Clinical Trials of Vaccines for Respiratory Syncytial Virus and Related Viruses

我们正在遵循两种策略开发小儿呼吸道合胞病毒减毒活疫苗。(i)我们的主要策略是开发RSV减毒活株，其减毒主要是通过缺失几个非必需基因中的一个，以及主要在L聚合酶中的错义和密码子缺失突变来实现的，并且通过反向遗传学已经稳定了抗去衰减。当前的目标是确定一种或两种适合进一步开发的鼻内儿科RSV疫苗。（ii）二级疫苗策略是使用PIV3减毒版本作为载体表达RSV抗原（主要是融合F蛋白），从而提供二价HPIV3/RSV活疫苗。随附的报告“副流感病毒的实验室和临床前研究”描述了这些piv载体疫苗的临床前开发情况。这两种疫苗战略都是根据与赛诺菲的合作研究与开发协议（CRADA）开发的。迄今为止，我们的临床试验主要集中在RSV减毒活株上。我们将于2023年在临床评估两种piv载体疫苗。

We are following two strategies to develop a live-attenuated pediatric RSV vaccine. (i) Our primary strategy is to develop live-attenuated RSV strains, with attenuation provided mainly by deletion of one of several nonessential genes and by missense and codon-deletion mutations that are mainly in the L polymerase and have been stabilized against de-attenuation using reverse genetics. The immediate goal is to identify one or two lead candidates suitable for further development as an intranasal pediatric RSV vaccine. (ii) A secondary vaccine strategy is to use attenuated versions of PIV3 as vectors to express RSV antigen (primarily the fusion F protein) which provide live bivalent HPIV3/RSV vaccines. The pre-clinical development of these PIV-vectored vaccines is described in the accompanying report "Laboratory and Pre-Clinical Studies of Parainfluenza Viruses". Both vaccine strategies are being developed under a Cooperative Research and Development Agreement (CRADA) with Sanofi. To date, our clinical trials have focused on live-attenuated RSV strains. We will evaluate two PIV-vectored vaccines in the clinic in 2023. One lineage of live-attenuated RSV vaccine candidates involves deletion of the ORF encoding the small (90 amino acids) viral M2-2 protein. The M2-2 protein plays a role in regulating RSV RNA synthesis, and its deletion results in down-regulated viral RNA replication (causing viral attenuation) and a global up-regulation of viral gene transcription and antigen synthesis. Increased antigen expression per genome raises the possibility of increased immunogenicity per infectious particle. Prototype delM2-2 candidates called RSV MEDI/delM2-2 and RSV LID/delM2-2 were evaluated and reported upon in past years; two reports on delM2-2 candidates were recently published, RSV LID/delM2-2/1030s (NCT02794870 and NCT0252339) and D46/NS2/N/delM2-2-HindIII (NCT03099291 and NCT03102034). Among these candidates, LID/delM2-2/1030s emerged as the most promising virus. It is attenuated through deletion of M2-2, combined with a stabilized missense mutation called 1030s that consists of Y1321K and S1313(TCA) mutations in the L polymerase. In a Phase 1 study in 6-24 months-old RSV seronegative children, LID/delM2-2/1030s was well tolerated, had excellent infectivity without evidence of genetic instability, induced durable immunity, and primed for strong anamnestic antibody responses to wildtype RSV infection, making it an attractive candidate for further evaluation. Over the 2022 fiscal year, a larger study to further evaluate the safety and immunogenicity of LID/delM2-2/1030s in RSV seronegative children is ongoing. A second lineage of RSV vaccine candidates contains deletion of the NS2 gene, whose encoded protein antagonizes host interferon and apoptosis responses to viral infection. The candidate RSV delNS2/del1313/I1314L contains the delNS2 mutation combined with a mutation called del1313/I1314L comprising deletion of codon 1313 in the L polymerase plus an adjacent missense mutation I1314L that stabilizes against de-attenuation. This vaccine is being evaluated in a Phase 1/2 study in a side-by-side comparison with a second delNS2-based vaccine candidate, RSV delNS2/1030s. This virus combines the delNS2 mutation with a stabilized missense mutation called 1030s that consists of Y1321K and S1313(TCA) mutations in the L polymerase. The 1030s mutation is somewhat less attenuating than the del1313/I1314L mutation, and therefore RSV delNS2/1030s should be less attenuated than RSV/delNS2/del1313/I1314L. The RSV delNS2/1030s and RSV/delNS2/del1313/I1314L candidates are presently being evaluated head-to-head in a Phase 1/2 clinical trial in seronegative infants and young children (NCT03916185). A third lineage of RSV vaccine candidates contains a deletion of the NS1 gene that, like NS2, encodes a protein that antagonizes host interferon and apoptosis responses, but does so more efficiently than NS2 and thus might confer a phenotype that is more attenuated and immunogenic. Two viruses were made that each contain the delNS1 deletion as the sole attenuating element, but in one virus the F and G genes have been moved to the first and second genome positions in order to increase their expression (RSV 6120/delNS1 and 6120/F1G2/delNS1, respectively). These viruses presently are being compared head-to-head in a Phase 1 clinical trial (NCT03596801). During the 2022 fiscal year, we completed the analysis of a side-by-side evaluation of the safety and immunogenicity of the lead delNS2 candidate, delNS2/del1313/I1314L, and the delM2-2 candidate RSV/276 in RSV-seronegative infants and children (NCT03227029/NCT03422237). We found that both candidates had excellent immunogenicity and were well-tolerated. The RSV/276 candidate seemed associated with mild cough. The cDNA-derived version of the wildtype RSV strain A2 is presently being evaluated in healthy adult volunteers in a dose-escalation study (NCT02484417). We also are evaluating a recent clinical isolate RSV A/Maryland/001/11 for which we have developed a reverse genetic system and recovered a recombinant virus in a Phase 1 trial in healthy adult volunteers (NCT03624790). These studies will provide an infection model that can be used to evaluate RSV therapeutic candidates and adult RSV vaccine candidates, and to study viral pathogenesis and the host response.