dr françois habersetzer hôpitaux universitaire de ... · dr françois habersetzer hôpitaux...

Dr François Habersetzer

Hôpitaux universitaire de Strasbourg

Inserm 1110

Vaccins thérapeutiques et VHC

Spontaneous Clearance

(1% ??)

Primary Infection

Spontaneous Clearance

(15-50%)

Chronic CarrierState

(50-85%)

Healthy Carriers(30%)

Acute phase (< 6 months) Chronic phase (>6 months)

HCV: natural course of infection

Components of the adaptative anti-hepatitis C virus immune responses

CD81, SRBI,

Occludine, Claudine

Adapted from Freeman AJ et al. Immunology and Cell Biology 2001: 79: 515-536.Rehermann et al. JCI, 2009

Spontaneous Clearance of HCV infection requires :

•Early and multispecific class 1 restricted CD8+ T cell and class II restricted CD4+ T cell responses directed to S and NS HCV proteins

• The quality of HCV clearance and protection from reinfection is determined by the functional potency and cytotoxic potential of HCV-specific CD8+cells

•NS3 is a key viral protein for HCV elimination

NAb responses to epitopes in E1 and E2 are associated with resolution of infection and protection against reinfection

●●●●●●●●● 4

Weeks after infection

HCVHCV

2 4 6 8 10 12 14 16 18

Active

replication

T cell T cell inductioninduction

66--8 weeks8 weeks

1

10

100

Vir

ion

s 1

06

/ m

l

Sustained Sustained

Adaptive Adaptive

responsesresponses

HCVHCV %tet.+CD8+ T cells

1

10

100V

irio

ns

10

6/

ml

0.4

0.8 % H

CV

tet .+

/ CD

8

Weeks after infection2 4 6 8 10 12 14 16 18 20

% IFNg+/CD8HCVHCV

Weeks after infection

1

10

100

Vir

ion

s 1

04

/ m

l

200

300

100

0

IFN

-g E

LISP

OT

CHIMPANZEE INFECTION

HUMAN INFECTION

0 8 16 24 32 40

Thimme, R. et al, J Exp Med 2001 Shoukry, N. et al, J Exp Med 2003

NS3 is a keytarget

Importance of HCV-Specific Intra-Hepatic CD8+ T Cell Immune Responses (IFN-γγγγ) in Control of HCV Replication

Mechanism of HCV Clearance and Persistance

Spontaneous Clearance of HCV infection

Persistance of HCV infection

Strong and wide CD8+ and CD4+ T –cell

responses to HCV epitopes

Limited T-cell responses and limited

reactivity to HCV epitopes;

Viral CD4+ and CD8+ escape mutants

Lack of memory T-cell maturation

Persistence of dysfunctional T-cells

Strong cytotoxic T cell responses Negative costimulators of T cells : PD-

1/PDL1 receptors-ligand;

Immunoregulatory cytokines IL10

Neutralising Ab to E1/E2 Escape Mutants

IL28B gene polymorphisms

C/C genotype

IL28B gene polymorphisms

T/T genotype

Impairment of DC maturation

Ferrari C. Gastroenterology 2008; 134: 1601-1604; Rehermann B et al. Nat Rev Immunol 2005; 5: 215-229;

Thomas DL et al. Nature 2009; 461: 798-801; Wherry EJ et al. J Virol 2004; 78: 5535-5545

For Preventing HCV infection: need of strong cross-reactive

neutralising (Ab) responses

To reconstitute efficient immune control in chronically

infected patients : by restoring functional T-cell responses

similar to those patients who resolve the HCV infection

spontaneously : le vaccin thérapeutique

Need to develop vaccine strategies

Therapeutic Vaccines for chronic hepatitis C

• Different strategies for immunization

� Peptides

� Proteins

� DNA-immunization

� Virus-like particules

� Tarmogens

� Life attenatued carriers : recombinant viruses and bacteria

Recombinant viruses are an efficient way to deliver heterologous DNA that can mediate a

large amount of HCV antigens potentially increasing the immunogenicity of the vaccine in

comparison with peptides and proteins

HCV Treatment: TG4040 Therapeutic Vaccine

Based on non-replicative, poxvirus MVA (Modified Viral Ankara strain) was choice because he was successfully administered to immunize high risk patients against smoll pox without any significant side effects in the primary vaccination of over 150 000 humans

T cell-based therapeutic vaccine: expressing 3 of the major non-structural HCV proteins (NS3, NS4, NS5B) that are prominant targets of host induced immune responses during clearance / control of infection

First viral-based vaccine in the field of HCV therapies having entered clinical development

Objective: to prime HCV specific functional CD4+ and CD8+ T lymphocytes capable to produce IFN-γ and lyse infected cells

Induction d’une réponse immunitaire cellulaire après injection de TG4040

www.cancer-info.com

Migration

+

Administration s.c. de TG4040 (Mécanisme d’induction de la réponse immunitaire)

Hépatocytes Infectés

Élimination VHC via les cytokines

Lyse des hépatocytes par les cellules CD8 spécifique anti-VHC

NK

CD8

DC

CD4

LT cytotoxique

Migration Au Foie

Voie non cytolytique

●●●●●●●●● 9

Infection et capture

TG4040

Mécanisme d’action supposé de TG4040

Etude de phase 1 - TG4040.01 - d’escalade de dose chez des patients ayant une hépatite chronique C minime

• Dose escalating study � Cohort 1: 106 pfu, 3 patients

� Cohort 2: 107 pfu, 3 patients

� Cohort 3: 108 pfu, 9 patients + boost at month 6

All patients: Prime injection (3 weekly injections)

8 12 16 20 40 44 4828 32 360

TG4040 inj (cohort 3, 4)

weeks4 24

TG4040 inj (cohort 5)TG4040 inj (cohort 6)

TG4040 injection

●●●●●●●●● 10

Habersetzer F et coll. Gastroenterology, 2011.

Étude de phase 1 d’escalade de dose: Evolution de la virémie

11

Change in HCV RNA from baseline

D22 D37 M2 M3 M4 M5 M6 M6+8 M6+22 M9D15D8D1

TG4040 injections

1,0

0,5

0,0

- 0,5

- 1,0

Ch

ange

in H

CV

RN

A (

log1

0)

106 pfu (n = 3)

107 pfu (n=3)

108 pfu (n=6)

� Pas d’effet sur charge virale 108 pfu

� Nadir après 37 j

� Diminution prolongée de la virémie de 37 à 6 mois 106 pfu

Rappel (108 pfu)


Patient 3 Corrélation réponse T et virémie C

-2 0neg

Pt 31

-1.5

-1

-0.5

0

0.5D1

D22 M6

2850

100

150

200

250

ND ND

NS4B NS5/1 NS5/2NS3/1 NS3/2 VL measurements

M2

D37M-1

Corrélation entre la diminution de la virémie et la réponse immunitaire spécifique au TG4040

ELISpot : Réponse augmentée contre NS3/1 et NS4B (> moy pré -thérapeutique + 2SD) et induction de réponse contr e NS3/2


Résultats étude de phase 1 : preuve de concept

Chez des patients ayant une hépatite C chronique

� Vaccin thérapeutique TG4040 bien toléré

� Baisse transitoire de la virémie chez 50% des patients

� Permet d’induire une réponse immunitaire chez 33% des patients

Nécessité d’envisager des combinaisons pour permettre une élimination

virale


●●●●●●●●● 14

4 80 16 20 24 40 44 48 52 56 60 64 68 7228 32 36

4 8 12 16 200 40 44 48 52 56 60 64 68 7228 32 36 76 80 84

TG4040, 107 pfu(subcutaneous injection)

Initiation of SOC

Second stopping rule

if viral load detectable after 24

weeks of SOC (all Arms)

Control Arm(n=31)

Primary endpoint: improvement of cEVR rates

First stopping rule if viral load decrease is inferior to

2 log10 IU/mL (Control Arm only)

4 80 16 20 24 40 44 48 52 56 60 64 68 7228 32 36

SOC: PegIFN/ribavirin(Pegasys®/Copegus®)

SOC Lead-In Arm(n=63)

TG4040 Lead-In Arm (n=59)

Weeks

TG4040 monotherapy

12

12

24

Randomized Open Label Phase II Trial

1:2:2Randomization

2 experimental arms

Treatment-naïve

Non-cirrhotic

Genotype 1

Patients

Evaluable population: ITT population excluding patients

who left study before cEVR evaluation

Wedemeyer H et al. EASL 2013

Résultats étude de phase 1 : preuve de concept

●●●●●●●●● 15

Control(n=31)

SOC Lead-In (n=63)

TG4040 Lead-In(n=59)

Mean Age in years 41 44 43.6

Gender, n females / n males 15/16 27/36 27/32

Caucasian, n (%) 30 (96.8) 60 (95.2) 59 (100)

Mean Baseline HCV RNA in log10 IU/mL (SD) 5.96 (0.68) 5.74 (0.81) 5.71 (0.81)

HCV genotype, n (%)

1a

1b

1a/b

6 (19.4)

25 (80.6)

0

12 (19)

50 (79.4)

1 (1.6)

15 (25.4)

44 (74.6)

0

IL28B n C-C / n non C-C(All data are not yet available)

7/17 14/33 16/32

F3 Fibrosis, n (%) (Biopsy or FibroScan®) 1 (3.2) 6 (9.5) 7 (11.8)

High Baseline ALT (≥ 2 ULN), n (%) 5 (16.1) 15 (23.8) 16 (27.1)

� Good balance between arms, including IL28B polymorphism and genotype 1a/1b

distributionWedemeyer H et al. EASL 2013

� Stratification by age (>vs≤50 years) and baseline viral load (>vs≤400 000 IU/mL)

Demographic and baseline characteristics

●●●●●●●●● 16

TG4040 Pre-Vaccination Improves cEVR Rates

� Primary objective of the study reached: significant improvement of cEVR rates in

TG4040 lead-in arm (64.2 %)

30%9/30

45,9%28/61

64,2%34/53

0

10

20

30

40

50

60

70

Control

SOC Lead-In

TG4040 Lead-In

cEVR

Percentage

of patients

*

*

p=0,003

Three-outcome one-stage design

based on: Ho < 40 %, HA > 60 %

According to final evaluable set of

patients in pre-vaccination arm:

Null hypothesis accepted if cEVR ≤

25 patients, rejected if cEVR ≥ 29


●●●●●●●●● 17

SVR24 Response Relapse and Viral BreakthroughP

erc

en

t o

f p

ati

en

ts

- ITT: at least one PR

administration

- LOD<10IU/mL

� Viral breakthrough (defined as greater than or equal 100IU/mL increase in HCV

RNA after drop to BLOD) occurred in 5% (3/63) and 2% (1/55) in PR lead-in and

TG4040 pre-treatment arms vs 0% in control arm

n/N = 15/31 32/63 32/55 6/31 6/63 7/55

SVR24 Relapse


TG4040 Induces HCV Specific T-Cell Responses

●●●●●●●●● 18

� NS3 specific ELISpot IFN-γ responses: 46% of patients

� Overall, 71% of patients had TG4040 specific T-cell responses

Baseline TG4040 pre-treatment

W9

W1

2

M-1

D1

TG4040 Pre-Treatment Arm (n=55)

No SFC/106 PBMC < 50 SFC/106 PBMC50-100 SFC/106 PBMC

150-200 SFC/106 PBMC> 200 SFC/106 PBMC

-SFC: Spot-forming cell-PBMC: Peripheral Blood Mononuclear Cells

100-150 SFC/106 PBMC

Representative ELISpot well

Negativecontrol

NS3M

ean

SFC

/10

6P

BM

C

Baseline(M-1; D1)

PegIFN/RBV +

TG4040(W14; W24)

End Of Study(W84)

TG4040 Pre-Treatment(W9; W12)

� Ex: NS3


●●●●●●●●● 19

Induction of Anti-MVA Humoral Immune Responses

� All TG4040 treated patients developed detectable anti-MVA humoral responses

� No significant correlation between neither total nor neutralizing antibodies and

virological response (cEVR and/or SVR24)

W2

W8

W9

W1

2

W1

4

W2

4

D1

Me

an F

old

Ch

ange

fro

m B

ase

line

(D

1)

Neutralizing anti-MVA antibodiesControl Arm

PegIFN/RBV lead-in Arm

TG4040 Pre-Treatment Arm


●●●●●●●●● 20

Cut-off: 24 weeks of PegIFN/riba. in each arm Control (n=31) SOC Lead-In (n=63) TG4040 Lead-In (n=59)

Any adverse events n (%) 27 (87.1%) 58 (92.1%) 57 (96.6%)

Adverse events related to PegIFN & ribavirin 25 (80.6%) 56 (88.9%) 51 (86.4%)

Adverse events related to TG4040 NA 21 (33.3%) 35 (59.3%)

Most common adverse events (more than 15%)(*; significant difference; p ≤ 0,05)

FatiguePyrexiaInjection site erythema*Influenza like illnessInjection site indurationInjection site pruritus

NeutropeniaAnaemiaLeukopenia

HeadacheInsomniaPruritusAlopeciaNauseaDecreased appetiteMyalgia

18 (58.1%)

6 (19.4%)

1 (3.2%) *8 (25.8%)

0

0

9 (29%)

8 (25.8%)

5 (16.1%)

7 (22.6%)

7 (22.6%)

6 (19.4%)

2 (6.5%)

5 (16.1%)

5 (16.1%)

4 (12.9%)

33 (52.4%)

15 (23.8%)

11 (17.5%)

11 (17.5%)

4 (6.3%)

4 (6.3%)

18 (28.6%)

8 (12.7%)

4 (6.3%)

13 (20.6%)

8 (12.7%)

9 (14.3%)

4 (6.3%)

5 (7.9%)

5 (7.9%)

12 (19%)

30 (50.8%)

21 (35.6%)

18 (30.5%) *8 (13.6%)

9 (15.3%)

9 (15.3%)

15 (25.4%)

16 (27.1%)

7 (11.9%)

17 (28.8%)

5 (8.5%)

9 (15.3%)

12 (20.3%)

7 (11.9%)

12 (20.3%)

9 (15.3%)

Grade 3/4 adverse events 7 (22.6%) 15 (23.8%) 13 (23.7%)

Safety

●●●●●●●●● 21

Safety

� As of today, 19 SAEs reported in 13 patients, none related to TG4040 alone

Control SOC Lead-In TG4040 Lead-In Total

Total SAEs (events) 4 11 4 19

Related to PegIFN/ribavirin only 2 5 0 7

Related to TG4040 only 0 0 0 0

Related to TG4040 & PegIFN/ribavirin - 2 3 5

SAEs unrelated to treatments 2 4 1 7

� SAEs related to PegIFN/ribavirin & TG4040 in 4 patients

� Three patients with severe peripheral thrombocytopenia (2 in SOC lead-in arm, 1 in vaccine lead-in

arm) and one patient with aplastic anemia in vaccine lead-in arm

� Recovery of blood parameters in 1 to 4 months, one recent case ongoing

� Common feature between the 3 patients with thrombocytopenia: HLA-DRB1*04 allele (statistical

association p=0.001)


●●●●●●●●● 22

�Pre-treatment with immunotherapeutic TG4040 followed by

PegIFNα2a/RBV significantly increased cEVR as compared to

PegIFNα2a/RBV alone, in treatment-naive patients with genotype 1

HCV: 64% compared to 30%

� In pre-treatment arm, higher SVR24 rate as compared to the

control arm: 58% vs 48%

� And lower relapse rate: 12% vs 19%

�TG4040 alone was generally well tolerated.

However, TG4040 treatment may be associated with exacerbation

of IFNa-related immune side effects in distinct HLA-backgrounds

Summary and Conclusions

●●●●●●●●● 23

�TG4040 induced HCV-specific T cell responses:

46% NS3-specific ELISpot IFN-gamma responses, 71% overall

�T cell and/or B cell responses against MVA were induced in all

patients

Summary and Conclusions

In Conclusion:

This study in chronic hepatitis C illustrates the potential value of viral vector-based immunotherapy for the treatment of chronic infections including viral hepatitis which warrants further evaluation

●●●●●●●●● 24

Acknowledgements

Poland•Robert Flisiak, Bialystok•Mazur Wlodzimierz, Chorzów•Maciej Jablkowski, Lodz•Ewa Janczewska-Kazek, CzeladzSpain•Vicente Carreno, Madrid•Moises Diago, Valencia•Manuel Romero Gomez, Sevilla•Ricardo Sola, Barcelona•Maria Trapero, MadridGermany•Frank Lammert, Hamburg•Ulrich Spengler, Bonn•Heiner Wedemeyer, Hannover•Stefan Zeuzem, Frankfurt

� The patients and their families� The HCVac investigators and their study staff

Romania•Mircea Calistru, Bucharest•Adrian Goldis, Timisoara•Ioan Sporea, Timisoara•Carol Stanciu, Iasi•Coman Tanasescu, BucharestFrance•Thomas Baumert•Cyrille Feray, Nantes•Véronique Grando, Créteil•François Habersetzer, Strasbourg

•Christian Trepo, Lyon•Jean-Pierre Vinel, Toulouse•Jean-Pierre Zarsky•Vicent Leroy

Israel•Yaacov Baruch, Haifa•Alexander Fich, Soroka•Ran Tur Kaspa, Petah Tikva•Yoav Lurie, Tel AvivUSA•Adrian Di Bisceglie, Saint Louis•Eugene Schiff, Miami

� Transgene �Geneviève Inchauspé�Jean Marc Limacher

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