GB2614916A - Intradermal vaccine complement - Google Patents

Abstract

The invention relates to a method of treating streptococcus pneumoniae with intradermal immunogenic compositions, methods of administering such compositions, methods of use of the compositions in combination with pneumococcal vaccines, and kits comprising intradermal delivery devices and pre-filled syringes of the compositions. The immunogenic composition may comprise serotypes 3, 19A, and 35B, and may be conjugated to CRM197. The pneumococcal vaccine may be a 13-valent pneumococcal conjugate vaccine, such as Prevnar 13® (PCV13).

Description

INTRADERMAL VACCINE COMPLEMENT

Field of Invention

The present invention relates to intradermal immunogenic compositions for use in the prevention and treatment of diseases caused by Streptococcus pneumoniae, the methods of administration of said intradermal immunogenic compositions to the epidermis or dermis of the skin, and the methods of use of said intradermal immunogenic compositions in combination with pneumococcal vaccines.

Background

Streptococcus pneumoniae (S. pneumoniae), also called pneumococcus, is a Gram-positive, spherical bacteria that can invade the bloodstream and cause invasive diseases such as meningitis, bacteraemic pneumonia or sepsis, primarily in subjects with a weaker immune system such as infants, elderly people, and immunocompromised individuals. Invasive pneumococcal diseases (IPDs) are estimated to have caused 294 000 (192 000-366 000) deaths in HIV-uninfected children aged <5 years in 2015 globally (Wahl et al., 2018). Pneumococci can also cause non-invasive diseases such as acute otitis media, non-bacteraemic pneumonia, bronchitis, sinusitis or conjunctivitis (IVAC, 2017). Among the bacteria that cause meningitis, S. pneumoniae is associated with the highest mortality rates (19-26%) (Hasbun, 2020) and the most severe long-term neurodevelopmental complications in children, reported in >30% of survivors (Jit, 2010). Cognitive impairment can occur even in patients with apparently good recovery (Myers and Gervaix, 2007). Besides subjects with a weaker immune system, subjects with specific conditions such as chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes, cochlear implants, cerebrospinal fluid leaks, asthma, alcoholism, or smokers, are also at increased risk of developing I PDs.

Most pneumococci are encapsulated, their surfaces composed of complex polysaccharides, which are one determinant of their pathogenicity. Those capsular polysaccharides are antigenic, and our immune system can learn to recognize them to produce specific antibodies. This is the basis for classifying pneumococci by serotypes, as their capsular polysaccharides vary. More than 90 pneumococcal serotypes have been documented based on their reaction with serotype-specific antisera (CDC, 2015).

There are two main types of vaccines licensed to protect against pneumococcal diseases: pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine (PPV). PPV elicits a T-cell independent response which is less immunogenic with a shorter duration of protection and does not impact nasopharyngeal carriage (Siber et al., 2008). It is used in adults only as it is poorly immunogenic in children <2 years. Consequently, PCVs have been developed to protect young children from pneumococcal diseases. The conjugation of a polysaccharide antigen to a protein carrier (i.e. conjugates, or glycoconjugates) results in a T-cell dependent response, high titres of anti-polysaccharide I mmunoglobulin G (IgG), and immunological memory in infants (Siber et al., 2008). In addition, PCVs protect against acquisition of vaccine serotype nasopharyngeal carriage, reducing the overall prevalence of colonization among vaccinated children and providing indirect protection (herd immunity) to unvaccinated children and elderly people (IVAC, 2017). Two PCVs have been on the market since 2009; the 10-valent (PCV10, Synflorix®, GlaxoSmithKline Plc) and the 13-valent (PCV13, Prevnar 13®, Pfizer Inc.) vaccines. PCV10 includes capsular polysaccharides from pneumococcal serotypes 1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F and 23F. In addition to those, PCV13 includes capsular polysaccharides from serotypes 3, 6A and 19A. In 2021, two new PCVs have been approved by regulatory authorities; a 15-valent (PCV15, Vaxneuvancee, Merck & Co., Inc.) and a 20-valent vaccine (PCV20, Prevnar 20®, Pfizer Inc.). In addition to the serotypes included in PCV13, PCV15 includes capsular polysaccharides from pneumococcal serotypes 22F and 33F In addition to the serotypes included in PCV15, PCV20 includes capsular polysaccharides from serotypes 8, 10A, 11A, 12F and 15B/C. All pneumococcal vaccines on the market (PCV and PPV) are administered intramuscularly (IM).

Although the wide use of PCVs in developed countries has reduced the number of IPDs, their numbers have now been increasing again every year in Europe since 2014 (ECDC, 2019) and treatment outcomes are affected by the emergence of antibiotic-resistant pneumococcal strains in the US (Kaur et al., 2021). This is because, as vaccine serotypes are removed from the nasopharynx, other pneumococcal serotypes emerge and occupy the niche, a phenomenon called serotype replacement. Serotype replacement has gradually reduced the impact of PCVs as the rates of carriage and disease caused by non-vaccine serotypes have increased (Ladhani et al., 2018). In Europe in 2017, the most common IPD serotypes among infants and children aged 1-4 years included 8, 10A, 12F and 24F, which are not included in any of the currently licensed PCVs (World Health Organization, 2019). In The European Surveillance System (TESSy), the proportion of IPD cases caused by non-PCV serotypes in 2017 was 75% and 72% in children <5 years of age and in adults 65 years or above, respectively (Cohen et al., 2017). Furthermore, Kaur et al have recently shown an increase in antibiotic-resistant S. pneumoniae strains since the introduction of PCV13 in the US in 2010 (Kaur et al., 2021). The study found that, beginning in 2013, S. pneumoniae isolates began to show less susceptibility to penicillin, third-generation cephalosporins, fluoroquinolones and carbapenems. Specifically, this pattern is due to the increased prevalence of non-vaccine serotypes 35B, 35F and 11A which have a competitive advantage due to multiple antibiotic resistance.

Consequently, WHO, CDC and ECDC have been calling for new vaccination strategies to prevent pneumococcal diseases and combat antimicrobial resistance (CDC, 2019; Cohen et al., 2017; ECDC, 2019). So far, companies responded using two different strategies; The first and the best one is to develop a vaccine capable of preventing pneumococcal diseases regardless of capsular type using highly conserved proteins. However, those protein vaccines have not been successful so far in clinical trials. The second and current strategy is to continue increasing the number of serotypes included in PCVs to produce a broad-spectrum vaccine (i.e., 20 to 30-valent PCVs). In addition to PCV20, several such vaccines are in development: the 24-valent pneumococcal conjugate vaccine (PCV24, CRM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F, 2, 8, 9N, 10A, 11A, 12F, 15B/C, 17F, 20B) being developed by Merck & Co Inc., and the 24-valent pneumococcal conjugate vaccine (P0V24, 0RM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F, 2, 8, 9N, 10A, 11A, 12F, 15B/C, 17F, 20B) being developed by Affinivax/Astellas. However, the strategy of including an increasing number of pneumococcal serotypes into the same IM formulation has 5 main limitations, as described below.

The first limitation comes from the fact that pneumococcal serotypes causing most IPDs in one region/population are different from the serotypes circulating in another region/population, and this distribution is also changing over time. The large number of pneumococcal serotypes and difficulty to predict future distributions across countries make it challenging for vaccine manufacturers to develop one-size-fits-all broad-spectrum PCV (i.e., the same formulation for all individuals in all countries).

The second limitation comes from the serotype replacement effect described above because it has been shown that, as for antibiotics, vaccinating against a large number of serotypes (which may not be circulating in a specific country) using broad-spectrum PCVs accelerates the emergence of new serotypes against which there is no vaccine available yet.

The third limitation comes from interferences, in the form of antigen competition or carrier-induced epitope, observed when many conjugates are combined into the same IM formulation. This results in a lower immune response against each individual conjugate (Senders et at, 2021; Pichichero, 2013). Such interferences have been shown in PCV13 trials where the serotype-specific IgG concentrations were lower compared to PCV7 (Yeh et al., 2010), and in PCV20 trials where the serotype-specific IgG concentrations were again lower compared to PCV13 (Essink et al., 2021; Fitz-Patrick et al., 2021). Whereas the reduced immune response does not prevent registration, since the current surrogate for efficacy noninferiority is the proportion of responders with IgG concentration 0.35 pg/mL (WHO, 2013), those differences in IgG concentrations can impact protection against mucosal diseases and nasopharyngeal carriage (Dagan, 2019). Efficacy against nasopharyngeal carriage in asymptomatic children is important to reduce transmission and provide indirect protection (herd immunity) in all age groups. Therefore, and counterintuitively, increasing the number of serotypes in one-sizefits-all broad-spectrum PCVs may result in reduced overall vaccine effectiveness depending on the serotypes circulating locally.

The fourth limitation is that broad-spectrum IM PCVs may not be able to produce the immune response required to fully protect individuals against IPDs caused by some serotypes included in their formulations. Because PCVs are licensed based on immuno-bridging studies showing non-inferior immunogenicity results against PCV7 and those products receive the same indication against IPDs and pneumonia, they must contain at least the 7 serotypes included in PCV7 and each of the vaccine serotypes should elicit IgG concentration above the aggregate correlate of protection of 0.35 pg/mL computed from multiple clinical trials (Jodar et al., 2003; WHO, 2013). Although the use of this aggregate correlate of protection has enabled the licensing of effective PCVs, more recent studies based on a larger number of IPD cases have shown that serotype-specific correlates of protection vary widely, with some S. pneumoniae serotypes requiring a much higher antibody concentration as correlate of protection (Andrews et al., 2014) for instance because of the density of their capsule (Kim et al., 1999; Poolman et al., 2009). In particular, Andrews et al estimated that a serum IgG concentration of 2.83 pg/mL would be needed for protection against S. pneumoniae serotype 3 (Andrews et al., 2014), whereas PCV13 trial showed an antipolysaccharide IgG geometric mean concentration (GMC) of 0.49 pg/mL (95% Cl: 0.43-0.55) and the proportion of subjects with antipolysaccharide IgG concentrations of 0.35 pg/mL was 63.5% (95% Cl: 57.1-69.4). Hence, even though PCV13 includes serotype 3, its efficacy, duration and herd immunity against serotype 3 are limited (Linley et al., 2019). Serotype 3 is the first cause of I PDs worldwide and across age groups, and a recent meta-analysis found serotype 3 infections were associated with complications like empyema, necrotizing pneumonia, and septic shock, as well as with reduced quality of life and high case-fatality rates (Grabenstein and Musey, 2014).

The fifth limitation to increasing the number of serotypes in PCVs is the direct impact on the complexity of the manufacturing process, production timeline and the number of tests involved in quality control to release one lot of multivalent PCV. This added complexity has in turn an impact on the price of the vaccine and the probability of quality control failure which can lead to vaccine supply shortages. The public health budget allocated to PCV programmes is already disproportionate (approximately 43% of Gavi's 2016-2020 vaccine expenditures) and may not sustain a constant increase in vaccine prices for serotypes which may not circulate in some countries.

Accordingly, there is a need in the art for a vaccine and vaccination methods for preventing and treating pneumococcal disease that overcome the limitations described above.

Summary of Invention

In a first aspect, the present invention provides a method of preventing or treating a Streptococcus pneumoniae infection or a pneumococcal disease in a subject, the method comprising the steps of: i) intradermally administering an immunogenic composition to the subject, said immunogenic composition comprising at least one pneumococcal polysaccharide or at least one immunogenic protein; and H) administering a pneumococcal vaccine to the subject.

In a second aspect, the present invention provides an immunogenic composition for use in the treatment or prevention of a Streptococcus pneumoniae infection or a pneumococcal disease in a subject in need thereof, wherein the immunogenic composition is for intradermal administration and comprises at least one pneumococcal polysaccharide or an immunogenic protein, and wherein the subject has been administered a pneumococcal vaccine.

In a third aspect, the present invention provides a pneumococcal vaccine for use in the treatment or prevention of a Streptococcus pneumoniae infection or a pneumococcal disease in a subject in need thereof, wherein the subject has been intradermally administered an immunogenic composition, and wherein the immunogenic composition comprises at least one pneumococcal polysaccharide or an immunogenic protein.

In a fourth aspect, the present invention provides a kit of parts comprising at least one delivery device adapted for shallow intradermal delivery, the immunogenic composition and/or the pneumococcal vaccine disclosed herein, and instructions for use.

The invention will now be described in more detail with reference to the following figures and examples.

Description of Figures

FIG. 1 provides a schema of a preclinical study where Group 1 (G1) is administered with IM PCV13 only [IM(PCV13)], Group 2 is administered with PCV13 and cPCV35B/19A/3 as one IM injection [IM(PCV13+cPCV35B/19A/3)], and Group 3 is simultaneously administered with IM PCV13 and ID cPCV35B/19A/3 using the NanoPass MicronJet600TM needle hub [I M (PCV13)+ID(cPCV35B/19A/3)].

FIG. 2 provides a drawing of the NanoPass MicronJet600TM needle hub, which is adapted for shallow ID delivery.

FIG. 3 shows serotype-specific opsonophagocytic killing activity of sera as determined by CPA assays at Post Dose 1 (PD1) and Post Dose 2 (PD2) following delivery of IM PCV13 only [IM(PCV13)], PCV13 and cPCV35B/19A/3 as one IM injection [IM(PCV13+cPCV358/19A/3)], and 1M PCV13 and ID cPCV35B/19A/3 simultaneously using the NanoPass MicronJet600TM needle hub [IM(PCV13) + ID(cPCV35B/19A/3)]. Data are reported as geometric mean titres (GMT ± 90%C1). The OPA titre represents the dilution of the immune serum killing 50% of the target bacteria. Assay results below the [[CO were set to 0.5 x LLOQ in the analysis. LLOQ = <8. *p-value <0.05, np-value <0.01, ***p-value <0.001.

FIG. 4 shows serotype-specific opsonophagocytic killing activity of sera as determined by OPA assays at Post Dose 1 and Post Dose 2 following delivery of IM PCV13 only (G1), PCV13 and cPCV35B/19A/3 as one IM injection (G2), and IM PCV13 and ID cPCV35B/19A/3 simultaneously using the NanoPass MicronJet600TM needle hub (G3). Data are reported as geometric mean titres (GMT ± 90%C1) and p-values. The CPA titre represents the dilution of the immune serum killing 50% of the target bacteria. Assay results below the LLOQ were set to 0.5 x LLOQ in the analysis. LLOQ = <8. p-value <0.05 are in grey.

FIG. 5 shows the anti-CPS35B, anti-CPS19A, and anti-CPS3 IgG antibody geometric mean concentration (GMC) in pg/mL (± 90% Cl) as determined by Multiplex Bead based ELISA Assay at Baseline, Post Dose 1 (PD1), and Post Dose 2 (PD2) following delivery of IM PCV13 only [IM(PCV13)], PCV13 and cPCV35B/19A/3 as one IM injection [IM(PCV13+cPCV35B/19A/3)], and IM PCV13 and ID cPCV35B/19A/3 simultaneously using the NanoPass MicronJet600TM needle hub [IM(PCV13) + I D(cPCV358/19A/3)]. *p-value < 0.05, np-value <0.01, ***p-value <0.001.

FIG. 6 shows the anti-CPS35B, anti-CPS19A, and anti-CPS3 IgG antibody geometric mean concentration (GMC) in pg/mL (± 90% Cl) as determined by Multiplex Bead based ELISA Assay at Baseline, Post Dose 1, and Post Dose 2 following delivery of IM PCV13 only (Cl), PCV13 and cPCV35B/19A/3 as one IM injection (G2), and IM PCV13 and ID cPCV35B/19A/3 simultaneously using the NanoPass MicronJetGOOTM needle hub (G3). p-value <0.05 are in grey.

FIG. 7 shows the IgG antibody geometric mean concentration (GMC) in pg/mL (± 90% Cl) elicited by the capsular polysaccharides not included in cPCV35B/19A/3 as determined by Standardized ELISAAssay at Baseline, Post Dose 1 (PD1), and Post Dose 2 (PD2) following delivery of IM PCV13 only [IM(PCV13)], PCV13 and cPCV35B/19A/3 as one IM injection [IM(PCV13+cPCV35B/19A/3)], and IM PCV13 and ID cPCV35B/19A/3 simultaneously using the NanoPass MicronJet600TM needle hub [IM(PCV13) + I D(cPCV35B/19A/3)]. *p-value < 0.05, np-value <0.01, ***p-value <0.001.

FIG. 8 shows the IgG antibody geometric mean concentration (GMC) in pg/mL (± 90% Cl) elicited by the capsular polysaccharides not included in cPCV35B/19A/3 as determined by Standardized ELISAAssay at Baseline, Post Dose 1 (PD1), and Post Dose 2 (PD2) following delivery of IM PCV13 only [IM(PCV13)], PCV13 and cPCV35B/19A/3 as one IM injection [IM(PCV13+cPCV35B/19A/3)], and IM PCV13 and ID cPCV35B/19A/3 simultaneously using the NanoPass MicronJet600TM needle hub [IM(PCV13) + ID(cPCV35B/19A/3)]. p-value < 0.05 are in grey.

FIG. 9 shows serotype-specific opsonophagocytic killing activity of sera as determined by OPA assays following delivery of only IM PCV13 (IM PCV13) or only ID cPCV35B/19A/3 using the NanoPass MicronJet600TM needle hub (ID cPCV35B/19A/3). Data are reported as geometric mean fold rise (GM FR ± 90%C1) of OPA titres from Post Dose 2 to Post Dose 3 (PD3). The OPA titre represents the dilution of the immune serum killing 50% of the target bacteria. Assay results below the LLOQ were set to 0.5 x LLOQ in the analysis. LLOQ = <8. *p-value < 0.05, **p-value <0.01, ***p-value <0.001.

FIG. 10 shows serotype-specific opsonophagocytic killing activity of sera as determined by OPA assays following delivery of only IM PCV13 (IM PCV13) or only ID cPCV35B/19A/3 using the NanoPass MicronJet600TM needle hub (ID cPCV35B/19A/3). Data are reported as geometric mean fold rise (GM FR ± 90%C1) of OPA titres from Post Dose 2 to Post Dose 3 (PD3) and p-values. The OPA titre represents the dilution of the immune serum killing 50% of the target bacteria. Assay results below the LLOQ were set to 0.5 x LLOQ in the analysis. LLOQ = <8. p-value <0.05 are in grey.

FIG. 11 shows the anti-CPS35B, anti-CPS19A, and anti-CPS3 geometric mean fold rise (GMFR ± 90% Cl) from Post Dose 2 to Post Dose 3 (PD3) of IgG antibody concentration as determined by Multiplex Bead based ELISA Assay following delivery of only IM PCV13 (IM PCV13) or only cPCV35B/19A/3 using the NanoPass MicronJet600TM needle hub (ID cPCV35B/19A/3).*p-value <0.05, **p value <0.01, ***p-value <0.001.

FIG. 12 shows the anti-CPS35B, anti-CPS19A, and anti-CPS3 geometric mean fold rise (GMFR ± 90% Cl) from Post Dose 2 to Post Dose 3 (P03) of IgG antibody concentration as determined by Multiplex Bead based ELISA Assay following delivery of only IM PCV13 (IM PCV13) or only cPCV35B/19A/3 using the NanoPass MicronJet600TM needle hub (ID cPCV35B/19A/3). p-value < 0.05 are in grey.

Detailed Description

The following description is presented to enable any person skilled in the art to make and use the invention. Various modifications to the disclosed embodiments will be readily apparent to those skilled in the art.

In order that the present invention may be more readily understood, certain terms are first defined. Additional definitions are set forth throughout the detailed description.

As used herein, the terms "transdermal", "intradermal", "ID", are used interchangeably and refer to a route of administration wherein active ingredients are delivered across the skin (stratum corneum) to the epidermis or dermis of the skin. "Shallow ID delivery" refers to administration of a composition to the individual's skin at a depth of between about 100 and about 700 microns from the surface of the skin. By use of the term "shallow ID delivery" it is not intended that a portion of the composition cannot be delivered outside of the desired range, e.g., a small portion of the composition may be released into the stratum corneum when the needle(s) of the ID delivery device are removed from the skin and/or a portion of the composition may migrate deeper into the skin after the initial delivery. Rather, the term refers to the initial delivery of most of a composition within the desired range.

As used herein, the term "composition" refers to any composition comprising an immunogenic agent and as such, is capable of inducing an immune response in a subject. Specifically, in the context of the present invention, the term "composition" refers to a composition capable of inducing an immune response against the bacterium S. pneumoniae.

As used herein, the term "immune response" refers to the action of, for example, lymphocytes, antigen presenting cells, phagocytic cells, granulocytes, and soluble macromolecules produced by the above cells or the liver (including antibodies, cytokines, and complement) that results in selective damage to, destruction of, or elimination from the human body of foreign antigens, for example, bacteria such as S. pneumoniae.

As used herein, the term "treatment" or "therapy" refers to administering an active agent with the purpose to cure, heal, alleviate, relieve, alter, remedy, ameliorate, improve, or affect a condition (e.g., a pneumococcal disease), the symptoms of the condition, or to prevent or delay the onset of the symptoms, complications, biochemical indicia of a disease, or otherwise arrest or inhibit further development of the disease, condition, or disorder in a statistically significant manner.

As used herein, the term "prophylaxis", refers to avoidance of disease manifestation, a delay of onset, and/or reduction in frequency and/or severity of one or more symptoms of a particular disease, disorder or condition (e.g., infection with S. pneumoniae). In some embodiments, prophylaxis is assessed on a population basis such that an agent is considered to provide prophylaxis against a particular disease, disorder or condition if a statistically significant decrease in the development, frequency, and/or intensity of one or more symptoms of the disease, disorder or condition is observed in a population susceptible to the disease, disorder, or condition.

As used herein, the term "a prophylactically effective amount" or "a prophylactically effective dose" refers to the amount or dose required to induce an immune response sufficient to delay onset and/or reduce in frequency and/or severity one or more symptoms caused by an infection with S. pneumoniae.

As used herein, the term "subject" is intended to include human and non-human animals. Preferred subjects include human patients in need of enhancement of an immune response. The methods are particularly suitable for treating human patients having a pneumococcal disease that can be treated by augmenting the immune response.

As used herein, the term "at risk" includes individuals at risk for developing pneumococcal diseases, particularly individuals under 5 years of age, above 65 years of age, or with the following at-risk conditions: asplenia, cancer, HIV, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes requiring insulin or oral hypoglycaemic medication, immunosuppression, cochlear implants, cerebrospinal fluid leaks, organ transplant, asthma, alcoholism, or smokers. The incidence of pneumococcal diseases increases with age, which correlates with declining cell-mediated immunity. Thus, in some embodiments of the invention, individuals "at risk" for developing pneumococcal diseases are 50 years of age or older. In alternative embodiments, those "at risk" are 55 years of age or older, 60 years of age or older, 65 years of age or older, 70 years of age or older, 75 years of age or older, or 80 years of age or older.

As used herein, the term "simultaneous" administration, as defined herein, includes the administration of one composition herein disclosed within the same medical visit, or within about 2 hours or less of another composition as herein defined. For example, the immunogenic composition maybe administered within 2 hours or less of the pneumococcal vaccine according to the claims.

As used herein, the term "sequential" administration, as defined herein, includes the administration of the composition herein disclosed in multiple doses on separate occasions. The composition of the invention may be administered to the subject before and/or after administration of an intramuscular pneumococcal vaccine, or indeed simultaneously.

The use of the alternative (e.g., "or") should be understood to mean either one, both, or any combination thereof of the alternatives. As used herein, the indefinite articles "a" or "an" should be understood to refer to "one or more" of any recited or enumerated component.

As used herein, the term "invasive pneumococcal diseases" or "IPD", refers to all diseases caused by S. pneumoniae invading a site of the body that is normally sterile Examples of such disease are meningitis, bacteraemia without a clinical focus of infection, bacteraemic pneumonia, cellulitis with bacteraemia, endocarditis, pericarditis, septic arthritis, osteomyelitis, peritonitis and epiglottitis.

As used herein, the term "non-invasive pneumococcal diseases", refers to all diseases caused by S. pneumoniae which are not invasive including acute otitis media, non-bacteraemic pneumonia, bronchitis, sinusitis, conjunctivitis, mastoiditis and periorbital cellulitis.

As used herein, the term "pneumococcal diseases", refers to both invasive and non-invasive diseases caused by S. pneumoniae.

As used herein, the term "correlate of protection", refers to an anticapsular polysaccharide antibody concentration (pg/mL) measured by standardized ELISA that is associated with protection against invasive pneumococcal disease.

As used herein, the term "conjugate" or "glycoconjugate", refers to the conjugation of a polysaccharide antigen to a protein carrier.

As used herein, the term "monovalent bulk conjugate" refers to a conjugate prepared from a single lot or pool of lots of polysaccharide and a single lot or a pool of lots of protein. This is the parent material from which the final bulk is prepared.

The following abbreviations are used herein and have the following meanings: CI=Confidence Interval, ELISA=Enzyme-Linked lmmunosorbent Assay, (M)OPA= (multiplex) opsonophagocytosis assay, S. pneumoniae=Streptococcus pneumoniae, GMC=Geometric Mean Concentration, GMT=Geometric Mean Titres, GMFR=Geometric Mean Fold Rise, PCV=Pneumococcal Conjugate Vaccine, I Dzintradermal, SC=subcutaneous, I M=i ntram uscular, PCR=Polymerase Chain Reaction, I gG=Immunoglobulin G, PCV10=the 10-valent PCV commercialized by GlaxoSmithKline Plc under the brand name SynflorixO, PCV13=the 13-valent PCV commercialized by Pfizer Inc. under the brand name Prevnar 130, PCV7=precursor of PCV13 containing seven serotypes and commercialized by Pfizer Inc. under the brand names Prevnar0, cPCV35B/19A/3=PCV complement containing S. pneumoniae serotypes 35B, 19A and 3, anti-CPS35B=anti-capsular polysaccharide 35B.

The present invention relates to a method of administering an immunogenic composition to a subject, which is useful for (1A) preventing pneumococcal infection and diseases, (1B) reducing the likelihood of pneumococcal infection and diseases, (1C) reducing the severity or duration of invasive and non-invasive pneumococcal diseases, or (1D) preventing, or reducing the likelihood, severity or duration of pneumococcal infection and diseases in an individual at risk of developing pneumococcal diseases, or (1E) inducing a protective immune response against specific serotypes of S. pneumoniae, or (1F) controlling the transmission of antibiotic-resistant S. pneumoniae strains including multidrugresistant strains, or (10) reducing injection pain and improving patient acceptability; said method comprising: administering an effective amount of the composition to the epidermis or the shallow dermis of the subject's skin at a depth of between about 100 and about 700 microns from the surface of the skin, wherein the composition is liquid and injected with an ID delivery device comprising one or more hollow microneedles for penetrating the skin, wherein the device is adapted for shallow ID delivery of the composition.

ID delivery has been tested with other vaccines, including inactivated influenza, attenuated, live measles virus, cholera, rabies, hepatitis B, varicella zoster virus, and inactivated polio virus. To the best of our knowledge, ID delivery of liquid pneumococcal vaccines (polysaccharide vaccine) has never been tested before. One study used a microprojection-based skin patch coated with PCV7 (dry-coating) in mice (Pearson et al., 2015), but the patch failed to generate a significant immune response for 5 of the 7 serotypes.

It is herein shown that delivery of a liquid composition containing pneumococcal capsular polysaccharides and CRM 197 to the shallow skin (epidermis and shallow dermis) through the methods described herein elicits strong serotypespecific immune responses, as measured by standardized CPA and ELISA (see Example 5). Administration to the shallow portion of the skin was accomplished through the use of a delivery device that targets this depth (MicronJetTm, Nanopass Technologies, Ltd., Nes Ziona, Israel). CPA titre is a direct measure of the functional capacities of anticapsular antibodies expressed as the reciprocal of the serum dilution needed to produce 50% killing of the relevant S. pneumoniae serotype. Thus, CPA is an indicator of pneumococcal disease protection. Furthermore, in previous studies, anficapsular polysaccharide antibody concentrations as measured by ELISA were examined in individuals who experienced pneumococcal diseases to successfully derive immunological correlates of disease protection (Andrews et al., 2014; Dagan, 2019; Jodar et al., 2003). Therefore, evidence suggests that ELISA is also an indicator of pneumococcal disease protection. It is shown herein that intracutaneous (intradermal) administration to the shallow skin (epidermis and shallow dermis) of a pneumococcal composition elicits a strong immune response against each serotype, which is similar or superior to IM delivery, based on antibody titres by CPA and antibody concentration by ELISA (see Example 5).

Without wishing to be bound by theory, it is believed that the strong immune response, including an antibody response as well as a 1-cell dependent response, obtained with the methods described herein utilizing shallow ID delivery were due to direct administration of the composition to the shallow skin (i.e., epidermis and shallow dermis). The narrow layer beneath the skin surface contains a higher density of potent antigen presenting dendrific cells (DC) and a wider variety of DC than deeper layers of skin (e.g., Langerhans cells are present in the epidermis, but not the dermis of the skin). Therefore, in accordance with the present invention, shallow ID delivery of a pneumococcal composition to skin dendritic cells may improve cell mediated immunity.

Besides the strong immune response, shallow ID delivery also reduces injection pain and improves patient acceptability. Devices which are adapted for shallow ID delivery, such as the MicronJetTM (Nanopass Technologies, Ltd., Nes Ziona, Israel), use hollow microneedles that are fabricated to be short and narrow enough to avoid stimulation of the dermal nerves. Therefore, there is almost no pain associated with vaccine administration via this route (Gill et al 2008; Ripolin et al 2017) which improves patient acceptability.

The composition of the invention is delivered to the dermis or shallow epidermis of the subject's skin at a depth of about 100 to about 700 microns from the surface of the skin. In alternative embodiments, shallow ID delivery comprises delivery at a depth of about 100 microns, about 200 microns, about 300 microns, about 400 microns, about 500 microns, about 600 microns or about 700 microns. In additional embodiments, shallow ID delivery comprises delivery to a depth of about 100 to about 600 microns, about 100 to about 500 microns, about 100 to about 400 microns, about 200 to about 700 microns, about 200 to about 600 microns, about 200 to about 500 microns, about 300 to about 700 microns, about 300 to about 600 microns, about 300 to about 500 microns, about 400 to about 700 microns, about 400 to about 700 microns, or about 400 to about 600 microns.

In the methods of the invention, shallow ID delivery is achieved through the use of an ID delivery device comprising one or more needles for penetrating the skin; wherein the device is adapted for shallow ID delivery. Said ID delivery device can be an apparatus that is capable of delivering a composition to the desired depth of the skin. For example, the ID delivery device may comprise a pre-filled syringe comprising a liquid pneumococcal composition for delivery to the desired depth through a single or multiple hollow needles. Alternatively, the device may comprise multiple, solid needles, such as a patch, which are coated with a dried pneumococcal composition. In either case, when the device is used for the methods described herein, the resulting depth of delivery should be to the epidermis or shallow dermis of the skin. Depth of delivery can be controlled, e.g., by varying the length of the one or more needles of the ID delivery device. For example, an ID delivery device equipped with one or more needles that are 600 microns in length (e.g., the MicronJetTM ID device), would be capable of delivering a composition to the desired depth and targeting the antigen-presenting dendritic cells in the shallow skin. Devices useful for the methods of the invention include, for example, devices described in WO 2010/067319. In exemplary embodiments of the invention, the ID delivery device is a MicronJetGOOTM needle hub and syringe (Nanopass Technologies Ltd., Nes Ziona, Israel).

The needle(s) of the ID delivery device may be made of a material that is safe for human use and is shaped to penetrate the skin. In embodiments of the invention, the needle is made of silicon, metal, such as stainless steel, or a polymer. Additionally, materials known for use in micro electromechanical systems may be used for the needle as long as said material is safe for use with human therapeutic methods. Advantageously, the needle should be shaped in a way that allows the piercing of the stratum corneum, or top layer of the skin. For example, the tip of the needle can be cut into a bevel to readily allow penetration of the skin. Additionally, it may be advantageous in some instances to use needles that at least partially dissolve upon penetrating the patient's skin.

Accordingly, the invention also provides an ID delivery device adapted for shallow ID delivery which comprises a pneumococcal composition and one or more needles for penetrating the skin. The one or more needles of the ID delivery device are made of silicon, stainless steel, a polymer, a biodegradable material or other material that is safe for human use and shaped for penetration of the skin.

In some embodiments of this aspect of the invention, the pneumococcal composition is liquid, and the one or more needles are hollow. In alternative embodiments, the pneumococcal composition is dried, and the one or more needles are solid.

The present invention relates to methods of administering the intradermal immunogenic composition simultaneously with an IM pneumococcal vaccine, which is useful for (2A) inducing a protective immune response against specific serotypes of S. pneumoniae included in the ID pneumococcal composition but not in the IM pneumococcal vaccine, this way broadening/complementing the protection against pneumococcal infection and diseases; (2B) boosting or inducing the elevation of immune responses (e.g., increasing the cell-mediated immunity) against specific serotypes of S. pneumoniae which are both included in the ID pneumococcal composition and the IM pneumococcal vaccine, this way improving the protection and herd immunity against pneumococcal infection and diseases caused by those serotypes; (20) avoiding or reducing interferences between glycoconjugates in IM PCVs by targeting a different site and immune cells with some serotypes instead of adding them into the same IM formulation, this way improving immune responses against all vaccine serotypes; (2D) boosting or inducing the elevation of immune responses (e.g. increasing the cell-mediated immunity) against serotypes of S. pneumoniae which are included in the IM pneumococcal vaccine but not in the ID pneumococcal composition, this way improving the protection and herd immunity against pneumococcal infection and diseases caused by IM non-ID serotypes; (2E) customizing/adapting pneumococcal immunization programmes by complementing IM pneumococcal vaccines with ID pneumococcal compositions containing the serotypes which are causing I PDs and antimicrobial resistance in a specific country or population; said method comprising: administering an effective amount of the composition to the shallow skin (epidermis and shallow dermis), and wherein the composition is injected simultaneously with an IM pneumococcal vaccine.

Simultaneous injections using the IM and ID routes was previously tested in one preclinical study evaluating plasmid DNA vaccination against HIV (Mann et al., 2014). The group showed that concurrent multiple-route DNA vaccinations induce strong cellular immunity, in addition to potent and high-avidity humoral immune responses. However, results observed with viral antigens expressed by host cells using a non-replicating plasmid vector cannot be extrapolated to bacterial polysaccharides purified from a fermented S. pneumonia culture. To our knowledge, this is the first report of simultaneous ID and IM delivery of pneumococcal vaccines to induce the elevation of immune responses against specific serotypes which have a higher correlate of protection.

It is herein shown that, surprisingly, the concurrent delivery of an IM pneumococcal vaccine with an ID composition comprising capsular polysaccharides and CRM 197 administered through the methods described in the first aspect, goes beyond the dose-response curve of IM immunization, eliciting a greater immune protection than IM immunization alone for serotypes included in both formulations, as measured by standardized CPA and ELISA (see Example 6). ID administration was accomplished through the use of a delivery device that targets this depth (MicronJetTm, Nanopass Technologies, Ltd., Nes Ziona, Israel). CPA titre is a direct measure of the functional capacities of anticapsular antibodies expressed as the reciprocal of the serum dilution needed to produce 50% killing of the relevant S. pneumoniae serotype. Thus, OPA is an indicator of pneumococcal disease protection. Furthermore, in previous studies, anticapsular polysaccharide antibody concentrations as measured by ELISA were examined in individuals who experienced pneumococcal diseases to successfully derive immunological correlates of disease protection (Andrews et al., 2014; Dagan, 2019; Jodar et al., 2003). Therefore, evidence suggests that ELISA is also an indicator of pneumococcal disease protection. It is shown herein that the simultaneous administration of an ID composition with an IM pneumococcal vaccine is superior to IM delivery of the pneumococcal vaccine alone for serotypes included in both formulations, based on antibody titres by CPA and antibody concentrations by ELISA (see Example 6).

Without wishing to be bound by theory, it is believed that the enhanced immune response, including both humoral and cellular responses, obtained with the use of the concurrent multiple-route ID + IM pneumococcal vaccination method described herein, is due to the simultaneous presentation of antigens at two different sites to reach a larger and more diverse network of antigen-presenting cells (APCs) which can increase the magnitude of polyfunctional CD4+ T cell responses.

Even more surprisingly, it is also herein shown that, the simultaneous delivery of the ID composition together with an IM pneumococcal vaccine through the methods described in the first aspect, also increases the immune response against the pneumococcal serotypes that are included in the IM pneumococcal vaccine but not in the ID composition (IM non-ID serotypes), as measured by ELISA and CPA (see Example 7). ID administration was accomplished through the use of a delivery device that targets this depth (MicronJetTm, Nanopass Technologies, Ltd., Nes Ziona, Israel). In previous studies, anticapsular polysaccharide antibody concentrations as measured by ELISA were examined in individuals who experienced pneumococcal diseases to successfully derive immunological correlates of disease protection (Andrews et al., 2014; Dagan, 2019; Jodar et al., 2003). Therefore, evidence suggests that ELISA is an indicator of pneumococcal disease protection. Furthermore, CPA titre is a direct measure of the functional capacities of anticapsular antibodies expressed as the reciprocal of the serum dilution needed to produce 50% killing of the relevant S. pneumoniae serotype. Thus, CPA is an indicator of pneumococcal disease protection. It is shown herein that concurrent ID and IM pneumococcal vaccination induces the elevation of immune responses against IM non-ID serotypes of S. pneumoniae compared to IM delivery alone, based on antibody concentrations by ELISA and antibody titres by OPA (see Example 7).

In Example 6 and 7, it is further demonstrated that the significant increase in CPA titre and IgG concentration elicited by the pneumococcal capsular polysaccharides which are (a) common to both the IM and ID formulations, and (b) only included in the IM formulation, is only due to the simultaneous ID administration of the composition according to the first aspect, and not to an increase in the quantity of polysaccharides and CRM 197. This is shown by using a second control group which was administered with both the pneumococcal vaccine and the composition as one IM injection.

The present invention also provides an IM pneumococcal vaccine for use in treating or preventing a pneumococcal disease in a subject, wherein the IM pneumococcal vaccine is for simultaneous administration to a subject who has been administered an ID composition of the present invention.

The IM pneumococcal vaccine may be any IM pneumococcal vaccine, conjugated or not. Preferably, the IM pneumococcal vaccine may be the 23-valent pneumococcal polysaccharide vaccine (PPV23, non-conjugated, comprising serotypes 1, 2, 3,4, 5, 63, 7F, 8, 9V, 9N, 10A, 11A, 12F, 14, 153, 17F, 180, 19F, 19A, 20, 22F, 23F, 33F) licensed in 1983 and commercialized by Merck & Co Inc. and affiliates under the brand name Pneumovax 23® in some countries, the 10-valent pneumococcal conjugate vaccine absorbed (PCV10, Non-Typeable Haemophilus influenzae (NTHi) protein D, diphtheria and tetanus toxoid conjugates, comprising serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F) licensed in 2008 and commercialized by GlaxoSmithKline Plc. and affiliates under the brand name Synflorix® in some countries, the 13-valent pneumococcal conjugate vaccine (PCV13, CRM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A) licensed in 2009 and commercialized by Pfizer Inc. and affiliates under the brand name Prevnar 130 in some countries, the 20-valent pneumococcal conjugate vaccine (PCV20, 0RM197 conjugates, comprising serotypes 4, 68, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 8, 10A, 11A, 12F, 15B, 22F, 33F) licensed in 2021 and commercialized by Pfizer Inc. and affiliates under the brand name Prevnar 20® in some countries, the 15-valent pneumococcal conjugate vaccine (PCV15, 0RM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F) licensed in 2021 and commercialized by Merck & Co Inc. and affiliates under the brand name Vaxneuvance® in some countries, the 24-valent pneumococcal conjugate vaccine (PCV24, CRM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F, 2, 8, 9N, 10A, 11A, 12F, 153/C, 17F, 20B) being developed by Merck & Co Inc., the 24-valent pneumococcal conjugate vaccine (PCV24, CRM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F, 2, 8, 9N, 10A, 11A, 12F, 153/C, 17F, 20B) being developed by Affinivax/Astellas, and/or the 10-valent pneumococcal conjugate vaccine (CRM197 conjugates, comprising serotypes 1,5, 6A, 6B, 7F, 9V, 14, 19A, 19F, 23F) being developed by Serum Institute of India under the brand name Pneumosil®.

The present invention relates to methods of using an ID pneumococcal composition sequentially with an IM pneumococcal vaccine, which is useful for (3A) inducing a protective immune response against specific serotypes of S. pneumoniae included in the ID pneumococcal composition but not in the IM pneumococcal vaccine, this way broadening/complementing the protection against pneumococcal infection and diseases; (3B) boosting immune responses against specific serotypes at regular time intervals to protect at-risk individuals against pneumococcal diseases; (3C) customizing/adapting pneumococcal immunization programmes by complementing traditional IM pneumococcal vaccines with ID pneumococcal compositions containing the serotypes which are causing IPDs and antimicrobial resistance in a specific country; said method comprising: administering an effective amount of the composition to the shallow skin (epidermis and shallow dermis), and wherein this ID pneumococcal composition is injected sequentially with an IM pneumococcal vaccine.

The present invention also provides an IM pneumococcal vaccine for use in treating or preventing a pneumococcal disease in a subject, wherein the IM pneumococcal vaccine is for sequential administration to a subject who has been administered an ID pneumococcal composition of the present invention.

The IM pneumococcal vaccine may be any IM pneumococcal vaccine, conjugated or not. Preferably, the IM pneumococcal vaccine may be the 23-valent pneumococcal polysaccharide vaccine (PPV23, non-conjugated, comprising serotypes 1, 2, 3,4, 5, 68, 7F, 8, 9V, 9N, 10A, 11A, 12F, 14, 15B, 17F, 180, 19F, 19A, 20, 22F, 23F, 33F) licensed in 1983 and commercialized by Merck & Co Inc. and affiliates under the brand name Pneumovax 23® in some countries, the 10-valent pneumococcal conjugate vaccine absorbed (PCV10, Non-Typeable Haemophilus influenzae (NTHi) protein D, diphtheria and tetanus toxoid conjugates, comprising serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F) licensed in 2008 and commercialized by GlaxoSmithKline Plc. and affiliates under the brand name Synflorix® in some countries, the 13-valent pneumococcal conjugate vaccine (PCV13, CRM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A, 19A) licensed in 2009 and commercialized by Pfizer Inc. and affiliates under the brand name Prevnar 130 in some countries, the 20-valent pneumococcal conjugate vaccine (PCV20, 0RM197 conjugates, comprising serotypes 4, 68, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 8, 10A, 11A, 12F, 15B, 22F, 33F) licensed in 2021 and commercialized by Pfizer Inc. and affiliates under the brand name Prevnar 20® in some countries, the 15-valent pneumococcal conjugate vaccine (PCV15, 0RM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F) licensed in 2021 and commercialized by Merck & Co Inc. and affiliates under the brand name Vaxneuvance® in some countries, the 24-valent pneumococcal conjugate vaccine (P0V24, CRM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F, 2, 8, 9N, 10A, 11A, 12F, 158/C, 17F, 20B) being developed by Merck & Co Inc., the 24-valent pneumococcal conjugate vaccine (PCV24, CRM197 conjugates, comprising serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F, 2, 8, 9N, 10A, 11A, 12F, 158/C, 17F, 20B) being developed by Affinivax/Astellas, and/or the 10-valent pneumococcal conjugate vaccine (CRM197 conjugates, comprising serotypes 1, 5, 6A, 6B, 7F, 9V, 14, WA, 19F, 23F) being developed by Serum Institute of India under the brand name Pneumosil® The invention also relates to the use of an ID pneumococcal composition for increasing the cell-mediated immunity to S. pneumoniae serotypes in a subject previously vaccinated with an IM pneumococcal vaccine, in particular in a subject who is at risk of developing pneumococcal diseases, and in particular for S. pneumoniae serotypes which have a higher correlate of protection compared to other pneumococcal serotypes. The methods of increasing the immune response against specific serotypes in at-risk individuals by administering one or multiple doses of an ID pneumococcal composition of this invention at regular time intervals following the administration of an IM pneumococcal vaccine are collectively referred to herein as "intradermal or ID pneumococcal boosters". This is useful to keep protecting subjects at risk of developing pneumococcal diseases in the long run.

Being able to boost cell-mediated immunity at regular intervals in individuals at increased risk of developing pneumococcal diseases, such as immunocompromised, is important. The mechanisms responsible for the development of immune hyporesponsiveness in infants against specific serotypes following the administration of multiple doses of an IM pneumococcal vaccine are not well understood. Without wishing to be bound by theory, it has been suggested that following the T-cell-dependent response induced by conjugated vaccines, subsequent exposure to polysaccharides induces a T-cell-independent immune response whereby immune memory cells are stimulated but not replenished, resulting in overall depletion of the memory-cell pool and attenuated responses on re-exposure to the same polysaccharide (Granoff and Pollard, 2007). By targeting the higher density and wider variety of potent antigen presenting DC present in the narrow layer beneath the skin surface (e.g., Langerhans cells), ID pneumococcal boosters can help mitigate this issue.

The timing of administration of ID compositions using the methods of the invention depends upon factors well known in the art. After the initial administration, one or more additional doses may be administered if necessary to maintain and/or boost immune responses against S. pneumoniae serotypes. In specific embodiments of the methods of prevention provided herein, the method further comprises allowing an appropriate predetermined amount of time to pass and administering to the patient one or more additional doses of the ID pneumococcal composition using the methods described herein. In said embodiments, one additional dose may be administered to the patient after an appropriate amount of time has passed, alternatively, two, three or four additional doses, each being administered after an appropriate amount of time has passed. One skilled in the art will realize that the amount of time between doses may vary depending on the patient population, dosage of the composition and/or patient compliance. In embodiments of the invention, a time period of about 1 month, about 6 months, about 1 year, about 2 years, about 5 years, about 7 years, about 10 years or about 15 years or more is allowed to pass between administrations of each dose to the patient. In embodiments of this aspect of the invention, the individual is an infant and receives doses at 2, 4, 6 and 12 months of age. In other embodiments, the individual is an adult and receives one dose at 60 or 65 years of age. In additional embodiments, the individual is considered at risk of pneumococcal diseases and receives doses every 5 years. In other embodiments, ID pneumococcal booster doses and IM pneumococcal booster doses are alternated at different time points and in any order as to optimize the level of cell-mediated immunity in at-risk individuals.

The present invention also provides an immunogenic composition for use in eliciting or increasing the immune response in a subject against S. pneumoniae when administered according to the methods herein disclosed.

The immunogens included in the composition may be pneumococcal capsular polysaccharides. In another embodiment, the immunogen may be a protein for simultaneous administration with an IM vaccine to enhance the immune response elicited by the pneumococcal capsular polysaccharides contained in the IM vaccine; preferably wherein the protein is CRM 197.

The pneumococcal polysaccharide serotypes of the composition of the invention may be selected from any S. pneumoniae serotype, for example, S. pneumoniae serotype 1,2, 3, 4, 5, 6A, 6B, 60, 6D, 6E, 6F, 60, 6H, 7F, 7A, 7B, 70, 8, 9A, 9L, 9N, 9V, 10F, 10A, 10B, 100, 11F, 11A, 11B, 110, 11D, 11E, 12E, 12A, 12B, 13, 14, 15F, 15A, 15B, 150, 16F, 16A, 17F, 17A, 18F, 18A, 18B, 180, 19F, 19A, 19B, 190, 20A, 20B, 21, 22F, 22A, 23F, 23A, 23B, 24F, 24A, 24B, 25F, 25A, 27, 28F, 28A, 29, 31, 32F, 32A, 33F, 33A, 33B, 330, 330, 33E, 34, 35F, 35A, 35B, 350, 36, 37, 38, 39,40, 41F, 41A, 42, 43, 44, 45, 46, 47F, 47A, 48, CWPS1, CWPS2, CWPS3.

Thus, the present invention provides immunogenic compositions that may comprise any of the preceding serotypes.

In a preferred embodiment, the pneumococcal polysaccharides of the composition herein disclosed may be selected from the group comprising S. pneumoniae serotypes 3, 19A, 35B and 24F. Alternatively, the pneumococcal polysaccharides of the composition herein disclosed may comprise emergent serotypes of S. pneumoniae or serotypes which are not appropriately controlled by current intramuscular pneumococcal vaccines. Accordingly, the compositions herein disclosed can be adapted in any unique combination to prevent and treat pneumococcal diseases associated with both known and unknown S. pneumoniae serotypes in accordance with the epidemiology and individual patient needs of a particular area.

The pneumococcal polysaccharides of the composition herein disclosed may be conjugated to a carrier molecule. As used herein, the term "carrier molecule" refers to any molecule that serves to improve the selectivity, effectiveness, and/or safety of the composition herein disclosed. In a preferred embodiment, the carrier molecule may be a protein carrier. The protein carrier may be a diphtheria toxin, tetanus toxoid, haemophilus influenza protein D, CRM 197, any other diphtheria toxin mutant or immunologically functional equivalents thereof. Preferably, the protein carrier is CRM 197 and/or haemophilus influenza protein D. The conjugation of a polysaccharide antigen to a protein carrier as described above results in a 1-cell dependent response, high titres of anti-polysaccharide Immunoglobulin G (IgG), immunological memory in infants (Goldblatt et al., 2008), and protection against nasopharyngeal carriage which provides herd immunity to unvaccinated individuals across age groups (IVAC, 2017). The capsular polysaccharide can be linked directly to the carrier molecule, for example, a carrier protein, or through a spacer/linker. Preferably, the conjugation of capsular polysaccharides to carrier proteins is carried out using homo-bifunctional and/or hetero-bifunctional linkers of specific lengths as described in US010688170B2.

The composition herein disclosed may further comprise a pharmaceutically acceptable carrier or excipient. The terms "pharmaceutically or pharmacologically acceptable" refers to molecular entities and compositions that do not produce an adverse, allergic, or other untoward reaction when administered to an animal, such as, for example, a human, as appropriate. Such preparations will be known to those skilled in the art. Moreover, for animal (e.g., human) administration, it will be understood that preparations should meet sterility, pyrogenicity, general safety and purity standards, as applicable.

As used herein, "pharmaceutically acceptable carrier/adjuvant/diluent/excipient" includes any and all solvents, dispersion media, coatings, surfactants, antioxidants, preservatives (e.g., antibacterial agents, antifungal agents), isotonic agents, absorption delaying agents, salts, preservatives, drugs, drug stabilizers, gels, binders, excipients, disintegration agents, lubricants, sweetening agents, flavouring agents, dyes, such like materials and combinations thereof, as would be known to one of ordinary skill in the art (see, for example, Remington's Pharmaceutical Sciences, 18th Ed. Mack Printing Company, 1990, pp. 12891329). Examples include, but are not limited to disodium hydrogen phosphate, soya peptone, potassium dihydrogen phosphate, ammonium chloride, sodium chloride, magnesium sulphate, calcium chloride, sucrose, borate buffer, sterile saline solution (0.9 % NaCI) and sterile water. Preferably, the adjuvant may be an aluminium-based adjuvant, for example, aluminium phosphate, aluminium sulphate and/or aluminium hydroxide.

The composition herein disclosed may be for use in treating or preventing a pneumococcal disease in a subject, the treatment of which may be tailored to the precise needs of the subject in question. The subject in any aspect may be any mammal, such as a human, a dog, a cat, a mouse, a rabbit, a goat, a horse, a cow, a pig, a sheep, or a rat. Preferably, said subject is a human.

The compositions for use herein disclosed elicit serotype-specific IgG antibodies of (D.35 pg/mL in a subject when administered intradermally to the subject according to the methods of the first aspect. Serum serotype-specific IgG levels may be determined via standard methods in the art, for example, an enzyme-linked immunosorbent assay. Preferably, the ELISA used is the ELISA assay validated by the World Health Organisation (WHO, 2013). The compositions for use herein described elicit serum serotype-specific functional antibodies in a subject as determined by opsonophagocytic activity (OPA) with a geometric mean titre (GMT) 1:8. (see Example 5) The compositions for use herein disclosed increase by at least two-fold the immune response, as measured by opsonophagocytic killing activity or immunoglobulin G antibodies, when administered intradermally to the subject according to the methods of the first aspect, for common serotypes present in both the ID and IM compositions (see Example 6).

The compositions for use herein disclosed may be administrated to a subject who has been administered the same composition on at least one previous occasion. Accordingly, the present invention provides for a "prime boost" regimen. For example, most infant pneumococcal immunization programmes in Europe use the 2p + 1 schedule (two primary doses followed by one booster dose) with administrations at 2, 4 and 12 months of age, respectively. In the US, the infant pneumococcal immunization programme uses the 3p + 1 schedule (three primary doses followed by one booster dose) with administrations at 2, 4, 6 and 12 months of age, respectively. Other infant pneumococcal vaccine schedules involving a reduced number of doses (e.g., 1p + 1 in the UK) and/or different ages at administration have been used. In healthy adults, immunization programmes commonly recommend vaccinating at 65 years, although it varies across countries. Furthermore, some subjects may need to receive more than one dose of the composition herein disclosed based on their individual characteristics. Such characteristics include, but are not limited to, age, weight, and any underlying health issues. Underlying health issues include, but are not limited to, asplenia/ dysfunction of the spleen, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic Liver disease, diabetes requiring insulin or oral hypoglycaemic medication, immunosuppression, cochlear implants and cerebrospinal fluid leaks. It is also understood that for some serotypes, a top-up dose of the composition herein disclosed may be necessary. For example, it is envisaged for certain serotypes, for example serotype 3, a booster dose could be needed at regular intervals (e.g., approximately every 5 years).

The amount of a particular glycoconjugate in an immunogenic composition can be calculated based on total polysaccharide for that conjugate (conjugated and non-conjugated). For example, a glycoconjugate with 20% free polysaccharide will have about 80pg of conjugated polysaccharide and about 20pg of nonconjugated polysaccharide in a 100pg polysaccharide dose. The saccharide concentration can be determined by the uronic acid assay.

The production of pneumococcal polysaccharide is based on a working seed lot system. Cultures derived from the working seed lots have the same characteristics as the cultures of the strain from which the master seed lot is derived. A working seed is thawed and expanded in Soy media complemented with Dextrose/Magnesium Sulfate.

S. pneumoniae is a Biosafety Level 2 (BSL-2) pathogen and represents a particular hazard to health through infection by the respiratory route. Accordingly, the organism should be handled under appropriate conditions for this class of pathogen.

As used herein, the term "working seed lot" refers to a quantity of live S. pneumoniae organisms derived from the master seed lot by growing the organisms and maintaining them in aliquots in the freeze-dried form or frozen state at or below -45°C. The working seed lot is used, when applicable, after a fixed number of passages, for the inoculation of production medium. As used herein, the term "master seed lot" refers to a bacterial suspension of S. pneumoniae derived from a strain that has been processed as a single lot and is of uniform composition. It is used for the preparation of the working seed lots. Master seed lots shall be maintained in the freeze-dried form or be frozen below -45°C.

Capsular polysaccharides from individual serotypes of S. pneumoniae are prepared by standard techniques known to those in the art (see WO 2006/110381). The polysaccharides are produced separately by similar processes. The pneumococcal saccharides are routinely produced by fermentation. One vial of the desired serotype is used to start a fermentation batch. Bottles are inoculated with different amounts of seed and incubated until the medium turns yellow. Tests for optical density (OD) and pH are carried out and one of the bottles is selected for inoculation of the seed fermenter. The culture is incubated in the seed fermenter and then in the intermediate fermenter, until the OD has reached an optimum level. The culture is inoculated into the production fermenter and allowed to grow to an endpoint. During fermentation, the following tests are carried out: Gram stain, purity check, OD, pH and Quellung test.

After the organism is killed by lysing the cells with the addition of Sodium Deoxycholate solution (DOC), the culture is harvested and the polysaccharide isolated and purified by techniques such as fractional precipitation, chromatography, enzyme treatment and ultrafiltration (see W08201995, WO 2006/110352, WO 2008/118752, and US 10,702,596). The polysaccharide is partially purified by fractional precipitation, washed, and dried to a residual moisture content shown to favour its stability. Purified pneumococcal polysaccharide and, when necessary, partially purified intermediates are stored at or below -20°C to ensure stability. Purified polysaccharide is filtered using a 0.22pm filter and dispensed into 50L stainless steel drums using a closed system. As used herein, the term "purified polysaccharide" refers to the material obtained after final purification. The lot of purified polysaccharides may be derived from a single harvest or a pool of single harvests processed together, wherein the term "single harvest" refers to the material obtained from one batch of cultures that have been inoculated with the working seed lot (or with the inoculum derived from it), harvested and processed together.

The conjugation method used may be similar to the one employed in the production of conjugate vaccines against Haemophilus influenzae type b; Polysaccharide are oxidized with periodate and the periodate-activated polysaccharide attached to free amino groups on the carrier protein by reductive amination. Alternatively, the polysaccharide can be randomly activated by cyanogen bromide, or a chemically similar reagent; a bifunctional linker is added, which then allows the polysaccharide to be attached to the carrier protein either directly or through a secondary linker (see US486012). In another embodiment, capsular polysaccharides are each covalently coupled to a PEG linker and a carrier protein using the methods described in US 10,729,763 and US 10,688,170.

The conjugation ratio is in the range 0.3-3.0 but varies with the serotype. After achieving optimal conjugation yield, the conjugate is purified by one or more of a variety of techniques known in the art. Unbound polysaccharides are separated using methods such as hydrophobic chromatography, acid precipitation, precipitation with carrier protein-specific antibodies, gel filtration and ultrafiltration. The preferred purification methods are GPC column chromatography, diafiltration, sterile filtration. The purified polysaccharide conjugates are then stored at less than 10°C, preferably below 4°C.

There are many proteins that could potentially be used as carriers in pneumococcal conjugate vaccines. The principal characteristics of the carrier protein should be that it is safe and, in the conjugate, elicits a T-cell-dependent immune response against the polysaccharide. Diphtheria CRM 197 protein is a non-toxic mutant of diphtheria toxin, isolated from cultures of Corynebacterium diphtheriae 0743197 (Giannini et al., 1984). Three frozen stock vials of the working seed are typically used to start a fermentation batch. The content is transferred to soy peptone agar slants, which are inoculated. The purity and identity are checked at the end of cultivation. The contents of each slant are transferred to CY medium and incubated until the OD59onn, reaches an optimum value. Again, purity and identity are checked at the end of the culture. The culture is aseptically inoculated in fermenters filled with sterile CY medium. The fermenter is operated, and samples are taken at approximately 2 hours intervals for determination of OD59onm. The culture is then used to inoculate another fermenter containing CY medium. The culture is tested for purity (colony morphology, growth on enriched media) and identity (Gram stain, latex agglutination test). The fermentation broth is transferred to a harvest tank and cooled. From the tank, the cells are separated from the broth by filtration. The permeate is further filtered through a 0.22pm filter, which is tested for integrity after use. The cell waste is heat sterilized and disposed of. The filtered culture broth is diafiltered against phosphate buffer. The protein is then precipitated through the addition of an appropriate reagent. The precipitated protein is captured on a depth filter and stored at 5°C. The protein is eluted from the filter using phosphate buffer and then again diafiltered. The protein is then further purified by column chromatography. The CRM 197 fraction is concentrated by ultrafiltration and the protein content and purity is tested. A cryoprotectant is added to the CRM 197 solution and agitated. The solution is membrane filtered through a 0.22pm filter and stored in polypropylene bottles at -65°C. CRM 197 solution is lyophilized in preparation for production of certain serotype conjugates. Lyophilized CRM 197 is also stored at -65°C.

The present invention also relates to a method of adapting pneumococcal immunization programmes based on the serotypes causing pneumococcal diseases and/or developing antimicrobial resistance in a specific area or population, which is useful for (5A) targeting the S. pneumoniae serotypes which need to be controlled meanwhile minimizing the serotype replacement observed with broad-spectrum PCVs, (5B) sparing antigens against non-circulating serotypes for when and if they become a burden in the future by avoiding serotype replacement, (50) controlling specific S. pneumoniae serotypes which are developing antibiotic resistance and/or multidrug resistance, this way sparing antibiotics, (5D) reducing the number of serotypes needed in an IM pneumococcal vaccine and this way preventing interferences and a lower immune response against each serotype, or (5E) optimizing the cost-effectiveness and affordability of pneumococcal immunization programmes; said method comprising: complementing an IM pneumococcal vaccine with an ID pneumococcal composition (vaccine complement) which contains the serotypes causing pneumococcal diseases and/or developing antimicrobial resistance in a specific area or population, wherein the ID pneumococcal vaccine complement is liquid and comprises capsular polysaccharides, and wherein the ID pneumococcal vaccine complement is injected with an ID delivery device comprising one or more hollow microneedles for penetrating the skin, wherein the device is adapted for shallow ID delivery of the pneumococcal vaccine complement.

Accordingly, the present invention provides for a series of ID pneumococcal vaccine complements, wherein each ID pneumococcal vaccine complement contains a different immunogenic composition comprising capsular polysaccharides from less than seven S. pneumoniae serotypes and wherein the said compositions comprising different serotypes can be administered together with an IM pneumococcal vaccine to create a "bespoke" vaccination programme. This approach allows public health authorities and healthcare professionals to develop new vaccination strategies to prevent pneumococcal diseases and combat antimicrobial resistance by complementing and adapting their current pneumococcal immunization programmes based on changing local epidemiology and individual patient needs.

The ID pneumococcal vaccine complement for use herein disclosed may be for administration to a subject who has been administered an IM pneumococcal vaccine. Alternatively, the ID pneumococcal vaccine complement for use herein disclosed may be for simultaneous or sequential administration to a subject with an IM pneumococcal vaccine. Accordingly, the ID pneumococcal vaccine complement for use herein may be used as a "booster", intended to strengthen the immune response of a subject against specific serotypes included in an IM pneumococcal vaccine that are circulating to provide stronger protection as needed, or to complement the current immunization programme of a particular area by supplementing the administration of an IM pneumococcal vaccine to provide protection against one or more other S. pneumoniae serotypes not already included in the IM pneumococcal vaccine. Thus, the series of ID pneumococcal vaccine complements provides flexibility for health professionals to respond to outbreaks or epidemics rapidly and with targeted vaccines tailored to the problem serotype of the moment.

In additional embodiments of this invention, the ID pneumococcal composition is administered concomitantly with one or multiple other commonly administered 'standard of care' therapies; or with other vaccines for targeted patient populations, including, for example, a varicella zoster virus (VZV) vaccine such as ZOSTAVAXTm (Merck, Whitehouse Station, N.J.), a hepatitis B (HBV) vaccine such as RECOMBIVAXTm HB (Merck) or ENGERIX-BTM (GlaxoSmithKline Biologicals, Rixensart, Belgium), flu vaccines, measles vaccines, mumps vaccines, rubella vaccines, M MR combined vaccines, poliovirus vaccines, diphtheria vaccines, tetanus toxoid vaccines, acellular pertussis vaccines, DTaP combined vaccines, or haemophilus b conjugate vaccines. Use of the term "concomitant administration" does not require that both or all of the vaccines be administered via ID delivery, just that a second or multiple vaccines are administered to the same patient within the same period of time (e.g., within a 24-hour period). In accordance with the methods of the invention, the pneumococcal composition is delivered to the shallow skin whereas the second or multiple other vaccines may be delivered by ID delivery or by a route of administration that has been shown to be safe and effective for the particular vaccine being administered.

The present invention further provides a first composition for use in treating or preventing a pneumococcal disease in a subject, wherein the first composition has a first set of serotypes, and wherein the first composition is for sequential or simultaneous administration to the subject with a second composition, and wherein the second composition has a second set of serotypes, and wherein the second set of serotypes is different to the first set of serotypes. The first composition and second composition are the composition herein disclosed and described in detail above. Further, the first composition and the second composition may be for sequential or simultaneous administration to the subject with a third composition according to the invention, and wherein the third composition has a third set of serotypes, and wherein the third set of serotypes is different to the first and second sets of serotypes. Further, the first, second and third compositions may be for sequential or simultaneous administration to the subject with a fourth composition according to the invention, and wherein the fourth composition has a fourth set of serotypes, and wherein the fourth set of serotypes is different to the first, second and third sets of serotypes. Thus, the medical use of this aspect may include many other compositions for sequential or simultaneous administration, where each composition has a different set of serotypes. The said compositions can also be combined in the same manner with intramuscular pneumococcal vaccines to complement and optimize immunization programmes as described above.

Accordingly, the present invention provides for a bespoke vaccination programme, tailored to the needs of the specific area and subject. For example, in countries with higher prevalence of serotype 3 in pneumococcal diseases, public health authorities and healthcare professionals could complement Prevnar 13® (Pfizer Inc.) with an ID pneumococcal vaccine complement containing serotype 3 to reach higher concentrations of anti-polysaccharide Immunoglobulin G (IgG) against serotype 3 (correlate of protection -2.83 pg/m L) and increase effectiveness. Each ID pneumococcal vaccine complement (ID injection, 0.1 ml) may be administered with each dose of Prevnar 13® (IM injection, 0.5 ml) in healthy infants and/or adults by using a device adapted for shallow ID delivery. It is understood that the ID pneumococcal vaccine complement containing serotype 3 described above could be substituted or combined with any other ID pneumococcal vaccine complement of the invention, which may contain pneumococcal capsular polysaccharides of either emergent serotypes of S. pneumonia° or serotypes which are not appropriately controlled by current IM pneumococcal vaccines.

Accordingly, the present invention also provides for a method for the prophylactic or therapeutic treatment of a pneumococcal disease in a subject, comprising administering to the subject at least one ID pneumococcal vaccine complement, wherein each ID pneumococcal vaccine complement comprises a different set of pneumococcal capsular polysaccharide serotypes. The invention also provides methods for the prophylactic or therapeutic treatment of a pneumococcal disease in a subject, comprising administering to the subject at least one IM pneumococcal vaccine with, or before or after, administration of an ID pneumococcal composition of the invention.

The determination of which ID pneumococcal vaccine complement to use may be based on official recommendations by public health authorities, taking into consideration the risk of invasive pneumococcal disease and pneumonia in different regions and populations, but it may also be based on health care professionals' recommendation to broaden the coverage afforded by the IM pneumococcal vaccine for some individuals based on age, underlying comorbidities (e.g., immunosuppressed), or employment (e.g., working with young children or elderly).

The present invention represents a shift from the post-WWII vaccination paradigm where vaccine manufacturers would develop, patent, and register a defined combination of antigens for all children in all countries (Poland et al., 2018). Today public health authorities and health care professionals are best placed to make those decisions based on surveillance data and individual patient needs. This shift in control happened successfully years ago in therapeutics and it is needed in pneumococcal vaccines in order to design new prevention strategies against invasive pneumococcal diseases and tackle S. pneumoniae antimicrobial resistance. Providing the right tools to the right people has the potential to significantly improve human health and optimize public health budgets.

Whilst the composition herein disclosed may be administered in combination with an IM pneumococcal vaccine, as described above, the composition may also be administered on its own in outbreak situations where the S. pneumoniae serotype causing the outbreak has been identified and thus tailored to the serotype causing the outbreak.

The present invention provides a kit of parts comprising at least one delivery device adapted for shallow intradermal delivery, the immunogenic composition and/or the pneumococcal vaccine herein disclosed, and instructions for use.

The present invention also discloses the use of an immunogenic composition in the manufacture of a medicament for the treatment or prevention of a Streptococcus pneumoniae infection or a pneumococcal disease in a subject in need thereof, wherein the immunogenic composition is for intradermal administration and comprises at least one pneumococcal polysaccharide and/or an immunogenic protein, wherein the subject has been intramuscularly administered a pneumococcal vaccine.

The present invention also discloses the use of a pneumococcal vaccine in the manufacture of a medicament for the treatment or prevention of a Streptococcus pneumoniae infection or a pneumococcal disease in a subject in need thereof, wherein the pneumococcal vaccine is for intramuscular administration, wherein the subject has been intradermally administered an immunogenic composition, and wherein the immunogenic composition comprises at least one pneumococcal polysaccharide and/or an immunogenic protein.

The immunogenic composition of the present invention may be a monovalent pneumococcal polysaccharide composition, a bivalent pneumococcal polysaccharide composition, a trivalent pneumococcal polysaccharide composition, a quadrivalent pneumococcal polysaccharide composition; or a multivalent pneumococcal polysaccharide composition. Preferably, the pneumococcal polysaccharides of the immunogenic composition are conjugated to CRM 197. In a preferred embodiment, the immunogenic composition may be a trivalent pneumococcal polysaccharide composition or the immunogenic composition may be a quadrivalent pneumococcal polysaccharide composition. Where the immunogenic composition is a trivalent pneumococcal polysaccharide composition, the trivalent pneumococcal polysaccharide composition may consist of capsular polysaccharides from Streptococcus pneumoniae serotype 3, 19A and 35B. Where the immunogenic composition is a quadrivalent pneumococcal polysaccharide composition, the quadrivalent pneumococcal polysaccharide composition may consist of capsular polysaccharides from Streptococcus pneumoniae serotype 3, 19A, 35B and 24F The present invention discloses a method wherein the immunogenic composition may be a trivalent pneumococcal polysaccharide composition, wherein the pneumococcal polysaccharides are conjugated to CRM 197 and wherein the intramuscularly administered pneumococcal vaccine may be a 13-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A and 19A. Preferably, the trivalent pneumococcal polysaccharide composition consists of capsular polysaccharides from Streptococcus pneumoniae serotype 3, 19A and 35B.

The present invention discloses a method wherein the immunogenic composition may be a quadrivalent pneumococcal polysaccharide composition, wherein the pneumococcal polysaccharides are conjugated to CRM 197 and wherein the intramuscularly administered pneumococcal vaccine may be a 13-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A and 19A. Preferably, the quadrivalent pneumococcal polysaccharide composition consists of capsular polysaccharides from Streptococcus pneumonia serotype 3, 19A, 35B and 24F.

The present invention discloses a method wherein the immunogenic composition may be a trivalent pneumococcal polysaccharide composition, wherein the pneumococcal polysaccharides are conjugated to CRM 197 and wherein the intramuscularly administered pneumococcal vaccine may be a 20-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 8, 10A, 11A, 12F, 15B, 22F and 33F. Preferably, the trivalent pneumococcal polysaccharide composition consists of capsular polysaccharides from Streptococcus pneumoniae serotype 3, 19A and 35B.

The present invention discloses a method wherein the immunogenic composition may be a quadrivalent pneumococcal polysaccharide composition, wherein the pneumococcal polysaccharides are conjugated to CRM 197 and wherein the intramuscularly administered pneumococcal vaccine may be a 20-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 8, 10A, 11A, 12F, 15B, 22F and 33F. Preferably, the quadrivalent pneumococcal polysaccharide composition consists of capsular polysaccharides from Streptococcus pneumonia serotype 3, 19A, 358 and 24F All publications mentioned herein are incorporated by reference for the purpose of describing and disclosing methodologies and materials that might be used in connection with the present invention.

Having described preferred embodiments of the invention, it is to be understood that the invention is not limited to those precise embodiments, and that various changes and modifications may be effected therein by one skilled in the art without departing from the scope or spirit of the invention as defined in the appended claims.

Examples

The present invention is further illustrated by the following examples. Examples 1 and 2 The present invention overcomes the first limitation of broad-spectrum PCVs described above and related to IPD serotypes varying by country, population and over time, which makes it impossible for companies to predict future S. pneumoniae epidemiology and include all relevant serotypes into a one-size-fitsall broad-spectrum PCV. The way the present invention solves this limitation is by providing public health authorities (PHAs) and healthcare professionals (HCPs) with a series of ID pneumococcal vaccine complements (ID cPCV), each containing a different set of serotypes, which they can use to complement the IM pneumococcal vaccine already included in their national immunization programme based on current local epidemiology and individual patient needs. With the increased quantity and quality of surveillance data available to PHAs and HCPs' understanding of individual patient needs, PHAs and HCPs are best placed to design flexible, adaptive, efficient, antibiotic-and antigen-sparing prevention programmes.

Example 1

To this date and to our knowledge, serotype 24F has not been included in any IM pneumococcal vaccine on the market or in development. However, its prevalence in IPDs in children has been increasing sharply in Europe in recent years (EU: 10.5%; UK: 7.4%; France: 16.1-21%; GE: 13.4% of IPD cases in < 5 years in 2017) (Levy et al., 2019). The present invention would allow PHAs and HCPs in countries where the incidence of serotype 24F is high to quickly react and complement their current IM pneumococcal vaccine with an ID cPCV containing serotype 24F, preventing around 573IPD cases/year in Europe, mainly in children. In this example, the ID cPCV containing 24F would be administered with PCV13 to healthy infants at 2, 4 and 12 months as part of a national immunization programme in Europe. HCPs would administer the ID cPCV containing 24F (0.1mI) through the use of a delivery device that targets this depth (e.g., MicronJetTM, Nanopass Technologies, Ltd., Nes Ziona, Israel), before or after performing PCV13 IM injection (0.5m1).

Example 2

In a different region, the US, the serotypes 35B has been increasing in IPDs in children and present multiple antibiotic resistance (Kaur et al., 2021). The emergence of multidrug-resistant bacteria for which no vaccines exist, has resulted in high mortality rates with limited or no therapeutic interventions available (Jansen et al., 2018). The present invention would allow PHAs and HCPs in the US to complement their current PCV13 programme with ID cPCV35B/19A/3 (i.e., ID pneumococcal vaccine complement containing serotypes 35B, 19A and 3). In this example, ID cPCV35B/19A/3 would be administered with PCV13 to healthy infants at 2, 4, 6 and 12 months as part of the US national immunization programme. HCPs would administer the ID cPCV35B/19A/3 (0.1mI) through the use of a delivery device that targets this depth (e.g., MicronJetTM, Nanopass Technologies, Ltd., Nes Ziona, Israel), before or after performing PCV13 IM injection (0.5m1).

Examples 3 and 4

The present invention overcomes the second limitation described above of highervalent PCVs accelerating the emergence of serotypes for which there is no vaccine available yet. The way the present invention solves this limitation is the same as what PHAs have recommended for antibiotic use across countries; Instead of systematically vaccinating all children in all countries with the same vaccine containing a large number of serotypes, which may not be circulating in some countries, a customized, more targeted vaccination strategy based on current local needs using ID cPCVs may spare second-line higher-valent vaccines in case those serotypes were to emerge at a later stage. For instance, if only one serotype outside of PCV7 (precursor of PCV13) was currently actively circulating in a specific country, such as for example serotype 19A, a better long-term vaccination strategy may be to complement PCV7 with an ID cPCV containing 19A and spare PCV13 for when and if the other five serotypes become an issue, as we know that implementing PCV13 has been shown to accelerate the emergence of serotypes not included in PCV13.

The present invention mitigates the third limitation described above of lower immune response when increasing the number of polysaccharidic antigens and the load of carrier proteins in broad-spectrum IM PCVs. The way the present invention mitigates this limitation is by providing PHAs and HCPs with more options to design targeted vaccination strategies containing only the antigens that are causing IPDs in a specific country. Although counterintuitive, interferences in the form of antigen competition or carrier-induced epitope suppression could make vaccination strategies containing less antigens more efficient overall than using a higher-valent vaccine because the higher immune response against more prevalent serotypes would have a greater impact on nasopharyngeal carriage and indirect protection (herd immunity) in all age groups. In addition to reducing the total number of polysaccharidic antigens, the present invention further mitigates the risk of interferences as ID cPCVs are administered intradermally using microneedles rather than injected in the muscle like broad-spectrum PCVs. By targeting a different site, the skin, the present invention can indeed minimize potential interferences with the IM PCV and elicit a stronger immune response thanks to the skin's dense network of epidermal Langerhans cells and dermal dendritic cells.

The present invention mitigates the fourth limitation described above of IM PCVs not being able to produce IgG concentrations above the serotype-specific correlates of protection for some serotypes included in their formulation. The way the present invention mitigates this limitation is by providing PHAs and HCPs with ID cPCVs that can be used to boost the immune response against specific S. pneumoniae serotypes. As demonstrated in the following examples, higher IgG concentrations can be achieved by using cPCVs simultaneously with IM pneumococcal vaccines.

Example 3

S. pneumonia° serotype 3 is the first cause of IPDs across regions and age groups. Although PCV13 includes serotype 3, its efficacy, duration and herd immunity are limited (Linley et al., 2019). Studies have shown that this lack of efficacy was not due to hyporesponsiveness (Sings et al., 2021), but rather to the thickness and/or density of the polysaccharide capsule and the release of free capsular polysaccharide during growth (Linley et al., 2019). This is aligned with the study of Andrews et al. which suggests that the current correlate of protection used for registration (i.e. 0.35 pg/mL) is more than eight-fold too low for serotype 3 (Andrews et al., 2014). The present invention would allow PHAs and HCPs in the US to boost the current PCV13 programme with ID cPCV35B/19A/3. In this example, ID cPCV35B/19A/3 would be administered with PCV13 to healthy infants at 2, 4, 6 and 12 months as part of the US national immunization programme. HCPs would administer ID cPCV35B/19A/3 (0.1mI) before or after performing PCV13 IM injection (0.5m1) according to the first aspect of this invention. As demonstrated herein, this method of use is able to achieve anti-polysaccharide IgG concentrations closer to 2.83 pg/mL which is the correlate of protection specific to serotype 3 (Andrews et al., 2014).

Example 4

In another example of the present invention, ID cPCV35B/19A/3 could be administered to adults at 65 years in combination with PPV23 as serotype 3 is responsible for an even larger number of IPDs and pneumonia in adults. In this case, only one dose of ID cPCV35B/19A/3 (0.1mI) would be administered, before or after performing PPV23 IM injection (0.5m1) during the same visit.

The present invention overcomes the fifth limitation described above of increased manufacturing costs, timeline and probability of quality control failure which can lead to vaccine supply shortages. The invention overcomes this limitation as ID cPCVs contain less serotypes and are simpler to manufacture than broad-spectrum IM pneumococcal vaccines. This way, with the increased pressure on public health budget, PHAs and HCPs can design new, more efficient vaccination strategies against pneumococcal diseases and antimicrobial resistance that could provide the same or more health benefits at a lower cost compared to highervalent pneumococcal vaccines.

Example 5

We conducted a blinded randomized immunisation animal study involving three groups of New Zealand White Rabbits (NZWR). Group 1 (G1, control group 1, n = 10) was administered two doses of IM PCV13 (0.5 ml) [IM(PCV13)] at Day 0 and Day 21; On Day 42 this group was dived into two smaller groups and received either a further dose of IM PCV13 (0.5 ml) (G1A, n = 5) or one dose of ID cPCV35B/19A/3 (0.1 ml) (G1B, n = 5). Group 2 (G2, control group 2, n = 10) received two IM injections at Day 0 and Day 21, each injection containing both PCV13 and cPCV35B/19A/3 (0.6 ml) [IM(PCV13+cPCV35B/19A/3)]. Group 3 (G3, experimental group, n = 10) was administered two doses of IM PCV13 (0.5 ml) at Day 0 and Day 21, each time simultaneously with ID cPCV35B/19A/3 (0.1 ml) [I M(PCV13) + ID(cPCV35B/19A/3)]. Blood samples were collected 14 days after vaccine administration (FIG. 1). Shallow ID delivery was performed using the MicronJet600TM (NanoPass Technologies Ltd.) needle hub. The MicronJet600TM is intended to be used as a substitute for a regular needle in procedures that require intradermal injections. The MicronJet600TM is a sterile plastic device equipped with 3 microneedles, each 600 micrometres (0.6 mm) in length. This device can be mounted on a syringe instead of a standard needle (FIG. 2). IM delivery was performed using a needle and syringe.

Injections were administered in the hind limb quadriceps muscle of the rabbits. In Group 3, the IM PCV13 was administered in one leg and the ID cPCV35B/19A/3 was administered on the opposite leg.

PCV13 (Prevnar13O) was purchased commercially. Per the manufacturer's product insert, each 0.5 mL IM dose of the vaccine is formulated to contain approximately 2.2pg of each of S. pneumoniae serotypes 1, 3, 4, 5, 6A, 7F, 9V, 14, 180, 19A, 19F, 23F saccharides, 4.4pg of 6B saccharides, 34pg 0RM197 carrier protein, 100pg polysorbate 80, 295pg succinate buffer and 125pg aluminium as aluminium phosphate adjuvant.

Each 0.1 ml ID dose of cPCV35B/19A/3 is formulated to contain approximately 2.2pg of each of S. pneumoniae serotypes 35B, 19A, 3 saccharides, 6.3pg CRM197 carrier protein, 5.0pg polysorbate 80, 77.58pg of L-Histidine and 219.15pg of sodium chloride, and no aluminium adjuvant.

The main objectives of the study were to demonstrate that ID cPCV35B/19A/3 co-administered with PCV13 could (1) elicit a strong immune response against ST35B (not included in PCV13), (2) significantly increase the immune response against ST19A and ST3 (included in PCV13), and (3) maintain a high immune response against PCV13-only serotypes.

The immune response at Post Dose 1 (PD1, Day 14) and Post Dose 2 (PD2, Day 35) in the 3 groups were measure using OPA and ELISA assays. The serotypespecific opsonophagocytic killing activity of sera was reported as geometric mean titre (GMT ± 90°/0C1). The OPA titre represents the dilution of the immune serum killing 50% of the target bacteria. Assay results below the LLOQ were set to 0.5 x LLOQ in the analysis. LLOQ = <8. The anticapsular IgG antibody geometric mean concentration (GMC) in pg/mL (± 90% Cl) was determined by Multiplex Bead based ELISA Assay and standardized ELISA assays. Serotype-specific CPA and ELISA geometric means and 2-sided 90% confidence intervals from each group were calculated based on the assay results in natural log scale and then exponenfiafing the results following the Student's t distribution.

For all subjects, whether receiving shallow ID or IM administration, the site staff administering the composition immediately assessed leakage at each injection site. Leakage was categorized by the amount of fluid leakage, based on a visual assessment. For subjects with more than one injection, the assessment was completed for each injection site. No significant leakage was observed during the study.

There was no statistical imbalance in baseline mean ELISA concentrations between the three groups (FIG. 5-6).

Serotype-specific CPA GMTs showed strong increases in the functional killing of S. pneumoniae serotype 35B by cPCV35B/19/3-induced anti-CPS35B antibodies in G3 at PD1 (GMT=142.20; 90%C1=91.62-220.69) and PD2 (GMT=628.93; 90%C1=444.84-889.21), which correspond to a 27.1-fold (p-va/ue<0.0001) and a 55.1-fold (p-va/ue<0.0001) increase compared with G1, respectively (FIG. 3-4).

Anti-CPS35B ELISA GMCs showed that ID-delivered cPCV35B/19A/3 in G3 elicited a strong immune response at PD1 (GMC=0.97pg/mL; 90%CI=0.67-1.42) and PD2 (GMC=3.43pg/mL; 90%C1=2.07-5.69), which correspond to a 5.3-fold (p-va/ue=0.0004) and a 18.7-fold (p-va/ue<0.0001) increase compared with G1, respectively (FIG. 5-6).

Geometric mean fold rise (GMFR) in CPA titres from PD2 to PD3 in G1B was 36.56 (90%C1=12.32-108.46) against S135B after only one dose of cPCV35B/19/3 administered intradermally on its own (p-va/ue=0.0015) (FIG. 910).

Geometric mean fold rise (GMFR) in ELISA concentrations from PD2 to PD3 in GIB was 6.46 (90%C1=5.55-7.52) against ST35B after only one dose of cPCV35B/19/3 administered intradermally on its own (p-va/ue<0.0001) (FIG. 1112).

Example 6

Methods are as described in Example 5.

Serotype-specific CPA GMTs demonstrated a significant increase in the functional killing of S. pneumoniae serotype 19A by anticapsular polysaccharide antibodies elicited by the simultaneous administration of ID cPCV35B/19A/3 and IM PCV13 (G3: GMT=2776.42; 90%C1=2033.78-3790.24) compared with IM PCV13 alone (G1: GMT=851.78; 90%C1=491.39-1476.50), which corresponds to a 3.3-fold increase (p-vaThe<0.0067) (FIG. 3-4).

Serotype-specific CPA GMTs demonstrated a significant increase in the functional killing of S. pneumoniae serotype 3 by anticapsular polysaccharide antibodies elicited by the simultaneous administration of ID cPCV35B/19A/3 and IM PCV13 (G3: GMT=371.73; 90%C1=259.88-531.72) compared with IM PCV13 alone (G1: GMT=159.70; 90%C1=101.89-250.33), which corresponds to a 2.3-fold increase (p-va/ue<0.0268) (FIG. 3-4).

Serotype-specific ELISA GMCs confirmed CPA results with significant increases in the concentration of anti-CPS19A and anti-CPS3 antibodies in G3 compared with G1 (FIG. 5-6).

Furthermore, we demonstrated in the current study that this increase in CPA GMTs and ELISA GMCs between G3 and G1 was not due to an increase in the quantity of capsular polysaccharides or CRM 197 in 03 by administering the exact same quantities as one intramuscular injection in G2. Indeed, results in FIG. 3-4 for CPA and in FIG. 5-6 for ELISA show that the immune response in G2 is not different than the immune response in G1 for serotype 19A and 3, and that the immune response in 03 is also statistically superior compared with G2. Therefore, we conclude that the simultaneous administration of cPCV35B/19A/3 according to the first aspect of the invention goes beyond the dose-response relationship afforded by I M PCVs and is the only source of superior immune response.

Example 7

Methods are as described in Example 5.

ELISA GMCs elicited by PCV13-only capsular polysaccharides (not included in cPCV35B/19A/3) were evaluated to ensure that the co-administration of vaccine complements according to the first aspect of the invention does not impact the immune response elicited by those polysaccharides. Surprisingly, our study shows that, to the contrary, the simultaneous ID administration of cPCV35B/19A/3 is also increasing the antibody concentrations elicited by IM PCV13-only polysaccharides. For all PCV13-only serotypes, GMCs in 03 were numerically superior compared with G1 and 52, and this difference was statistically significant for ST1, 5T4, ST6A, ST7F ST9V, ST18C at P01 or P02 (FIG. 7-8). Among PCV13-only serotypes, only ST1 and ST5 were evaluated by OPA; ST1 showed a statistical increase compared with Si and 02, and ST5 showed a numerical increase (FIG. 3-4). No numerical trend was observed between G1 and G2 in FIG 7-8, suggesting limited interferences between the conjugates of PCV13 and cPCV358/19A/4 when administered as one IM injection. This could be due to the differences in their conjugation method and/or the relatively low quantities of polysaccharides and CRM 197 contained in cPCV35B/19A/3.

This cross-serotype booster effect of ID cPCV35B/19A/3 when administered according to the first aspect is especially welcome considering the decreasing trend in serotype-specific immune response observed between PCV7 and PCV13 (Yeh et al., 2010), and again observed between PCV13 and PCV20 (Essink et al., 2021; Fitz-Patrick et al., 2021).

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Cohen, 0., Knoll, M., O'Brien, K., Farrar, J., Pilishvili, T., Whitney, C., others, 2017. Pneumococcal conjugate vaccine (PCV) review of impact evidence (PRIME).

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Claims (25)

1. CLAIMS1. A method of preventing or treating a Streptococcus pneumoniae infection or a pneumococcal disease in a subject, the method comprising the steps of.i) intradermally administering an immunogenic composition to the subject, said immunogenic composition comprising at least one pneumococcal polysaccharide or at least one immunogenic protein; and ii) administering a pneumococcal vaccine to the subject.
2. 2. The method of claim 1, wherein the immunogenic composition is administered to the epidermis or the dermis of the subject at a depth of between 100 and 700 microns, preferably wherein the depth is between 100 and 600 microns.
3. 3. The method of claim 1 or 2, wherein the immunogenic composition is administered simultaneously with the pneumococcal vaccine, or wherein the immunological composition is administered sequentially either prior to or after administration of the pneumococcal vaccine.
4. 4. The method according to any one of claims 1 to 3, wherein the pneumococcal disease is invasive or non-invasive, preferably wherein the invasive pneumococcal disease is meningitis, bacteraemia and/or pneumonia, and wherein the non-invasive pneumococcal disease is acute otitis media and/or sinusitis
5. 5. The method according to any one of claims 1 to 4, wherein the at least one pneumococcal polysaccharide of the immunogenic composition is selected from the group comprising Streptococcus pneumoniae serotype 1, 2, 3, 4, 5, 6A, 6B, 60, 6D, 6E, 6F, 6G, 6H, 7F, 7A, 7B, 70, 9A, 9L, 9N, 9V, 10F, 10B, 100, 11F, 11B, 110, 11D, 11E, 12A, 128, 13, 14, 15F, 15A, 16F, 16A, 17F, 17A, 18F, 18A, 18B, 180, 19F, 19A, 193, 190, 20A, 203,21, 22A, 23F, 23A, 233, 24F, 24A, 24B, 25F, 25A, 27, 28F, 28A, 29, 31, 32F, 32A, 33A, 33B, 330, 33D, 33E, 34, 35F, 35A, 35B, 350, 36, 37, 38, 39, 40, 41F, 41A, 42, 43, 44, 45, 46, 47F, 47A, 48, CWPS1, CWPS2, CWPS3, or any combination thereof; preferably wherein the at least one pneumococcal polysaccharide of the immunogenic composition is selected from the group comprising Streptococcus pneumoniae serotype 3, 19A, 35B, 24F, or any combination thereof
6. 6. The method of claim 5, wherein the at least one pneumococcal polysaccharide of the immunogenic composition is conjugated to a carrier molecule.
7. 7. The method of claim 6, wherein the carrier molecule is a protein carrier, preferably wherein the protein carrier is diphtheria toxin, tetanus toxoid, haemophilus influenza protein D, CRM 197, any other diphtheria toxin mutant or immunologically functional equivalents thereof, preferably wherein the protein carrier is CRM 197 and/or haemophilus influenza protein D.
8. 8. The method according to any one of claims 1 to 4, wherein the at least one immunogenic protein of the immunogenic composition is selected from the group comprising diphtheria toxin, tetanus toxoid, haemophilus influenza protein D, CRM 197, any other diphtheria toxin mutant or immunologically functional equivalents thereof, or any combination thereof; preferably wherein the immunogenic protein is CRM 197.
9. 9. The method according to any one of claims 1 to 8, wherein the pneumococcal vaccine is a pneumococcal conjugate vaccine.
10. 10. The method according to any one of claims 1 to 9, wherein the pneumococcal vaccine is administered intramuscularly.
11. 11. The method according to claim 10, wherein the intramuscular pneumococcal vaccine is i) a 23-valent pneumococcal polysaccharide vaccine consisting of serotypes 1, 2, 3,4, 5, 68, 7F, 8, 9V, 9N, 10A, 11A, 12F, 14, 158, 17F, 180, 19F, 19A, 20, 22F, 23F and 33F; ii) a 10-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1,5 and 7F; iii) a 13-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A and 19A; iv) a 20-valent pneumococcal conjugate vaccine consisting of serotypes 4, 68, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 8, 10A, 11A, 12F, 15B, 22F and 33F; v) a 15-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1,5, 7F, 3, 6A, 19A, 22F and 33F; vi) a 24-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 22F, 33F, 2, 8, 9N, 10A, 11A, 12F, 158/C, 17F and 20B; vii) a 24-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14180, 19F, 23F, 1,5, 7F, 3, 6A, 19A, 22F, 33F, 28, 9N, 10A, 11A, 12F, 158/C, 17F and 208; and/or viii) a 10-valent pneumococcal conjugate vaccine consisting of serotypes 1, 5, 6A, 6B, 7F, 9V, 14, 19A, 19F and 23F.
12. 12. The method according to any one of claims 1 to 11, wherein the immunogenic composition is a liquid formulation or a dried formulation.
13. 13. The method according to any one of claims 1 to 12, wherein the immunogenic composition increases the immune response in the subject elicited by at least one of the capsular polysaccharides contained in the pneumococcal vaccine by at least two-fold, as measured by opsonophagocyfic killing activity and/or immunoglobulin G antibodies.
14. 14. The method according to any one of claims 1 to 13, wherein the immunogenic composition further comprises a pharmaceutically acceptable carrier or excipient.
15. 15. The method according to any one of claims 1 to 14, wherein the immunogenic composition elicits serum serotype-specific immunoglobulin G antibodies of 0.35 pg/mL and/or opsonophagocytic killing activity of 1:8 in the subject.
16. 16. The method according to any one of claims 1 to 7, or claims 9 to 15, wherein the immunogenic composition is a monovalent pneumococcal polysaccharide composition, a bivalent pneumococcal polysaccharide composition, a trivalent pneumococcal polysaccharide composition, a quadrivalent pneumococcal polysaccharide composition, or a multivalent pneumococcal polysaccharide composition.
17. 17. The method according to any one of claims 1 to 7, or claims 9 to 16, wherein the immunogenic composition is a monovalent pneumococcal polysaccharide composition, a bivalent pneumococcal polysaccharide composition, a trivalent pneumococcal polysaccharide composition, a quadrivalent pneumococcal polysaccharide composition; or a multivalent pneumococcal polysaccharide composition, wherein the pneumococcal polysaccharides are conjugated to CRM 197.
18. 18. The method according to any one of claims 1 to 7, or claims 9 to 17, wherein the immunogenic composition is a trivalent pneumococcal polysaccharide composition or a quadrivalent pneumococcal polysaccharide composition, wherein the pneumococcal polysaccharides are conjugated to CRM 197.
19. 19. The method of claim 18, wherein the trivalent pneumococcal polysaccharide composition consists of capsular polysaccharides from Streptococcus pneumoniae serotype 3, 19A and 358
20. 20. The method of claim 18, wherein the quadrivalent pneumococcal polysaccharide composition consists of capsular polysaccharides from Streptococcus pneumoniae serotype 3, 19A, 358 and 24F.
21. 21. The method according to any one of claims 18 to 20, wherein the intramuscularly administered pneumococcal vaccine is a 13-valent pneumococcal conjugate vaccine consisting of serotypes 4, 6B, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A and 19A, or a 20-valent pneumococcal conjugate vaccine consisting of serotypes 4, 68, 9V, 14, 180, 19F, 23F, 1, 5, 7F, 3, 6A, 19A, 8, 10A, 11A, 12F, 15B, 22F and 33F
22. 22. An immunogenic composition for use in the treatment or prevention of a Streptococcus pneumoniae infection or a pneumococcal disease in a subject in need thereof, wherein the immunogenic composition is for intradermal administration and comprises at least one pneumococcal polysaccharide or an immunogenic protein, wherein the subject has been administered a pneumococcal vaccine; and preferably, wherein the pneumococcal vaccine was administered intramuscularly.
23. 23. A pneumococcal vaccine for use in the treatment or prevention of a Streptococcus pneumoniae infection or a pneumococcal disease in a subject in need thereof, wherein the subject has been intradermally administered an immunogenic composition, and wherein the immunogenic composition comprises at least one pneumococcal polysaccharide or an immunogenic protein; and, preferably, wherein the pneumococcal vaccine is for intramuscular administration.
24. 24. The immunogenic composition for use according to claim 22, or the pneumococcal vaccine for use according to claim 23, wherein the immunogenic composition is an immunogenic composition according to any one of claims 1 to 21; and/or wherein the pneumococcal vaccine is a pneumococcal vaccine according to any one of claims 1 to 21.
25. 25. A kit of parts comprising at least one delivery device adapted for shallow intradermal delivery, the immunogenic composition and/or the pneumococcal vaccine according to any one of claims 1 to 21, and instructions for use.