein conjugate vaccine; and b) administering said tetravalent meningococcal polysaccharide protein conjugate vaccine to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

4. A method for administering an immunogenic composition to a subject comprising, a) providing: i) a subject, wherein said subject has been vaccinated with a monovalent N. meningitidis serogroup C meningococcal vaccine; ii) a tetravalent meningococcal polysaccharide protein conjugate composition; and b) administering said tetravalent meningococcal polysaccharide protein conjugate vaccine to said subject at least twelve months after said was vaccination with said monovalent meningococcal conjugate vaccine.

5. A method of preventing meningococcal disease in a subject comprising administering to said subject a therapeutically effective dose of a tetravalent meningococcal conjugate vaccine at least twelve months after said subject has been vaccinated with a monovalent meningococcal conjugate vaccine.

6. A method of preventing meningococcal disease in a subject comprising administering to said subject a therapeutically effective dose of a tetravalent meningococcal conjugate vaccine at least twelve months after said subject has been vaccinated with monovalent N, meningitidis serogroup C meningococcal vaccine.

7. A method of stimulating an immunologic response in a subject comprising administering to said subject a therapeutically effective dose of a tetravalent meningococcal conjugate vaccine at least twelve months after said subject has been vaccinated with a monovalent meningococcal conjugate vaccine.

8. A method of inducing an immune response in a subject against one or more serogroups of N. meningitidis bacteria, the method comprising administering to said subject a therapeutically effective dose of a tetravalent meningococcal conjugate vaccine at least twelve months after said subject has been vaccinated with a monovalent meningococcal conjugate vaccine.

9. The method of claim 8, wherein said tetravalent meningococcal conjugate vaccine is formulated as 0.5ml of a sterile liquid in a single use syringe.

10. The method of claim 10, wherein 0.5ml said tetravalent meningococcal conjugate vaccine comprises from about 0.01 μg to about 10 μg of purified capsular polysaccharides from each of serogroups A, C, Y, and W-135 of N. meningitidis.

11. The method of claim 11 , wherein 0.5ml said tetravalent meningococcal conjugate vaccine comprises about 4 μg of purified capsular polysaccharides from each of serogroups A, C, Y, and W-135 of TV. meningitidis.

12. The method of claim 11, wherein 0.5ml said tetravalent meningococcal conjugate vaccine comprises from about 0.05 μg to about 5 μg of purified capsular polysaccharides from serogroups A, C, Y, and W-135 of N. meningitidis.