Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Kallas EG, Precioso AR, Palacios R, et al. Safety and immunogenicity of the tetravalent, live-attenuated dengue vaccine Butantan-DV in adults in Brazil: a two-step, double-blind, randomised placebo-controlled phase 2 trial. Lancet Infect Dis 2020; published online Matrch 24. hhttps://doi.org/10.1016/S1473-3099(20)30023-2.
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Supplementary appendixThis appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors.
Supplement to: Kallas EG, Precioso AR, Palacios R, et al. Safety and immunogenicity of the tetravalent, live-attenuated dengue vaccine Butantan-DV in adults in Brazil: a two-step, double-blind, randomised placebo-controlled phase 2 trial. Lancet Infect Dis 2020; published online Matrch 24. hhttps://doi.org/10.1016/S1473-3099(20)30023-2.
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APPENDIX
Safety and immunogenicity of Butantan-DV, a tetravalent, live
attenuated dengue vaccine evaluated in adults in an endemic region: a
Esper G. Kallás, Alexander Precioso, Ricardo Palacios, Beatriz Thomé, Patrícia E. Braga,
Tazio Vanni, Lúcia M. A. Campos, Lilian Ferrari Gabriella Mondini, Maria da Graça
Salomão, Anderson da Silva, Heloisa M. Espinola, Joane do Prado Santos, Cecilia L. S.
Santos, Maria do Carmo S. T. Timenetsky, João Luiz Miraglia , Neuza M. F. Gallina,
Daniela Weiskopf, Alessandro Sette, Raphaella Goulart, Rafael Tavares Salles, Alvino
Maestri, Adriana Maluf Elias Sallum, Sylvia Costa Lima Farhat, Neusa K. Sakita, Juliana
C. O. A. Ferreira, Cassia G. T. Silveira, Priscilla R. Costa, Isaias Raw, Stephen S.
Whitehead, Anna P. Durbin, Jorge Kalil.
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CONTENTS
Appendix A – Eligibility criteria for healthy adults, of both sexes, and between 18 and 59 years of age. To be included in the study participants had to meet all the inclusion criteria and could not fulfill any of the exclusion criteria. ................................................ 3
I. Inclusion criteria .................................................................................................... 3
II. Exclusion criteria ................................................................................................... 3
Appendix B ........................................................................................................................ 6
I. Severity classification ............................................................................................ 6 II. Causal relationship classification .......................................................................... 9
Appendix C ...................................................................................................................... 11
Figure 1: CD8+ T cell immune responses after vaccination. ..................................... 11
Table 1. Step A: Adverse Reactions after the first dose of Butantan-DV, TV003, or placebo ........................................................................................................................ 12
Table 2. Rash characteristics in participants from StepA and in all Butantan-DV recipients, after the first dose. ..................................................................................... 13 Table 3. Multivalent immune response after the first in Step A and all Butantan-DV recipients. .................................................................................................................... 14
Table 4. Frequency of vaccine rash according to the multivalent immune response in Step A and in all Butantan-DV recipients, after the first dose.................................... 15
Table 5. Step A: Frequency of seroconversion after first (S1) and second (S2) doses. .................................................................................................................................... 16
Table 6. Step A: Geometric mean titers following the first and second doses. .......... 17
Appendix D ..................................................................................................................... 18 Statistical Analysis Plan for the study “A Phase II, stepwise, randomized, double-blind, controlled clinical trial to evaluate the safety and immunogenicity of the lyophilized formulation of the Dengue 1,2,3,4 (attenuated) vaccine among healthy adults” ......................................................................................................................... 18
Data Sharing Statements ............................................................................................. 19
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Appendix A – Eligibility criteria for healthy adults, of both sexes, and between 18 and 59 years of age. To be included in the study participants had to meet all the inclusion criteria and could not fulfill any of the exclusion criteria.
I. Inclusion criteria
Potential participants will be included in the study only if they fulfill all criteria described below:
a. To be a healthy adult, of both sexes, and between 18 and 59 years of age;
b. To be available during the entire study period, which will be of approximately five years;
c. To demonstrate the intention to participate in the study, documented by the signature of the free informed consent form (FICF);
d. For females: volunteers with childbearing potential should be willing to use birth control methods until their last safety evaluation visit, which corresponds to the S12 visit for Step A, and the S6 visit for Step B. All female volunteers will be considered as having childbearing potential, except those that have a documented history of hysterectomy, tubal ligation or have reached menopause (12 months of amenorrhea after the last menstrual period). The volunteers who declare themselves as not having childbearing potential, because of sexual abstinence or non-reproductive sexual practices, until their last safety evaluation visit, which corresponds to the S12 visit for Step A, and the S6 visit for Step B, will not need to use birth control methods.
II. Exclusion criteria
Potential participants who fulfill any of the criteria described below will not be included in the study:
a. For females: Pregnancy (confirmed by a β-hCG positive test) or breastfeeding;
b. Evidence of active neurological, heart, lung, liver or kidney disease according to clinical history, physical examination and/or laboratory tests;
c. Diseases that impair the immune system, including: diabetes, cancer (except basal cell carcinoma) and autoimmune diseases;
d. Behavioral, cognitive or psychiatric diseases that in the opinion of the principal investigator or of his medical officer, could affect the ability of the potential participant to understand and collaborate with the requirements of the study protocol;
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e. Values of absolute neutrophil count, alanine aminotransferase (ALT) or serum creatinine equal to or greater than Grade 1, as defined in this Protocol;
f. Any use considered abusive of alcohol or drugs in the 12 months preceding the inclusion in the study (V1 visit) that caused medical, professional or family problems, as indicated by the medical history;
g. History of severe allergic reaction or anaphylaxis;
h. Diagnosis of asthma with a history of hospitalization due to the illness in the last six months prior to the inclusion in the study (V1 visit);
i. Suspected or confirmed fever within 72 hours prior to the vaccination or axillary temperature higher than 37.8°C on the day of the vaccination (V1 visit);
j. Screening or confirmatory test positive for HIV-1;
k. Screening or confirmatory test positive for hepatitis C virus (HCV);
l. Positive test for the hepatitis B virus surface antigen (HBsAg), or for the antibody against the hepatitis B virus "core" antigen (anti-HBc) alone;
m. Use of corticosteroids (excluding topical or nasal) or other immunosuppressive drugs during the 42 days prior to the inclusion in the study (V1 visit). It will be considered as immunosuppressive a dose of corticosteroids equivalent to ≥10 mg prednisone per day for more than 14 days;
n. Use of anticoagulant medication;
o. To have been vaccinated with a live virus vaccine within the last 28 days or with an inactivated virus vaccine within the last 14 days prior to the inclusion in the study (V1 visit), or to have any immunization scheduled for the first 42 days after the inclusion in the study (V1 visit);
p. History of asplenia;
q. To have received blood products in the last six months prior to study inclusion (V1 visit), including transfusions or immunoglobulin, or to have scheduled the administration of blood products or immunoglobulin during the first 42 days after vaccination (V1 visit);
r. Use of any investigational product within 42 days prior to the inclusion in the study (V1 visit), or to have scheduled to receive it after the inclusion in the study (V1 visit);
s. Participation in another clinical trial within the six months preceding the inclusion in the study (V1 visit);
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t. To deny permission for the storage of biological material for future research as defined in the FICF;
u. Any additional condition which, in the opinion of the principal investigator or his medical officer, could jeopardize the safety or the rights of a potential participant, or that could prevent her/him from complying with this protocol.
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Appendix B
I. Severity classification
Based on the guide “Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials” from the US Food and Drug Administration (USFDA).1,2
Classification of the severity of the solicited clinical adverse events.
Adverse Event Grade 1 Grade 2 Grade 3 Grade 4
Pain at the injection site of the investigational product
Does not interfere
with daily activities
Repeated use of non-narcotic
analgesic >24 hours OR
Mild interference with daily activities
Any use of a narcotic
analgesic OR
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Erythema at the injection site of the investigational product †
25 – 50 mm 51 – 100 mm >100 mm
Necrosis OR
Exfoliative dermatitis
Swelling at the injection site of the investigational product †
25 – 50 mm
51 – 100 mm OR
Mild interference with daily activities
>100 mm Necrosis
Induration at the injection site of the investigational product †
25 – 50 mm
51 – 100 mm OR
Mild interference with daily activities
>100 mm Necrosis
Pruritus at the injection site of the investigational product
Does not interfere
with daily activities
Mild interference with daily activities
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Nausea
Does not interfere
with daily activities
OR 1 to 2
episodes in 24 hours
Mild interference with daily activities
OR More than 2
episodes in 24 hours
Prevent daily activities, it requires IV hydration
Emergency department
visit* OR
Hospitalization OR
Hypovolemic shock
Vomiting
Does not interfere
with daily activities
OR 1 to 2
episodes in 24 hours
Mild interference with daily activities
OR More than 2
episodes in 24 hours
Prevent daily activities, it requires IV hydration
Moderate chills in the entire body, it requires the use of
narcotics
Serious or prolonged, no
response to narcotics
-----
Headache
Does not interfere
with daily activities
Repeated use of non-narcotic
analgesic >24 hours OR
Mild interference with daily activities
Any use of a narcotic
analgesic OR
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Retro-orbital pain
Does not interfere
with daily activities
Repeated use of non-narcotic
analgesic >24 hours OR
Mild interference with daily activities
Any use of a narcotic
analgesic OR
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Photophobia
Does not interfere
with daily activities
Mild interference with daily activities
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Fatigue
Does not interfere
with daily activities
Mild interference with daily activities
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Myalgia
Does not interfere
with daily activities
Mild interference with daily activities
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Arthralgia
Does not interfere
with daily activities
Mild interference with daily activities
Prevent daily activities
Emergency department
visit* OR
Hospitalization
Viral skin eruption (viral rash) ‡
Present, but asymptomatic
Symptomatic (pruritus/pain), but mild interference
with daily activities
Symptomatic, prevent daily
activities
Emergency department
visit* OR
Hospitalization * It requires 12 hours or more of admission to a ward or emergency department for the management of the adverse event. † The value recorded should be measured at the largest diameter and as a continuous variable. ‡ Specify whether the skin rash is located in any region of the body or if it is widespread.
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Classification of the severity of the laboratory adverse events.
Bilirubin – when accompanied by any increase in ALT or AST – increase by factor
1.1 – 1.25 x ULN
1.26 – 1.5 x ULN
1.51 – 1.75 x ULN >1.75 x ULN
Bilirubin – when ALT and AST are normal – increase by factor
1.1 – 1.5 x ULN
1.6 – 2.0 x ULN
2.0 – 3.0 x ULN >3.0 x ULN
ILN: inferior limit of the normal range.ULN: upper limit of the normal range. * If the ILN is less than the upper limit of Grade 1, the ILN will be used as an upper limit to Grade 1.† If the ULN is greater than the lower limit to Grade 1, the ULN will be used as a lower limit to Grade 1.According to criteria NIC/NIH NCI3
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II. Causal relationship classification
All adverse events had their causal relationship to the investigational product classified according to the adapted classification of the "Uppsala Monitoring Centre" of the World4.
Classification of the causal relationship of the adverse events.
A reasonable causal relationship A causal relationship NOT reasonable
The Adverse Event is considered an Adverse Reaction The Adverse Event cannot be considered an Adverse Reaction
Certain Probable Possible Unlikely Not related A clinical event, including a laboratory test abnormality (abnormal value) with a plausible temporal relationship to the administration of the intervention;
A clinical event, including a laboratory test abnormality (abnormal value) with a reasonable temporal relationship to the administration of the intervention;
A clinical event, including a laboratory test abnormality (abnormal value) with a reasonable temporal relationship to the administration of the intervention;
A clinical event, including a laboratory test abnormality (abnormal value) that due to the timing of the administration of the intervention has an unlikely relationship, but not impossible;
A clinical event, including a laboratory test abnormality (abnormal value) that due to the timing of the administration of the intervention has no relationship;
It cannot be explained by a concurrent disease or other intervention or medication; The event must be definitive pharmacologically or phenomenologically (i.e., is an objective and specific disorder or a pharmacologically recognized phenomenon);
It is unlikely to be attributed to a concomitant disease or other medication or intervention;
It can also be explained by a concurrent disease or other medication or interventions;
Another disease or another medication provides a plausible explanation.
Another disease or another medication provides a plausible explanation.
The response to an interruption or withdrawal is plausible (pharmacologically, pathologically);
The response to the interruption or withdrawal is clinically reasonable;
There is a lack of information or lack of clarity about the withdrawal or interruption of treatment.
A satisfactory rechallenge procedure if necessary.
A rechallenge procedure is not necessary.
References
1. CBER/USFDA/USDHHS Guidance for Industry: Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials
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[Internet]. Silver Spring: US Food and Drug Administration; 2007 [cited 2011 Set 29].Available at: http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Vaccines/ucm091977.pdf
2. ICH Clinical Safety Data management: Definitions and Standards for Expedited Reporting [Internet]. Genebra: International Conference on Harmonisation of Technical Requirements ror Registration of Pharmaceuticals for Human Use; 1994 [cited 2012 Oct 15]. E2A. Available at: http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E2A/Step4/E2A_Guideline.pdf
3. NIC/NIH NCI Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. Available at: http://evs.nci.nih.gov/ftp1/CTCAE/About.html.
4. UMC/WHO The use of the WHO-UMC system for standardised case causality assessment [Internet]. Uppsala:The Uppsala Monitoring Centre. Available at: http://www.who-umc.org/Graphics/24734.pdf.
Figure 1: CD8+ T cell immune responses after vaccination.
A. 15 DENV-naïve volunteers were evaluated for antigen-specific CD8+ T cell responses by flow cytometry after stimulation with DENV-derived peptide pool after first and second TV003 doses. Responses were documented in all, but one, vaccine, compared to none in the placebo group; after the second shot, most vaccinees maintained detectable antigen-specific immune responses; only one placebo recipient developed detectable immune responses after confirmed DENV1 natural infection documented before the second vaccine shot. (B) 94% (35 of 37) of DENV-naïve and DENV-exposed participants who received one shot of Butantan-DV mounted antigen-specific CD8+ T cell immune responses at Day 91 after vaccination, as opposed to 13% (2 of 18) of placebo recipients.
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Table 1. Step A: Adverse Reactions after the first dose of Butantan-DV, TV003, or placebo