Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K39/12—Viral antigens
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
  • A61P31/12—Antivirals
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
  • A61P31/12—Antivirals
  • A61P31/14—Antivirals for RNA viruses
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/51—Medicinal preparations containing antigens or antibodies comprising whole cells, viruses or DNA/RNA
  • A61K2039/525—Virus
  • A61K2039/5254—Virus avirulent or attenuated
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/51—Medicinal preparations containing antigens or antibodies comprising whole cells, viruses or DNA/RNA
  • A61K2039/525—Virus
  • A61K2039/5256—Virus expressing foreign proteins
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/545—Medicinal preparations containing antigens or antibodies characterised by the dose, timing or administration schedule
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/70—Multivalent vaccine
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12N—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA
  • C12N2770/00—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA ssRNA viruses positive-sense
  • C12N2770/00011—Details
  • C12N2770/24011—Flaviviridae
  • C12N2770/24111—Flavivirus, e.g. yellow fever virus, dengue, JEV
  • C12N2770/24134—Use of virus or viral component as vaccine, e.g. live-attenuated or inactivated virus, VLP, viral protein
• • Y—GENERAL TAGGING OF NEW TECHNOLOGICAL DEVELOPMENTS; GENERAL TAGGING OF CROSS-SECTIONAL TECHNOLOGIES SPANNING OVER SEVERAL SECTIONS OF THE IPC; TECHNICAL SUBJECTS COVERED BY FORMER USPC CROSS-REFERENCE ART COLLECTIONS [XRACs] AND DIGESTS
  • Y02—TECHNOLOGIES OR APPLICATIONS FOR MITIGATION OR ADAPTATION AGAINST CLIMATE CHANGE
  • Y02A—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE
  • Y02A50/00—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE in human health protection, e.g. against extreme weather
  • Y02A50/30—Against vector-borne diseases, e.g. mosquito-borne, fly-borne, tick-borne or waterborne diseases whose impact is exacerbated by climate change

Definitions

• This invention relates to vaccination against dengue virus infection.
• Dengue a disease caused by four distinct species of dengue virus (named as serotypes 1-4), is the most important vector-borne disease of humankind. Approximately 100 million persons are affected by dengue viruses annually in tropical and subtropical regions of the world (Halstead, "Epidemiology of Dengue and Dengue Hemorrhagic Fever," CABI Publ., New York, pp. 23-44, 1997; Gubler,
• DHF dengue virus serotype
• the pathogenesis of DHF drives the design of dengue vaccines.
• DHF is an immunopathological disease, which occurs primarily in individuals who have sustained a prior infection with one dengue serotype and then are exposed to a second, different (heterologous) serotype. Infection with any one of the four serotypes of dengue provides durable immunity to that homologous serotype, based on neutralizing antibodies. However, immunity to other, heterologous dengue serotypes following infection with one dengue serotype is of short duration, if it occurs at all (Sabin, Am. J. Trop. Med. Hyg. 1:30-50, 1952). Typically, after a few weeks or months, only binding and not neutralizing antibodies to heterologous serotypes are present. These binding but non-neutralizing antibodies may enhance subsequent infection with a heterologous dengue virus serotype, increasing the risk of severe disease (Rothman et al., Virology 257:1-6, 1999).
• the method of the present invention which uses an immunization regimen comprising the administration of a first yellow fever vaccine followed by the administration of a chimeric flavivirus-based dengue vaccine, allows the induction of a cross-neutralizing immune response against dengue viruses, which presents the advantages of appearing early (within 30 days) after the administration of the dengue vaccine, being long-lasting, and being cross-reactive against the four serotypes. Furthermore, the method of the present invention presents the additional benefit of inducing a protective immune response against yellow fever. Price et al. (Am. J. Epid.
• Kanesa-thasan et al. (Am. J. Trop. Med. Hyg. 69(Suppl 6):32-38, 2003) discovered boosted heterologous responses and anti-dengue antibody titers in subjects remotely vaccinated with YF following vaccination with attenuated dengue vaccines. These short-term (to day 30) antibody responses were demonstrated with antibody assays including neutralization, but the authors concluded that evidence for protection against subsequent dengue infection was inconclusive. Unlike the present invention, the authors could not demonstrate conclusively the prior timing or receipt of YF vaccination, long-term broad neutralization antibody responses, or provide evidence for cross-reative T cell responses to dengue.
• the present invention provides a method of inducing a long-lasting, cross- neutralizing immune response to dengue virus in a patient, comprising administering to the patient: (i) one dose of a yellow fever virus vaccine, and
• a chimeric flavivirus vaccine comprising at least one chimeric flavivirus comprising a yellow fever virus backbone in which the sequence encoding envelope protein of the yellow fever virus have been replaced with a sequence encoding the envelope protein of a dengue virus, wherein the chimeric flavivirus vaccine is administered at least 30 days and up to 10 years after administration of the yellow fever vaccine.
• the dengue envelope sequence is a shuffled sequence.
• the chimeric flavivirus comprises a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue virus.
• either or both of these dengue sequences are shuffled sequences.
• the chimeric flavivirus vaccine is administered to the patient 30, 60, or 90 days after administration of the yellow fever vaccine.
• the chimeric flavivirus used in the dengue vaccine of the invention is composed of a yellow fever 17D (YF 17D) virus backbone.
• YF 17D yellow fever 17D
• the yellow fever virus vaccine used in the method of the invention comprises a YF17D strain.
• the chimeric flavivirus vaccine used in the method of the invention comprises one chimeric flavivirus comprising a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 1 virus.
• the chimeric flavivirus vaccine used in the method of the invention comprises one chimeric flavivirus comprising a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 2 virus.
• the chimeric flavivirus vaccine used in the method of the invention comprises one chimeric flavivirus comprising a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 3 virus.
• the chimeric flavivirus vaccine used in the method of the invention comprises one chimeric flavivirus comprising a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 4 virus. .
• the chimeric flavivirus vaccine used in the method of the invention is a monovalent vaccine or a tetravalent vaccine.
• the method of the invention further comprises the administration of a booster dose of the above-defined chimeric flavivirus vaccine, 6 months to 10 years after the first dose of the chimeric flavivirus vaccine.
• the present invention concerns a kit comprising:
• a chimeric flavivirus vaccine comprising at least one chimeric flavivirus comprising a yellow fever virus backbone in which the sequence encoding the envelope protein of the yellow fever virus has been replaced with the sequence encoding the envelope protein of a dengue virus.
• the dengue envelope sequence is a shuffled sequence.
• the chimeric flavivirus comprises a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue virus.
• either one or both of these dengue sequences are shuffled sequences.
• the yellow fever virus vaccine comprises a YF17D strain, wherein YF17D comprises a number of substrains used for vaccination against yellow fever (including 17D-204, 17D-213, and 17DD).
• the chimeric flavivirus is composed of a YF17D virus backbone.
• the chimeric flavivirus vaccine comprises one chimeric flavivirus comprising a YFl 7D virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 1 virus.
• the chimeric flavivirus vaccine comprises one chimeric flavivirus comprising a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow YF17D virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 2 virus.
• the chimeric flavivirus vaccine comprises one chimeric flavivirus comprising a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the YF17D virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 3 virus.
• the chimeric flavivirus vaccine comprises one chimeric flavivirus comprising a YF17D virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with sequences encoding the membrane and envelope proteins of a dengue serotype 4 virus.
• the kit as defined above further comprises at least one booster dose of a chimeric flavivirus vaccine as defined above.
• the invention concerns the use of the viruses noted above and elsewhere herein in the prevention and treatment of dengue virus infection, as well as the use of these viruses in the preparation of medicaments for this purpose. Definitions
• cross-neutralizing immune response we mean a specific immune response comprising neutralizing antibodies against multiple (up to 4) different dengue serotypes. Induction of a cross-neutralizing immune response can be easily determined by a reference plaque reduction neutralization assay (PRNTso). For example, induction of a cross- neutralizing immune response can be determined by one of the PRNTso assays as described in Example 1. A serum sample is considered to be positive for the presence of cross- neutralizing antibodies when the neutralizing antibody titer thus determined is at least superior or equal to 1 :10 in at least one of these assays.
• long-lasting immune response we mean a positive cross-neutralizing immune response as defined above, which can be detected in human serum at least 6 months, advantageously, at least 12 months after the administration of a chimeric flavivirus vaccine as defined below.
• patient we mean yellow fever-na ⁇ ve individuals including adults and children.
• yellow fever naive individuals we mean individuals with no documented vaccination against yellow fever for more than 10 years and/or no certified yellow fever virus infection for more than 10 years.
• yellow fever immune individuals we thus mean, within the framework of the present invention, individuals with a documented vaccination against yellow fever and/or with a certified yellow fever virus infection that has occurred 10 years ago or less, e.g., 5 years or less, e.g., 4, 3, 2, or 1 years ago, or even 6, 5, 4, 3, or 2 months ago, and in any case more than 30 days ago.
• chimeric flavivirus we mean a chimeric flavivirus composed of a yellow fever virus backbone in which the sequence encoding the envelope protein of the yellow fever virus has been replaced with the sequence encoding the envelope protein of a dengue virus.
• a chimeric flavivirus is composed of a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with the sequences encoding the membrane and envelope proteins of a dengue virus.
• the yellow fever backbone can advantageously be from a vaccine strain, such as YF17D or YF 17DD.
• chimeric flaviviruses are defined in more detail below and are named YF/dengue-N, with N identifying the dengue serotype.
• chimeric flavivirus vaccine we mean an immunogenic composition comprising an immunoeffective amount at least one chimeric flavivirus as defined above and a pharmaceutically acceptable excipient.
• the chimeric flavivirus vaccine is said to be "monovalent" when the vaccine comprises one chimeric flavivirus expressing protein(s) of one dengue serotype.
• monovalent vaccines are vaccines comprising YF/dengue-1, YF/dengue-2, YF/dengue- 3, or YF/dengue-4, advantageously YF/dengue-2.
• the chimeric flavivirus vaccine is said to be "bivalent" when the vaccine comprises chimeric flaviviruse(s) expressing protein(s) of two different dengue serotypes.
• bivalent vaccines are vaccines comprising YF/dengue-2 and YF/dengue-4, or YF/dengue-2 and YF/dengue-3, or YF/dengue-2 and YF/dengue-1.
• the chimeric flavivirus vaccine is said to be "trivalent” when the vaccine comprises chimeric flaviviruse(s) expressing protein(s) of three different dengue serotypes.
• trivalent vaccines are vaccines comprising YF/dengue-2, YF/dengue-1, and YF/dengue-4, or YF/dengue-2, YF/dengue-3, and YF/dengue-4.
• the chimeric flavivirus vaccine is said to be "tetravalent” when the vaccine comprises chimeric flaviviruse(s) expressing protein(s) of four different dengue serotypes.
• An example of a tetravalent vaccine is a vaccine that includes YF/dengue-1, YF/dengue-2, YF/dengue-3, and YF/dengue-4.
• immunoeffective amount of a chimeric flavivirus we mean an amount of chimeric flavivirus capable of inducing, after administration in a yellow fever immune individual, a cross-neutralizing immune response as defined above.
• an immunoeffective amount of a chimeric flavivirus is comprised of between 10 and 10 , e.g., between 10 3 and 10 6 , such as an amount of 10 4 , 10 5 , or 10 6 , infectious units (e.g., plaque-forming units or tissue culture infectious doses) per serotype, per dose.
• infectious units e.g., plaque-forming units or tissue culture infectious doses
• a central advantage of the method of the present invention is the ability to induce neutralizing antibodies against all four dengue serotypes quickly and simultaneously, thereby protecting against dengue fever and thus avoiding the potential associated risks of developing dengue hemorrhagic fever on subsequent natural exposure to dengue infection.
• Neutralizing antibodies directed against the dengue envelope protein are considered the principal mediator of protective immunity against infection, therefore the demonstration of neutralizing antibodies is considered as a relevant surrogate of a neutralizing immunity in patients.
• Fig. 1 is a graph showing IFN ⁇ responses to vaccine (study Day 31 minus Day 1). The two doses of ChimeriVaxTM-Den2 gave equivalent T cell responses. The response was not inhibited in subjects previously vaccinated with yellow fever virus vaccine.
• the invention provides a method for inducing in a patient long-lasting, cross- neutralizing immunity to all four dengue serotypes (1-4) using a simple, two-step procedure.
• the targeted population is thus composed especially of the following patients at risk of dengue infection: foreign travelers, expatriate and military personnel, as well as inhabitants of regions in which dengue is endemic.
• a patient is first immunized with a dose (preferably one dose, but possibly more than one dose (e.g., 2 or 3 doses)) of a yellow fever virus vaccine (e.g., a commercially available, live attenuated vaccine; see below).
• a dose preferably one dose, but possibly more than one dose (e.g., 2 or 3 doses)
• a yellow fever virus vaccine e.g., a commercially available, live attenuated vaccine; see below.
• the second step of the method involves administration of one dose of a chimeric flavivirus vaccine comprising one or more live, attenuated chimeric viruses, each comprising a yellow fever virus backbone in which one or more sequences encoding structural proteins (e.g., pre-membrane and envelope proteins) have been replaced with the sequences encoding the corresponding proteins of a dengue virus (e.g., dengue 1, 2, 3, or 4).
• structural proteins e.g., pre-membrane and envelope proteins
• dengue virus e.g., dengue 1, 2, 3, or 4
• the first step of the method of the invention involves administration to a patient of one dose of a yellow fever virus vaccine.
• vaccines that can be used in the invention include live, attenuated vaccines, such as those derived from the YF17D strain, which was originally obtained by attenuation of the wild-type Asibi strain (Smithburn et al., "Yellow Fever Vaccination," World Health Organization, p. 238, 1956; Freestone, in Plotkin et al. (eds.), Vaccines, 2 nd edition, W.B. Saunders, Philadelphia, U.S.A., 1995).
• YF17D strain from which vaccines that can be used in the invention can be derived is YFl 7D-204 (YF-VAX ® , Sanofi-Pasteur, Swiftwater, PA, USA; Stamaril ® , Sanofi-Pasteur, Marcy- L'Etoile, France; ARILVAXTM, Chiron, Speke, Liverpool, UK; FLAVIMUN ® , Berna Biotech, Bern, Switzerland; YF17D-204 France (X15067, X15062); YF17D-204, 234 US (Rice et al., Science 229:726-733, 1985)), while other examples of such strains that can be used are the closely related YF 17DD strain (GenBank Accession No. U
• any other yellow fever virus vaccine strains found to be acceptably attenuated in humans, such as human patients, can be used in the invention.
• the yellow fever virus vaccines used in the invention can be obtained from commercial sources (see above) or can be prepared using methods that are well known in the art. hi one example of such methods, chicken embryos are inoculated with virus at a fixed passage level, and then virus isolated from supernatants of centrifuged homogenate is freeze-dried.
• the yellow fever strain is grown in cultured chicken embryo fibroblasts (see, e.g., Freire et al., Vaccine 23(19):2501-2512, 2005) or other cultured cells for manufacture of viral vaccines such as Vero cells.
• the yellow fever virus vaccines are generally stored in lyophilized form prior to use.
• the vaccines are reconstituted in an aqueous solution (typically, about 0.5 mL), such as a 0.4% sodium chloride solution, and then are administered by subcutaneous injection in, e.g., the deltoid muscle.
• the first step of the method of the invention consists of the administration of one dose of StamarilTM or of one dose of YF -VAX ® .
• the method of the present invention can also be adapted to be used with yellow fever immune patients.
• the method only comprises the second step involving the administration of one dose of a chimeric flavivirus vaccine as defined below.
• the said method is also included within the scope of the present invention.
• the second step of the method of immunization according to the invention comprises administration of one dose of a chimeric flavivirus vaccine as defined above.
• the invention is only defined in relation to the use of chimeric flaviviruses in which the chimeric flavivirus is composed of a yellow fever virus backbone in which the sequences encoding the membrane and envelope proteins of the yellow fever virus have been replaced with the sequences encoding the membrane and envelope proteins of a dengue virus.
• the invention also includes the use of other chimeras, such as chimeras in which only one protein (e.g., the envelope protein) of a yellow fever vaccine strain has been replaced, or chimeras in which all three structural proteins have been replaced.
• Chimeric viruses that can be used in the present invention include those based on the human yellow fever vaccine strain, YF17D (e.g., YF17D-204, YF17D-213, or YF 17DD), as described above, in these viruses, the pre-membrane and envelope proteins of the yellow fever virus are replaced with the pre-membrane and envelope proteins of a dengue virus (serotype 1, 2, 3, or 4).
• YF17D e.g., YF17D-204, YF17D-213, or YF 17DD
• the chimeric viruses are composed of a YF17D-204 backbone in which the sequence encoding pre-membrane and envelope proteins of the yellow fever virus are replaced with the sequences encoding the pre-membrane and envelope proteins of wild type dengue serotype 1, 2, 3, and/or 4, e.g., with the sequences encoding the pre- membrane and envelope proteins of dengue 1 virus PUO-359, dengue 2 virus PUO- 218, dengue 3 virus PaH-881/88, or dengue 4 virus 1228.
• Details of the construction of these and related chimeric virus constructs are provided, for example, in the following publications: WO 98/37911; WO 01/39802; Chambers et al., J.
• chimeric flavivirus As one specific example of a chimeric flavivirus that can be used in the invention, we make note of the following chimeric flavivirus, which was deposited with the American Type Culture Collection (ATCC) in Manassas, Virginia, U.S.A. under the terms of the Budapest Treaty and granted a deposit date of January 6, 1998: Chimeric Yellow Fever 17D/Dengue Type 2 Virus (YF/DEN-2; ATCC accession number ATCC VR- 2593).
• ATCC American Type Culture Collection
• YF/DEN-2 ATCC accession number ATCC VR- 2593
• the chimeric flaviviruses used in the methods of the invention can, optionally, include attenuating mutations in dengue virus sequences.
• the dengue sequences can include a deletion or substitution of envelope amino acid 204 (dengue serotypes 1, 2, and 4) or 202 (dengue serotype 3), which is lysine in the wild type viruses, hi one example of such a substitution, the lysine at this position is replaced with arginine.
• one or more other amino acids in the region of amino acids 200-208 are mutated, with specific examples including the following: position 202 (K) of dengue- 1; position 202 (E) of dengue-2; position 200 of dengue-3 (K); and positions 200 (K), 202 (K), and 203(K) of dengue-4.
• residues can be substituted with, for example, arginine.
• chimeras can be made using shuffling technology, which involves cycles of fragmentation, rejoining, and selection of sequences that are being shuffled (see, e.g., Locher et al., DNA Cell Biol. 24(4):256-263, 2005).
• sequences encoding envelope and/or pre-membrane proteins from a desired subset of dengue serotypes (or all dengue serotypes) can be processed in this way to generate shuffled envelope and/or pre- membrane sequences, which are then used to substitute the corresponding sequences of a yellow fever virus backbone as described herein (e.g., YFl 7D).
• Such a chimeric YF/Denl-4 shufflant (assuming shuffled sequences include epitopes from all four serotypes) can be produced by, for example, transfection of Vero cells with chimeric RNA transcripts and recovery of live virus from the supernatant as described previously (Guirakhoo et al., J. Virol. 75(16):7290-7304, 2001) and mentioned elsewhere herein.
• These shuffled chimeras can be used in the invention in vaccination regimens involving administration of the shuffled chimera following yellow fever (e.g., YF17D) vaccination, or in any of the combination methods described elsewhere herein.
• RNA molecules corresponding to the genome of a virus can be introduced into primary cells, chicken embryos, or diploid cell lines, from which (or the supernatants of which) progeny virus can then be purified.
• Other methods that can be used to produce the viruses employ heteroploid cells, such as Vero cells (Yasumura et al., Nihon Rinsho 21:1201-1215, 1963).
• a nucleic acid molecule e.g., an RNA molecule
• virus is harvested from the medium in which the cells have been cultured, harvested virus is treated with a nuclease (e.g., an endonuclease that degrades both DNA and RNA, such as
• the nuclease-treated virus is concentrated (e.g., by use of ultrafiltration using a filter having a molecular weight cut-off of, e.g.,
• chimeric viruses used in the methods of the invention can be carried out using methods that are standard in the art. Numerous pharmaceutically acceptable solutions for use in vaccine preparation are well known and can readily be adapted for use in the present invention by those of skill in this art (see, e.g., Remington 's Pharmaceutical Sciences (18 th edition), ed. A. Gennaro, 1990, Mack Publishing Co., Easton, PA).
• the viruses are formulated in Minimum Essential Medium Earle's Salt (MEME) containing 7.5% lactose and 2.5% human serum albumin or MEME containing 10% sorbitol.
• MEME Minimum Essential Medium Earle's Salt
• the chimeric flaviviruses can simply be diluted in a physiologically acceptable solution, such as sterile saline or sterile buffered saline.
• the viruses can be administered and formulated, for example, in the same manner as the yellow fever 17D vaccine, e.g., as a clarified suspension of infected chicken embryo tissue or a fluid harvested from cell cultures infected with a chimeric virus.
• the chimeric flavivirus vaccines of the invention are classically stored either in the form of a frozen liquid composition or in the form of a lyophilized product.
• the chimeric flavivirus can be mixed with a diluent classically a buffered aqueous solution comprising cryoprotective compounds such as sugar alcohol and stabilizer.
• the lyophilized product is mixed with a pharmaceutically acceptable diluent or excipient such as a sterile NaCl 4% solution to reconstitute a liquid injectable chimeric flavivirus vaccine.
• the chimeric flavivirus vaccine can be a monovalent, a bivalent, a trivalent, or a tetravalent vaccine.
• the chimeric flavivirus vaccine is a monovalent vaccine in which the chimeric virus is composed of a YF17D-204 backbone in which the sequence encoding pre-membrane and envelope proteins of the yellow fever virus are replaced with the sequences encoding the pre-membrane and envelope proteins of dengue 2 virus PUO-218.
• the chimeric flavivirus vaccine is a tetravalent vaccine i.e. a vaccine comprising chimeric virus(es) expressing antigen(s) from the four dengue (1 to 4) virus serotypes.
• this tetravalent vaccine includes advantageously four chimeric flaviviruses composed respectively of a YFl 7D-204 backbone in which the sequences encoding pre-membrane and envelope proteins of the yellow fever virus are replaced with sequences encoding the pre-membrane and envelope proteins of dengue 1 virus PUO-359 (YF/denguel), dengue 2 virus PUO-218 (YF/dengue2), dengue 3 virus PaH-881/88 (YF/dengue3), or dengue 4 virus 1228 (YF/dengue4).
• This specific tetravalent vaccine is named in Example 2 below ChimeriVaxTM- DEN tetravalent.
• tetravalent chimeric flavivirus vaccines appropriate to be used in the method of the invention are also described in detail in WO 03/101397, the content of which is integrated herein by reference.
• Multivalent vaccines may be obtained by combining individual monovalent dengue vaccines.
• the chimeric viruses of the invention can be administered using methods that are well known in the art.
• the viruses can be formulated as sterile aqueous solutions containing between 10 2 and 10 7 , e.g., containing between 10 3 and 10 6 , such as 10 4 , 10 5 , or 10 6 infectious units (e.g., plaque-forming units or tissue culture infectious doses) per serotype in a dose volume of 0.1 to 1.0 mL, to be administered by, for example, subcutaneous, intramuscular, or intradermal routes.
• the chimeric flavivirus vaccine is a monovalent, bivalent, trivalent, or tetravalent vaccine comprising advantageously 10 5 pfu per serotype, per dose, and is administered subcutaneously.
• flaviviruses may be capable of infecting the human host via mucosal routes, such as the oral route (Gresikova et al., "Tick-borne Encephalitis," In The Arboviruses, Ecology and Epidemiology, Monath (ed.), CRC Press, Boca Raton, Florida, 1988, Volume IV, 177-203), an administration by mucosal (e.g., oral) routes could also be contemplated.
• mucosal routes such as the oral route (Gresikova et al., "Tick-borne Encephalitis," In The Arboviruses, Ecology and Epidemiology, Monath (ed.), CRC Press, Boca Raton, Florida, 1988, Volume IV, 177-203)
• mucosal routes such as the oral route (Gresikova et al., "Tick-borne Encephalitis," In The Arboviruses, Ecology and Epidemiology, Monath (e
• adjuvants that are known to those skilled in the art can be used in the administration of the viruses used in the invention.
• adjuvants that can be used to enhance the immunogenicity of the chimeric flaviviruses include, for example, agonists and antagonists of toll-like receptors (TLRs). Immunization Methods
• the invention generally involves administration of a yellow fever vaccine strain (e.g., a YF17D strain, as is noted above), followed by administration of one or more chimeric flaviviruses, in each of which the pre- membrane and envelope proteins of the yellow fever virus have been replaced with the corresponding proteins of a dengue virus (serotype 1, 2, 3, or 4).
• a yellow fever vaccine strain e.g., a YF17D strain, as is noted above
• administration of one or more chimeric flaviviruses in each of which the pre- membrane and envelope proteins of the yellow fever virus have been replaced with the corresponding proteins of a dengue virus (serotype 1, 2, 3, or 4).
• the yellow fever virus vaccine is administered using standard methods (e.g., by subcutaneous, intramuscular, or intradermal injection, or by percutaneous administration employing a device that delivers virus to the superficial skin), in amounts ranging from, for example, 2-5 (e.g., 3 or 4) log 10 plaque forming units (PFU) per dose, which typically is in a volume of about 0.5 mL for subcutaneous injection, 0.1 mL for intradermal injection, or 0.002-0.02 mL for percutaneous administration.
• standard methods e.g., by subcutaneous, intramuscular, or intradermal injection, or by percutaneous administration employing a device that delivers virus to the superficial skin
• PFU plaque forming units
• the chimeric flavivirus vaccine is administered at least between 30 days and 10 years, in particular between 30 days and 5 years, such as between 30 days and 1 to 3 years, advantageously, 30, 60, or 90 days, after the yellow fever vaccine, using standard methods and in amounts ranging from, 10 2 and 10 7 , e.g., from 10 3 and 10 6 , such as 10 4 , 10 5 , or 10 6 infectious units (expressed as pfu or tissue culture infection doses) per serotype per dose.
• the amounts of each chimera in such a vaccine are equivalent, although use of differing amounts of each chimera is also included in the invention.
• the methods of the invention can thus involve, for example, administration of a yellow fever virus vaccine on Day 0 and administration of a YF/dengue-1, YF/dengue-2, YF/dengue-3, and/or YF/dengue-4 chimera on Day 30 (or at a later time, as noted above).
• the chimera can be administered as a monovalent vaccine (i.e., a vaccine including only one of the following chimeric virus: YF/dengue-1, YF/dengue-2, YF/dengue-3, or YF/dengue-4), a bivalent formulation (e.g., a vaccine including two of the chimeras listed above, e.g., including advantageously YF/dengue-2 and YF/dengue-4, or YF/dengue-2 and YF/dengue-3, or YF/dengue-2 and YF/dengue-1), a trivalent vaccine (e.g., a vaccine including three of the chimeras listed above, advantageously, a vaccine comprising YF/dengue-2, YF/dengue-1, and YF/dengue-4, or YF/dengue-2, YF/dengue-3, and YF/dengue-4 ), or a tetravalent vaccine.
• a monovalent vaccine i
• the method of the invention leads to a seroconversion (i.e., induction of a neutralizing immune response) for four dengue serotypes after only one dose of the chimeric flavivirus vaccine.
• a seroconversion i.e., induction of a neutralizing immune response
• additional doses of the chimeric flavivirus vaccine are not needed to reach the desired seroconversion and long-lasting, cross- neutralizing immune response
• administration of booster doses of the chimeric flavivirus vaccine are contemplated in the present invention.
• the booster dose(s) of the chimeric vaccine of the invention may be needed to sustain the cross-neutralizing immune response for a longer period of time and can be administered between 6 months and 5 to 10 years after the first chimeric dengue vaccine dose, e.g., 6 months, 1 year, 2 years, 3 years, 4 years, or 5 years, or even 10 years after the first chimeric flavivirus vaccine dose.
• the booster chimeric flavivirus vaccine can be different from or advantageously identical to the first chimeric flavivirus vaccine administered.
• the description given above in relation to the chimeric flavivirus vaccine to be administered in the method of the invention applies mutatis mutandis to the chimeric flavivirus vaccine booster.
• the booster can thus be a monovalent, bivalent, trivalent, or tetravalent vaccine, with respect to the dengue serotypes present in the vaccine.
• a method of the invention may involve administration of one dose of a yellow fever vaccine, followed by one dose of a monovalent chimeric flavivirus vaccine (dengue 1, 2, 3, or 4, advantageously, dengue 2), which is then followed by administration of (i) a monovalent chimeric flavivirus vaccine of the same or different serotype as the initially administered chimera (advantageously of serotype 4), (ii) a bivalent chimeric flavivirus vaccine, which may or may not include the same serotype as the initial chimera (e.g., advantageously dengue 1 and 2 followed by dengue 3 and 4), (iii) a trivalent chimeric flavivirus vaccine, which may or may not include the same serotype as the initial chimera, or (iv) a tetravalent chimeric flavivirus vaccine.
• the invention thus also concerns a composition for inducing in a patient a long-lasting, cross-neutralizing immune response to dengue virus including (i) a yellow fever virus vaccine and (ii) a chimeric flavivirus vaccine for a sequential administration, in which the chimeric yellow fever vaccine is administered at least 30 days and up to 10 years after administration of the yellow fever virus vaccine.
• kits that include a yellow fever virus vaccine and/or one or more chimeric flavivirus vaccine(s), as described herein.
• kits of the invention can also include instructions for using the kits in the vaccination methods described herein. These instructions can include, for example, indications as to the amounts of vaccine to administer and/or information as to when the vaccines are to be administered.
• AU publications and patent applications cited in this specification are herein incorporated by reference as if each individual publication or patent application were specifically and individually indicated to be incorporated by reference.
• the invention is based, in part, on the experimental results described in the following Examples.
• ChirneriVaxTM-DEN2 is a live, attenuated, genetically engineered virus in which the sequences encoding two structural proteins (prM and E) of YF17D vaccine virus are replaced with the corresponding sequences of the DEN2 virus (strain PUO-218 isolated from a case of classical dengue fever, Bangkok, Thailand).
• the genetic construction of a chimeric viral genome is accomplished using circular cloned deoxyribonucleic acid (cDNA). Full-length cDNA is transcribed to ribonucleic acid (RNA) and the RNA used to transfect cell cultures, which produce live virus (Guirakhoo et al., J. Virol. 75:7290-7304, 2001).
• the vaccine virus was produced according to current Good Manufacturing Practice (cGMP).
• the virus is grown in Vero (African green monkey kidney) cells from cell banks that have been tested for adventitious agents, according to Food and Drug Administration (FDA) guidelines for mammalian cell culture derived products.
• Supernatant fluid from Vero cell cultures containing vaccine virus is harvested, clarified from cellular debris by filtration, and treated with a nuclease (Benzonase ® ) to digest nucleic acid molecules derived from host cells.
• the nuclease-treated bulk virus is then concentrated by ultrafiltration and purified by diaflltration.
• the vaccine is formulated with Human Serum Albumin (HSA) USP (2.5%) and lactose USP (7.5%).
• HSA Human Serum Albumin
• the vaccine was shown to be sterile and free of mycoplasma, retroviruses [by Product Enhanced Reverse Transcriptase (PERT)], and adventitious viruses by in vitro and in vz ' vo tests.
• the final vial of vaccine was tested for sterility, potency, identity, pH, appearance, osmolality, HSA, lactose, endotoxin, safety (modified general safety in mice and guinea pigs), and mouse neurovirulence.
• ChimeriVaxTM-DEN2 is highly immunogenic and well tolerated after inoculation of doses ranging from 2 to 5 logio PFU (Guirakhoo et al., J. Virol. 74(12):5477-5485, 2000).
• a low-grade viremia occurred during the first week after vaccination in monkeys, similar to that induced by yellow fever 17D vaccine.
• a single subcutaneous injection of 2 logio PFU vaccine (the minimum tested dose) induced neutralizing antibodies after 15-30 days, which protected against challenge with wild type DEN2 virus.
• YF-na ⁇ ve subjects were randomized equally into 3 groups (high or low dose ChimeriVaxTM-DEN2 or YF-VAX ® ).
• 14 subjects received a single subcutaneous (SC) vaccination with ChimeriVaxTM-DEN2 (high or low dose) or YF-VAX ® .
• SC subcutaneous
• ChimeriVaxTM-DEN2 high or low dose
• YF-VAX ® high dose
• Safety assessments were performed at specified time points during Days 1-31.
• the proportion of subjects who developed neutralizing antibodies at a level > 1 :10 to different strains representing the four dengue serotypes was determined.
• the effect of prior immunization with YF on the DEN2 seroconversion rate in the YF-immune and YF- na ⁇ ve groups receiving high dose ChimeriVaxTM-DEN2 was analyzed.
• the geometric mean neutralizing antibody titers in each treatment group and to all four dengue serotypes were measured at various time intervals after vaccination, up to 12 months.
• Virus circulating in the blood is a measure of replication of the different live, attenuated vaccines used in the study. Viremia was assayed by a plaque assay in Vero cells. The number of subjects who developed viremia in the 11 days after vaccination is shown by day of visit in Table 1. More YF-na ⁇ ve subjects vaccinated with ChimeriVaxTM-DEN2 than YF-VAX ® developed viremia on one or more study days: 8 (57%) in the ChimeriVaxTM-DEN2 5.0 log 10 PFU group and 9 (64%) in the ChimeriVaxTM-DEN2 3.0 log 10 PFU group, compared with 2 (14%) in the YF-VAX ® group.
• PFU plaque-forming units, measured in Vera cell cultures b Area under the curve c Pairwise comparison of ChimeriVaxTM-DEN2 5.0 logTM in YF na ⁇ ve versus immune subjects
• the Plaque Reduction Neutralization Test (PRNT50) used for CVD2, PR-159, and JAH comprises the following steps:
• Heat-inactivated serum was serially diluted two-fold and mixed with an equal volume of virus to achieve 30-50 pfu/well.
• the serum-virus mixtures were incubated at 4 0 C for 18 +/-2 hours, then added to Vero cell monolayers in 12-well culture plates. After a 60 +/-10 minute incubation, the monolayers were overlaid with 0.84% carboxymethylcellulose in growth medium. Plates were then incubated at 37 0 C under 5% CO 2 for 3-5 days.
• Monolayers were fixed with 7.4% formalin, then blocked and permeabilized with 2.5% non-fat dry milk in PBS-Tween20 plus 0.5% Triton X- 100.
• Anti-Dengue 2 primary antibody (3H5, 1 :5000) was incubated 60 +/-10 minutes, followed by goat anti-mouse IgG alkaline phosphatase (1 :500). After 60 +/-10 minutes incubation, substrate, BCIP-NBT containing 0.36 mM levamisole was added. The reaction was stopped after sufficient staining had occurred. Plaques were counted and PRNT50 titers determined. PRNTso titers were defined as the first serum dilution in which the plaque count is equal to or less than 50% of the negative control plaque count.
• a serum is considered to be positive for the presence of neutralizing antibodies when the neutralizing antibody titer thus determined is at least superior or equal to 1:10.
• the PRNTso assay has been carried out in another laboratory according to the following protocol described by Russell et al. (J. Immunol. 99:285-290, 1967). Plaque count was determined by using the LLC-MK2 plaque assay single overlay technique. Sera are thawed, diluted, and heat-inactivated by incubation at 56 0 C for 30 minutes. Serial, 4-fold dilutions of serum are made (1:5, 1 :10, 1 :40, 1 :160, and 1 :640).
• the percent reduction of plaques at each dilution level is plotted to determine the 50% reduction titer: plaque reduction points between 15% and 85% are used. Results are expressed as reciprocal of dilution.
• a serum is considered to be positive for the presence of neutralizing antibodies when the neutralizing antibodies titer thus determined is at least superior or equal to 1:10. Response 30 days after vaccination
• ChimeriVaxTM-DEN2 vaccine induced very low cross-neutralizing antibody titers to the heterologous serotypes 1, 3, and 4 in YF-na ⁇ ve subjects (Table 3).
• Geometric mean neutralizing antibody titers against heterologous dengue serotypes at Day 31 were significantly higher in YF-immune subjects vaccinated with ChimeriVaxTM-DEN2 than in YF-na ⁇ ve subjects.
• geometric mean antibody titers in YF-immune subjects and YF-na ⁇ ve subjects vaccinated with either 5.0 or 3.0 logio PFU ChimeriVaxTM-DEN2 were 79 vs. 10 and 12, respectively (pO.OOOl).
• titers were 73 vs. 13 and 12 (pO.OOOl) (Table 3). None of the YF-na ⁇ ve subjects seroconverted to DEN4. The geometric mean neutralizing antibody titer to DEN4 in YF-immune subjects was 57.
• DEN4 strain 1036 0 0 0 100 Table 3. Geometric mean antibody titer by treatment group, day 31
• T cell responses were evaluated by IFN ⁇ production in response to viral antigen in culture supernatants. Subjects were screened with inactivated viral cell lysate, which has been shown to generate primarily CD4+ T cell responses to the vaccine, but some CD8+ cells are also produced (Mangada et al., J. Immunol. Methods 284:89-97, 2004).
• the T cell response was evaluated on Days 1 and 31 by measuring the production of IFN ⁇ by PBMC stimulated in culture with inactivated virus antigen.
• Whole blood was collected on Days 1 and 31 in Vacutainer cell preparation tubes (CPT, BDBiosciences) and sent to Acambis, Inc. for isolation and cryopreservation of PBMC.
• Cells were washed in RPMI 1640, cryopreserved in heat-inactivated human AB serum (SeraCare, Oceanside CA) containing 10% DMSO, stored in liquid nitrogen, and thawed immediately before testing.
• PBMC peripheral blood mononuclear cells
• glutaraldehyde-inactivated virus cell antigens were cultured in 96- well flat bottom plates at 1.5 x 10 5 cells per well for 7 days at 37°C with 3 different glutaraldehyde-inactivated virus cell antigens: (1) ChimeriVaxTM-DEN2 virus (grown in Vero cells), (2) dengue 2 strain PUO218 virus (wild type dengue 2 virus grown in C6/36 cells), and (3) YF virus (grown in Vero cells). Controls consisted of inactivated mock-infected Vero or C6/36 cells.
• Inactivated viral antigen or control cell antigen was added at a concentration of 1 : 100 (15).
• PBMC were also stimulated with 1 ⁇ g/ml ConA as an assay positive control.
• IFN ⁇ production was determined by ELISA using culture supernatants collected on Day 7.
• IFN ⁇ cytokine production was compared at Day 1 and Day 31 of the study (before vaccination and at Day 30 after vaccination) by testing the response to inactivated virus antigens.
• the administered vaccine ChomeriVaxTM-DEN2
• the parent wild type dengue-2 virus PEO2178
• the administered control virus YF- VAX ®
• ChimeriVaxTM-DEN2 grown in Vero cells had very low background at Day 0, while dengue-2 virus grown in C6/36 cells produced responses in some of the subjects. Nonetheless, both of these antigens increased IFN ⁇ production in each of the four vaccine groups.
• the inactivated YF-V AX ® was not very immunogenic in any of the subjects, but it did show an increase at Day 31 relative to Day 1, especially in the YF vaccinated subjects.
• Positive response defined as 5-fold background, or > 50 pg/ml at day 30 if Day 1 is less than 10 pg/ml (below sensitivity).
• the T cell responses in this clinical trial were consistent with the neutralizing antibody responses, in that both doses of vaccine stimulated similar T cell immune responses, and prior immunity to yellow fever virus did not inhibit the T cell response to ChimeriVaxTM-DEN2.
• the IFN ⁇ responses were virtually the same for the 2 doses of ChimeriVaxTM-DEN2 (10 3 and 10 5 pfu).
• the IFN ⁇ response to ChimeriVaxTM- DEN2 was not diminished by prior vaccination with yellow fever virus and even higher numbers of responders were seen, suggesting a trend for enhanced T cell immunity in YF pre-immune subjects.
• the inactivated antigen used in the assay identified the strongest responders but did not determine the specific proteins against which the immune response was generated. Inasmuch as an inactivated dengue antigen has been used, it is probable that primarily CD4+ responses are measured.
• Example 2 Tetravalent Dengue Vaccine
• the second stage of the trial evaluated safety and immunogenicity of sequential administration of YF-VAX ® /tetravalent ChimeriVaxTM-DEN versus two doses of tetravalent ChimeriVaxTM-DEN given at a 5-9 month interval.
• the study consisted of a screening period of 3 to 21 days before first vaccination, a double blind treatment period after first vaccination of 1 month, and a second 3 to 21 day screening period, before an open-label treatment period of 30 days commencing 5 to 9 months after first vaccination. A follow up visit at 12 months was planned.
• subjects Prior to conducting any study-related procedures, subjects provided written informed consent. During screening, eligibility was assessed by a medical history, a physical examination, vital signs, clinical chemistry, hematology and serology (including serum pregnancy in female subjects), and a urine sample for urinalysis. On Day 1, subjects received a double-blind subcutaneous vaccination in the deltoid area and then attended the clinic on Days 3, 5, 7, 9, 11, 13, 15, 17, 19, and 21 for AE interview and blood sample collection for viremia. In addition, on Days 5, 9, 11, and 15, subjects provided a blood sample for clinical laboratory assessments. On Days 11 and 31, and at 5-9 months, subjects provided a blood sample for antibody analysis. At 5 to 9 months, continued eligibility was assessed and an interim medical history recorded.
• the accurate Tetravalent ChimeriVax TM -DEN dose per serotype is determined by TCID 50 assay as being 3.7 / 3.1 / 3.8 / 3.2 TCID50 for serotype 1, 2, 3, and 4 respectively.
• the primary endpoint for immunogenicity is the seroconversion rate to dengue serotypes 1-4 at Day 31, using constant- virus, serum-dilution 50% plaque-reduction neutralization test (PRNTso) performed as described in Example 1. This analysis defines seroconversion rates to all four dengue serotypes and to each individual serotype. Subjects that are seronegative at baseline ( ⁇ 1 :10) will require a PRNTso titer of >1: 10 to meet the criteria for seroconversion.
• PRNTso plaque-reduction neutralization test
• Secondary endpoints included the analysis of geometric mean neutralizing antibody titer to each dengue serotype and seroconversion rate 5 to 9 months after the first vaccination and 12 months after the first vaccination (i.e., 3-7 months after the second, booster vaccination). These serological responses are compared for subjects who received (a) a single dose of ChimeriVaxTM-DEN tetravalent; (b) two doses of ChimeriVaxTM-DEN tetravalent, or (c) a dose of yellow fever 17D vaccine (YF- VAX ® ) followed by 1 dose of ChimeriVaxTM-DEN tetravalent administered 5-9 months later.
• YF- VAX ® yellow fever 17D vaccine
• the objective of the study was to evaluate the breadth of the immune response across all 4 dengue serotypes following different immunization regimes.
• the goal of immunizing human subjects against dengue virus disease is to achieve as broad a cross-neutralizing antibody response as possible.
• the immune responses of all subjects (which were dengue and yellow fever-na ⁇ ve at baseline) 30 days after the second dose of study medication are shown in Table 11 (results against wild type strains).
• Group 2 are shown in Table 11. The breadth of the neutralizing antibody response in Group 2 was greater than that in subjects who received either 1 dose of ChimeriVaxTM-DEN tetravalent or two doses of ChimeriVaxTM-DEN tetravalent separated by 5-9 months. 92% and 65% of subjects receiving sequential immunization with yellow fever vaccine and ChimeriVaxTM-DEN tetravalent vaccine developed neutralizing antibodies to at least 3 or 4 dengue serotypes, respectively.
• At least one serotype 0 days Yes 26 ( 95.3%) 6 ( 23.1%) 7 ( 13.0%)
• Day 0 is the day at which the second vaccination was administered at 5-9 mo.
• the antibody measured at this time- point is the result of the first vaccination 5-9 mo.

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