Despite the almost universal application of preemptive antiviral therapy, cytomegalovirus (CMV) still remains the cause of major health complications, profound defects in immune reconstitution, and significant morbidity in post-transplant recovery of immune-compromised HCT recipients. Substituting antivirals with a vaccine that harnesses the abundant native immune response to CMV may improve outcomes for HCT recipients.
While we are seeking to confirm a therapeutic benefit of CMVPepVax in HLA-A*0201 (Project 1) hematopoietic cell transplant (HCT) recipients, broadening the eligibility of the population to all HLA types that would benefit from a vaccination strategy is best approached by employing a safe delivery vector that expresses full length CMV antigens. We have used modified vaccinia Ankara (MVA) virus for that purpose in collaboration with NCI-NExT to manufacture a candidate for clinical testing. The clinical manufacturing of CMV-MVA-Triplex took place at City of Hope, and IND-directed toxicology at SRI (Birmingham, AL). We will conduct three clinical trials that will comprehensively evaluate our clinical vaccine candidate.
Modified Vaccinia Ankara (MVA), a vaccinia virus being investigated as a smallpox vaccine by the Defense Department, is a safe and robust delivery system to treat or prevent a wide range of diseases including HIV and cancer. Replication-defective MVA is safe, well tolerated and strongly immunogenic when used in HCT recipients or AIDS patients. We developed a multiple-antigen recombinant MVA with genes encoding 3 immunodominant CMV proteins: UL83 (pp65), UL123 (IE1-exon4), and UL122 (IE2-exon5) (CMV-MVA-Triplex), and established its pre-clinical safety and immunogenicity using humanized HLA transgenic mouse models and human PBMC from CMV-positive healthy volunteers and HCT recipients.
Defining safety, persistence of the virus, maximum tolerated dose and immunogenicity of CMV-MVA-Triplex in healthy volunteers was a critical first step in its clinical development for HCT recipients as mandated by the FDA. In a Phase I trial (NCT01941056), these endpoints were evaluated in 24 healthy volunteers (age:18-60), with or without prior immunity to CMV and vaccinia. Three escalating dose levels (DL) were administered intramuscularly (DL1=10xE7; DL2=5x10E7; DL3=5x10E8 pfu/dose) in 8 subjects/DL, with a booster injection 28 days later, and follow up for 1 year.
A safety trial has been successfully completed in healthy volunteers who are equivalent health-wise to immunocompetent HCT donors as required by the FDA and established the safety and dose level for a second trial in HCT. A double-blind Phase 2 trial has started in December 2015 in which 104 HCT recipients with HLA-matched related donors (MRD) or unrelated donors (URD) are being randomized equally to receive either vaccine or placebo. Immune responses and clinical correlates of vaccine-stimulated protection will be followed in HCT recipients enrolled in the Phase 2 clinical trial.
CMV-MVA-Triplex is the first vaccine against CMV that uses a recombinant MVA incorporating multiple CMV antigens, developed for HCT recipients, who are at risk for CMV reactivation. The safety and marked immunogenicity of CMV-MVA-Triplex in this Phase I trial justified testing of the vaccine in the HCT setting.
We will discover the optimal formula for immunizing HCT recipients to prevent CMV viremia and minimize usage of potentially toxic antiviral agents. Success with this CMV vaccine would have a significant clinical and cost-saving effect on recipient management after MRD or URD HCT.
1. Limaye AP, La Rosa C Longmate J, Diamond DJ. Plasma IL-10 levels to guide antiviral prophylaxis prevention of late-onset CMV disease. Transplantation, 100(1):210-6, 1/2016. PMC4685744
2. Davis Z, Cooley S, Cichocki F, Felices M, Wangen R, Luo X, DeFor TE Bryceson YT, Diamond DJ, Brunstein C, Blazar BR, Wagner JE, Weisdorf DJ, Horowitz A, Guethlein LA, Parham P, Verneris MR, Miller JS. Adaptive NK cell and KIR-expressing T cell responses are induced by CMV and are associated with protection against CMV reactivation after allogeneic donor hematopoietic cell transplantation. doi:10.1016/j.bbmt.2015.05.025, BBMT, 2015. PMID:26055301
3. La Rosa, C. and Diamond DJ. The immune response to human cytomegalovirus. Future Virology, 7(3): 279-293, 2012. PMC3539762
4. La Rosa C, Limaye A, Krishnan A, Blumstein G, Longmate J, Diamond DJ. Primary response against CMV during antiviral prophylaxis with valganciclovir in solid organ transplant recipients. Transplant International, 24(9):920-931, 2011. PMC3514504
5. Seidel A, Smith D, Yung E, Aquino L, Srivastava T, Pullarkat V, Spielberger R, Forman SJ and Diamond DJ. CD154 expression correlates with neutralizing antibody titer against Influenza post- vaccination in stem cell transplant patients and healthy adults. BBMT, 17(4):524-533, 2011. PMC2933414
6. Manuel ER, Wang Z, Li Z, La Rosa C, Zhou W, Diamond DJ. Intergenic region 3 of MVA is a stable site for insert gene expression and facilitates potent antigen-specific immune responses. Virology, 403(2):155-162, 2010. PM:20471051
7. Krishnan A, Zhou W, Lacey SF, Limaye AP, Diamond DJ and La Rosa C. PD-1 and IL-10 in liver transplant recipients at high risk for late cytomegalovirus disease. Transplant Infectious Disease. 12(4):363-70, 2010. PMC2950160
8. Wang Z, Zhou W, La Rosa C, Martinez J, Li Q, Srivastava T, Rawal R, Britt WJ, Diamond DJ. Modified H5 promoter improves stability of insert genes while maintaining immunogenicity during extended passage of genetically engineered MVA vaccines. Vaccine, 28(6):1547-1557, 2010. PMC2821965
9. Zhou W, Longmate J, Lacey SF, Palmer JM, Gallez-Hawkins G, Thao L, Spielberger R, Nakamura R, Forman SJ, Zaia JA, and Diamond DJ. Impact of donor CMV status on viral infection and reconstitution of multifunction CMV-specific T cells in CMV-positive transplant recipients. Blood 113 (25):6465-6476, 2009. PMC2710937
10. Gallez-Hawkins GM, Thao L, Palmer J, Dagis A, Li X, Franck AE, Tegtmeier B, Lacey SF, Diamond DJ, Forman SJ, and Zaia JA. Increased programmed death-1 molecule expression in CMV disease and acute graft-versus-host disease after allogeneic hematopoietic cell transplantation. BBMT, 15(7):872-880, 2009. PM:19539220
11. Zaia JA, Sun JY, Gallez-Hawkins GM, Thao L, Oki A, Lacey S, Dagis A, Palmer J, Diamond DJ, Forman SJ, Senitzer D. The effect of single and combined activating KIR genotypes on CMV infection and immunity after hematopoietic cell transplant. BBMT, 15:315-325, 2009. PM:19203722
12. Krishnan A, Wang Z, Srivastava T, Rawal R, Manchanda P, Diamond DJ, and La Rosa C. A novel approach to evaluate the immunogenicity of viral antigens of clinical importance in HLA transgenic murine models. Immunology Letters, 120:108-116, 2008. PM:18706443 PMC2577668
13. Wang Z, Zhou W, Srivastava T, La Rosa C, Mandarino A, Forman SJ, Zaia JA, Britt WJ, Diamond DJ. A fusion protein of HCMV IE1 exon4 and IE2 exon5 stimulates potent cellular immunity in an MVA vaccine vector. Virology, 377(2): 379-390, 2008. PMC2504324
14. La Rosa C, Krishnan A, Longmate J, Martinez J, Manchanda P, Lacey SF, Limaye AP and Diamond DJ. PD-1 expression in liver transplant recipients as a prognostic indicator of CMV disease. J Infect.Dis. 197 (1):25-33, 2008. PM:18171281
15. La Rosa C, Limaye AP, Krishnan A, Longmate J and Diamond DJ. Longitudinal assessment of CMV-specific immune responses in liver transplant recipients at high risk for late CMV disease. J. of Infectious Diseases, 195:633-644, 2007. Editorial Commentary by Boeckh and Riddell in same issue (195:615-617). PM:17262704
16. Wang Z, La Rosa C, Li Z, Ly H, Krishnan A, Martinez J, Britt WJ, and Diamond DJ. Vaccine Properties of a Novel Marker Gene-Free Recombinant Modified Vaccinia Ankara (MVA) Expressing Immunodominant CMV Antigens pp65 and IE1. Vaccine, 25(6):1132-1141, 2006. PMC1852509
17. Lacey SF, La Rosa C, Zhou W, Sharma MC, Martinez J, Krishnan A, Gallez-Hawkins G, Thao L, Longmate J, Spielberger R, Forman SJ, Limaye A, Zaia JA, and Diamond DJ. Functional Comparison of T-Cells Recognizing CMV pp65 and IE1 Polypeptides in HSCT and SOT Recipients. J. of Infectious Diseases 194: 1410-1421, 2006. PM:17054071
18. La Rosa C, Wang Z, Lacey SF, Lalimarmo MM, Krishnan A, Longmate J, Diamond DJ. In Vitro Expansion of Polyclonal T cells Subsets for Adoptive Immunotherapy by Recombinant Modified Vaccinia Ankara. Experimental Hematology, 34(4):497-507, 2006. PM:16569596
19. Wang Z, La Rosa C, Lacey SF, Ly H, Lalimarmo M, Britt W, Diamond DJ. Attenuated poxvirus expressing three immunodominant CMV antigens as a vaccine strategy for CMV infection. J. of Clinical Virology, 35(3):324-331, 2006. PM:16388983
20. Khanna, R and Diamond, DJ. Human cytomegalovirus vaccine: Time to look for alternative options. Trends in Molecular Medicine, 12(1):26-33, 2006. PM:16337831
21. Gallez-Hawkins G, Thao L, Lacey SF, Martinez J, Xiuli L, Franck AE, Lomeli NA, Longmate J, Diamond DJ, Speilberger R, Forman SJ, Zaia JA. CMV Immune reconstitution occurs in recipients of allogeneic hematopoietic cell transplantation irrespective of detectable CMV infection. BBMT, 11(11):890-902, 2005. PM:16275592
22. Lacey SF, Martinez J, Gallez-Hawkins G, Thao L, Longmate J, Haq W, Spielberger R, Forman SJ, Zaia JA, and Diamond DJ. Simultaneous Reconstitution of Multiple CMV-Specific CD8+ T–cell Populations with Divergent Functionality In Hematopoietic Stem Cell Transplant Recipients. J. of Infectious Disease, 191 (6):977-84, 2005. PM:15717275
23. La Rosa C, Wang Z, Lacey SF, Markel SF, Sharma MS, Martinez J, Lalimarmo MM and Diamond DJ. Characterization of Host Immunity to CMV-pp150 (UL32). Hum. Immunol., 66 (2):115-125, 2005. PM:15694996
24. Gallez-Hawkins G, Li X, Franck AE, Thao L, Lacey S, Diamond DJ, and Zaia JA. DNA and low titer, helper-free, recombinant AAV for CMV prime boost vaccination induces an immune response to CMV-pp65 and CMV-IE1 in transgenic HLA A*0201 mice. Vaccine, 23 (6):819-826, 2004. PM:15542207
25. Wang Z, La Rosa C, Mekhoubad S, Lacey S, Villacres M, Markel S, Ellenhorn JDI, Siliciano RF, Buck C, Britt WJ and Diamond DJ. Attenuated Poxviruses Generate Clinically Relevant Frequencies of CMV-Specific T cells. Blood, 104(3):847-856, 2004. PM:15090456
26. Lacey S, Diamond DJ, and Zaia JA. Assessment of Cellular Immunity to Human Cytomegalovirus in Recipients of Allogeneic Stem Cell Transplants. BBMT, 10(7):433-447, 2004. PM:15205665
27. Gibson L, Piccinini B, Lilleri D, Revello MG, Wang Z, Markel S, Diamond DJ, Luzuriaga K. Human Cytomegalovirus Proteins pp65 and IE1 are Common Targets for CD8+ T cell Responses in Children with Congenital or Postnatal Human CMV infection. J. Immunol., 172(4): 2256-2264, 2004. PM:14764694
28. Lacey SF, Villacres MC, La Rosa C, Wang Z, Longmate J, Martinez J, Brewer JC, Mekhoubad S, Maas R, Forman SJ, Zaia JA and Diamond DJ. Relative dominance of HLA-B*07-Restricted CD8+ T-lymphocyte immune responses to human cytomegalovirus pp65 in persons sharing HLA-A*02 and HLA-B*07 alleles. Hum. Immunol. 64: 440-452, 2003
29. G. Gallez-Hawkins, N. A. Lomeli, X. Li, Yao Z-Q, C. La Rosa, D. J. Diamond, and John A. Zaia. Kinase-deficient CMVpp65 triggers a CMVpp65-specific T-cell immune response in HLA-A*0201 transgenic mice after DNA immunization. Scan. Journal of Immunology 55: 592-598, 2002
10/2014 – 7/2019
CMVPepVax to Protect HCT Recipients from Cytomegalovirus Infection
NExT Proposal 253529
Approved for funding
Production of a clinical lot of Tet-CMV vaccine for HCT recipients
3/2012 - 11/2013
Cancer Center Support Grant
Evaluation of safety and correlative immunogenicity studies of a CMV peptide vaccine co-injected with PF03512676 adjuvant in recipients of allogeneic HCT
10/1992 - 3/2012
Bone Marrow Transplantation for Hematologic Malignancy: Project III “Acquisition of Immunity to CMV”
3/1998 - 2/2009
Peptide vaccine to prevent CMV disease after HSCT
6/2004 - 9/2005
Design of an in vivo Assay to Measure the Potency of the PADRE-CMV and Tetanus-CMV Peptides
9/2001 - 8/2004
HLA Tetramer-Guided Analysis of CMV Immunity After BMT
10/2000 - 12/2002
NCI, SAIC Frederick
Preclinical Evaluation of Mono- and dilipidated Vaccines for Activity Against Cytomegalovirus
9/1997 – 8/2002
Therapeutic Vaccine to Limit CMV Infection After BMT
BB-IND13124 “CMV Fusion Peptide (PADRE T-cell helper epitope and Tetanus T-cell helper epitope; synthetic; Bachem California) Vaccine with and without Oligodeoxynucleotide Immunomodulator (CPG 7909; Coley Pharmaceutical Group, Inc.)”