**Vaccines and Related Biological Products Advisory Committee**

**Meeting Date: July 26 and 27, 2001**

**FDA Briefing Document for**

**Aviron**

**Cold Adapted Influenza Vaccine, Trivalent - FluMist**

**Clinical Section**

**ChrisAnna M. Mink M.D.**

**Wasima N. Rida, Ph.D.**

**Antonia Geber, M.D.**

**Summary of Clinical Trials Performed with FluMist.**

+--------------+----------------+---------+---------+---------+-------+
| ### P        |                |         | ###  {  | #       | ###   |
| EDIATRIC TRI |                |         | #sectio | ##  {#s |  {#se |
| ALS  {#pedia |                |         | n .unnu | ection- | ction |
| tric-trials  |                |         | mbered} | 1 .unnu | -2 .u |
| .unnumbered} |                |         |         | mbered} | nnumb |
|              |                |         |         |         | ered} |
+--------------+----------------+---------+---------+---------+-------+
| ##           | ### Study Go   | ###     | **      | **Fl    | *     |
| # Protocol N | al {#study-goa | Age Ran | Total** | uMist** | *Plac |
| umber {#prot | l .unnumbered} | ge  {#a |         |         | ebo** |
| ocol-number  |                | ge-rang |         |         |       |
| .unnumbered} |                | e .unnu |         |         |       |
|              |                | mbered} |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV002      | Dose           | 18-71   | 238     | 155     | 83    |
| ^a^**        | Escalation     | months  |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV002-2    | Dose           | 18-71   | 118     | 79      | 39    |
| ^a^**        | Escalation     | months  |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV006**    | Efficacy       | 15-71   | Year 1, | 1070    | 532   |
|              | against        | months  | 1602    |         |       |
|              | Culture        |         |         | 917     | 441   |
|              | Confirmed      |         | Year 2, |         |       |
|              | Influenza      |         | 1358    |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV011**    | Challenge of   | 34-91   | 222     | CAIV-M  | \-    |
|              | Subset of      | months  |         |         |       |
|              | AV006 subjects |         |         |         |       |
|              | with Vaccine   |         |         |         |       |
|              | Strain H1N1    |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV007**    | Lot            | 12-36   | 500     | Cons    | 100   |
|              | Consistency    | months  |         | istency |       |
|              | Study          |         |         | lots,   |       |
|              |                |         |         | n=300;  |       |
|              |                |         |         | e       |       |
|              |                |         |         | fficacy |       |
|              |                |         |         | lot,    |       |
|              |                |         |         | n=100   |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV010**    | Safety in      | 9-17    | 48      | 24      | 24    |
|              | Asthmatics     | years   |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV012**    | Herd Immunity  | 18 mo   | Year 1, | 4298    | \-    |
|              | Trial          | -- 18   | 4298    |         |       |
|              |                | years   |         | 1958    | \-    |
|              |                |         | Year 2, |         |       |
|              |                |         | 1958^a^ | 5173    | \-    |
|              |                |         |         |         |       |
|              |                |         | Year 3, |         |       |
|              |                |         | 5173    |         |       |
|              |                |         | ^a^     |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV014**    | Consistency    | 12-42   | 225     | 225     | \-    |
|              | from Two       | months  |         |         |       |
|              | Manufacturing  |         |         |         |       |
|              | Facilities     |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV015**    | Safety of      | 3-8     | 949     | 949     | \-    |
|              | Re-vaccination | years   |         |         |       |
|              | in Year 3 of   |         |         |         |       |
|              | Subset of      |         |         |         |       |
|              | AV006 Subjects |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV017      | Safety of      | 1-10    | 1245    | 1129    | 116   |
| ^a^**        | revaccination  | years   |         |         |       |
|              | in prior       |         |         |         |       |
|              | FluMist and    |         |         |         |       |
|              | placebo        |         |         |         |       |
|              | recipients     |         |         |         |       |
|              | (1-3 doses)    |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV018      | Concomitant    | 12-15   | 73 of   | blinded | bl    |
| ^a^**        | MMR and        | months  | planned |         | inded |
|              | Varicella      |         | 1200    |         |       |
|              | Immunizations  |         |         |         |       |
|              | with FluMist   |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV019**    | Safety         | 1-17    | 9689    | 6473    | 3216  |
|              | Assessment in  | years   |         |         |       |
|              | Northern       |         |         |         |       |
|              | California     |         |         |         |       |
|              | Kaiser         |         |         |         |       |
|              | Permanente     |         |         |         |       |
|              | Clinics        |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **A          | Safety of      | 6       | 65 --   | 65      | \-    |
| R001^a.,b^** | Classical vs.  | months  | c       |         |       |
|              | Recombinant    | and     | hildren |         |       |
|              | Processes for  | over    |         |         |       |
|              | Preparation of |         | 449 -   |         |       |
|              | FluMist        |         | total   |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **ADULT      |                |         |         |         |       |
| TRIALS**     |                |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV001      | Phase I/II     | 18-65   | 239     | 181     | 58    |
| ^a^**        | spray *vs*.    | years   |         |         |       |
|              | drops          |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV003**    | Efficacy       | 18-40   | 103,    | 36      | 34    |
|              | Against        | years   |         |         |       |
|              | I              |         | 92 were | (       |       |
|              | nvestigational |         | cha     | TIV=33) |       |
|              | Challenge with |         | llenged |         |       |
|              | Wild Type      |         |         |         |       |
|              | Influenza      |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV004      | Safety         | 18-65   | 20      | 15      | 5     |
| ^a^**        |                | years   |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV005      | Safety of 2    | 18-45   | 32      | 16      | 16    |
| ^a^**        | doses          | years   |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV008      | Safety in      | [\      | 200     | 100     | 100   |
| ^a^**        | elderly, high  | >]{.und |         |         |       |
|              | risk           | erline} |         |         |       |
|              |                | 65      |         |         |       |
|              |                | years   |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AV009**    | Safety and     | 18-64   | 4561    | 3041    | 1520  |
|              | Effectiveness  | years   |         |         |       |
|              | in Healthy     |         |         |         |       |
|              | Adults         |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **AR001      | As above       |         |         |         |       |
| ^a.,b^**     |                |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **VA #448    | Safety and     | [\      | 2215    | 1107    | 1108  |
| ^a^**        | Efficacy of    | >]{.und |         |         |       |
|              | FluMist or     | erline} |         |         |       |
|              | Placebo when   | 50 with |         |         |       |
|              | given with TIV | COPD    |         |         |       |
|              | in COPD        |         |         |         |       |
+--------------+----------------+---------+---------+---------+-------+
| **DMID       | Safety in      | 18-40   | 111,    | 55      | 56    |
| #98-005**    | HIV-infected   | years   |         |         |       |
|              | compared to    |         | In      |         |       |
|              | HIV-negative   |         | fected, |         |       |
|              | Adults         |         | n=57    |         |       |
|              |                |         |         |         |       |
|              |                |         | Ne      |         |       |
|              |                |         | gative, |         |       |
|              |                |         | n=54    |         |       |
+--------------+----------------+---------+---------+---------+-------+

a -- Not summarized in briefing document; includes some studies still
ongoing and/or complete reports not submitted to BLA.

b -- Children and adults participated in this protocol

**INDICATION SOUGHT BY AVIRON**

Active immunization for the prevention of influenza in children,
adolescents and adults 1-64 years of age. In 1-8 year old children,
FluMist has been shown to reduce influenza and influenza associated
illnesses including otitis media, lower respiratory illness and febrile
illness. In adults adults 18-64 years of age, FluMist has been shown to
be effective in reducing influenza-like illnesses with an associated
reduction in work loss, decrease in the number of healthcare provider
visits, and decrease in the use of prescription and non-prescription
medications during the influenza outbreak period.

An indication for travelers to areas where influenza viruses are
circulating is also being sought.

Question 1. Are the data adequate to support the efficacy of FluMist in
individuals aged 12 months -- 64 years?

# **STUDIES SUBMITTED IN SUPPORT OF EFFICACY**

**Study AV006:** Years 1 and 2 -- Clinical endpoint efficacy study
against culture-confirmed influenza in children aged 15-71 months of
age.

**Study AV011:** Efficacy against shedding of vaccine strain following
challenge with a monovalent vaccine strain A/Shenzhen (H1N1) in a subset
of Year 1 and 2 AV006 participants.

**Study AV009:** Clinical endpoint efficacy study against illness during
influenza outbreak periods in adults ages 18-65.

**Study AV003:** Primary endpoint was protective efficacy following
FluMist or inactivated influenza vaccine in healthy serosusceptible
adults against intranasal challenge with wild-type influenza.

Efficacy and immunogenicity results from these studies are summarized in
this section of the briefing document.

## STUDIES SUBMITTED IN SUPPORT OF CONSISTENCY OF MANUFACTURING

Study AV007: Lot consistency trial, including comparison with efficacy
lot using immunogenicity as measure of consistency. Performed in healthy
children, ages 12-36 months.

**Study AV014:** Manufacturing bridging study comparing vaccines blended
and filled at Aviron-

PA with vaccines blended and filled at Medeva with immunogenicity as
measure of consistency,

performed in healthy children, ages 12- 42 months.

The immunogenicity results from these studies are also summarized in
this section of the briefing document.

**EFFICACY DATA BY STUDY**

**STUDY AV006 (Years 1 and 2)**

# **Title: A Phase 3, Randomized, Double-blind, Placebo-controlled, Trial to Assess the** 

# **Safety, Immunogenicity and Efficacy of Influenza Virus Vaccine, Trivalent, Types A&B,** 

# **Live, Cold-Adapted (CAIV-T) in Healthy Children.**

## INTRODUCTION/ STUDY DESIGN

This is a prospective, randomized, double-blind, placebo-controlled,
multi-center trial conducted over two years at 10 study sites. In Year
1, children 15-71 months of age (before their 6^th^ birthday) were
randomized 2:1 to receive vaccine or placebo. Subjects were enrolled
into either a 1 or 2-dose regimen, but the study was not planned as a
comparison of the 1 *vs.* 2 dose regimens. The plan was to enroll
subjects into the 2-dose cohort until mid-October, and thereafter to
enroll subjects into the 1-dose cohort. The 2-dose regimen with a 60-day
interval was chosen based upon historical data using CAIV-T in infants,
which suggested there was minimal immune response to H1N1 after one dose
of vaccine, possibly due to interference from the other influenza
strains. In comparison, the response to H3N2 was relatively robust after
one dose. The 2-dose regimen was also chosen because that is the
recommended schedule for inactivated influenza vaccine for first time
vaccination of children less than nine years of age. No preliminary
studies to evaluate the optimal dosing interval were performed. The
1-dose regimen was included because, in practice, some children may only
receive 1 dose of vaccine before the influenza season. Essentially, 8 of
10 sites enrolled children in the 2-dose regimen between August and
October 1996, and 2 sites (Baylor and UCLA) enrolled subjects into 1
dose regimen from mid-Sept through Dec.

In Year 2, efficacy and safety of one dose re-vaccination was assessed.
Subjects remained in the same treatment group, i.e., they were not
re-randomized. Thus, no assessment of long-term efficacy of FluMist was
planned since all subjects who had received FluMist in Year 1, also
received FluMist in Year 2.

LOCATION: United States, multi-center; Collaborative Research and
Development Agreement (CRADA) with NIAID

STUDY PERIOD: 2 years: Year 1 -- 1996-97 (1^st^ enrolled 8/96), Year 2
-- 1997-98

PIVOTAL TRIAL: Yes, Phase 3 Efficacy

POPULATION: Healthy children, ages 15-71 months at enrollment

SAMPLE SIZE: **Year 1:** Total - n=1602; FluMist -- n= 1070; Placebo --
n= 532

> Two-dose regimen -- n= 1304; One-dose regimen- n= 288)
>
> Immunogenicity cohort -- n=214 (209 considered valid).
>
> **Year 2:** Total - n=1358; FluMist -- n=917; Placebo -- n=441.
>
> Two-dose regimen -- n=755; One-dose regimen -- n=162.
>
> Immunogenicity cohort -- n=162 (160 considered valid).

## [OBJECTIVES (Year 1)]{.underline} 

######### Primary Efficacy: 

-   To demonstrate that children [receiving]{.underline} a 2-dose
    primary vaccine regimen of FluMist are protected from culture
    confirmed influenza illness caused by community-acquired subtypes
    antigenically similar to those contained in the vaccine for the
    influenza season directly following vaccination.

######### Secondary Efficacy 

-   To demonstrate that children [enrolled]{.underline} in a 2-dose
    primary regimen of FluMist are protected from culture confirmed
    influenza illness caused by community-acquired subtypes
    antigenically similar to those contained in the vaccine for the
    influenza season directly following vaccination (i.e., 2-dose
    regimen, as randomized).

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-   To estimate the efficacy of a 1-dose primary vaccination regimen of
    FluMist to protect children against community-acquired subtypes
    antigenically similar to those contained in the vaccine for the
    influenza season directly following vaccination.

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-   To demonstrate the efficacy of either a 1 or 2-dose primary
    vaccination regimen of FluMist to protect children against
    community-acquired subtypes antigenically similar to those contained
    in the vaccine for the influenza season directly following
    vaccination.

-   To demonstrate the efficacy of a 2^nd^ year's single dose of Flumist
    to protect children who received a 1 or 2-dose primary vaccination
    regimen of Flumist in the previous year against community-acquired
    subtypes antigenically similar to those contained in the vaccine for
    the influenza season directly following the 2^nd^ year's vaccination
    (Year 2, Follow-on Study Cohort).

######### Other Objectives 

**Immunogenicity:** To assess the immunogenicity of Dose 1 and Dose 2 of
FluMist in a subset of children from each of the 10 clinical study
sites. In the Follow-on study, the immunogenicity of Year 2 will be
assessed in the same subset.

**Relatedness:** To determine the relatedness of influenza strains in
the vaccine to strains circulating in the community during the study as
assessed by HAI antibodies in a subset of the immunogenicity cohort.

**Tolerability and Safety:** To assess the safety and tolerability of
FluMist in children.

**Severity of Illness:** To assess the efficacy of FluMist to reduce the
severity of influenza illness in children as measured by reduction in 1
or more of the following: the duration and height of fever, respiratory
symptoms, restrictions in activity, pneumonia, and hospitalizations for
respiratory illness.

**Economic impact resulting from influenza:** To assess the efficacy of
FluMist to reduce the economic impact of influenza in children as
measured by reduction in 1 or more of the following: the number of days
of outpt and ER visits for influenza; days home from daycare, pre-school
and school; days of lost work time for parents or guardians because of
influenza; medication for influenza.

**Economic impact resulting from non-specific respiratory illness:** To
assess the efficacy of FluMist to reduce the economic impact of
respiratory illness in children as measured by reduction in 1 or more of
the following: the number of days of outpt and ER visits for respiratory
illness; days home from daycare, pre-school and school; days of lost
work time for parents or guardians because of influenza; medication for
respiratory illness.

## Vaccines 

1.  FluMist -- Each 0.5 ml dose contained 10^6.7^ TCID~50~ of each
    strain of virus (2 type A and 1 type B) in normal allantoic fluid
    (NAF) containing sucrose-phosphate-glutamate (SPG). 1996-97
    influenza strains were A/Texas/36/91 (H1N1), A/Wuhan/359/95 (H3N2)
    and B/Harbin/7/94-like. There were 2 lots of FluMist (CAF014 and
    CAF015) used in this trial. In Year 2, the 1997-98 strains were
    A/Shenzhen/227/95 (H1N1), A/Wuhan/359/95 (H3N2) and
    B/Harbin/7/94-like, filled trivalent lot #CAF023.

2.  Placebo -- Lot CAF013 of NAF was used in Year 1, and lot CAF025 was
    used in Year 2. The placebo was described as being indistinguishable
    from vaccine in appearance and taste.

**Vaccine administration and schedule**: Vaccines were administered by
intranasal spray 0.5 ml (0.25 ml per nostril) using Becton-Dickson
Accuspray device, delivering 20-100 μm droplets into the nasal
passages. For the 2-dose regimen, the 2^nd^ dose was scheduled for 60
days ([+]{.underline} 14 days, range 46-74 d) later.

**Inclusion/Exclusion criteria** -- Healthy children 15-71 months, with
no chronic illnesses, no history of wheezing or bronchodilator use
within 3 months, no current (\< 72 hours) URI symptoms or febrile
illnesses within 1 week, no allergy to eggs, no immunocompromised
household members, no prior influenza vaccines, and no nasal medications
in prior 10 days.

**Assignment to Group***.* At the time of enrollment, subjects were
randomized 2:1 to the FluMist or placebo groups by a computer-generated
schedule. Enrollment into the 1-dose and 2-dose regimens was not random.
A separate sequentially-numbered list was provided for each study site,
and randomization was achieved by assigning subjects to the next number.

**Vaccine Contraindication.** Dose 2 was to be contraindicated in
subjects who experienced a vaccine-related SAE or any vaccine-related
"unusual or alarming" event post-dose 1.

## 

## Concomitant Vaccinations and Medications. No concomitant immunizations were permitted with the study vaccines. All concomitant medications taken within first 10 days post0vaccination were to be recorded on the CRF. Use of aspirin (ASA) and ASA-containing meds were discouraged, because of the association of ASA and influenza with Reye Syndrome. 

## Monitoring

## Efficacy

Active surveillance was based upon regular phone contacts with the
parents/guardians of the children. Initially calls were made every 2-3
weeks starting on the 11^th^ day after the 1^st^ vaccination. Once an
influenza outbreak was declared (defined as an identified outbreak in
the community or in a study subject at that site), the calls were
increased to at least once every 7-10 days. Parents were instructed to
call the study site if their child had any illness consistent with
influenza. The criteria, [prior]{.underline} to influenza season, for
obtaining a culture were 2 signs or symptoms in category "a" OR
[\>]{.underline} 1 sign or symptoms from category "b". Once influenza
season began, criteria for viral culture were 1 sign or symptoms in
category "a" or 2 from category "b."

a)  Fever ([\>]{.underline} 101^o^F rectal or oral; or 100.4 ^o^F
    axillary); wheezing; shortness of breath; pneumonia; or ear
    infection (acute otitis media), suspected or diagnosed.

b\) Runny nose or nasal congestion; sore throat (pharyngitis); cough;
muscle aches; chills; headache; irritability; decreased activity; or
vomiting.

Additionally, a viral culture could also be performed if the
investigator thought a patient's symptom complex warranted it. However,
obtaining cultures from subjects in the first 10 days post-vaccination
was discouraged because of concerns for potentially unblinding the
study.

**Cultures:** Viral cultures were performed at the study sites.
Influenza positive specimens were sent to Aviron for official
determination, including subtyping of all isolates and phenotyping of
those isolated obtained within 28 days of vaccination. Attempts were
made to obtain specimens from subjects within 4 days of onset of
symptoms (though sample could be collected at anytime). Throat and nasal
swabs were obtained at all sites. Some sites also obtained nasal wash
samples, and these could be added to the throat swab in lieu of the
nasal swab. Nasal and throat specimens were stored at 4 ^o^ C until
inoculated. In the lab, RMK cells were inoculated with the nasal and
throat specimens within 4 hours of collection, or as soon thereafter as
possible.

A quality control assessment (blinded specimens were sent to the sites)
of the sites' abilities to grow influenza virus was performed in August
1996, and a few of the sites were unsuccessful at growing type B, no
additional information was provided. The investigators elected to repeat
QC testing in November of 1996, and reported that all sites grew type B
influenza. The assessment was that in August the viral content of the
specimens was too low to successfully grow the isolates, but data about
the concentrations of viruses tested was not provided.

## Immunogenicity 

## Year 1

A subset of 214 children (\~ 1^st^ 21 enrollees at each site) had a
blood sample obtained. In the 2-dose regimen, serum was obtained
pre-1^st^ dose, pre-2^nd^ dose (60 days [+]{.underline} 14 days) and
[\>]{.underline} 28 days after the 2^nd^ vaccination. In the 1-dose
regimen, serum was obtained pre-dose and 42 days ([+]{.underline} 7
days) after the dose. Serum samples were tested for anti-hemaglutinin
(HA) antibodies by hemagglutinin inhibition (HAI) and IgA and IgG
anti-HA by ELISA, and assays were performed at Aviron, Mountain View CA.
At Vanderbilt, a small subset of subjects (n=19) had nasal wash samples
obtained for IgA anti-HA by ELISA. Subjects in the immunogenicity study
who were vaccinated within 42 days of influenza season were to be
excluded from the immunogenicity analysis for that particular strain.

**Statistical Methods**

All analyses were performed by EMMES, and the sponsor states that all of
the primary and secondary analyses planned in the data analysis plan
(DAP) were completed. EMMES Corp. were unblinded to the full data set
for Year 1 on June 30, 1997. Unblinding of the Year 1 data [by
group]{.underline} for the investigators, AVIRON and NIAID occurred on
July 12, 1997. A full analysis was planned at the end of Year 1 before
proceeding to Year 2. No methods to correct for multiple comparisons
were used.

## 

## Efficacy Analyses (Year 1)

**Case Definition** - A culture-confirmed case of influenza illness was
defined by a positive culture of a wild-type virus subtype antigenically
similar to one contained in the vaccine, that occurred at least 15 days
after receiving the 1^st^ dose of vaccine or placebo. "Antigenically
similar" was not defined in the protocol.

Efficacy point estimates were calculated in customary fashion:

100 x (1-relative risk of vaccinee becoming a case) = 100 x (1- P~v~/
P~p~)

where P~v~=proportion of vaccinees and P~p~=proportion of placebo.

Confidence intervals (CI) were calculated using the method of Koopman
for the ratio of binomial proportions.

Sample size (Year 1) was based upon the following assumptions:

-   True efficacy of the vaccine is 60%.

-   The true event rate in the control group will be 33% in the 96-97
    season.

-   The case ascertainment rate is assumed to be 75%. Therefore, the
    observed event rate will be 25% (3/4 X 33%).

-   The loss to f/u will be 10% during the study season.

-   The criteria for efficacy will be that the point estimate will be
    above 50% and the lower bound of the 95% CI will be above 30%.

The probability, or power, that these criteria will be met is \~90%.

Amendment #3 provided for increasing the sample size to 1400 because the
attack rate was lower than the predicted 25% (\~16% during the study
period).

## Year 1 Efficacy Endpoints and Efficacy Results

**Primary efficacy endpoint:** The first episode of culture-confirmed
community-acquired influenza in a study participant occurring anytime on
the day of or after receipt of the 2^nd^ dose of FluMist or placebo.

###  {#section-5 .unnumbered}

**Secondary efficacy endpoints:** The 1^st^ episode of culture-confirmed
influenza illness occurring at least 15 days after the 1^st^ dose of
vaccine or placebo in a study participant following:

-   Receipt of 1 or 2 doses

-   Enrollment to receive 2 doses (2 dose as randomized)

-   Enrollment to receive 1 dose

All of these endpoints were also investigated separately for the
specific influenza strains circulating in 1996-97 season (i.e., A/H3N2
and B).

## 

## Other Efficacy Endpoints

Efficacy against all wild-type influenza strains was to be evaluated
(i.e., those antigenically similar as well as those unrelated to vaccine
strains). Additionally, severity of illness was examined in 2 ways:

1\. By evaluating illness characteristics in subjects with
culture-confirmed influenza and assessing severity in the following
manner:

-   Culture-confirmed influenza accompanied by fever ([\>]{.underline}
    101^o^F rectal or [\>]{.underline} 100.4^o^F axillary)

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-   Culture-confirmed influenza accompanied by otitis media **(No
    pre-specified definition of otitis media was stated in the
    protocol)**.

-   Culture-confirmed influenza accompanied by missed school or daycare,
    lost work days for the primary care provider, and the number of
    health care visits

2\. By evaluating illness characteristics in all participants where a
culture was taken or was to be obtained because of an illness,
regardless of the culture results. In these subjects, severity of
illness regardless of culture result or culture obtained was analyzed as
the number of episodes per participant as follows:

-   Any illness events

-   Any illness event and antibiotic prescribed

-   Any febrile illness event

-   Any febrile illness event and antibiotic prescribed

-   Any otitis media

-   Any otitis media and antibiotic prescribed

-   Any febrile otitis media

-   Any febrile otitis media and antibiotic prescribed

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-   Any illness accompanied by missed school or daycare, lost work days
    for the primary care provider, and the number of health care
    provider visits.

##### [RESULTS]{.underline}  {#results .unnumbered}

**AV006 -- Year 1 Baseline Characteristic of Study Enrollees.**

+----------------------------------------+--------------+--------------+
|                                        | **FluMist**  | **Placebo**  |
|                                        |              |              |
|                                        | **N= 1070**  | **N= 532**   |
+----------------------------------------+--------------+--------------+
| **Mean Age, Months (Std. Dev.)**       | 43.0 (16.6)  | 41.5 (16.5)  |
+----------------------------------------+--------------+--------------+
| ## Race/Ethnicity, %                   |              |              |
+----------------------------------------+--------------+--------------+
| White                                  | 85           | 84           |
+----------------------------------------+--------------+--------------+
| Black                                  | 9            | 10           |
+----------------------------------------+--------------+--------------+
| Hispanic                               | 4            | 3            |
+----------------------------------------+--------------+--------------+
| Asian                                  | 0.9          | 0.8          |
+----------------------------------------+--------------+--------------+
| Other                                  | 2            | 2            |
+----------------------------------------+--------------+--------------+
| ## Gender, %                           |              |              |
+----------------------------------------+--------------+--------------+
| Male                                   | 47           | 49           |
+----------------------------------------+--------------+--------------+
| Female                                 | 53           | 51           |
+----------------------------------------+--------------+--------------+
| **Household Composition**              |              |              |
|                                        |              |              |
| **Mean (Std. Dev.)**                   |              |              |
+----------------------------------------+--------------+--------------+
| Adults                                 | 2.1 (0.6)    | 2.1 (0.6)    |
+----------------------------------------+--------------+--------------+
| Children                               | 2.6 (1.2)    | 2.6 (1.1)    |
+----------------------------------------+--------------+--------------+
| **Primary Caretaker Works Outside      | 49           | 50           |
| Home, %**                              |              |              |
+----------------------------------------+--------------+--------------+
| **Number of Day Care/Preschool         | 2.4 (2.1)    | 2.3 (2.1)    |
| Days/Week Expected at Time of          |              |              |
| Enrollment, Mean (Std. Dev.)**         |              |              |
+----------------------------------------+--------------+--------------+

Overall, the FluMist and placebo groups had comparable demographic
characteristics at enrollment. There were some differences in the
demographics of subjects who received one dose vs. those who received
two doses. Most subjects in the one-dose regimen, 261 of 288 (91%) were
enrolled at the Baylor or UCLA sites. Sixty-eight % of these were
Caucasian and 16% Hispanic. In the 2-dose regimen, 88% were Caucasian
and \< 1% were Hispanic. Additionally, only 43% of subjects in the
1-dose regimen had a sibling in the trial as compared to 54% in the
2-dose regimen. No statistical comparisons were performed for the 1-dose
vs. 2-dose groups.

###### The immunogenicity cohort demographics (n=214) also had some differences compared to those subjects not in the cohort. Caucasians accounted for 73% on the immunogenicity cohort compared to 86% of the non-immunogencity cohort, Fisher's exact p value \< 0.001. 

###### The immunogenicity cohort was not a random sampling of the subjects, but was the first 21 subjects per site. The sponsor states this group was selected to obtain blood samples before influenza started in the community. However, there were some sites where the 1^st^ 21 consecutive subjects were NOT the subjects enrolled into the immunogenicity cohort. 

Distribution of the participants across the 10 study sites was
comparable for the FluMist and placebo recipients within both dosing
regimens. All participants in Houston and Los Angeles were enrolled in
the 1-dose regimen, except 15 subjects in Houston who were in the 2-dose
regimen and enrolled into the Immunogenicity cohort. All other
participants were enrolled into the 2-dose regimen, except 2 subjects in
Rochester and 25 in Bardstown who were enrolled at the end of the
enrollment period and were intentionally enrolled into the 1-dose
regimen.

## Protocol Compliance

There were a total of 205 of 1602 participants with protocol deviations
(136 in FluMist group, 69 in placebo group). Subjects missing
appropriate data (not defined) for safety or efficacy analyses were
excluded. Among the protocol deviations, eight Accuspray devices
(FluMist n=5, placebo n=3) were found to be defective requiring study
vaccine replacement (this occurred without unblinding of the subjects).

Ninety seven percent of subjects in the 2-dose regimen completed study
visits and 93% of 2-dose subjects received dose 2 within the specified
window of 46-74 days post-dose. A total of 42 subjects did not receive
dose 2 (27 FluMist, 15 placebo). The most frequent reasons were refusal
(n=3, FluMist n=2, placebo n=1), consent withdrawal (n=11, FluMist n=5,
placebo n=6) and 4 subjects experienced adverse events (AEs) related to
dose 1 (FluMist n=2, placebo n=2). The two AEs in the FluMist group were
wheezing (onset 4 days post-dose 1) and allergies requiring an inhaler
therapy (onset 7 days post-dose 1). An additional subject in the FluMist
group developed new onset juvenile rheumatoid arthritis after dose 1 of
FluMist and was not given a second dose.

For the immunogenicity subset, 209 of 214 subjects were evaluable for
analyses. 5 subjects were excluded (except ITT analysis) because they
had received an influenza vaccine (CAIV or TIV, trivalent inactivated
vaccine, i.e., the licensed injectable influenza vaccine) previously.
Ninety seven percent of the immunogenicity subset completed Year 1 of
the study.

## Efficacy (Year 1)

A total of 3127 viral cultures were obtained from all subjects. Of
these, 139 positive cultures for influenza were reported to the
statistical center by the local laboratories. However, one of these was
lost in shipment to or at Quintilles, and could not be confirmed at
Aviron. There were 18 positive cultures obtained within 14 days of Dose
1 and thus, not included in the primary efficacy analysis. All 18 of
these isolates were phenotyped as CAIV, i.e., one of the vaccine strains
(details below). One subject was initially reported as having two
distinct H3N2 isolates, but Aviron could not confirm the second culture
and it was eliminated from the analysis. Two sibling participants had
cultures obtained on the same day, and one was positive and the other
was negative for influenza. However, these samples were mislabeled and
could not be definitely identified. The siblings were in different
treatment groups and one positive culture was excluded from analysis
(based upon a pre-determined rule for study procedures, before study
unblinding). Five subjects had 2 positive cultures (obtained 3-5 days
later) for the same virus, and only the 1^st^ isolate was counted in the
analysis. Six placebo recipients were culture positive for type A/H3N2
and later culture positive for type B. These subjects contributed a
single event to "any strain" analysis and a single event to both H3N2
and B analyses. Thus, the analysis included 114 positive influenza
cultures \[139- (1+1+18+5)\] from 108 subjects for wild type influenza
(types A/H3N2 and B). Of the 114 positive cultures, 14 were in FluMist
recipients (n=11 for 2-dose and n=3 in 1-dose regimen) and 100 were in
placebo recipients (n=86 for 2-dose and n= 14 in the 1-dose regimen).

AV006- Year 1. Efficacy of FluMist in Preventing Culture-Confirmed
Influenza Illness.

+---------------------------+------------+-----------------------------+
| ## Analysis Group         | ## Strain  | **Estimated Efficacy % (95% |
|                           |            | CI)**                       |
+---------------------------+------------+-----------------------------+
| **Participants Receiving  | Any        | 93.4 (87.5, 96.5)           |
| Two Doses**               |            |                             |
+---------------------------+------------+-----------------------------+
|                           | H3N2       | 96.0 (89.4, 98.5)           |
+---------------------------+------------+-----------------------------+
|                           | B          | 90.5 (78.0, 95.9)           |
+---------------------------+------------+-----------------------------+
| **Participants in Two     | Any        | 93.2 (87.6, 96.3)           |
| Dose Regimen**            |            |                             |
+---------------------------+------------+-----------------------------+
|                           | H3N2       | 95.5 (89.3, 98.1)           |
+---------------------------+------------+-----------------------------+
|                           | B          | 90.5 (78.0, 95.9)           |
+---------------------------+------------+-----------------------------+
| **Participants in One     | Any        | 88.8 (64.5, 96.5)           |
| Dose Regimen**            |            |                             |
+---------------------------+------------+-----------------------------+
|                           | H3N2       | 86.9 (46.6, 96.8)           |
+---------------------------+------------+-----------------------------+
|                           | B          | 91.3 (45.6, 98.6)           |
+---------------------------+------------+-----------------------------+
| ## Al                     | Any        | 92.6 (87.3, 95.7)           |
| l Randomized Participants |            |                             |
+---------------------------+------------+-----------------------------+
|                           | H3N2       | 94.5 (88.3, 97.4)           |
+---------------------------+------------+-----------------------------+
|                           | B          | 79.5 (79.5, 95.7)           |
+---------------------------+------------+-----------------------------+

**H1N1 did not circulate in the community and no field efficacy data
were generated for this strain.**

AV006 -- Year 1. Efficacy of FluMist by Age, Gender, and Race

+-----------------+-----------------+-----------------+-----------------+
| **Category**    | ## Any S        | ##              | ## B % (95% CI) |
|                 | train % (95 CI) | H3N2 % (95% CI) |                 |
+-----------------+-----------------+-----------------+-----------------+
| ## Age (mos.)   |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| \< 24           | 84.7 (57.5,     | 89.6 (59.1,     | 71.4 (-31.6,    |
|                 | 94.6)           | 97.4)           | 93.8)           |
+-----------------+-----------------+-----------------+-----------------+
| 24-35           | 96.2 (85.8,     | 94.3 (78.7,     | 100 (81.2, 100) |
|                 | 99.0)           | 98.5)           |                 |
+-----------------+-----------------+-----------------+-----------------+
| 36-48           | 87.0 (66.8,     | 88.7 (63.1,     | 83.4 (27.8,     |
|                 | 94.9)           | 96.5)           | 96.2)           |
+-----------------+-----------------+-----------------+-----------------+
| 48-60           | 100 (89.9, 100) | 100 (84.8, 100) | 100 (77.1, 100) |
+-----------------+-----------------+-----------------+-----------------+
| \>60            | 90.6 (70.3,     | 100 (79.2, 100) | 83.6 (44.1,     |
|                 | 97.1)           |                 | 95.2)           |
+-----------------+-----------------+-----------------+-----------------+
| ## Gender       |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| Female          | 91.8 (83.8,     | 94.0 (85.6,     | 86.4 (61.1,     |
|                 | 95.8)           | 97.6)           | 95.3)           |
+-----------------+-----------------+-----------------+-----------------+
| Male            | 93.8 (85.0,     | 95.5 (82.8,     | 93.2 (79.0,     |
|                 | 97.4)           | 98.8)           | 97.8)           |
+-----------------+-----------------+-----------------+-----------------+
| ## Race         |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| ## White        | 92.3 (96.5,     | 94.8 (88.8,     | 89.5 (76.9,     |
|                 | 95.7)           | 97.7)           | 95.2)           |
+-----------------+-----------------+-----------------+-----------------+
| ## Non-White    | 94.9 (70.0,     | 91.6 (47.6,     | 100 (52.0, 100) |
|                 | 99.2)           | 98.7)           |                 |
+-----------------+-----------------+-----------------+-----------------+

Of note, the analyses by age provided in the study report include some
overlapping age ranges (48 months).

**Severity of Illness**

The p-values are not adjusted for multiple comparisons.

Illness associated with culture positive influenza:

Efficacy was demonstrated for febrile ([\>]{.underline} 101.0^o^F oral
or rectal or [\>]{.underline} 100.4^o^F ax) influenza illness of 95%
(95%CI: 90, 97.5) and febrile illness associated with otitis media(OM)
of 97.5% (85.5, 99.6) in the FluMist vs. placebo groups.

Illness regardless of culture status:

Flumist decreased the rate of febrile illnesses by 20% (0.78 *vs.* 0.98,
p \< 0.01), and for antibiotic use for febrile illnesses by 31% (0.31
*vs.* 0.46 events, p\<0.01) and for antibiotic use for febrile OM (0.14
*vs*. 0.22 events, p\< 0.01) for all participants. There was not a
significant decrease in OM without fever, for any OM for which
antibiotics were prescribed, or for "any illness."

AV006 -- Year 1. Number of Illness Events Per Participant by Dosing
Regimen and Treatment Group

  --------------- ------------ ------ ---------- ------------ ---------- ------------
                  Treatment    N^a^   Any        Febrile      Otitis     Febrile
                  Group               Illness    Illness      Media      Otitis Media

  2 Doses         FluMist      849    2.28       0.82         0.52       0.16
  Received                                                               

                  Placebo      410    2.40       0.99         0.58       0.24

                  p-Value^b^          0.21       **0.01**     0.33       **0.01**

  Enrolled in     FluMist      189    1.58       0.62         0.34       0.10
  One-Dose                                                               
  Regimen                                                                

                  Placebo      99     1.70       0.99         0.36       0.17

                  p-Value^b^          0.54       **\<0.01**   0.91       0.17

  All             FluMist      1070   2.14       0.78         0.48       0.15
  Participants                                                           

                  Placebo      532    2.25       0.98         0.54       0.23

                  p-Value^b^          0.23       **\<0.01**   0.29       **\<0.01**
  --------------- ------------ ------ ---------- ------------ ---------- ------------

a - All participants in analysis group

b - Wilcoxon Rank sum test

AV006 -- Year 1. Number of Illness Events with Antibiotic Prescribed Per
Participant by Dosing Regimen and Treatment Group

  --------------- ------------ ------ ---------- ---------- ---------- ----------
                  Treatment    N^a^   Any        Febrile    Otitis     Febrile
                  Group               Illness    Illness    Media      Otitis
                                                                       Media

  2 Doses         FluMist      849    0.86       0.32       0.51       0.16
  Received                                                             

                  Placebo      410    0.98       0.44       0.57       0.23

                  p-Value^b^          0.14       \<0.01     0.43       0.02

  Enrolled in     FluMist      189    0.68       0.29       0.34       0.10
  One-Dose                                                             
  Regimen                                                              

                  Placebo      99     0.84       0.49       0.35       0.16

                  p-Value^b^          0.18       0.02       0.87       0.13

  All             FluMist      1070   0.83       0.31       0.48       0.14
  Participants                                                         

                  Placebo      532    0.95       0.46       0.53       0.22

                  p-Value^b^          0.04       \<0.01     0.36       \<0.01
  --------------- ------------ ------ ---------- ---------- ---------- ----------

a - All participants in analysis group

b - Wilcoxon Rank sum test

FluMist significantly reduced the number of health-care provider visits
(13.4% decrease, p=0.02). FluMist did not significantly reduce the
number of missed school or daycare days or lost workdays for primary
care provider, however, these parameters were significantly reduced
(p\<.01) when the analysis was restricted to subjects with
culture-confirmed influenza.

## Year 1 Immunogenicity Results 

###### **Enrollment and Compliance in Immunogenicity Substudy** 

Not all of the subjects in the Immunogenicity cohort had all samples
obtained and not all samples were included in the analyses, and the
reasons for the exclusions are not provided.

###### All subjects with available data were included in the post-dose 1 analysis (regardless if they were in the 1-dose or 2-dose regimen) and only subjects who received 2 doses are included in the post-dose 2 assessments. The time of obtaining the serum samples in the 1-dose and 2-dose regimens is not summarized. As noted under study design, the serum samples were to be obtained at different times for subjects in the 1-dose regimen (42 [+]{.underline} 7 days post-dose 1) than for subjects in the 2-dose regimen (60 [+]{.underline} 14 days post-dose 1 and [\>]{.underline} 28 days post-dose 2 with no upper time limit stated). 

## AV006 -- Year 1. Strain-Specific HAI Geometric Mean Titers (GMT) Following Dose One or Two in All Participants.

+-------+---------+---------+---------+---------+---------+---------+
|       | GMT     |         |         |         |         |         |
|       | (95%    |         |         |         |         |         |
|       | CI)     |         |         |         |         |         |
+-------+---------+---------+---------+---------+---------+---------+
|       | P       |         | Po      |         | Po      |         |
|       | re-vacc |         | st-Dose |         | st-Dose |         |
|       | ination |         | 1       |         | 2       |         |
+-------+---------+---------+---------+---------+---------+---------+
| S     | FluMist | Placebo | FluMist | Placebo | FluMist | Placebo |
| train |         |         |         |         |         |         |
+-------+---------+---------+---------+---------+---------+---------+
| n     | 136     | 67      | 131     | 63      | 115     | 58      |
+-------+---------+---------+---------+---------+---------+---------+
| H1N1  | 5.4     | 4.7     | 8.9     | 4.6     | 18.8    | 5.0     |
|       |         |         |         |         |         |         |
|       | (4.2,   | (3.4,   | (6.6,   | (3.3,   | (14.2,  | (3.4,   |
|       | 6.9)    | 6.5)    | 12.0)   | 6.4)    | 25.0)   | 7.1)    |
+-------+---------+---------+---------+---------+---------+---------+
| H3N2  | 9.5     | 8.6     | 39.5    | 9.9     | 43.8    | 10.5    |
|       |         |         |         |         |         |         |
|       | (7.2,   | (6.0,   | (33.5,  | (6.8,   | (37.4,  | (6.8,   |
|       | 12.5)   | 12.2)   | 46.7)   | 14.4)   | 51.3)   | 16.1)   |
+-------+---------+---------+---------+---------+---------+---------+
| B     | 4.1     | 4.5     | 18.3    | 4.6     | 25.8    | 4.5     |
|       |         |         |         |         |         |         |
|       | (3.4,   | (3.5,   | (15.6,  | (3.5,   | (22.6,  | (3.3,   |
|       | 5.0)    | 5.9)    | 21.3)   | 6.1)    | 29.4)   | 6.0)    |
+-------+---------+---------+---------+---------+---------+---------+

In a subset of subjects with data available from appropriate time
points, geometric mean fold rises (GMFR) were calculated from
pre-vaccine to post-dose 1 and for pre-vaccine to post-dose 2.
Respectively, these GMFR's were: H1N1 - 1.7 (1.4, 1.9) and 3.4 (2.7,
4.2); H3N2 -- 4.3 (3.3, 5.6) and 4.7 (3.5, 6.2); and B -- 4.5 (3.7, 5.6)
and 6.3 (5.0, 7.8).

The percent of FluMist recipients with post-dose 2 HAI GMTs
[\>]{.underline} 1:32 was: H1N1 -- 52%; H3N2- 83% and B- 57%. (Although
not an established correlate of immunity, HAI titers [\>]{.underline}
1:32 has been associated with protection following wild type influenza
infection and after inactivated influenza vaccine).

###### AV006 -- Year 1. Strain-Specific HAI Seroconversion Following Dose One or Dose Two in Seronegative Participants in the FluMist Group

+----------+---------+--------------+----------+----------+----------+
| FluMist  |         |              |          |          |          |
+----------+---------+--------------+----------+----------+----------+
|          |         |              | Initial  |          | C        |
|          |         |              | Seroco   |          | onverted |
|          |         |              | nversion |          | P        |
|          |         |              | at       |          | ost-Dose |
|          |         |              |          |          | Two      |
+----------+---------+--------------+----------+----------+----------+
| Strain   |         | Seronegative | P        | P        |          |
|          |         |              | ost-dose | ost-Dose |          |
|          |         | Pre          | One      | Two      |          |
|          |         | -Vaccination |          |          |          |
+----------+---------+--------------+----------+----------+----------+
| H1N1     | n/N     | 89/136       | 14/86    | 33/60    | 45/74    |
|          |         |              |          |          |          |
|          | Pro     | 0.65         | 0.16     | 0.55     | 0.61     |
|          | portion |              |          |          |          |
|          |         | (0.57, 0.73) | (0.09,   | (0.42,   | (0.49,   |
|          | 95% CI  |              | 0.26)    | 0.68)    | 0.72)    |
+----------+---------+--------------+----------+----------+----------+
| H3N2     | n/N     | 66/136       | 59/64    | 3/4      | 54/56    |
|          |         |              |          |          |          |
|          | Pro     | 0.49         | 0.92     | 0.75     | 0.96     |
|          | portion |              |          |          |          |
|          |         | (0.40, 0.57) | (0.83,   | (0.19,   | (0.88,   |
|          | 95% CI  |              | 0.26)    | 0.99)    | \>0.99)  |
+----------+---------+--------------+----------+----------+----------+
| B        | n/N     | 93/136       | 80/91    | 6/8      | 75/78    |
|          |         |              |          |          |          |
|          | Pro     | 0.68         | 0.88     | 0.75     | 0.96     |
|          | portion |              |          |          |          |
|          |         | (0.60, 0.76) | (0.79,   | (0.35,   | (0.89,   |
|          | 95% CI  |              | 0.94)    | 0.97)    | 0.99)    |
+----------+---------+--------------+----------+----------+----------+

Among those who were seronegative at baseline in the placebo group 1/40
seroconverted to H1N1, 2/26 to H3N2, and 1/38 to B.

AV006 -- Year 1. Four-Fold Rise in Strain Specific HAI Titers For All
Participants in FluMist Group Following Dose One or Dose Two

+-------------+------------+-------------+-------------+-------------+
| FluMist     |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
|             |            | Initial     |             | Overall     |
|             |            | Four-Fold   |             | Post-Dose   |
|             |            | Rise        |             | Two         |
+-------------+------------+-------------+-------------+-------------+
| Strain      |            | Post-dose   | Post-Dose   |             |
|             |            | One         | Two         |             |
+-------------+------------+-------------+-------------+-------------+
| H1N1        | n/N        | 25/131      | 34/88       | 55/115      |
|             |            |             |             |             |
|             | Proportion | 0.19        | 0.39        | 0.48        |
|             |            |             |             |             |
|             | 95% CI     | (0.13,      | (0.28,      | (0.38,      |
|             |            | 0.27)       | 0.50)       | 0.57)       |
+-------------+------------+-------------+-------------+-------------+
| H3N2        | n/N        | 68/131      | 6/54        | 61/115      |
|             |            |             |             |             |
|             | Proportion | 0.52        | 0.11        | 0.53        |
|             |            |             |             |             |
|             | 95% CI     | (0.43,      | (0.04,      | (0.44,      |
|             |            | 0.61)       | 0.23)       | 0.62)       |
+-------------+------------+-------------+-------------+-------------+
| B           | n/N        | 81/131      | 9/41        | 78/115      |
|             |            |             |             |             |
|             | Proportion | 0.62        | 0.22        | 0.68        |
|             |            |             |             |             |
|             | 95% CI     | (0.53,      | (0.11,      | (0.58,      |
|             |            | 0.70)       | 0.38)       | 0.76)       |
+-------------+------------+-------------+-------------+-------------+

Proportions in columns:

1.  Based on all participants in treatment group.

2.  Response to Dose 2 among participants who did not seroconvert after
    dose 1.

3.  Response following Dose 2 among participants with pre-vaccine and
    post-Dose 2 results.

Among placebo recipients, the numbers (%) of subjects with four
fold-rises in HAI titers were 2/58 (3.4%) for H1N1, 3/56 (5.3%) for
H3N2, and 2/58 (3.4%) for B.

ELISA IgG anti-HA seroconversion rates were also measured in \~202
subjects. Seroconversion was defined as a 2-fold rise in IgG anti-HA
titer. Values below the assay cutoff were converted to equal the cut-off
value for calculations of GMTs and ratios pre-to-post vaccination.
FluMist and placebo groups had equivalent pre-titers. Less than 6% of
placebo recipients had strain-specific seroconversion following Dose 1
or Dose 2. The seroconversion rates (95% CI) following FluMist were:
post-dose 1 → 24% to H1N1, 55% for H3N2 and 70% for B, and post-dose 2 →
54% (44,63) for H1N1, 63% (54,72) for H3N2, and 77% (69, 85) for B,
regardless of when the seroconversion occurred. The mean fold rises (95%
CI) from baseline to post-dose 2 were H1N1 at 3.2 (2.4, 4.3), H3N2 at
24.6 (18.3, 33) and B at 20.8 (17, 25.3).

Nasal IgA anti-HA antibodies were measured in 19 subjects (FluMist =13
and placebo = 6) and thus, no formal comparisons could be performed.

**Heterotypic immunity***.* Sera from 92 of the 203 children were
available for assessment of heterotypic immunity. HAI antibody titers
against 6 different H3N2 virus types were assessed. HAI assays were
performed at Vanderbilt. Following FluMist (n=62), the seroconversion
rates for the seronegative subjects (n\~25) from baseline to post-dose 2
were as follows: A/Russian/269/95 - 78%; A/Johannesburg/33/94 - 52%;
A/Wuhan, A/Sydney/05/97 -- 96%; A/Nanchang/933/95 -- 96% and
A/Thessalonika/1/95 - 96%. The percent with 4-fold rises was \~50% for
each strain (range of 31% for A/Johannsburg to 56% for A/Sydney). For
the seronegative subjects in the placebo group (n=30), between 7 and 14%
seroconverted to each of the strains. No statistical comparisons between
the FluMist and placebo groups were provided.

There were nine subjects in the immunogenicity cohort (all placebo
recipients) who were culture positive for H3N2 influenza during the
course of the study. There were six subjects in the cohort who were
culture positive for type B (3 in the placebo group and 3 in the FluMist
group). All 3 subjects in the FluMist group had 4-fold rises in anti-HA
titers post-FluMist and before disease.

**CAIV Culture-Positive Subjects**

Within the 1^st^ 14 days of vaccination, 116 subjects had 117 cultures
performed. Subjects who had cultures met surveillance criteria, as
stated above. Sixty-six of 116 were FluMist recipients and cultures were
obtained after Day 11, consistent with specified date for surveillance.
Thirty-eight placebo subjects also had cultures obtained, but no
information is provided about these subjects. Between Day 2 and Day 11,
17 FluMist recipients had 18 samples obtained which grew 20 CAIV
isolates. Sixteen of the subjects who had cultures obtained were from
the Houston site (total FluMist recipients in Houston was 144), and one
subject was from Maryland. Of these, 11 subjects grew type B, 5 grew
type A (subtype not stated) and 2 grew both a type A and type B. Results
for growth of other viruses were not provided. The symptom complexes for
the FluMist subjects who were culture-positive for a CAIV were different
from the FluMist subjects who were culture-negative for a CAIV strain,
statistical comparisons not performed (see below).

AV006 -- Year 1. Selected Reactogenicity Events (Days 0-10) for FluMist
Recipients with Cultures Obtained within 14 Days of Vaccinations by
Culture Results.

+------------------------------------+----------------+----------------+
|                                    | **Culture      |                |
|                                    | Results**      |                |
+------------------------------------+----------------+----------------+
| **Participants who returned Diary  | Positive\*     | Negative       |
| Cards**                            |                |                |
+------------------------------------+----------------+----------------+
|                                    | N=17           | N=60^a^        |
+------------------------------------+----------------+----------------+
| **Event , n(%)**                   |                |                |
+------------------------------------+----------------+----------------+
| **Any Event**                      | 17 (100)       | 52 (86.7)      |
+------------------------------------+----------------+----------------+
| **[\>]{.underline} 3 events on     | 12 (70.6)      | 25 (41.7)      |
| same day**                         |                |                |
+------------------------------------+----------------+----------------+
| **CDC-ILI ^b^**                    | 7 (41.2)       | 8 (13.3)       |
+------------------------------------+----------------+----------------+
| **Runny nose/congestion**          | 17 (100)       | 44 (73.3)      |
+------------------------------------+----------------+----------------+
| **Cough**                          | 11 (64.7)      | 33 (55)        |
+------------------------------------+----------------+----------------+
| **Irritability**                   | 9 (52.9)       | 19 (31.7)      |
+------------------------------------+----------------+----------------+
| **Vomiting**                       | 5 (29.4)       | 4 (6.7)        |
+------------------------------------+----------------+----------------+
| **Muscle aches**                   | 1 (5.9)        | 7 (11.7)       |
+------------------------------------+----------------+----------------+
| **Decreased activity**             | 9 (52.9)       | 15 (25)        |
+------------------------------------+----------------+----------------+
| **Fever**                          | 12 (70.6)      | 14 (23.3)      |
|                                    |                |                |
| **Temp 1: \>100^o^F**              | 2 (11.8)       | 4 (6.7)        |
|                                    |                |                |
| **Temp 2: \>102**                  | 1 (5.9)        | 0              |
|                                    |                |                |
| **Temp 3: \>104**                  |                |                |
+------------------------------------+----------------+----------------+

\* CAIV culture postive

a.  61 subjects were vaccinated, but only 60 returned the diary card.

b.  CDC influenza like illness, defined as fever with cough or sore
    throat on the same day or consecutive days.

## 

## 

## STUDY AV006 -Year 2

## Of the 1602 subjects originally enrolled, 1561 completed Year 1 of the study and 1358 (87%) returned for Year 2. As noted above, subjects returning for Year 2 remained in their original treatment group. All enrollees were vaccinated with a single dose of study vaccine, either placebo or Flumist containing the 1997-98 strains, according to their randomization assignment in Year 1. With this, the sponsor reports potential biases included: 1) self-selection for Year 2 enrollment and 2) different immune experiences of Flumist and placebo recipients during Year 1 (e.g., placebo recipients had much higher attack rate of influenza in Year 1). 

## The procedures for monitoring for safety and efficacy in Year 2 were similar to those in Year 1. Participants in the Immunogenicity cohort from Year 1 who returned were offered enrollment into the Year 2 Immunogenicity substudy. Serum was obtained to characterize further the strain-specific responses to HA by HAI and IgG ELISA (assays were performed at Aviron). Pre-vaccination titers were obtained just prior to vaccination and post-titers were obtained 28 to 56 days after vaccination. At Vanderbilt, a very small subset of subjects (13 subjects of 19 from Year 1) had nasal washes obtained for IgA anti-HA by ELISA at the same time that serum samples were obtained.

## 

## VACCINES: The vaccines used are listed under Vaccines in Year 1. The A/H3N2 and B strains were the same for Year 1 and Year 2; however, the H1N1 strains were different. In Year 1, the H1N1 was A/Texas/36/91 and in Year 2 it was A/Shenzhen/227/95.

## Efficacy Endpoints And RESUlts for Year 2

### Primary {#primary .unnumbered}

The **primary efficacy endpoint** is the 1^st^ episode of
culture-confirmed influenza caused by subtypes of influenza
antigenically similar to strains contained in the vaccine in a study
child following re-vaccination with a dose of vaccine or placebo.

A **culture-confirmed case** of influenza illness is one that occurred
at least 15 days after receiving a dose of vaccine or placebo and that
is defined by a positive culture of a wild-type virus subtype
antigenically similar to one contained in the vaccine. "Antigenically
similar" is not defined in the protocol.

### Secondary {#secondary .unnumbered}

The **secondary efficacy endpoints** are the 1^st^ episode of
culture-confirmed influenza illness caused by subtypes of influenza
antigenically similar to strains contained in the vaccine occurring at
least 15 days after re-vaccination with a dose of vaccine or placebo in
a study participant who in Year 1:

-   Received 2 doses

-   Was enrolled to receive 2 doses

-   Was enrolled to receive 1 dose

All of these endpoints were also investigated separately for the
specific influenza strains circulating in 1997-98 season, including
A/Sydney (H3N2), a variant strain.

## Other Efficacy Endpoints

Severity of illness was examined in 2 ways: by evaluating illness
characteristics in 1) subjects with culture-confirmed influenza and 2)
all participants regardless if a culture was taken or using the same
variables as for year 1.

##### RESULTS (YEAR 2) {#results-year-2 .unnumbered}

**Enrollment and Demographics***.*

The characteristics of the two study groups at the time of enrollment
into Year 2 were similar: the mean age was 55 months and 52 months; 86%
and 85% were Caucasian; and 54% and 51% were female, FluMist and placebo
groups respectively.

As compared to subjects who chose not to participate, Year 2
participants were more likely to have a primary caretaker working
outside of the home (51% *vs* 39%). Otherwise, the participants in Year
2 were comparable to non-participants. For the 203 subjects that did not
participate in Year 2, the reasons listed for not returning were
comparable between the FluMist and placebo groups. The 3 primary reasons
(accounting for 73% of subjects) for not returning were withdrew consent
(33% -n=66, FluMist n=35), moved away (25%- n=50, FluMist 35) and unable
to contact (16%- n=33, FluMist n=24). Other reasons (accounting for less
than 5% each) included: no longer meets Inc/Exc criteria, changed
insurance, and "other."

For the immunogenicity cohort, 162 of 209 (78%) subjects returned for
participation in Year 2. This percent of subjects who returned is lower
than the percent of overall study participants who returned (78% vs
87%). As in Year 1, there was a lower percentage of subjects who were
Caucasian in the immunogenicity cohort (75% in immunogenicity subset
*vs* 85% in entire study cohort). Within the immunogenicity cohort, the
FluMist (n=108) and placebo (n=54) recipients had similar demographics
except more FluMist recipients had primary caretakers who worked outside
of the home as compared to placebo (65% *vs* 52%).

75% of Year 2 subjects received their vaccination in Sept., 25% in
October and all dosing was complete by Nov 14, 1997.

## Protocol Compliance

1343 participants (99%) completed Year 2 of the study. There were a
total of 170 of 1358 (13%) of participants with protocol deviations,
information was provided as line listings. Most violations related to
enrolling subjects (n=30, Flumist n=24) who developed exclusion
criteria, such as asthma or other chronic illnesses. A total of 15
subjects (11 FluMist and 4 placebo recipients) withdrew from the study.
Six subjects were withdrawn because of lack of compliance, 3 subjects
moved from the study area, 3 did not return for observation, and 1
subject withdrew consent. At one site, 37 subjects received only ½ dose
of study vaccinations. A missed phone call accounted for 61 protocol
violations. No information about defective Accuspray devices was
provided.

## Efficacy

**H1N1 did not circulate in the community in Year 1 or Year 2, and no
field efficacy data were generated for this strain.**

During Year 2 influenza season, 1808 cultures were obtained, 1188 in the
FluMist group and 620 in the placebo group. Of the total, seventy-one
(4%) cultures were positive for influenza, 15 (1%) of FluMist recipient
cultures and 56 (9%) of placebo recipient cultures.

###  {#section-10 .unnumbered}

### In the primary efficacy analysis, the sponsors have not included the type A/Sydney (H3N2) isolates and conclude that efficacy was 100% against wild-type strains "antigenically similar" to vaccine strains. The predominant circulating strain in Year 2 was A/Sydney (H3N2), which was considered to be a variant, whereas in Year 1 the circulating strain A/H3N2 was more closely matched to the A/Wuhan (H3N2) vaccine strain. However, the protocol did not define "antigenically similar" for the purposes of the primary analysis.  {#in-the-primary-efficacy-analysis-the-sponsors-have-not-included-the-type-asydney-h3n2-isolates-and-conclude-that-efficacy-was-100-against-wild-type-strains-antigenically-similar-to-vaccine-strains.-the-predominant-circulating-strain-in-year-2-was-asydney-h3n2-which-was-considered-to-be-a-variant-whereas-in-year-1-the-circulating-strain-ah3n2-was-more-closely-matched-to-the-awuhan-h3n2-vaccine-strain.-however-the-protocol-did-not-define-antigenically-similar-for-the-purposes-of-the-primary-analysis. .unnumbered}

###  {#section-11 .unnumbered}

### AV006 -- Year 2 Overall Efficacy of FluMist in Preventing Culture-Confirmed Influenza Illness {#av006-year-2-overall-efficacy-of-flumist-in-preventing-culture-confirmed-influenza-illness .unnumbered}

+--------------------+----------------+-------+-------+--------------+
| ## Analysis Group  | ## Strain      | #     |       | **Estimated  |
|                    |                | # Num |       | Efficacy**   |
|                    |                | ber o |       |              |
|                    |                | f Iso |       | **% (95%     |
|                    |                | lates |       | CI)**        |
+--------------------+----------------+-------+-------+--------------+
|                    |                | ## Fl | ## Pl |              |
|                    |                | uMist | acebo |              |
+--------------------+----------------+-------+-------+--------------+
| **All Year Two     | All community  | 15    | 56    | 87.1 (77.7,  |
| Participants**     | acquired       |       |       | 92.6)        |
|                    | strains        |       |       |              |
+--------------------+----------------+-------+-------+--------------+
|                    | Strains in     | 0     | 5     | 100 (63.1,   |
|                    | FluMist        |       |       | 100)         |
|                    | \[A/Wuhan      |       |       |              |
|                    | (H3N2), B\]\*  |       |       |              |
+--------------------+----------------+-------+-------+--------------+
|                    | A/Sydney       | 15    | 51    | 85.9 (78.0,  |
|                    | (H3N2)         |       |       | 91.9)        |
+--------------------+----------------+-------+-------+--------------+
| **Participants     | All community  | 14    | 52    | 87 (77.0,    |
| Enrolled in the    | acquired       |       |       | 92.6)        |
| Two-Dose Regimen   | strains        |       |       |              |
| in Year One**      |                |       |       |              |
+--------------------+----------------+-------+-------+--------------+
|                    | Strains in     | 0     | 4     | 100 (53.7,   |
|                    | FluMist        |       |       | 100)         |
|                    | \[A/Wuhan      |       |       |              |
|                    | (H3N2), B\]    |       |       |              |
+--------------------+----------------+-------+-------+--------------+
|                    | A/Sydney       | 14    | 48    | 85.9 (75.0,  |
|                    | (H3N2)         |       |       | 92.1)        |
+--------------------+----------------+-------+-------+--------------+
| **Participants in  | All community  | 0     | 4     | 100 (54.9,   |
| One-Dose Regimen   | acquired       |       |       | 100)         |
| in Year One**      | strains        |       |       |              |
+--------------------+----------------+-------+-------+--------------+
|                    | Strains in     | 0     | 4     | 100 (54.9,   |
|                    | FluMist        |       |       | 100)         |
|                    | \[A/Wuhan      |       |       |              |
|                    | (H3N2), B\]    |       |       |              |
+--------------------+----------------+-------+-------+--------------+
|                    | A/Sydney       | 0     | 3     | 100 (39.8,   |
|                    | (H3N2)         |       |       | 100)         |
+--------------------+----------------+-------+-------+--------------+

\*Primary analysis according to sponsor's study report.

No participant in Year 2 had more than 1 case of influenza. The sponsor
does not state the number of cultures obtained in the first 15 days
post-vaccination. There were no positive cultures for CAIV. The mean
number of days between vaccination and influenza was 141 for FluMist
recipients and 124 for placebo recipients, p=0.05.

An additional analysis, which excluded 48 subjects with protocol
violations, was provided. The protocol violations included 37 subjects
(FluMist, n=21 and placebo, n=16) at one site who inadvertently received
½ dose of vaccination. The other 11 included: 7 subjects (FluMist n=1,
placebo n=6) who had received TIV prior to Year 1 or Year 2 vaccination,
3 subjects (FluMist n=2) who had influenza, and 1 placebo recipient who
received Vancenase (nasal steroids) within 4 days of vaccination. As
noted above, there were a total of 170 protocol deviations and it is not
clear why only 48 were excluded or why subjects with influenza prior the
second dose in Year 1 were excluded. Nevertheless, efficacy in this
analysis was similar, 87% against all circulating strains and 100%
against strains similar to those in the vaccine.

Efficacy against A/H3N2 afforded by wild type infection in Year 1 was
86.1% (25.9, 97.6). which is similar to the efficacy of 86.9% against
all community-acquired A/H3N2 in FluMist recipients. One of the 52
placebo recipients with wild-type A/H3N2 in Year 1 also had A/H3N2 in
Year 2. This is compared to 54 of 389 placebo recipients without
wild-type A/H3N2 in Year 1 who were infected in Year 2.

AV006 - Year Two. Efficacy of FluMist by Age, Gender, and Race

+-----------------------------------+-----------------------------------+
| **Category**                      | ## Any Strain % (95 CI)           |
+-----------------------------------+-----------------------------------+
| ## Age (mos.)                     |                                   |
+-----------------------------------+-----------------------------------+
| \< 24                             | NA                                |
+-----------------------------------+-----------------------------------+
| 24-35                             | 84.4 (35.2, 96.3)                 |
+-----------------------------------+-----------------------------------+
| 36-48                             | 84.5 (56.8, 94.5)                 |
+-----------------------------------+-----------------------------------+
| 48-60                             | 92.2 (69.0, 98.0)                 |
+-----------------------------------+-----------------------------------+
| ≥ 60                              | 86.9 (70.8, 94.1)                 |
+-----------------------------------+-----------------------------------+
| ## Gender                         |                                   |
+-----------------------------------+-----------------------------------+
| Female                            | 81.7 (65.3, 90.4)                 |
+-----------------------------------+-----------------------------------+
| Male                              | 94.1 (82.0, 98.1)                 |
+-----------------------------------+-----------------------------------+
| ## Race                           |                                   |
+-----------------------------------+-----------------------------------+
| ## White                          | 87.6 (78.1, 93.0)                 |
+-----------------------------------+-----------------------------------+
| ## Non-White                      | 75.4 (-85.6, 96.7)                |
+-----------------------------------+-----------------------------------+

Of note, the analyses provided by ages include overlapping age ranges.
The number of subjects included per age group was not provided.

**Severity of Illness**

Illness associated with culture positive influenza:

Culture positive influenza illness was categorized into 3 symptom
groups: 1) afebrile upper respiratory infection (URI) - 3 cases in
FluMist group and 2 in placebo 2) febrile URI - 12 cases in the FluMist
group and 54 in the placebo group and 3) lower respiratory symptoms - 0
in FluMist group, 8 in placebo (100%, with 95%CI 77, 100), events shown
against "any wild-type" strain. Of note, lower respiratory symptoms were
not described and case definition for this diagnosis was not provided.

Efficacy for febrile ([\>]{.underline} 101.0^o^F oral or rectal or
[\>]{.underline} 100.4^o^F ax) influenza illness in the FluMist *vs.*
placebo groups was 89.3% (80.4, 94.2) and associated with otitis media
was 94.3% (78.1, 98.5). However, no efficacy was demonstrated against
all otitis media. The mean duration of febrile illness due to any
wild-type strain of influenza was significantly less for FluMist than
placebo recipients (2.1 vs. 4.9, p\<0.01,)

Illness regardless of culture status:

There were significantly fewer number of illnesses per participant in
the FluMist group than in the placebo group (1.46 vs. 1.61; p =0.01),
and fewer febrile illness (0.61 vs. 0.77; p\<0.01).

No efficacy was demonstrated against "any otitis media" (0.32 *vs.*
0.34, p = 0.16) or episodes of febrile otitis media (0.11 vs. 0.14, p
=0.6) in the FluMist compared to placebo group. The number of episodes
per participant of otitis media requiring antibiotics was small (0.11 in
the FluMist group vs. 0.13 in the placebo group) but reached statistical
significance with p= 0.04. There was no pre-specified definition for the
diagnosis of otitis media stated in the protocol.

For economic impact (evaluation began 15 days post-vaccination), FluMist
recipients missed significantly fewer school, pre-school or daycare days
for "all illnesses" (0.93 vs 1.11 p =0.01) and for culture-confirmed
influenza (0.02 vs. 0.23; p \<0.01) than did placebo recipients. Also,
significantly fewer lost workdays for primary care provider and HCP
visits were noted for FluMist vs placebo recipients with
culture-confirmed influenza (p \<0.01).

## AV006 - Year 2 Immunogenicity Results

Of the 162 subjects who returned for Year 2, 160 subject had valid pre-
and post-vaccination samples for HAI titers and 159 for IgG by ELISA.
The reasons for missing data in subjects were not provided.

## AV006- Year 2. Strain-Specific HAI Geometric Mean Titers (GMT)Following Revaccination in Year Two by Treatment Group.

+------------------+-------+----------+----------+----------+----------+
|                  |       | GMT (95% |          |          |          |
|                  |       | CI)      |          |          |          |
+------------------+-------+----------+----------+----------+----------+
|                  |       | FluMist  |          | Placebo  |          |
+------------------+-------+----------+----------+----------+----------+
| Strain           |       | Pre-Dose | P        | Pre-Dose | P        |
|                  |       |          | ost-Dose |          | ost-Dose |
+------------------+-------+----------+----------+----------+----------+
| N\*              |       |          |          |          |          |
+------------------+-------+----------+----------+----------+----------+
| H1N1             | GMT   | 10.3     |          | 4.1      |          |
|                  |       |          |          |          |          |
| A/Texas (Yr 1    | 95%   | (7.8,    |          | (3.0,    |          |
| Strain)          | CI    | 13.6)    |          | 5.7)     |          |
+------------------+-------+----------+----------+----------+----------+
| H1N1             | GMT   | 8.7      | 24.8     | 5.0      | 4.6      |
|                  |       |          |          |          |          |
| A/Shenzhen (Yr 2 | 95%   | (6.3,    | (19.2,   | (3.3,    | (3.1,    |
| Strain)          | CI    | 12.1)    | 32.0)    | 7.5)     | 6.8)     |
+------------------+-------+----------+----------+----------+----------+
| H3N2             | GMT   | 73.4     | 91.1     | 21       | 22.1     |
|                  |       |          |          |          |          |
|                  | 95%   | (62.3,   | (77.9,   | (12.5,   | (13.1,   |
|                  | CI    | 86.5)    | 106.5)   | 35.2)    | 37.2)    |
+------------------+-------+----------+----------+----------+----------+
| B                | GMT   | 18.5     | 42.4     | 6.0      | 6.1      |
|                  |       |          |          |          |          |
|                  | 95%   | (15.7,   | (37.1,   | (4.3,    | (4.4,    |
|                  | CI    | 21.7)    | 48.4)    | 8.2)     | 8.5)     |
+------------------+-------+----------+----------+----------+----------+

Table combines subjects who received one or two doses in Year 1.

\*N, number of participants included was not provided.

Prior to Year 2 vaccination, all FluMist recipients were seropositive to
A/H3N2, 92.4% to type B, and 57% to A/H1N1, see Table below.

AV006-Year 2. Strain-Specific HAI Seroconversion Following
Re-Vaccination in Seronegative Participants in the FluMist Group

+----------+---+---------+--------------+---------------+---------------+---+
|          |   | FluMist |              |               |               |   |
|          |   | Rec     |              |               |               |   |
|          |   | ipients |              |               |               |   |
+----------+---+---------+--------------+---------------+---------------+---+
| Strain   |   |         | Seronegative | S             | Cumulative    |   |
|          |   |         |              | eroconversion | Seropositive  |   |
|          |   |         | Pre          | Post-dose in  |               |   |
|          |   |         | -Vaccination | Year 2        |               |   |
+----------+---+---------+--------------+---------------+---------------+---+
| H1N1     | n |         | 46/107       | Not provided  | Not provided  |   |
|          | / |         |              |               |               |   |
| A/Texas  | N |         | 43           |               |               |   |
| (Year 1) |   |         |              |               |               |   |
|          | P |         | (33, 53)     |               |               |   |
|          | e |         |              |               |               |   |
|          | r |         |              |               |               |   |
|          | c |         |              |               |               |   |
|          | e |         |              |               |               |   |
|          | n |         |              |               |               |   |
|          | t |         |              |               |               |   |
|          |   |         |              |               |               |   |
|          | 9 |         |              |               |               |   |
|          | 5 |         |              |               |               |   |
|          | % |         |              |               |               |   |
|          | C |         |              |               |               |   |
|          | I |         |              |               |               |   |
+----------+---+---------+--------------+---------------+---------------+---+
| H1N1     | n |         | 57/106       | 38/57         | 87/106        |   |
|          | / |         |              |               |               |   |
| A/       | N |         | 54           | 67            | 82            |   |
| Shenzhen |   |         |              |               |               |   |
| (Year 2) | P |         | (44, 64)     | (3, 79)       | (73, 89)      |   |
|          | e |         |              |               |               |   |
|          | r |         |              |               |               |   |
|          | c |         |              |               |               |   |
|          | e |         |              |               |               |   |
|          | n |         |              |               |               |   |
|          | t |         |              |               |               |   |
|          |   |         |              |               |               |   |
|          | 9 |         |              |               |               |   |
|          | 5 |         |              |               |               |   |
|          | % |         |              |               |               |   |
|          | C |         |              |               |               |   |
|          | I |         |              |               |               |   |
+----------+---+---------+--------------+---------------+---------------+---+
| H3N2     | n |         | 0/106        | \-            | 106/106       |   |
|          | / |         |              |               |               |   |
|          | N |         | 0            | \-            | 100           |   |
|          |   |         |              |               |               |   |
|          | P |         | (0, 3)       | \-            | (97, 100)     |   |
|          | e |         |              |               |               |   |
|          | r |         |              |               |               |   |
|          | c |         |              |               |               |   |
|          | e |         |              |               |               |   |
|          | n |         |              |               |               |   |
|          | t |         |              |               |               |   |
|          |   |         |              |               |               |   |
|          | 9 |         |              |               |               |   |
|          | 5 |         |              |               |               |   |
|          | % |         |              |               |               |   |
|          | C |         |              |               |               |   |
|          | I |         |              |               |               |   |
+----------+---+---------+--------------+---------------+---------------+---+
| B        | n |         | 8/106        | 7/8           | 106/106       |   |
|          | / |         |              |               |               |   |
|          | N |         | 8            | 88            | 100           |   |
|          |   |         |              |               |               |   |
|          | P |         | (3, 14)      | (47, 100)     | (97, 100)     |   |
|          | e |         |              |               |               |   |
|          | r |         |              |               |               |   |
|          | c |         |              |               |               |   |
|          | e |         |              |               |               |   |
|          | n |         |              |               |               |   |
|          | t |         |              |               |               |   |
|          |   |         |              |               |               |   |
|          | 9 |         |              |               |               |   |
|          | 5 |         |              |               |               |   |
|          | % |         |              |               |               |   |
|          | C |         |              |               |               |   |
|          | I |         |              |               |               |   |
+----------+---+---------+--------------+---------------+---------------+---+

Definitions for seronegative (HAI [\<]{.underline} 1:4) and
seroconversion (4-fold rise in seronegative subjects) used in Year 1
were the same for Year 2. For the placebo group, the percent
seronegative, percent seroconversion, and cumulative seropositive rates
for the 3 vaccine strains were as follows: H1N1 (A/Shenzen): 72%, 0%,
26%; H3N2: 37%, 5%, 65%; B: 52%, 0%, 46%.

After re-vaccination in Year 2 strain-specific HAI titers
[\>]{.underline} 1:32 were observed in 57% (47, 66) to H1N1, 97% (92,
99) to H3N2, and 85% (77, 91) to type B of FluMist recipients.

AV006- Year 2. Four-Fold Rise in Strain Specific HAI Titers Regardless
of Baseline Following Re-Vaccination in Year Two by Treatment Group

+-----------------+---------------+-----------------+-----------------+
| Strain          |               | FluMist         | Placebo         |
+-----------------+---------------+-----------------+-----------------+
| H1N1            | n/N           | 43/106          | 0/54            |
|                 |               |                 |                 |
|                 | Percent       | 41              | 0               |
|                 |               |                 |                 |
|                 | 95% CI        | (31, 51)        | (0, 5)          |
+-----------------+---------------+-----------------+-----------------+
| H3N2            | n/N           | 5/106           | 1/54            |
|                 |               |                 |                 |
|                 | Percent       | 5               | 2               |
|                 |               |                 |                 |
|                 | 95% CI        | (2, 11)         | (0,10)          |
+-----------------+---------------+-----------------+-----------------+
| B               | n/N           | 32/106          | 0/54            |
|                 |               |                 |                 |
|                 | Percent       | 30              | 0               |
|                 |               |                 |                 |
|                 | 95% CI        | (22, 40)        | (0, 5)          |
+-----------------+---------------+-----------------+-----------------+

Table combines subjects who received one or two doses in Year 1.

The ELISA IgG index was considered negative in it was [\<]{.underline}
the strain-specific cutoff values of: H1N1 = 0.04, H3N2 = 0.13, and B=
0.06. The proportion of seronegative subjects for IgG followed a similar
pattern to HAI antibodies for all 3 strains. Seronegative subjects
(FluMist, n=105 vs. placebo, n=54) respectively were: H1N1 (39% vs 61%),
H3N2 (0% vs. 30%), and B (1% vs. 48%). Seroconversion (defined as a
2-fold rise in IgG index) occurred in 0 seropositive placebo subjects
and in 1of 33 to H1N1, 1 of 16 to H3N2, and 0 of 26 to B seronegative
placebo recipients.

FluMist group -- All FluMist recipients were seropositive to H3N2 in
pre-titers for Year 2. For H1N1, 24 of 41 (59%) of seronegative FluMist
seroconverted to IgG-HA. For B, the only seronegative FluMist subject
seroconverted. After Year 2 re-vaccination, the cumulative immune
responses of FluMist recipients were 84% seropositive to H1N1, 100% to
H3N2 and B.

Nasal IgA anti-HA antibodies were measured in 13 subjects (FluMist = 8)
and thus, no formal comparisons could be performed.

Cross-reactivity between H1N1 A/Texas/36/91 (Year 1 FluMist strain) and
A/Shenzhen/227/95 (Year 2 FluMist strain) was assessed by comparing
pre-vaccination titers to the two strains for 95 subjects in the
immunogenicity subset. The sponsor noted that antibody titers
pre-vaccination to the two strains were highly correlated (0.91, p =
0.0001) and concluded that cross-reactivity was suggested. However, the
analysis appears to include both vaccine and placebo recipients and,
therefore, if cross-reactivity is present, the current analysis does
allow an assessment as to whether this might be due to an immune
response to the FluMist vaccine.

# **STUDY -- AV011** 

**TITLE: A Phase 3, Randomized, Prospective, Open-label Challenge Study
to Assess Viral**

**Shedding of Influenza Virus Vaccine, Monovalent, Type A, Live,
Cold-Adapted (CAIV-M)**

**in Healthy Children.**

## INTRODUCTION/DESIGN

In Year One of study AV006 FluMist was shown to be efficacious in
children ages 15-71 months against the circulating outbreak viral
strains which included A/H3N2 and B strains. In Year Two, efficacy was
again demonstrated against circulating outbreak strains even though the
predominant strain was A/Sydney/H3N2, which was a variant strain from
the A/Wuhan/359/95 vaccine strain. There were no circulating A/H1N1
strains during either influenza season and, therefore, field efficacy
data against A/H1N1 strains was not obtained. Study AV011 was designed
to "challenge" a subset of AV006 vaccine and placebo recipients with an
intranasal dose of cold-adapted monovalent A/H1N1 vaccine strain
(CAIV-M) and to compare viral shedding between prior vaccine recipients
and prior placebo recipients. *The sponsor proposed that demonstrating
decreased viral shedding of this H1N1 vaccine strain in previous FluMist
recipients as compared to prior placebo recipients be viewed as a
surrogate marker of vaccine efficacy for A/H1N1 strain.*

The study was an open-label study in which all subjects received a
single challenge dose of CAIV-M A/H1N1 vaccine \~ 5 - 8 months after
receipt of FluMist (CAIV-T) or placebo as part of the Year Two AV006
study. Children who had completed both years of AV006 (n=1343) were
recruited for this study. AV011 was performed at the same 10 sites as
AV006, and each site was to enroll \~ 20 subjects with priority for
enrolling children who had been in the immunogenicity substudy to permit
additional analysis of serologic data. Study sites submitted their list
of proposed participants to the Statistical Center (SC) prior to
enrollment and a list of enrolled subjects midway through enrollment.
The SC suggested substitute participants as necessary to ensure a ratio
of Flumist and placebo participants of 2:1 to 1:1. Serostatus and prior
influenza infection were not considered in this selection.

STUDY PERIOD: 4/13/98 -- 6/17/98

PIVOTAL: Yes

POPULATION: Children, who had completed Year 1 and 2 of AV006 (Efficacy
Trial)

SAMPLE SIZE: Total - 222; FluMist -- total, n=144 (Year 1 regimen:
1-dose, n = 16 and 2-dose, n= 128); Placebo -- total, n=78 (Year 1
regimen: 1-dose, n = 7 and 2-dose, n = 71).

## OBJECTIVES

## Primary

To compare the frequency of viral shedding of CAIV, Monovalent (CAIV-M)
vaccine strain A/(H1N1) in participants previously vaccinated with
FluMist (1 or 2 dose regimen in Year 1, and 1 dose regimen in Year 2 in
AV006) to the frequency of viral shedding in previously unvaccinated
participants in AV006 (placebo recipients).

## Secondary Immunogenicity and Efficacy Objectives

-   To compare previously vaccinated children to children who previously
    received placebo for the following parameters:

> \- Quantity of CAIV-M virus shed
>
> \- Duration of CAIV-M virus shedding

-   To compare the relationship between viral shedding and the following
    immunologic measures:

> \- Quantity of pre-existing serum HAI titers and IgG titer to
> A/Shenzhen/H1N1
>
> \- Quantity of pre-existing nasal IgA antibody to A/Shenzhen/H1N1

**VACCINE**

The challenge vaccine was CAIV-M, Type A/Shenzhen/227/95 (H1N1). Each
0.5 ml dose contained 10^7^ TCID~50~ of vaccine virus in normal
allantoic fluid (NAF) containing sucrose-phosphate-glutamate (SPG). The
H1N1 lot number was CAE036, which was the same lot used for FluMist
vaccine in 1997-98, though the challenge H1N1 was mixed with a different
lot of NAF than used for FluMist. In the 1996-97 vaccine, the H1N1
strain was A/Texas/36/91.

## PROCEDURES

## Inclusion criteria

Healthy children who completed Year 1 and 2 of AV006 were eligible. The
family had to have availability by telephone and be able to understand
and comply with the protocol.

**Exclusion criteria**

Newly developed (since being in AV006) hypersensitivity to eggs or egg
protein; newly diagnosed immunodeficiency or immunosuppressive
treatment, or household member with newly diagnosed immunosuppression
(since participation in AV006); acute febrile illness within 1 week;
current URI (including common cold or nasal congestion) within 72 hours;
administration of live virus vaccine within 1 month; administration of
an inactivated vaccine within 2 weeks; receipt of inactivated influenza
vaccine since 1996; receipt of a blood product within 3 mo prior or
planned receipt within the study duration; expected administration of
nasal medications during the 10 days before or after vaccination; any
condition the investigator though might interfere with vaccine
evaluation. Pregnant household member or daycare provider was not an
exclusion.

**Vaccine Administration and Schedule**

On Study Day 0, subjects had medical and vaccine histories obtained and
a brief physical exam performed. Just prior to vaccination, serum
samples were obtained from all subjects at all study sites and nasal
wash samples were collected at 9 of 10 sites. At the Bardstown site, no
nasal washes were obtained per protocol for feasibility reasons. At
least 10 minutes after the nasal wash, each subject received 0.5 ml of
vaccine (0.25 ml per nostril) while in the upright position. Subjects
remained sitting for 30 seconds after vaccination. Only 2 sites (Saint
Louis University, SLU and Vanderbilt) obtained 28-42 day
post-vaccination serum samples.

## Concomitant Vaccinations and Medications

No concomitant vaccinations were permitted. Use of aspirin or
ASA-containing products was discouraged. All medications given in the
1^st^ 10 days post-vaccination were recorded on CRF.

## Monitoring

## Immunogenicity

Serum samples were obtained prior to vaccination, and in a subset of
subjects at 28-42 days post-vaccination. Sera were tested at Aviron for
HAI and ELISA IgG index using HA derived from A/Shenzhen/227/95 (H1N1).
Nasal wash samples (\~10 ml) were obtained for testing total IgA and
specific HA to A/Texas/36/91 (H1N1). HA from A/Shenzhen was not used
because of technical difficulties with this antigen (details
[not]{.underline} provided). The sponsor notes that the HA from A/Texas
and A/Shenzhen were cross reactive in serum HAI testing in AV006, with a
high correlation, r=0.91, p=0.0001 for the 2 H1N1 antigens (See summary
for AV006-Year 2).

## Virology

Subjects had nasal and throat swabs obtained for culture on
post-vaccination days 1, 2, 3 and 4 to assess shedding of CAIV-M vaccine
strain. Both swabs were placed into the same tube of transport medium
and the inoculated media were divided into three aliquots. One aliquot
of the sample was inoculated onto RMK cells, and 2 other aliquots were
frozen. If the study site isolated influenza, one of the frozen aliquots
was sent to SLU for quantitative assaying with results reported in
plaque-forming units per milliliter (pfu/ml) of A/Shenzhen/227/95.

**Statistical Analysis Plan**

## Efficacy Endpoints

## Primary

The primary efficacy endpoint was the percent of subjects with shedding
of CAIV-M on Days 1, 2, 3 or 4.

## Secondary

-   The number of days of viral shedding

-   The 1^st^ day of viral shedding

```{=html}
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```
-   Shedding by day (i.e., on which day viral shedding occurred).

## [Analysis of Viral Shedding]{.underline}

Viral shedding for the primary analysis was defined as at least 1
positive culture from Days 1,2,3, or 4 post-vaccination. Vaccine
efficacy against viral shedding was calculated as: \[1- (event rate in
prior vaccinees/event rate in prior placebo recipients)\] x 100%.

Efficacy p-values and confidence limits were computed using Koopman's
method for the confidence intervals on the ratio of two binomial
proportions. Number of days of shedding and distribution of plaque assay
results of shedding were compared using the Krusai-Wallis test. Time to
first day of shedding was compared using log rank test. Fisher's exact
test was used to compare daily shedding results.

### [Analysis of Immunogenicity]{.underline} {#analysis-of-immunogenicity .unnumbered}

Paired comparison of seronegative vs. seropositive children between HAI
and nasal IgA was performed.

### [Determination of Sample Size]{.underline} {#determination-of-sample-size .unnumbered}

Sample size was anticipated to be \~ 200 (133 FluMist and 67 placebo
recipients). The primary hypothesis was tested by means of a confidence
interval (CI) for efficacy of FluMist against viral shedding. Power was
calculated as the probability that the lower limit of the 2-sided 95% CI
would exceed 0. Based upon HAI data form AV006, \~30% of placebo
recipients were expected to have antibodies to A/H1N1, which might
reduce shedding in this group.

## RESULTS

## Enrollment and Demographics

A total of 222 subjects (previous recipients of FluMist, n=144 and
placebo, n=78) were enrolled into AV011. Of the 144 FluMist recipients,
128 had received the 2-dose regimen and 16 received the 1-dose regimen
in Year 1 of study AV006. Of the 78 prior placebo recipients, 71 had
received the 2-dose regimen and 7 the 1-dose regimen in Year 1. The mean
interval since dosing in Year 2 was not provided, but ranged from 5-8
months.

## 

The demographic profiles of AV011 participants were similar to AV011
non-participants as noted by comparison of the characteristics at the
time of enrollment into AV006. There were no statistically significant
differences for demographics between the prior FluMist and prior placebo
recipients. The ethnicity of subjects was 81 % Caucasian, 13% Black, 3%
Hispanic, and 3% other. The mean age ([+]{.underline} SD) of enrollees
was 59.8 ([+]{.underline} 17.4) month for prior FluMist and 63.1
([+]{.underline} 16.8) for prior placebo recipients. Both groups had
slightly more females (FluMist -- 53% and placebo -- 56%). About ½ of
participants had a primary caretaker who worked outside of the home.
More previous placebo recipients (87%) than FluMist recipients (74.3%)
spent some time ([\>]{.underline} 1 day) in daycare. No statistical
comparisons were provided.

## Protocol Compliance

All 222 subjects completed the trial. There were no withdrawals.

[Protocol Deviations]{.underline}

There were a total of 64 protocol deviations, none of which merited
ending study participation. The protocol deviations were presented as
line listings. The most common deviations included, vaccine was
administered too soon after nasal wash (n=24), refusal of
post-vaccination blood draws (n=7), missing or delayed diary card data
(n=9). For 6 subjects viral and Group A strep cultures were not obtained
for illness events in the first 10 days post-vaccination as specified in
the protocol. Five subjects missed one or both (nasal/throat)
post-vaccination cultures on one of the Days 1-4 post-vaccination.

### [Specimen Acquisition]{.underline} {#specimen-acquisition .unnumbered}

Nasal and throat swabs were obtained from 97-100% of each group of
subjects on Days 1,2,3 and 4 post-vaccination. All swabs collected were
analyzed. Pre-vaccination nasal wash specimens for antibodies were
obtained from 199 subjects (131 FluMist and 68 placebo,) which is 100%
from the 9 sites that collected nasal washes. All subjects had
pre-vaccination serum samples obtained. Post-vaccination serum samples
were obtained from 26/31 (84%) prior FluMist recipients and 15/17 (88%)
prior placebo recipients who were expected to have samples obtained
(Vanderbilt and SLU). Five serum samples (3 FluMist and 2 placebo) from
the pre- or post-vaccination samples were not analyzed because of sample
loss or inadequate identification.

### AV011 -- Efficacy as Determined by H1N1 Shedding After Challenge with CAIV-M (A/H1N1) by Treatment Group {#av011-efficacy-as-determined-by-h1n1-shedding-after-challenge-with-caiv-m-ah1n1-by-treatment-group .unnumbered}

  -------------------------- ------------------------ --------------------
                             **Prior FluMist (N=      **Prior Placebo
                             144)**                   (N=78)**

  **Shedding on Any Day, N   6 (4)                    19 (25)
  (%)**                                               

  **Efficacy (95% CI)**      **82.9% (60.2, 92.7)**   

  **Shedding on Day, N (%)**                          

  **1**                      2 (1)                    2 (3)

  **2**                      5 (3)                    10 (13)\*

  **3**                      1 (0.7)                  9 (12)\*

  **4**                      0 (0)                    6 (8)\*
  -------------------------- ------------------------ --------------------

\* Statistically significant (p\<0.05)

###  Table combines Year 1 one-dose and two-dose recipients. {#table-combines-year-1-one-dose-and-two-dose-recipients. .unnumbered}

On Day 4, 6 placebo recipients had viral shedding, but no cultures were
taken after Day 4, so total duration of shedding cannot be determined.
However with this in mind, the mean duration of shedding in the first 4
days post-vaccination was significantly reduced in the prior FluMist
group compared to the prior placebo group (respectively 0.06
[+]{.underline} 0.3 vs. 0.3 [+]{.underline} 0.7, p=0.0001).

Of note, shedding rates in prior placebo recipients differed between
sites with a range of 0% to 62%. However, samples sizes in these groups
were small, with a range of 2-13 subjects. No shedding was observed in
the 16 prior vaccine recipients and 7 prior placebo recipients of the
AV006 Year One "one-dose group". The overall efficacy against shedding
in the subset of AV006 Year One "two-dose group" was nearly identical to
the overall efficacy for all participants listed in the table above.

### Viral Shedding and Immunologic Measures {#viral-shedding-and-immunologic-measures .unnumbered}

HAI titers to A/H1N1 could have resulted from FluMist vaccination or
natural exposure to wild type influenza (though little A/H1N1 was
circulating during the preceding 2 influenza seasons). The percent of
prior FluMist recipients with HAI titers [\>]{.underline} 1:8
(considered to be seropositive) prior to vaccination with the monovalent
CAIV-M vaccine was 68% (96/141) compared to 33% (25/75) of prior placebo
recipients, p\<0.0001.

Seropositive subjects were less likely to shed CAIV-M than seronegative
subjects, though the correlation was not perfect (see table below). Of
the 6 prior FluMist recipients who shed CAIV-M, two were seropositive,
one with a titer of 1:8 and one with a titer of 1:32 and each shed virus
for 1 day. All prior placebo recipients who shed virus were
seronegative. Seronegative subjects who shed virus (4 prior vaccinees
and 19 prior placebo recipients) all shed virus for at least 2 days and
six subjects shed virus on day 4.

Nasal IgA data are expressed as the HA-specific IgA antibody normalized
to the total IgA in secretions, and a value of \> 0.1 was considered to
be positive. Of the 199 subjects, 88/129 (68%) of prior FluMist and
23/68 (34%) of prior placebo recipients were positive for nasal IgA
antibodies pre-challenge with CAIV-M. Of the IgA-positive prior FluMist
recipients, 1% shed virus vs. 12% who were nasal IgA-negative (p=0.01).
For prior placebo recipients 13% of IgA-positive compared to 36% of
IgA-negative placebo recipients shed CAIV-M (p=0.05). Overall, 43% nasal
IgA-positive vs. 25% (p\<0.0001) shed CAIV-M, and the duration was
statistically significantly shorter (mean number of days 0.04 vs. 0.4
days, p=0.0001) in nasal IgA-positive subjects vs. nasal IgA negative
subjects.

The relationship of serum HAI and nasal IgA anti-HA was evaluated only
in subjects who had both measurements performed and \~ 1/3 of subjects
had discordant IgA and HAI values.

## AV011. H1N1 Shedding by Serum HAI and Nasal IgA Antibody Status

+----------------+----------------+-----------+-----------+-----------+
| **Assay        |                | ####### S |           |           |
| Results Pre    |                | hedding o |           |           |
| CAIV-M         |                | n ≥ 1 Day |           |           |
| Vaccination**  |                | s Post-Va |           |           |
|                |                | ccination |           |           |
+----------------+----------------+-----------+-----------+-----------+
| **HAI**        | **IgA**        | **Yes**   | **No**    | **Total** |
+----------------+----------------+-----------+-----------+-----------+
| Negative       | Negative       | 20        | 30        | 50        |
+----------------+----------------+-----------+-----------+-----------+
| Negative       | Positive       | 3         | 27        | 30        |
+----------------+----------------+-----------+-----------+-----------+
| Positive       | Negative       | 1         | 32        | 33        |
+----------------+----------------+-----------+-----------+-----------+
| Positive       | Positive       | 1         | 79        | 80        |
+----------------+----------------+-----------+-----------+-----------+
|                | Total          | 25        | 168       | 193       |
+----------------+----------------+-----------+-----------+-----------+

###  {#section-13 .unnumbered}

### Quantity of CAIV-M Shedding {#quantity-of-caiv-m-shedding .unnumbered}

Quantification of the amount of virus shed by plaque assay revealed that
the amount of virus shed was low, and the peak viral titer (log 10
pfu/ml) shed by Flumist recipients (2.5) was similar to placebo
recipients (4.2).

# **Durability of Antibodies**

# No comparisons of serum HAI antibodies pre-challenge with post-dose Year 2 in AV006 was performed.

# 

# **STUDY -- AV009** 

**TITLE: A Prospective, Randomized, Double-blind, Placebo-controlled,
Trial to Assess the**

**Safety, Tolerability, and Effectiveness of Influenza Virus Vaccine,
Trivalent, Types A and**

**B, Live, Cold-Adapted (CAIV-T) in Healthy working Adults to Reduce
Influenza-Like**

**Illness, Absenteeism from Work and Health Care Costs During Influenza
Outbreaks.**

**INTRODUCTION/DESIGN**

Healthy working adults, without risk factors for influenza
complications, are not targeted for annual influenza immunizations.
However, if infected with influenza, healthy adults are at risk for
acute illness and absenteeism from work. Immunization of working adults
against influenza has been shown to reduce the cost of absenteeism,
associated medical costs and employer expenses. This trial was performed
to assess the safety, tolerability, and effectiveness of FluMist to
support an indication for use of the vaccine in healthy working adults.

This was a prospective, randomized, double-blind, placebo-controlled,
multi-center trial conducted at 13 study sites Subjects were randomized
2:1 to receive FluMist vs. placebo.

LOCATION: United States, multi-center -- 13 sites; CRADA with NIAID

STUDY PERIOD: Sept. 18, 1997 -- Mar. 31, 1998

PIVOTAL TRIAL: Yes, Phase 3 Trial

POPULATION: Healthy, working adults ages 18-64 years (not had 65^th^
birthday).

SAMPLE SIZE: Original n=3600, increased to 4,200.

Final enrollment, n=4561 (FluMist n= 3041 and placebo n=1520).

**OBJECTIVES**

### Primary  {#primary-3 .unnumbered}

-   To show similar safety and tolerability profiles of FluMist compared
    to placebo, and

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-   To show a smaller proportion of the FluMist participants has [any
    febrile illness]{.underline} (AFI) during influenza outbreaks than
    the placebo recipients. *In the original protocol this objective was
    stated as, "During influenza outbreaks, a smaller proportion of
    working adults randomized to CAIV-T than randomized to placebo will
    have an episode of influenza-like illness." The data analysis plan
    (DAP) included AFI as the primary endpoint (see below).*

### Secondary {#secondary-2 .unnumbered}

-   In healthy working adults, to show that during the entire influenza
    season (11/1/97-3/31/98) an immunization program using FluMist is
    cost-effective using a model of direct and indirect costs.

-   During influenza outbreaks, healthy working adult CAIV-T recipients
    compared to placebo recipients had lower average:

a)  number of days if illness-associated absenteeism from work,

b)  number of days of illness-associated medically attended illnesses,

c)  number of illness episodes, and

d)  number of days of illness episodes.

-   To estimate the effect of FluMist compared to placebo for the
    proportion of subjects who have [\>]{.underline} 1 days of
    illness-associated:

a)  absenteeism from work,

b)  medically-attended illness (MAI),

c)  health care provider (HCP) visits,

d)  prescription antibiotic use,

e)  OTC med use,

f)  Hospitalization,

g)  Medical tests, and

h)  Absenteeism from work or reduced work effectiveness.

-   To estimate the effect of FluMist compared to placebo on the average
    number of days of:

a)  Absenteeism from work or reduced work effectiveness,

b)  OTC med use,

c)  HCP visits,

d)  Medical tests

e)  Prescription antibiotic use,

f)  Prescription med use, and

g)  Hospitalization.

All of the illness-associated objectives were applied to the entire
study period, and all of these objectives were applied to febrile URIs,
severe febrile illness (SFI) and all URIs during outbreaks, as well as
during the entire study period.

## 

## Vaccines

1.  FluMist -- Each 0.5 ml dose contained 10^7^ TCID~50~ of each strain
    of virus (2 type A and 1 type B) in normal allantoic fluid (NAF)
    containing sucrose-phosphate-glutamate (SPG). The 1997-98 strains
    were A/Shenzhen/227/95 (H1N1), A/Wuhan/359/95 (H3N2) and
    B/Harbin/7/94-like, filled trivalent lots #CAF023 (same lot as AV006
    -- Year 2 vaccine), CAF 024 and CAF 026 were used.

2.  Placebo -- 1 lot (CAF022) of NAF was used.

At the 1^st^ visit (Study Day 0), the subjects received one dose of
vaccine or placebo while in the sitting position. Vaccines were
administered by intranasal spray (0.25 ml per nostril) using
Becton-Dickson Accuspray device, and they could be self-administered or
given by study personnel.

### Procedures {#procedures-1 .unnumbered}

## Schedules and Vaccine Administration

**Inclusion criteria** -- Healthy working adults ages 18-64 years were
recruited. They had to work outside of the home [\>]{.underline} 30
hours/week for a single employer, have health insurance and availability
by telephone.

**Exclusion criteria**:

Significant chronic illnesses for which inactivated influenza vaccine is
recommended or commonly used; receipt of TIV for the 1997-98 season;
acute URI symptoms or febrile illnesses within 72 hours; allergy to eggs
or egg proteins; immune deficiency or immunosuppressive therapy;
participation in other investigational trials until after 3/31/98;
self-reported pregnancy or risk for pregnancy within 3 months of the
trial; concerns for non-compliance with the protocol.

Of note, a history of wheezing or bronchodilator use within 3 months of
vaccination, concomitant immunizations, and nasal medications were not
listed as exclusion criteria.

## Concomitant Medications

Patients were discouraged from taking medications, except for oral
contraceptive and medications for pre-existing conditions, from Day 0-7
post-vaccination. Chronic use of aspirin (ASA) or ASA-containing
medications was permitted. Use of other medications was to be recorded
on diary cards. Use of concomitant vaccines is not described.

## Monitoring

**Effectiveness (Clinical Efficacy)**

Subjects were provided with monthly effectiveness diary cards (months
November -- March) to record illness information. Study personnel were
to conduct automated telephone calls approximately every 2 weeks to
remind subjects to complete and return these cards. If a diary card was
misplaced, the information was to be collected over the phone and mailed
to the subject for review and signature. Replacement cards for future
months were mailed if needed.

The monthly diary card had 3 sections to capture effectiveness measures:

[Sections 1A]{.underline} - queried for fever, runny nose, sore throat,
cough, h/a, muscle aches, chills, and tired/weak.

[Section 1B]{.underline} - queried for healthcare utilization or missed
work because of symptoms in Part 1A as follows: "I took an OTC
medication," "I went to a healthcare provider," "I had a medical test
done," "I took a prescription antibiotic," "I took a non-antibiotic
prescription medication," "I was hospitalized," "I was less effective at
my job," and " I missed work."

[Section 2]{.underline} - queried for healthcare utilization for illness
other than those in Part 1A, as follows: "I went to a healthcare
provider (HCP)," "I had a medical test done," "I took a prescription
antibiotic," " I took a non-antibiotic prescription," "I was
hospitalized," and "I missed work."

**Definition of outbreak**

Outbreak periods for each site were determined by the AV009
Effectiveness Committee using an pre-defined algorithm, generally by 1)
select the peak week and 2) check that it contain 80% of the Cxs, if not
add one adjacent week (whichever has the most positive cx's) to reach
80%. If the peak week is not unique, then the influenza surveillance
data from the CDC corresponding to the local community will be used. If
there are too few cases (\<10) to identify an outbreak, then an
independent expert (blinded to the trial) was to evaluate surveillance
data (local, nearby sites, CDC or WHO) to determine the outbreak period.

**[Statistical Methods]{.underline}**

Subjects who returned at least one monthly diary card during the
site-specific outbreak, 14-week outbreak period, and entire 5 month
period were evaluable for the effectiveness endpoints.

**Effectiveness Endpoints** **(according to the DAP)**

The definitions of illness provided in the study report are said to be
interpretations of endpoint descriptions provided in the protocol. The
definitions for acute febrile illness (AFI) and upper respiratory
illness (URI) were modified, prior to unblinding of the study, after
discussion with the protocol Effectiveness Committee to require symptoms
for 2 days, rather than 1 day.

AFI was the illness definition used for most analyses of efficacy. Other
illness definitions applied to the data are listed following the listing
of primary and secondary endpoints.

**Primary effectiveness endpoint**

[Occurrence of any AFI]{.underline}*.* Participants were counted as
reaching this endpoint if:

-   They had at ≥ 2 consecutive days of symptoms in Part 1A of diary

-   1 of the symptoms on at least 1 of the days was fever, and

-   There must have been at least 2 symptoms present on 1 day.

### Secondary effectiveness endpoints {#secondary-effectiveness-endpoints .unnumbered}

The secondary effectiveness objectives were to assess the effect of
FluMist on complications associated with AFIs as measured by absenteeism
from work and medically attended illness. The start of an AFI was the
1^st^ day of symptoms proceeded by at least 2 symptom-free days. The end
of the episode was the last symptom day followed by 2 consecutive
symptom-free days. The days with symptoms had to meet definition for
AFI.

-   [Number of days of AFI-assoc. absenteeism.]{.underline} The number
    of missed work days checked in Part 1B of the diary that overlapped
    with AFI episodes.

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-   [Number of days of AFI-associated medically attended illness
    (MAI)]{.underline}*.* The number of days for which at least 1 MAI
    (went to a health-care provided, had a medical test done, took a
    prescription medication or antibiotic, or was hospitalized) occurred
    during an AFI was calculated.

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-   [Number of AFI episodes]{.underline}*.* The number of AFI episodes
    that occurred during an outbreak for each participant.

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-   [Days of AFI episodes]{.underline}*.* For each participant, the
    total number of days was counted by summing the duration of each
    episode, and duration was calculates as follows: start date - stop
    date +1.

## Other Endpoints

-   [Occurrence of AFI-assoc. absenteeism from work]{.underline}*.*
    Participants who missed worked (from part in part 1B of the diary)
    counted once if absence occurred during an AFI episode.

-   [Occurrence of AFI-assoc. MAI.]{.underline} Participants who had a
    MAI (from part 1B of the diary), were counted once if the MAI was
    associated with an as AFI.

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-   [AFI-assoc. health care provided (HCP) visit]{.underline}.
    Participants, who checked the box, "I went to a HCP" in 1B of the
    diary and it overlapped with an AFI episode were counted as meeting
    this endpoint. Also, the total number of days of HCP visits were
    calculated for each participant during AFIs by summing the number of
    boxes checked for this endpoint.

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-   [AFI-assoc. prescription antibiotic use.]{.underline} Participants
    were counted if they checked at least 1 box "I took a prescription
    antibiotic", during the time of an AFI episode (section 1B of the
    diary). Also, the total number of days of prescription Abx use was
    calculated by summing the total number of boxes checked for this
    endpoint.

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-   [AFI-assoc. prescription medication use:]{.underline} as above if "I
    took a non-antibiotic prescription medication" or "I took a
    prescription antibiotic medication" box was checked.

-   [AFI-associated over-the- counter medication use:]{.underline} as
    above for OTC medication use.

-   [AFI-assoc. hospitalization]{.underline}*.* As above, participants
    were counted "was hospitalized" during AFIs box was checked. Also,
    the total number of days was calculated for each participant during
    AFIs by summing the total number of boxes checked.

-   [AFI-assoc. medical test]{.underline}. Participants were counted as
    meeting this endpoint if at least 1 box in Section 1B was checked
    for "I had a medical test done" during AFIs. Total number of days
    was also calculated similar to above.

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-   [AFI-assoc. absenteeism from work or reduced work
    effectiveness.]{.underline} Participants were counted as meeting
    this endpoint if at least 1 box in Section 1B was checked indicating
    "I missed work" or "I was less effective at my job" during AFIs.

[Other Illness Definitions]{.underline}:

[Upper Respiratory Infection (URI)]{.underline} : participant must have
had two consecutive days of URI symptoms in part 1A of effectiveness
diary card.

[Febrile URI:]{.underline} as above and in addition, fever must have
been present on at least one day.

[Severe Febrile Illness:]{.underline} If there were at least 3 days of
symptoms for part 1A of effectiveness diary card, fever on at least one
day, and at least 2 symptoms on all three days.

In addition to these prespecified definitions, three other definitions
were applied to data in post-hoc analyses:

[CDC influenza-like illness (ILI)]{.underline} -- fever plus either
cough or sore throat, must be present on the same day or on consecutive
days.

[DoD ILI]{.underline} -- cough plus either fever or chills, also must be
present on the same day or consecutive days.

[AV ILI]{.underline} -- 1) 2 consecutive days of symptoms, 2) at least 1
day of fever, 3) [\>]{.underline} 1 URI symptom, 4) at least 1
non-febrile systemic symptoms and 5) [\>]{.underline} 2 symptoms on at
least 1 days.

The planned analyses of the effectiveness endpoints were applied during
influenza outbreaks, during the entire study period (11/1/97 --
3/31/98), and in post-hoc analyses to site-specific influenza outbreak
periods, and to a pooled, 14-week outbreak period 12/14/97-3/21/98. Key
effectiveness parameters were to evaluated across demographic subgroups
-- 1) men and women, 2) Caucasian and non-Caucasian, and 3) age \< 40
yrs and [\>]{.underline} 40 years. A cost effectiveness analysis was
performed but the study report contains results of individual components
of health care-utilization measures without costs applied.

**Sample Size Estimates**

Vaccine effectiveness was assumed to be 60% and it was assumed that 4-6%
of placebo recipients would have an AFI secondary to influenza and that
70% of absenteeism would be due to influenza. (The protocol did not say
how these assumptions would be verified, and cultures were not
obtained). With 4200 study participants and assuming 80% of subjects
were evaluable, the study would have 90% power to demonstrate 60% VE.

##### AV009 - RESULTS {#av009---results .unnumbered}

## Enrollment and Demographics

  ------------------------------------------ ------------- --------------
                                             **FluMist**   **Placebo**

  **Randomized**, **N**                      3041          1520

  **Age**                                                  

  Mean                                       38            38

  Range                                      18-66         18-65

  **Race/Ethnicity %**                                     

  White                                      84.7          83.5

  Black                                      9.6           10.9

  Asian                                      2.3           2.5

  Hispanic                                   2.24          2.11

  Native American                            0.33          0.20

  Other                                      0.85          0.79

  **Gender %**                                             

  Male                                       45.3          45.7

  Female                                     54.7          54.3

  **Bachelor's degree or higher %**          48            46
  ------------------------------------------ ------------- --------------

## Protocol Compliance

Of 4561 subjects, 98% of each treatment group returned the 7 day diary
card, and 97.5% provided safety information for the 1^st^ 28 day
monitoring period. There were 116 subjects who did not complete the Day
0-28 safety diary (FluMist 78, Placebo 38). The most common reason for
not completing the 28 day period follow-up was lost-to-follow-up
\[FluMist n=65 placebo n=31\]. Two subjects in the FluMist group and 1
in the placebo group withdrew due to an AE. One of the FluMist subjects
withdrew due to abdominal pain and vomiting with onset 2 days
post-vaccination and then diarrhea 7 days post-vaccination, which was
recorded Crohns' Disease and coded as "probably not" vaccine-related.
The other FluMist subject was withdrawn due to accidental death 16 days
post-vaccination. The placebo subject withdrew due to a diagnosis of
personality disorder, noted 17 days post-vaccination.

Approximately 95.5% of subjects (FluMist n=2902/3041 and placebo
n=1453/1520) returned at least 1 monthly diary card and 88% returned 4
or more monthly diaries. For each month of the study, \~90% in each
treatment group returned the effectiveness diary cards each month.

There were \~369 (8.1%) of 4561 participants with protocol deviations.
The most common deviations (n=171, 3.7%) were subjects who provided the
Day 28 diary data prior to Day 28 (the mean for day of return is not
stated) and 86 subjects (1.9%) did not provide the diary card.
Seventy-nine participants were in violation of the eligibility criteria
at enrollment, most commonly because subjects had an occupation or
condition for which influenza vaccine is recommended. Seventy-one
percent of the vaccines were self-administered with 3.8% of subjects
having some problem (no details provided). Of the 29% administered by
study personnel, 2.5% reported some problem (1.84% for FluMist and 3.85%
for placebo).

**Effectiveness**

There was no significant difference in effectiveness between the FluMist
and Placebo groups in the primary analysis of effectiveness (i.e.,
occurrence of any febrile illness \[AFI\]) during Site-Specific Outbreak
Periods.

**AV009 - Percentage of Participants Having One or More Illness during
the Site-Specific Outbreak Periods**

  ------------------- ---------------- ------------- -------------- ---------------
  **Endpoint**        **FluMist**      **Placebo**   **%            **p-value\***
                                                     Reduction**    

                      N = 2,883        N = 1,420                    

                      \% with          \% with                      

  **Any Febrile       13.2             14.6          9.7            0.19
  Illness\*\***                                                     

  Severe Febrile      10.1             12.2          17.4           0.031
  Illness                                                           

  Febrile URI         8.5              10.8          21.9           0.011

  CDC-ILI^+^          10.7             13.9          23.2           0.0018

  DoD-ILI^+^          10.4             13.7          23.5           0.0017
  ------------------- ---------------- ------------- -------------- ---------------

\* unadjusted for multiple comparisons

\*\* primary endpoint

^+^ post-hoc analyses

Severe Febrile Illness (SFI) and febrile URIs (FURI) were less common in
the FluMist than placebo group. Post-hoc analyses applied to the data
revealed significantly fewer CDC-ILI and DoD-ILI in the FluMist
recipients.

Similarly, the rate of AFI episodes (number of AFI episodes/1000 subject
per 7-week outbreak period) was not significantly different between the
FluMist and placebo groups: 151.3 FluMist *vs.* 168.1 placebo. However,
the rates of SFI (111.0 FluMist *vs.* 136.7 placebo; p 0.0019) and FURI
(92.4 vs. 121.0; p\<0.0001) were significantly different.

The rate of AFI days during outbreaks (# of days of AFI/1,000 subjects
per 7-week outbreak period) was significantly lower in FluMist group vs.
placebo (1,888 vs. 1,541.2; p= 0.0001) as was the rate of SFI (1,021 vs.
1404.5 p= \<0.0001) and FURI (875.7 vs. 1,164.7 p\<0.0001). The rate of
CDC-ILI days and DoD ILI days were significantly fewer in the FluMist
group.

The rates of missed work days during outbreak periods (# of days
missed/1,000 subjects) for AFI was not significantly different in the
FluMist vs. placebo group (173.3 vs. 199.5; p= 0.065). There was a
significant lower rate of days missed for SFI (154.7 vs. 188.3; p =0.12)
and for FURI (107.0 vs 149.4; p\<0.0001).

**Health Resource Utilization** was assessed by calculating for AFI,
FURI, SFI-associated events. There was significantly less health
resource utilization in the FluMist group compared to the placebo group
(see table below for AFI-associated events). Similar results were seen
in post-hoc analyses for CDC and DoD-ILI illness.

AV009 - Rate of AFI-associated Events during the Site-Specific Outbreak
Periods

  ------------------ --------------- --------------- ------------- -------------
  **Endpoint**       **FluMist**     **Placebo**     **%           **p-value**
                                                     Reduction**   

                     N = 2,883       N = 1,420                     

                     (# of days or                                 
                     events/1000                                   
                     subjects per                                  
                     7-wk outbreak                                 
                     period)                                       

  Days of OTC        576.9           752.3           23.3          0.0002
  Medication use                                                   

  Days with at least 44.0            51.5            14.7          0.055
  1 Health Care                                                    
  Provider Visit                                                   

  Days taking At     195.6           342.9           42.9          \<0.0001
  least One                                                        
  Prescription                                                     
  Antibiotic                                                       

  Days taking Any    250.0           413.9           39.6          \<0.0001
  Prescription                                                     
  Antibiotic                                                       
  ------------------ --------------- --------------- ------------- -------------

During site-specific outbreaks, \<1% of subjects reported medical tests
and only 4 subjects (2 FluMist and 2 placebo) had hospitalizations for
AFI. Similarly, there were few of these events associated with other
illnesses (SFI, FURI) and thus no analyses could be performed.
Significant reductions were noted for SFI-associated events, FURI, CDC
ILI and DoD ILI for days of OTC meds, days taking at least 1
prescription Abx and days taking any prescription med for the FluMist
group, p [\<]{.underline} 0.0002.

The prior analyses were also performed for 14-week period, pooled
outbreak period as well as the entire 5-month study period, and results
were generally consistent with those presented for site-specific period.
The effectiveness of FluMist was noted though the circulating strain in
1997-98 was a variant not contained in the vaccine.

######## Subgroups analyses {#subgroups-analyses .unnumbered}

[Gender]{.underline} - Overall, the effectiveness of FluMist was similar
for men and women, though there were some differences in the rates of
events. Women were slightly more likely than men to have 1 or more
illness (illnesses in placebo groups: women = 15.2% and in men=13.9%).
The reduction in days of illness in FluMist recipients was comparable
between men and women.

[Ethnicity]{.underline} -- Of note, only 16% of enrollees were
non-Caucasian. Generally, the number of and days of illness events were
similar between Caucasians and non-Caucasians and the effectiveness of
FluMist was similar across ethnicity and illness definitions. There was
a difference in the reduction of episodes of AFI (decrease of 7.1% for
Caucasians and 25.6% for non-Caucasians). A rate of missed work days was
much higher for non-Caucasians in both the FluMist and placebo groups
for all illness definitions. FluMist was more effective in reducing
missed work days during AFIs for non-Caucasians (26.5%) than Caucasians
(8% reduction). Health resource utilization was different in Caucasian
compared to non-Caucasian placebo recipients. OTC medication use was
higher in Caucasians, but HCP visits and prescription medication use was
higher in non-Caucasians. Prescription antibiotic use was similar
between the groups.

[Age]{.underline} - Differences of illness events were noted in placebo
recipients \< 40 and those [\>]{.underline} 40 years of age, generally
rates of events were higher in the \<40-year-olds. However, the
effectiveness of FluMist on reducing the outcomes was generally higher
in those [\>]{.underline} 40 years.

**Health Economic Results** -- a summary of economic analysis from this
study is provided. For this analysis, no resource costs or hourly wage
data were collected and all of the costing information came from
secondary sources, primarily from Medtap (Bethesda, MD), a contract
health-economic research organization. Placebo recipients were assumed
to be representative of unvaccinated subjects, and event rates in the
placebo recipients assumed to provide estimated of event rates in
unvaccinated subjects. Thus, event rate (placebo) and relative event
rates (FluMist *vs.* placebo) were the only economic model inputs
derived from the clinical data.

The overall break even value of FluMist and administration, during an
influenza season in which the predominant circulating influenza virus
strain was a variant (definition for variant not provided) from the
vaccine strains was found to be \$31 during AFI's and URI's. This was
primarily due to the effectiveness of FluMist in reducing work and
health-care provider visits during AFI and URI. The break-even cost
increases to \$50 when evaluating the reduction in missed work days and
health-care provider visits during any illness. Sensitivity analyses
indicate that the main cost drivers were: hourly wage, the effectiveness
of FluMist for reducing missed work days, and the rate of missed work
days in the "unvaccinated" groups. The break-even cost of FluMist and
administration was insensitive to the cost of treating the illnesses.

The validity of the assumptions and model have not been reviewed. For
licensure FDA considers risk benefit analyses of vaccines and biologic
products but not cost benefit analyses.

# 

# **STUDY AV003** 

**TITLE:** **A Phase 3 Double-blind, Placebo-Controlled Challenge Study
to Assess the**

**Efficacy of Cold-Adapted Influenza Virus Vaccine, Live Trivalent
(CAIV-T, FluMist) in**

**Healthy Adults.**

LOCATION: United States, two centers; CRADA with NIAID

STUDY PERIOD: 12/11/95 -- 2/15/96

PIVOTAL TRIAL: Yes, Phase 3

POPULATION: Healthy Adults

SAMPLE SIZE: Total for challenge, n= 92; Flumist, n=29; Placebo, n=31;

> Inactivated Influenza, n=32

### INTRODUCTION {#introduction .unnumbered}

AV003 was performed to assess the efficacy of FluMist and of the
trivalent inactivated influenza vaccine (TIV) in protecting subjects
from laboratory diagnosed influenza disease following a challenge with a
wild-type influenza virus This study was performed early in Aviron's
clinical development of FluMist. Originally the study was performed to
establish that FluMist was protective in seronegative adults and thus,
merited evaluation in field trials in the pediatric population.

### OBJECTIVES {#objectives-1 .unnumbered}

1.  **Co-primary**

-   To assess the efficacy of FluMist compared to placebo post-challenge
    with wild type influenza against laboratory-documented influenza
    illness.

-   To assess the efficacy of FluMist compared to trivalent inactivated
    influenza (TIV - Fluvirin manufactured by Evans Medeva)
    post-challenge with wild type influenza against
    laboratory-documented influenza illness.

-   To assess the safety and immunogenicity of FluMist in adults
    serosusceptible to at least one of the virus strains (H1N1, H3N2,
    and B) contained in the influenza vaccines (FluMist and TIV).

-   *Post-hoc:* To assess the reduction of viral shedding post-challenge
    with wild type influenza.

Laboratory-documented illness was defined: symptoms of influenza
accompanied by wild-type viral shedding on one or more days and/or
[\>]{.underline} 4-fold rise in HAI antibody to the challenge virus from
Day 28 to Day 56.

Illness was defined: [\>]{.underline} 1 respiratory symptom of moderate
or greater severity OR [\>]{.underline} 2 respiratory symptoms of any
severity on 2 consecutive days. Respiratory symptoms include nasal
stuffiness, runny nose, ear ache, sore throat, hoarseness, or difficulty
breathing (not due to stuffiness). Subjects with myalgias or fever were
defined as having "influenza-like illness."

### DESIGN {#design .unnumbered}

AV003 was a randomized, double-blind, placebo-controlled challenge study
performed in healthy adults, 18-41 years old. Subjects were immunized
with FluMist, TIV or placebo and then 28 days later received intranasal
challenge with wild-type influenza (the strain to which the subject was
serosusceptible) to assess protection.

**VACCINES AND CHALLENGE STRAINS**

1.  Flumist -- Each 0.5 ml contained 10^7^ TCID~50~ of each strain of
    virus (2 type A and 1 type B) in normal allantoic fluid (NAF)
    containing sucrose-phosphate-glutamate (SPG). The 1994-95 strains
    were A/Texas/36/91-like (H1N1, lot CAE002), A/Shandong/9/93 (H3N2,
    lot CAE006) and B/Panama/45/90 (lot CAE003). Filled trivalent lot
    CAF003 with NAF lot CAE008 was used.

2.  Inactivated influenza vaccine (TIV) -- The licensed vaccine (0.5ml
    dose) from Evans Medeva also contained the recommended 1994-95
    strains listed under FluMist.

3.  Challenge viral strains -- Each 0.5 ml (0.25 ml per nostril)
    challenge dose contained 10^7^ TCID~50~ of one of the following
    strains: H1N1 A/Texas/36/91 -- WT (lot E-349); H3N2
    A/Shangdong/9/93-WT (E-337) or B/Panama/45/90-WT. The challenge
    strains were delivered by nasal drops. The wild type strains were
    prepared by Dr. Lou Potash, under contract with NIAID.

4.  Placebos

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a.  Intranasal - NAF in SPG, lot CAE008 was used.

b.  Injectable -- saline (PBS with 0.1% thimerosal)

## PROCEDURES

**Schedule and Vaccine Administration**

There were three phases to the study, 1) screening, 2) vaccination with
post-vaccination safety monitoring and 3) challenge. Screening was
performed within one month of vaccination to identify subjects who were
serosusceptible (defined as HAI titers [\<]{.underline}1:8) to at least
1 of the vaccine strains. Upon meeting eligibility criteria (Inc/Exc
criteria, signed CF and brief PE) subjects were randomized to study
group, in 1:1:1 ratio, FluMist:TIV:placebo. The study was designed to
have three mutually exclusive groups, one each for those serosusceptible
to H1N1, H3N2, and for type B. Some subjects in each group may have also
been serosusceptible to one or both of the other strains. Subjects
within each serosusceptibility group were randomly assigned to one of
the three study groups. To maintain blinding, each subject received one
IM injection and one intranasal immunization, as shown on Table 1.

## AV003 - Vaccine Study Groups

  ----------------------- ----------------------- -----------------------
  Treatment Group         Study Vaccines          

                          Intranasal Spray        IM Injection

  FluMist                 FluMist                 Saline

  TIV                     NAF                     TIV

  Placebo                 NAF                     Saline
  ----------------------- ----------------------- -----------------------

On Day 0, study vaccines were administered with the subject in the
seated position. The intranasal vaccinations were delivered by spray
device. Subjects remained seated for 30 seconds and stayed at the site
for 15 minutes post-vaccination to observe for immediate reactions.

Participants were given vaccine diary cards to record their temperature
and reactogenicity events (RE's) for seven days post-vaccination. RE's
included temperature, chills, cough, sore throat, muscle aches, and
runny nose. Subjects returned at 1 week to report diary card entries,
which study personnel entered into the CRF. Personnel also entered any
information reported by the subject during the visit. On Day 15, study
personnel contacted subjects to inquire about occurrence of any adverse
events (AE's) since Day 7.

Subjects were instructed to contact the study site if they experienced
an AE, fever \>100^o^F, or [\>]{.underline} 2 RE's listed on the diary
card. A subject with an upper respiratory infection (URI) during the
study, if the investigator deemed the event as clinically relevant, was
to have a physical assessment and a nasopharyngeal (NP) specimen
obtained for viral and bacterial cultures. If results of the viral
culture were needed for medical care, they were to be revealed only to
the subject's doctor (not the investigator or Aviron, until the study
blind was broken).

At the end of Week 4, subjects had nasal wash samples and serum samples
obtained for antibodies to influenza. Then, the subjects, who
participated in the challenge phase, had a brief PE and remained at the
site for 24 hour observation. These subjects received intranasal
challenge with the homologous strain to which they had been
serosusceptible at screening (challenge strains listed above). The
participants were then sequestered for seven days. During sequestration,
subjects received limited PE's, had their temperatures measured twice a
day, and provided daily nasal wash samples for viral isolation.

About Day 45 (2 weeks post-challenge) study personnel called
participants to check for the occurrence of any AE's. At the end of Week
8 (4 weeks post-challenge), subjects returned to the study site for
final collection of blood and nasal wash samples. Brief PE and exit
interviews were also performed. The total study duration was 56 days.

**Inclusion/Exclusion Criteria**

**Inclusion criteria** -- Healthy adults, between the ages of 18-40
years, serosusceptible to at least 1 of the influenza strains (H1N1,
H3N3, or B) and signed informed consent. Women capable of pregnancy had
to practice a reliable means of birth control during the study.

#### Exclusion criteria -- These criteria were similar to AV009.

**Concomitant Vaccinations and Medications**

No concomitant immunizations, aspirin-containing meds or nasal
medications (for 7 days post-vaccination and post-challenge) were
permitted. Use of other medications, except birth control pills, was
discouraged during the study period.

**Immunogenicity**

Serum samples were collected at 4 time points: screening (within 1 mo of
vaccination), Day 0 (vaccination day), Day 28 (challenge day), and Day
56 (4 weeks post-challenge). Serum was tested for HAI strain-specific
antibodies and IgG ELISA. Nasal wash samples were obtained at the same
time points for measuring IgA ELISA antibodies. Day 0 titers (not
screening titers) were used for baseline data for calculating 4-fold
rises and GMT ratios. Some subjects who were serosusceptible
([\<]{.underline}1:8) at screening had titers [\>]{.underline}1:16 at
Day 0, details in Results section.

**Primary Efficacy Endpoint**

The primary measure of protective efficacy of FluMist was the difference
between the rates of laboratory-documented influenza illness in the
FluMist and placebo groups. FluMist would be considered protective if,
after wild-type challenge, the rate of laboratory-documented illness in
the FluMist group was significantly less that the rate in the placebo
group (2 sided p-value [\<]{.underline} 0.05). With the enrolled sample
size (\~ 30 per group), the study had about 90% power to detect a
difference in rates of laboratory-documented influenza if the true rate
for the placebo group and FluMist group were 50% and 10% respectively.

### RESULTS {#results-2 .unnumbered}

**Enrollment**

A total of 383 subjects were screened for study participation. 135
subjects satisfied eligibility criteria, and 103 subjects (18-41 years
of age) were randomized for vaccination to assure that \~90 subjects
were eligible for challenge (allowing \~10% drop-out). The dispositions
of the 32 subjects not randomized are not described. Randomization by
group yielded: FluMist - n= 36, TIV -- n= 33, and placebo -- n= 34
subjects.

**Demographics**

The mean age in each of the study groups was \~ 25 years and 74% of
subjects were male. The ethnicity was comparable between the groups,
about 52% of subjects were Caucasian, 40% Black, 4% Hispanic and 4%
Asian.

The serosusceptibility of the subjects is shown in the table below. The
study was designed so the challenge would include three mutually
exclusive groups of \~30 subjects each, i.e., all subjects in one group
would be serosusceptible to H1N1, the 2^nd^ group to H3N2, and the 3^rd^
group to type B. Some subjects in a group were serosusceptible to one or
both of the other strains. Of note, though all participants enrolled in
the vaccine phase of the protocol were serosusceptible (HAI
[\<]{.underline} 1:8) to at least one strain at screening, seven
subjects challenged with H3N2 and nine subjects challenged with type B
had HAI titers [\>]{.underline} 1:16 on Day 0 (vaccination day). The
sponsor attributed this, in part, to assay variability.

**AV003 -- Serosusceptibility of Study Subjects**.

+------------------+---------+---------+---------+---------+---------+
|                  |         | S       |         |         |         |
|                  |         | erosusc |         |         |         |
|                  |         | eptible |         |         |         |
|                  |         | S       |         |         |         |
|                  |         | ubjects |         |         |         |
+------------------+---------+---------+---------+---------+---------+
| Time point       | Study   | N       | H1N1    | H3N2    | B       |
|                  | Group   |         |         |         |         |
+------------------+---------+---------+---------+---------+---------+
| Baseline         | FluMist | 36      | 24      | 23      | 10      |
+------------------+---------+---------+---------+---------+---------+
|                  | TIV     | 33      | 23      | 17      | 12      |
+------------------+---------+---------+---------+---------+---------+
|                  | Placebo | 34      | 24      | 18      | 11      |
+------------------+---------+---------+---------+---------+---------+
|                  |         |         |         |         |         |
+------------------+---------+---------+---------+---------+---------+
| Day 28           | FluMist | 29      | 23      | 21      | 10      |
|                  |         |         |         |         |         |
| (Prior to        |         |         |         |         |         |
| challenge)       |         |         |         |         |         |
+------------------+---------+---------+---------+---------+---------+
|                  | TIV     | 32      | 23      | 16      | 11      |
+------------------+---------+---------+---------+---------+---------+
|                  | Placebo | 31      | 24      | 17      | 11      |
+------------------+---------+---------+---------+---------+---------+
|                  |         |         |         |         |         |
+------------------+---------+---------+---------+---------+---------+
| Subjects         | FluMist | 29      | 10      | 9       | 10      |
| challenged with  |         |         |         |         |         |
| the homologous   |         |         |         |         |         |
| strain           |         |         |         |         |         |
+------------------+---------+---------+---------+---------+---------+
|                  | TIV     | 32      | 10      | 12      | 11      |
+------------------+---------+---------+---------+---------+---------+
|                  | Placebo | 31      | 12      | 8       | 11      |
+------------------+---------+---------+---------+---------+---------+

**Protocol Compliance**

Of the 103 subjects randomized, 98 completed the vaccine phase of the
study. Five subjects (FluMist n=3 and placebo n=2) withdrew prior to
completing the vaccination safety phase. The reasons for withdrawal
included --one subject with an SAE not vaccine related (onset of
hypertension 1 month post-FluMist), two subjects (1 each for FluMist and
placebo) with poor compliance with the protocol and two (1 each for
FluMist and placebo) withdrew for "personal reasons," which were not
stated. The sponsor states because of space limitations at the challenge
facilities, 92 subjects proceeded to the challenge phase of the study,
and 90 completed it. Two TIV recipients were lost to follow-up prior to
completing the challenge phase, but the reasons are not provided.

#### Efficacy Results

#### Primary Efficacy Endpoint

The primary measure of protective efficacy of FluMist was the difference
between the rates of laboratory-documented influenza illness in the
FluMist and placebo groups.

**AV003 -- Percent Protective Efficacy of FluMist and TIV Relative to
Placebo by Serotype for All Challenged Participants with HAI Titers \<
1:8 on Day 0.**

+---------+---------+---------+---------+---------+---------+---------+
|         | **Viral | *       | **      | **Resp  | **Any   | *       |
|         | She     | *4-Fold | Infecti | iratory | Illne   | *Labora |
|         | dding** | Rise in | on^b^** | Il      | ss^c^** | tory-co |
|         |         | HAI     |         | lness** |         | nfirmed |
|         | **%**   | Tite    | **%**   |         | **%**   | in      |
|         |         | rs^a^** |         | **%**   |         | fluenza |
|         |         |         |         |         |         | Illne   |
|         |         | **%**   |         |         |         | ss^d^** |
|         |         |         |         |         |         |         |
|         |         |         |         |         |         | **%**   |
+---------+---------+---------+---------+---------+---------+---------+
| #####   |         |         |         |         |         |         |
| ## H1N1 |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| FluMist | 40      | 60      | 49      | 14      | 14      | 80      |
+---------+---------+---------+---------+---------+---------+---------+
| TIV     | 60      | 100     | 66      | 31      | 31      | 60      |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| #####   |         |         |         |         |         |         |
| ## H3N2 |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| FluMist | -50     | 67      | 33      | 75      | 75      | 83      |
+---------+---------+---------+---------+---------+---------+---------+
| TIV     | -20     | 100     | 50      | 40      | 40      | 70      |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| ##      |         |         |         |         |         |         |
| ##### B |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| FluMist | 43      | 24      | 54      | -14     | -14     | 100     |
+---------+---------+---------+---------+---------+---------+---------+
| TIV     | 100     | 100     | 100     | -52     | -52     | 100     |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| **All   |         |         |         |         |         |         |
| (95%    |         |         |         |         |         |         |
| CI)**   |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| FluMist | 25      | 52      | 42      | 31      | 31      | 84 (16, |
|         | (-      | (-52,   | (-32,   | (-58,   | (-58,   | 100)    |
|         | 159,84) | 91)     | 82)     | 76)     | 76)     |         |
+---------+---------+---------+---------+---------+---------+---------+
| TIV     | 51      | 100(21, | 68 (9,  | 11      | 11      | 69 (-9, |
|         | (-94,   | 100)    | 95)     | (-96,   | (-96,   | 97)     |
|         | 93)     |         |         | 60)     | 60)     |         |
+---------+---------+---------+---------+---------+---------+---------+

A negative protective rate means the incidence in vaccinees was higher
than in placebo recipients.

**^a^** Missing 4 participants: 2 H1N1-challenged placebo recipients and
2 TIV-challenged subjects

**^b^** Defined as viral shedding on any day and/or \> 4-fold rise in
HAI antibody to the challenge strain (missing 2 TIV-challenged subjects
missing 4-fold rises in HAI titers).

**^c^** Respiratory illness, systemic illness or febrile illness.

**^d^** Defined as any influenza illness and infection (missing 1 of the
2 TIV group missing 4-fold rises in HAI titers).

For this analysis for all participants (whether or not they were
serosusceptible at screening), 2/29 (7%) of FluMist, 4/32 (13%) of TIV,
and 14/31 (45%) of placebo had cases of laboratory documented illness.
Compared to placebo, the protective efficacy (95% CI) of FluMist was 85%
(28, 100); p=0.001 and TIV was 71% (2, 97); p=0.006; Mantel-Haenszel
test stratified by strain. The study was not large enough to produce
precise estimates of strain-specific efficacy. The efficacy rates
between FluMist and TIV were not statistically different.

[Viral Shedding]{.underline}

Only 3 FluMist, 2 TIV and 7 placebo recipients shed virus for
[\>]{.underline} one day post-challenge, and these results were not
statistically significantly different. Compared to placebo, FluMist was
25% (-150, 84) protective against viral shedding while TIV was 52% (-77,
94) protective. Compared to placebo, FluMist was 54% (-41, 91)
protective against disease as denoted by \>4-fold rises in HAI titers,
while TIV was 100% (32, 100). The results were similar when the
evaluations were performed with only the serosusceptible subjects.

**Immunogenicity**

For serosusceptible subjects, TIV induced high serum HAI GMT ratios from
Day 28 (4 weeks post-vaccination) to Day 0, the values were H1N1 = 66,
H3N2 = 14 and B = 20. These GMT ratios for FluMist, were all \< 3 and
were similar to placebo.

The percent of subjects with 4-fold rises from Day 0 to Day 28 were also
high for TIV (H1N1 = 96%, H3N2 = 94% and B = 92%). These values were
lower for the FluMist group (H1N1 = 29%, H3N2 = 39%, and B = 10%) and
the placebo group (H1N1 = 22%, H3N2 = 11% and B = 0%). Serum IgG ELISA
added little to the HAI information. The nasal IgA results were
inconclusive. The H1N1 responses were higher post-TIV (GMT and percent
with 2-fold rise) and H3N2 responses were higher post-FluMist, and the
type B responses were similar for both groups. The post-challenge
immunogenicity results showed that no TIV recipients, 21% of FluMist and
45% of placebo recipients had 4-fold rises in HAI titers from Day 28 to
Day 56. Although efficacy was observed after FluMist and TIV, no
correlate of protection was identified; however, the sample size was
small.

## STUDY AV007

**TITLE: A Prospective, Randomized, Double-Blind, Placebo-Controlled
Trial to Assess the**

**Safety, Tolerability, and Immunogenicity of Three Manufacturing Lots
of Influenza Virus**

**Vaccine, Trivalent Types A and B, Cold-Adapted (CAIV-T).**

## DESIGN

This study was performed to demonstrate consistency of lot production.
The study was a randomized, double-blind, placebo controlled study in
healthy children, ages 12-36 months, from the Kaiser-Permanente Southern
California outpatient clinics. Participants were randomized to one of
five treatment groups (3 lot consistency lots, the AV006 efficacy lot,
one placebo lot) and administered two doses of vaccine (28-60 days
apart) in a blinded fashion. The participants returned for a final study
visit 28-42 days after their second dose.

LOCATION: United States, multi-center; CRADA with NIAID

STUDY PERIOD: 4/21/97 -- 11/08/97

PIVOTAL: Yes

POPULATION: Children age 12-36 months.

SAMPLE SIZE: n=500 (100 each for 3 consistency lots, Flumist lot used in
AV006 and placebo).

## OBJECTIVES

**Primary**

To compare the safety, tolerability, and immunogenicity of 2 doses
(given 28-60 days apart) of 3 consistency lots of Flumist in healthy
children 12-36 months of age. Consistency of manufacturing is to be
concluded if a 4-fold or greater range in the post-dose 2 geometric mean
fold rise across lots is ruled out with 95% confidence.

**Secondary**

To compare the safety of the 3 consistency lots of Flumist to placebo
[and]{.underline} to Flumist used in AV006 (FM-AV006).

## Other Objectives

-   To compare the immunogenicity of the consistency lots with that of
    the efficacy lot.

-   To calculate post-Dose 2 seroconversion rates for recipients of each
    lots, to assess the consistency of those lots, and compare them with
    the rates for recipients of the efficacy lot.

-   To assess the immunogenicity post-Dose 1 and to compare the
    immunogenicity at this timepoint two post-Dose 2 results in a subset
    of 100 subjects.

-   To compare the responses to H1N1 strains A/Shenzhen/227/95 in the
    consistency lots and A/Texas/36/91 in the efficacy lot.

## VACCINES

a.  Flumist -- Each 0.5 ml dose contained 10^6.7-7^ TCID~50~ of each
    strain of virus (2 type A and 1 type B) in normal allantoic fluid
    (NAF) containing sucrose-phosphate-glutamate (SPG). The strains and
    lots used are listed in the table.

b.  Placebo -- 1 lot of NAF with SPG stabilizer was used.

**AV007 -- Study Vaccines and Lots Used**

+-----------------+-----------------+-----------------+-----------------+
| **Treatment     | **Filled        | **Monovalent    | **Strain        |
| Group**         | Trivalent       | Harvest**       | Reference**     |
|                 | Lots**          |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **Placebo**     | CAF013          | CAE013          | NAF             |
+-----------------+-----------------+-----------------+-----------------+
| **FluMist --    | CAF016          | CAE034          | A/Shenzhen      |
| Lot 1**         |                 |                 | (H1N1)          |
|                 |                 | CAE026          |                 |
|                 |                 |                 | A/Wuhan (H3N2)  |
|                 |                 | CAE024          |                 |
|                 |                 |                 | B/Harbin-like   |
|                 |                 | CAE019          |                 |
|                 |                 |                 | NAF             |
+-----------------+-----------------+-----------------+-----------------+
| **FluMist --    | CAF017          | CAE035          | A/Shenzhen      |
| Lot 2**         |                 |                 | (H1N1)          |
|                 |                 | CAE027          |                 |
|                 |                 |                 | A/Wuhan (H3N2)  |
|                 |                 | CAE025          |                 |
|                 |                 |                 | B/Harbin-like   |
|                 |                 | CAE022          |                 |
|                 |                 |                 | NAF             |
+-----------------+-----------------+-----------------+-----------------+
| **FluMist --    | CAF020          | CAE036          | A/Shenzhen      |
| Lot 3**         |                 |                 | (H1N1)          |
|                 |                 | CAE033          |                 |
|                 |                 |                 | A/Wuhan (H3N2)  |
|                 |                 | CAE029          |                 |
|                 |                 |                 | B/Harbin-like   |
|                 |                 | CAE023          |                 |
|                 |                 |                 | NAF             |
+-----------------+-----------------+-----------------+-----------------+
| **AV006         | CAF014          | CAE014          | A/Texas(H1N1)   |
| Efficacy Lot**  |                 |                 |                 |
|                 |                 | CAE017          | A/Wuhan (H3N2)  |
|                 |                 |                 |                 |
|                 |                 | CAE016          | B/Harbin-like   |
+-----------------+-----------------+-----------------+-----------------+
|                 | CAF015          | CAE018          | A/Texas(H1N1)   |
|                 |                 |                 |                 |
|                 |                 | CAE017          | A/Wuhan (H3N2)  |
|                 |                 |                 |                 |
|                 |                 | CAE016          | B/Harbin-like   |
+-----------------+-----------------+-----------------+-----------------+

## PROCEDURES

## Inclusion criteria:

Healthy children between 12 to 36 months of age, inclusive, and had a
telephone in the home.

**Exclusion criteria**:

Hypersensitivity to eggs or egg protein; significant chronic illness for
which the CDC ACIP recommends inactivated influenza vaccines; immune
deficiency disease, immunosuppressive treatment, or lived in the same
household as an immunosuppressed individual; acute febrile illness
within 1 week; current URI (including common cold or nasal congestion)
within 72 hours; experienced wheezing within one week or had used a
bronchodilator medication within 2 weeks of vaccination in the study;
past receipt of cold adapted or inactivated influenza vaccine;
administration of live virus vaccine within 1 month of vaccination.;
administration of an inactivated vaccine within 2 weeks; receipt of a
blood product within 3 mo prior or planned receipt within the study
duration; expected administration of nasal medications during the 10
days before or after vaccination. Pregnant household member or daycare
provider was not an exclusion criterion.

**Vaccine Administration and Schedule**

On Study Day 0, enrollees had a health assessment and a brief PE
performed. While in upright position, each subject was given 0.5ml (0.25
ml per nostril) of study vaccine intranasally administered with an
Accuspray device. Between Day 28 and 60, subjects were to return for
Dose 2 vaccination. The same study vaccine was given for Dose 1 and Dose
2. However, subjects who experienced a "vaccine-related AE" after Dose 1
were not to receive Dose 2.

## Concomitant Vaccinations and Medications

No concomitant vaccinations were permitted. Use of aspirin or
ASA-containing products was prohibited. All medications given in the
1^st^ 10 days post-vaccination were recorded on CRF.

## Monitoring

## Immunogenicity

All subjects had pre-vaccine and post-dose two (28-42 days post-dose 2)
blood samples obtained. A subset of subjects, supposedly the 1^st^ 100
subjects enrolled, were to also have serum obtained just prior to Dose 2
(28-60 days after Dose 1). These samples were to be assayed for
strain-specific HAI titers. Subjects were considered to be seronegative
if serum HAI titer [\<]{.underline} 1:4. A 4-fold rise in titer was
considered to be seroconversion.

##### [Lab Methods]{.underline} {#lab-methods .unnumbered}

The influenza HAI assays were performed at Aviron. The H1N1 assays were
performed with HA from A/Shenzhen/227/95 for FluMist recipients in the
consistency lots, and with the HA from A/Texas/36/91 for the FM-AV006
recipients.

**Statistical Analysis Plan**

## Efficacy Endpoints

## Primary

-   Lot-to-lot consistency for the three vaccine lots required similar
    geometric mean titer (GMT) ratios (post-dose 2 to baseline) for each
    strain in each of the three lots. The null hypothesis is that the
    absolute value of 1 or more of the 9 GMT fold-differences (3
    influenza strains from 3 lots of vaccines) is at least 4. The study
    protocol and data analysis plan (DAP) specified that if all 9
    confidence intervals (CI's) excluded 0.25 and 4, the consistency
    lots would be declared consistent.

## 

## Secondary

-   The percent of seronegative participants with [\>]{.underline}
    4-fold rise in HAI titers would be similar among the three lots.

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```
-   To assess the immunogenicity post-dose 1 and to compare this to the
    immunogenicity post-dose 2 in a subset of 100 subjects,

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```
-   To compare the responses to the H1N1 strains in the consistency lots
    (A/Shenzhen/227/95) with the H1N1 in the FM-AV006 vaccine lot
    (A/Texas/36/91).

## Equivalence

##### The combined consistency lots and the FM-AV006 vaccines were to be declared similar if the strain-specific GMT ratio for the 3 lots combined were similar to the GMT ratio elicited by FM-AV006. 

##### The strain-specific titer ratios elicited by the 3 consistency lots were compared to titer ratios elicited by FM-AV006.

-   H1N1 strain in the consistency lots (A/Shenzhen) was different than
    the H1N1 used in FM-AV006 (A/Texas). Observed differences between
    the consistency lot and FM-AV006 may be due to use of different
    strains.

# 

# **Sample size**

Sample size was calculated based upon the following assumptions:

-   Drop-out was not greater than 10%

-   Age of enrollees is uniformly distributed between 12 and 36 mo

-   Variability of post-dose 2 antibodies is similar to post-dose 1
    antibodies observed in previous Aviron trials with CAIV-T

-   The percent of seronegative subjects at 12, 24, and 36 mo is similar
    to that seen in earlier trials

-   Antibody responses are independent over strains.

For the primary outcome, the estimated GMTs after Dose 2 were expected
to have 95% CI for all strains, not exceeding [+]{.underline} 25% of the
GMT for a single lot and not exceeding [+]{.underline} 13% for the 3
consistency lots combined.

The secondary outcome, seroconversion after Dose 2, was measured by the
percent of seronegative participants with [\>]{.underline} 4-fold rise
in titer. The study was expected to provide 95% assurance that the true
seroconversion rates for all strains and all lots were within
[+]{.underline} 12% of measured rates. The study was not designed with
adequate power to show equivalence in seroconversion rates between lots.

# **RESULTS**

## Enrollment and Demographics

Five hundred subjects were randomized, 100 to each of the five treatment
groups. Demographic characteristics were similar among all five groups.
Mean age was 21-22 months in all groups except in the efficacy lot, it
was (24 months ± 7).

## Protocol Compliance

Twenty-six subjects withdrew prior to receiving the 2^nd^ dose and 33
subjects did not complete the study. Withdrawals were evenly distributed
among groups (Lot 1, n=7; Lot 2, n= 5; Lot 3, n= 5; Efficacy Lot, n= 6;
and placebo, n= 9). The most common reasons were parent's request (n=23)
and unsatisfactory compliance (n=6).

There were 76 protocol violations. Twenty of these were violations of
the exclusion criteria (8 with asthma, 5 with a respiratory illness, 3
had received varicella vaccine, 1 had previous flu vaccine, 1 with egg
allergy, 1 with history of seizures, and 1 with febrile illness within
72 hours). For the other 56 violations, 47 were study visits outside of
the windows, 8 subjects had illness at the time of vaccination, and 1
subject received the wrong study number vaccine (but it was from the
correct lot).

## Lot Consistency

For all 3 pairs of consistency lots (Lot 1/Lot2, Lot 2/Lots 3 and Lot
1/Lot 3) for all 3 strains, the 95% CI for ratios of HAI titers were
within the range of ¼ and 4.

## AV007 - Comparison of Post-Dose Two HAI Titer Ratios Among Consistency Lots

+---------------+--------------------------+---------------------------+
|               | **Ratio of Titer         | **95% CI for Ratios of**  |
|               | Ratios**                 |                           |
|               |                          | **HAI Titer Ratios**      |
+---------------+--------------------------+---------------------------+
| **H1N1**      |                          |                           |
+---------------+--------------------------+---------------------------+
| Lot 1/Lot 2   | 0.70                     | 0.48, 1.03                |
|               |                          |                           |
| Lot 1/Lot 3   | 1.49                     | 1.01, 2.19                |
|               |                          |                           |
| Lot 2/Lot 3   | 2.12                     | 1.44, 3.11                |
+---------------+--------------------------+---------------------------+
| **H3N2**      |                          |                           |
+---------------+--------------------------+---------------------------+
| Lot 1/Lot 2   | 0.79                     | 0.49, 1.29                |
|               |                          |                           |
| Lot 1/Lot 3   | 1.24                     | 0.76, 2.01                |
|               |                          |                           |
| Lot 2/Lot 3   | 1.56                     | 0.96, 2.53                |
+---------------+--------------------------+---------------------------+
| **B**         |                          |                           |
+---------------+--------------------------+---------------------------+
| Lot 1/Lot 2   | 1.03                     | 0.72, 1.49                |
|               |                          |                           |
| Lot 1/Lot 3   | 0.90                     | 0.63, 1.30                |
|               |                          |                           |
| Lot 2/Lot 3   | 0.88                     | 0.61, 1.25                |
+---------------+--------------------------+---------------------------+

## 

## AV007 - Comparison of Post-Dose Two HAI Titer Ratios between Consistency Lots and Efficacy Vaccine

+----------+------------------+------------------+-------------------+
|          |                  | **Ratio of Titer | **95% CI for      |
|          |                  | Ratios**         | Ratios of**       |
|          |                  |                  |                   |
|          |                  |                  | **HAI Titer       |
|          |                  |                  | Ratios**          |
+----------+------------------+------------------+-------------------+
| **       | Lots 1,2,        | **4.17**         | 3.06, 5.69        |
| H1N1\*** | 3/Efficacy       |                  |                   |
+----------+------------------+------------------+-------------------+
| ####     | Lots 1,2,        | 1.01             | 0.68, 1.51        |
| ### H3N2 | 3/Efficacy       |                  |                   |
+----------+------------------+------------------+-------------------+
| **B**    | Lots 1,2,        | 1.06             | 0.79, 1.42        |
|          | 3/Efficacy       |                  |                   |
+----------+------------------+------------------+-------------------+

> \*

**\*The efficacy H1N1 vaccine lot contained H1N1 strain A/Texas/36/91,
and the consistency lots contained H1N1 strain A/Shenzhen/227/95. Sera
from the lot consistency groups were assayed using the relevant H1N1
strain (i.e., A/Shenzhen) and those from the efficacy lot were assayed
using the relevant H1N1 antigen (i.e., A/Texas/36/91)**

The strains of H3N2 and B contained in the consistency lots and FM-AV006
were the same, and the GMT ratios between the consistency lots and
FM-AV006 were similar.

Seroconversion rates for all subjects and seronegative subjects were not
statistically different between the consistency lots and FM-AV006 for
H3N2 and B. For H1N1, higher seroconversion rates were observed in the
consistency lot recipients than for the FM-AV006 recipients.

AV007 - Strain-Specific Seroconversion Rates for All Participants and
for Seronegative participants by Treatment Group

+--------------+----------+---------+---------+------------+---------+
| **Serum      | **Lot    | **Lot   | **Lot   | **Efficacy | **Pl    |
| HAI**        | 1**      | 2**     | 3**     | Lot**      | acebo** |
+--------------+----------+---------+---------+------------+---------+
|              | **       |         |         |            |         |
|              | H1N1^a^, |         |         |            |         |
|              | %        |         |         |            |         |
|              | (        |         |         |            |         |
|              | 95%CI)** |         |         |            |         |
+--------------+----------+---------+---------+------------+---------+
| **All**      | 78       | 88      | 73      | 37         | 2       |
|              |          |         |         |            |         |
|              | (68, 86) | (80,    | (63,    | (27, 48)   | (0.3,   |
|              |          | 94)     | 81)     |            | 8)      |
+--------------+----------+---------+---------+------------+---------+
| **Se         | 87       | 94      | 79      | 42         | 2       |
| ronegative** |          |         |         |            |         |
|              | (78, 93) | (87,    | (69,    | (31, 53)   | (0.3,   |
|              |          | 98)     | 87)     |            | 8)      |
+--------------+----------+---------+---------+------------+---------+
|              | **H3N2,% |         |         |            |         |
|              | (        |         |         |            |         |
|              | 95%CI)** |         |         |            |         |
+--------------+----------+---------+---------+------------+---------+
| **All**      | 68       | 72      | 66      | 65         | 7       |
|              |          |         |         |            |         |
|              | (58, 78) | (62,    | (56,    | (54, 74)   | (2, 14) |
|              |          | 81)     | 760     |            |         |
+--------------+----------+---------+---------+------------+---------+
| **Se         | 100      | 99      | 100     | 100        | 7       |
| ronegative** |          |         |         |            |         |
|              | (94,     | (92,    | (94,    | (94, 100)  | (2, 17) |
|              | 100)     | 99.50   | 100)    |            |         |
+--------------+----------+---------+---------+------------+---------+
|              | **B, %   |         |         |            |         |
|              | (        |         |         |            |         |
|              | 95%CI)** |         |         |            |         |
+--------------+----------+---------+---------+------------+---------+
| **All**      | 68       | 64      | 72      | 70         | 1       |
|              |          |         |         |            |         |
|              | (58, 78) | (53,    | (61,    | (60, 79)   | (0.03,  |
|              |          | 73)     | 80)     |            | 6)      |
+--------------+----------+---------+---------+------------+---------+
| **Se         | 96       | 100     | 100     | 100        | 2       |
| ronegative** |          |         |         |            |         |
|              | (87,     | (93,    | (93,    | (94, 100)  | (0.05,  |
|              | \>99.50  | 100)    | 100)    |            | 11)     |
+--------------+----------+---------+---------+------------+---------+

**^a^** **HAI assays were performed using the HA antigen with which the
subject was immunized.**

## Cross-reactivity

A subset of subjects had serum tested against both A/Shenzhen/227/95 (in
the consistency lots) and A/Texas/36/91 (in FM-AV006) and generally,
more responders were noted to the strain in the vaccine that the subject
had received. For the consistency lots combined, from pre to post-dose
2, 80% (75, 84) of recipients had a [\>]{.underline} 4-fold rise to
A/Shenzhen and 49% (39, 60) to A/Texas. For FM-AV006 recipients, 15% (8,
24) had [\>]{.underline} 4-fold rise to A/Shenzhen and 37% (27, 48) to
A/Texas. Seventeen (6%) of the placebo recipients had [\>]{.underline}
4-fold rise in HAI titers against either strain. A similar pattern of
responses was also seen with GMT ratios.

**Immunogenicity after 1 dose**

100 subjects had blood samples after Dose 1 (just prior to Dose 2) to
assess the immunogenicity of 1 dose. For the consistency lot recipients,
the percent responders and GMT (\~100 for each lot) for H3N2 were
equivalent after 1 dose to after 2 dose. However, GMT's were
significantly higher (p=0.0001) post-dose 2 compared to post-dose 1 for
both H1N1 and type B in the consistency lots. For FM-AV006 recipients,
no significant increase in GMT was noted for H3N2 or B from Dose 1 to
Dose 2, but there was a significant increase in the GMT to H1N1
(p=0.015).

**Subgroup analyses**

Analyses were performed by gender (male- n=251, female -- n=216), age
(12-17 mo -- n=101, 18-23 mo -- n=182, and 24-36 mo-n=184), ethnicity
(Caucasian-n=169, and Hispanic/Central American- n=223), and time
between vaccinations (28-41 days -- n=406 and 42-60 days -- n=55). There
were too few Blacks (n=37) and other ethnic groups (n=17) to perform any
comparisons. The study did not have sufficient power to test comparisons
between the subgroups, so no formal statistical comparisons were made.
The combined consistency lot post-dose 2 GMT's for females appeared
higher than GMT's for males for all 3 strains (non-overlapping 95% CI
for H1N1 and type B), and Hispanics/Central Americans appeared to have
slightly higher GMTs than Whites/Caucasians for H3N2 and type B, but
95%CI did overlap. Neither age nor time between vaccines appeared to
effect the immune response.

# **STUDY AV014** 

**TITLE:** **A Randomized, Prospective, Double-Blind Trial in Healthy
Children Comparing**

**the Safety, Tolerability, and Immunogenicity of Influenza Virus
Vaccine, Trivalent, Types**

**A and B, Live, Cold-Adapted (Flumist) from Two Different Manufacturing
Facilities.**

LOCATION: Australia, Two study sites

STUDY PERIOD: 12/7/98 -- 4/9/98

PIVOTAL TRIAL: Yes, Consistency of facilities

POPULATION: Healthy children, 12- 42 months of age

SAMPLE SIZE: Total: n= 225

### DESIGN {#design-2 .unnumbered}

This was a prospective, randomized, double-blind trial to compare the
safety, tolerability and immunogenicity Flumist blended and filled at 2
different facilities, Medeva and Aviron-PA. All of the vaccines were
manufactured at the U.K. facility, and all vaccine lots used in clinical
trials in the BLA, including AV006 - Pediatric Efficacy Study, AV009 -
Effectiveness in Adults, and AV007 - Lot Consistency Trial, were blended
and filled at the Medeva facility.

The study was a two-dose regimen (28 -- 42 days apart) and was performed
in healthy children age 12-42 months, in Australia. Subjects were
randomly assigned to one of the 2 treatment groups in a 3:2 ratio,
Medeva to Aviron-PA. The Southern Hemisphere was chosen so not to have
interference by circulating influenza during the influenza season in the
Northern Hemisphere.

## OBJECTIVES

## Primary

To compare the immunogenicity profiles for influenza virus vaccine
strains (1997-1998) of Flumist blended and filled at Medeva to Flumist
blended and filled at Aviron-PA.

## Secondary

To compare the safety and tolerability profiles of the Flumist blended
and filled at Medeva to Flumist blended and filled at Aviron-PA.

#### VACCINES

Flumist -- Each 0.5 ml dose contained 10^7^ TCID~50~ of each strain of
virus (2 type A and 1 type B) in normal allantoic fluid (NAF) containing
sucrose-phosphate-glutamate (SPG). The strains and lots used are in the
table below. The 2 lots of vaccine were indistinguishable in appearance.

## AV014 -- Study Vaccines and Lots Used

+-----------------+-----------------+-----------------+-----------------+
| **Treatment     | **Filled        | **Monovalent    | **Strain        |
| Group**         | Trivalent       | Harvest**       | Reference**     |
|                 | Lots**          |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **FluMist**     | CAF1009         | CAE037          | A/Shenzhen      |
|                 |                 |                 | (H1N1)          |
| **(Aviron-PA)** |                 | CAE033          |                 |
|                 |                 |                 | A/Wuhan (H3N2)  |
|                 |                 | CAE041          |                 |
|                 |                 |                 | B/Harbin - like |
|                 |                 | CAE047          |                 |
|                 |                 |                 | NAF             |
+-----------------+-----------------+-----------------+-----------------+
| **FluMist**     | CAF020\*        | CAE036          | A/Shenzhen      |
|                 |                 |                 | (H1N1)          |
| **(Medeva)**    |                 | CAE033          |                 |
|                 |                 |                 | A/Wuhan (H3N2)  |
|                 |                 | CAE029          |                 |
|                 |                 |                 | B/Harbin - like |
|                 |                 | CAE023          |                 |
|                 |                 |                 | NAF             |
+-----------------+-----------------+-----------------+-----------------+

##### \* The same lot as lot #3 in AV007, the lot consistency study. {#the-same-lot-as-lot-3-in-av007-the-lot-consistency-study. .unnumbered}

#####  {#section-20 .unnumbered}

##### PROCEDURES {#procedures-4 .unnumbered}

## Entry Criteria

## Inclusion criteria

Children 12-42 months of age in good health, available by telephone or
home visits, and had a signed informed consent by parent/guardian.

## Exclusion criteria

Hypersensitivity to eggs or egg protein; significant underlying chronic
illness for which the inactivated influenza vaccine is recommended;
prior receipt of any influenza vaccine.

Immunodeficiency, immunosuppression or household contact (or daycare
provider) with immunosuppression.; acute febrile (\> 38^o^C) illness
within 72 hours of enrollment; URI including wheezing or nasal
congestion within 72 hours of vaccination; receipt of aspirin (ASA) or
ASA-containing products within 1 month of enrollment or anticipated use
during the study; administration of a live viral vaccine within 1 month
or expected receipt within 1 month of study vaccination; administration
of an inactivated vaccine within 2 weeks or expected receipt within 2
weeks of study vaccination; administration of any investigational drug
within 1 month prior to enrollment or anticipated receipt during the
study; receipt of any blood product within 3 months or anticipated
during the study; any condition that the investigator thought might
interfere with evaluation of the vaccines. A pregnant household contact
was not an exclusion criterion.

Also, mild asthmatics who had not used therapeutic interventions
(β-agonist, steroids, etc) within 30 days and met all other Inc/Exc
criteria could be enrolled at the discretion of the investigator. "Mild
asthmatic" was not defined.

## Vaccine Schedule and Administration: Subjects received 2 doses of Flumist given 28-42 days apart. The vaccine was given intranasally 0.5ml (0.25 ml per nostril) using an Accuspray device with the subjects in an upright or sitting position.

## Concomitant Vaccinations and Medications

No concomitant immunizations were permitted. No ASA or ASA-containing
products were permitted. EMLA was permitted for venipuncture.

## Immunogenicity

Serum samples were obtained just prior to vaccination at Dose 1 (Day 0)
and Dose 2 (28-42 days later) and at Visit 3 (28 days [+]{.underline} 5
days after Dose 2). Samples were to be tested by HAI, which was
performed at Aviron. The sponsor states that attempts were made to
perform all samples from a subject simultaneously.

**Statistical Methods**

## Immunogenicity Endpoints

[Co-primary endpoints]{.underline}:

-   Seroconversion rate → strain-specific seroconversion rate post-dose
    2 in baseline seronegative subjects. Similarity between the two
    groups was defined as rates within 20 percentage points.

```{=html}
<!-- -->
```
-   Geometric mean titers (GMT) → strain-specific HAI GMT's post-dose 2
    in all participants regardless of baseline titers. Testing of
    similarity was based on the 90% two-sided CI's for the GMT ratio. If
    the confidence intervals for all three strains were included within
    the range of ¼ and 4 then the two treatment groups would be declared
    similar.

[Secondary endpoints:]{.underline}

-   Post-dose 2 seroresponse in all subjects.

-   Post-dose 2 strain-specific HAI GMT in baseline seronegative
    subjects.

-   Post-dose 1 seroconversion in baseline seronegative subjects and all
    subjects.

-   Post-dose 1 strain-specific HAI GMT in baseline seronegative and all
    subjects.

-   Post-dose 1 strain-specific HAI GMT in seroresponders.

-   Post-dose 2 strain-specific HAI GMT in seroresponders.

> [Definitions:]{.underline}

-   Seronegative → defined as strain-specific HAI titers
    [\<]{.underline} 1:4.

-   Seroconversion → [\>]{.underline} 4-fold rise in strain-specific HAI
    titers in seronegative subjects.

-   Seroresponder → [\>]{.underline} 4-fold rise in HAI titer regardless
    of baseline serostatus.

```{=html}
<!-- -->
```
-   For statistical analysis, HAI titers \< 1:4 were set as equal to
    1:2.

### Sample Size {#sample-size-1 .unnumbered}

The proportion of baseline seronegative subjects and seroconversion
rates were estimated from Study AV007, as it was assumed that the rates
would be similar. If the true seroconversion rates were 85% for
Aviron-PA and 95% for Medeva, and 65% of subjects were seronegative,
there was a 33% probability for observing [\>]{.underline} 20%
difference. For GMT ratios, assuming that the true degree of GMT ratio
between the two groups was 2-fold, the study had 99% power to show that
the GMT ratios for all 3 strains were within 4-fold (and would be
declared similar). Power to show similarity within 3-fold was lower,
ranging from 72%-98%.

### RESULTS {#results-4 .unnumbered}

## Enrollment

225 subjects were randomized 3:2 (Medeva, n=135: Aviron-PA, n=90) into
the study.

## Demographics

Generally, the 2 study groups had similar baseline characteristics. In
both groups, the mean age was 2.5 years, and \~57% were male. In the
Aviron-PA group, 94% were Caucasian, 1% was Asian, 1% was
Polynesian/Maori, and 3% other. In the Medeva group, 89% were Caucasian,
with 2% each Asian and Polynesian/Maori and 7% were other ethnic groups.

## Protocol Compliance

There were 3 "voluntary withdrawals " after Dose 1 but prior to Dose 2,
however no details were provided. There were 118 minor protocol
deviations, 69 in the Medeva group and 49 in the Aviron-PA group. All of
the deviations were study procedures which were performed outside of the
protocol windows, most frequently was performing the Day 42 phone call
late (Aviron-PA, n=37 and Medeva, n=41).

Immunogenicity

All subjects had pre-vaccine serum samples obtained and analyzed.
Post-dose 2, there were six subjects (2 Aviron-PA and 4 Medeva) with
samples missing from analysis. The reasons for the missing samples were
not provided.

## Analyses of Co-Primary Endpoints

At baseline for all subjects, 99% were seronegative for H1N1, \~80% were
seronegative to B, and \~40% were seronegative to H3N2. Seroconversion
rates are shown in the table below.

## AV014 - Seroconversion Post-Dose Two in Baseline Seronegative

+-------+----+-----------+--------+-----------------+-----------------+
| **Str | *  | #######   | **Me   | **Difference in | **95% CI of     |
| ain** | *N | Aviron-PA | deva** | %**             | Difference\***  |
|       | ** |           |        |                 |                 |
+-------+----+-----------+--------+-----------------+-----------------+
| H1N1  | 88 | 85%       | 69%    | 16%             | (5.3, 27.1)     |
+-------+----+-----------+--------+-----------------+-----------------+
| H3N2  | 40 | 100%      | 100%   | 0               | (-12,7, 9.5)    |
+-------+----+-----------+--------+-----------------+-----------------+
| B     | 71 | 100%      | 100%   | 0               | (-7.3, 4.9)     |
+-------+----+-----------+--------+-----------------+-----------------+

AV014 - Post-Dose Two GMT in All Participants

+-------+----+-----------+--------+-----------------+-----------------+
| **Str | *  | #######   | **Me   | ##              | **90% CI for    |
| ain** | *N | Aviron-PA | deva** | ##### GMT Ratio | GMT Ratio \***  |
|       | ** |           |        |                 |                 |
|       |    | ##        | #####  |                 |                 |
|       |    | ##### GMT | ## GMT |                 |                 |
+-------+----+-----------+--------+-----------------+-----------------+
| H1N1  | 88 | 18.3      | 10.9   | 1.67            | (1.27,2.17)     |
+-------+----+-----------+--------+-----------------+-----------------+
| H3N2  | 88 | 81.7      | 74.2   | 1.10            | (0.93, 1.30)    |
+-------+----+-----------+--------+-----------------+-----------------+
| B     | 88 | 42.2      | 41.7   | 1.01            | (0.87, 1.17)    |
+-------+----+-----------+--------+-----------------+-----------------+

## 

## Secondary Endpoints

-   Post-dose 1 seroconversion in baseline seronegative subjects and all
    subjects.

```{=html}
<!-- -->
```
-   Greater differences between the Aviron-PA and Medeva groups in
    seroconversion rates were observed post-dose 1 than had been noted
    post-dose 2 for all strains for all subjects and for H1N1for the
    seronegative subjects. For H1N1, the difference was 25.6 (14.2,
    37.4) for all subjects and 25.4 (14, 37) for seronegative subjects.

**AV014 - Proportion of Participants with ≥** 4-fold Rise in
Strain-Specific HAI Titer by Dose and Treatment Group for All
Participants

+----------+-----+---+--------------+----+--------------+------------+
|          |     | * |              | ** |              |            |
|          |     | * |              | Me |              |            |
|          |     | A |              | de |              |            |
|          |     | v |              | va |              |            |
|          |     | i |              | ** |              |            |
|          |     | r |              |    |              |            |
|          |     | o |              |    |              |            |
|          |     | n |              |    |              |            |
|          |     | - |              |    |              |            |
|          |     | P |              |    |              |            |
|          |     | A |              |    |              |            |
|          |     | * |              |    |              |            |
|          |     | * |              |    |              |            |
+----------+-----+---+--------------+----+--------------+------------+
| **Dose** | *   | * | **%          | *  | **%          | **Rate     |
|          | *St | * | Sero         | *n | Sero         | Di         |
|          | rai | n | conversion** | /N | conversion** | fference** |
|          | n** | / |              | ** |              |            |
|          |     | N | **(95% CI)** |    | **(95% CI)** | **90% CI** |
|          |     | * |              |    |              |            |
|          |     | * |              |    |              |            |
+----------+-----+---+--------------+----+--------------+------------+
| **P      | H   | 4 | 53 (42, 64)  | 3  | 28 (20, 36)  | 25.6       |
| ost-dose | 1N1 | 7 |              | 7/ |              | (14.2,     |
| 1**      |     | / |              |    |              | 37.4)      |
|          |     | 8 |              | 1  |              |            |
|          |     | 8 |              | 33 |              |            |
+----------+-----+---+--------------+----+--------------+------------+
|          | H   | 4 | 47 (36, 58)  | 6  | 50 (41, 58)  | 3.0        |
|          | 3N3 | 1 |              | 6/ |              | (-15.2,    |
|          |     | / |              |    |              | 8.4)       |
|          |     | 8 |              | 1  |              |            |
|          |     | 8 |              | 33 |              |            |
+----------+-----+---+--------------+----+--------------+------------+
|          | B   | 6 | 69 (59, 79)  | 9  | 68 (59, 76)  | 1.6 (-9.5, |
|          |     | 1 |              | 0/ |              | 13.9)      |
|          |     | / |              |    |              |            |
|          |     | 8 |              | 1  |              |            |
|          |     | 8 |              | 33 |              |            |
+----------+-----+---+--------------+----+--------------+------------+
|          |     |   |              |    |              |            |
+----------+-----+---+--------------+----+--------------+------------+
| **P      | H   | 7 | 85 (76, 92)  | 9  | 69 (60, 77)  | 16.5 (5.8, |
| ost-dose | 1N1 | 5 |              | 0/ |              | 27.6)      |
| 2**      |     | / |              |    |              |            |
|          |     | 8 |              | 1  |              |            |
|          |     | 8 |              | 31 |              |            |
+----------+-----+---+--------------+----+--------------+------------+
|          | H   | 4 | 51 (40, 62)  | 7  | 59 (50, 67)  | -7.8       |
|          | 3N2 | 5 |              | 7/ |              | (-19.7,    |
|          |     | / |              |    |              | 3.7)       |
|          |     | 8 |              | 1  |              |            |
|          |     | 8 |              | 31 |              |            |
+----------+-----+---+--------------+----+--------------+------------+
|          | B   | 7 | 84 (75, 91)  | 1  | 85 (77, 90)  | -0.6       |
|          |     | 4 |              | 11 |              | (-11.6,    |
|          |     | / |              | /1 |              | 8.8)       |
|          |     | 8 |              | 31 |              |            |
|          |     | 8 |              |    |              |            |
+----------+-----+---+--------------+----+--------------+------------+

Question 2. Are the data adequate to support the safety of FluMist in
subjects, 12 months to 64 years of age?

Approximately 20,000 subjects have received at least one dose of FluMist
in clinical trials. However, not all studies were finalized at the time
of submission of the BLA and complete study reports have not been
submitted for all studies. CBER's review of data from the incomplete
study reports, therefore, is not complete.

## The Frequency of Subjects by Age Group (in years), and Treatment Assignment for Select Protocols\* Combined. (Data submitted by Aviron through April 30, 2001.)

  ------------- ---------- -------- -------- ------------- ------------- ------------- ------------- ------------- ------------------------ -----------
                **Age                                                                                                                       
                Group (in                                                                                                                   
                years)**                                                                                                                    

                **\<2**    **2.0-   **6.0-   **10-12.9**   **13-18.9**   **19-29.9**   **30-49.9**   **50-64.9**   **[\>]{.underline}65**   **Total**
                           5.9**    9.9**                                                                                                   

  **FluMist**   1254       5864     4104     2522          2499          940           2241          511           111                      20,046

  **Placebo**   378        1651     906      594           572           439           1025          209           101                      5875

  **TIV^\#^**   0          0        0        0             3             18            12            0             0                        33

                                                                                                                                            
  ------------- ---------- -------- -------- ------------- ------------- ------------- ------------- ------------- ------------------------ -----------

\*Protocol = first administration of FluMist or placebo in protocols
98-005, AR001, AV001, AV002, AV002-2, AV003, AV004, AV005, AV006 (Year
1), AV007, AV008, AV009, AV010, AV012 (Year 1), AV012 (Year 2 new
recruits), AV014, AV017 (new recruits), and AV019.

^\#^Trivalent inactivated influenza vaccine, the licensed product.

Frequency of Subjects under 2 Years of Age (in months) and Treatment
Assignment for Selected Protocols\* Combined

  -------------- -------------- -------------- -------------- --------------
                 **12- 15       **16 -- 19     **20-23        **Total**
                 months**       months**       months**       

  **Received 1                                                
  or 2 Doses**                                                

  **FluMist**    200            507            547            1254

  **Placebo**    88             142            148            378

                                                              

  **Received 2                                                
  Doses**                                                     

  **FluMist**    133            272            211            616

  **Placebo**    58             90             89             237
  -------------- -------------- -------------- -------------- --------------

\*Protocols includes AR001, AV002, AV002-2, AV006 (Year 1), AV007, AV012
(Year 1 and new recruits Year 2), AV014, AV017 (new recruits), and
AV019.

## STUDIES SUBMITTED IN SUPPORT OF SAFETY

## Monitoring performed in clinical trials

All trials in this section had some safety monitoring performed.
Generally, Aviron monitored for three categories of adverse events
(AEs): 1) solicited reactogenicity events (REs), 2) other AEs
(unsolicited AEs) and 3) serious adverse events (SAEs). In all studies
SAEs were defined as death, immediately life-threatening, results in
permanent or substantial disability, hospitalization or prolongation of
hospitalization, cancer, congenital anomaly, or is the result of an
overdose (accidental or intentional). The definitions for SAEs were
similar to 21 CFR 312.32. Of note, not all studies had active monitoring
for all three types of AEs.

## [Pediatric Trials]{.underline}

**Studies AV006 (Years 1 and 2) AV011 and AV015 (Year 3 for AV006
participants)**: AV006 is described above in Efficacy section.

**Studies AV007 and AV014:** Safety and tolerability data were compared
in these studies of consistency of lot production and consistency of
manufacturing, as described above.

**Study AV012**: Reports of SAEs in a study performed to assess herd
immunity of FluMist in an HMO in a Texas community.

**Study AV019:** Comparison of medically-attended events and SAEs after
FluMist or placebo in Children ages 1 to 17 years in Northern California
Kaiser Permanente.

## [Adult Trials]{.underline}

**Studies AV003 and AV009:** Report of the safety profile of FluMist,
compared to placebo, in adults in efficacy trials described above.

No data were submitted for the safety of annual administration of
FluMist in adults.

Additional trials submitted in the BLA include Phase 1 and 2 studies
(AV001, AV004 and AV005) which were performed to establish safety and
dosing (spray *vs.* drops and 2-dose regimen) before proceeding with
product development. Study AR001, which was a comparison of FluMist
prepared by classical reassortant *vs.* recombinant reassortant, was
also submitted to the BLA. However, all clinical trials have been
performed with classical reassortants, and AR001 is not discussed in
this briefing document.

## [Subjects at "High Risk" for Influenza]{.underline}

**Study AV010:** - Evaluation of safety and tolerability of FluMist
*vs.* placebo is children 9-17 years of age with moderate to severe
asthma.

**Study AV012:** Evaluation of a subset of subjects in this trial, who
were identified as having asthma.

**DMID #98-005:** Comparison of the safety and tolerability of FluMist
vs. placebo in adults infected with HIV and adults without HIV
infection.

## [Other Safety Concerns]{.underline} 

1.  Transmission of the Influenza Strains contained in FluMist

> No study submitted in the BLA was specifically performed to assess
> transmissibility of FluMist. Aviron addressed transmissibility with
> the following:

-   Assessment from AV006.

> Transmissibility was assessed by applying statistical modeling for
> evaluating wild type influenza attack rate in 183 sibling pairs (1
> Flumist recipient and 1 placebo recipient,) as compared to 513 Flumist
> and 258 placebo recipients without siblings in the trial. The
> sponsor's rationale was if there was a high rate of transmissibility,
> placebo recipients with Flumist siblings should have a lower attack
> rate than observed in other placebo recipients. Placebo recipients
> with siblings had 16% attack rate which was equivalent to the 20% in
> placebo recipients without siblings receiving Flumist, and the sponsor
> considered this as evidence of no significant transmissibility.

2.  Reassortment with Wild-type Influenza Strains

-   No human studies were submitted in the BLA to assess the occurrence
    of reassortment of influenza strains contained in FluMist with wild
    type influenza strains. The sponsor notes that the mutations
    responsible for the attenuation of FluMist are not fully defined,
    and that the full expression of attenuation may require that all six
    internal genes of Master Donor Virus work in concert.

# 

# **SAFETY DATA BY STUDY**

# **STUDY AV006** (**Years 1, 2, and 3 \[AV015\])** 

**TITLE: A Phase 3, Randomized, Double-blind, Placebo-controlled, Trial
to Assess the**

**Safety, Immunogenicity and Efficacy of Influenza Virus Vaccine,
Trivalent, Types A&B,**

**Live, Cold-Adapted (CAIV-T) in Healthy Children.**

LOCATION: United States, multi-center

STUDY PERIOD: 2 years: Year 1 -- 1996-97 (1^st^ enrolled 8/96), Year 2
-- 1997-98

PIVOTAL TRIAL: Yes

POPULATION: Healthy children, ages 15-71 months at enrollment

SAMPLE SIZE: Year 1 -- Total -- n=1602 (1070 FluMist, 532 Placebo)

> Year 2 -- Total - n=1358 (917 FluMist, 441 Placebo)

This was a prospective, randomized, double-blind, placebo-controlled,
multi-center trial conducted at 10 study sites. The study was designed
as a 2-year study, with the primary objective to assess efficacy of
FluMist. A single cohort was recruited in Year 1 (receiving either a 1
dose or 2-dose regimen), and remaining in the same study group to be
re-vaccinated with 1 dose in Year 2. In Year 1, children 15-71 months of
age (not had their 6^th^ birthday) were randomized 2:1 to receive
vaccine or placebo. Subjects who completed Year One were invited to
participate in the Year 2 study. Randomization is described above in the
Efficacy Section. In Year three, an open label study design was followed
in order to offer previous placebo recipients vaccine and to collect
safety data in previous vaccinees on FluMist given in a 3^rd^
consecutive year. Year three was designated as study AV015.

## Safety Monitoring

Monitoring procedures for safety were the same for Years 1 and 2 of the
study. A physical exam was performed on the day of enrollment. Subjects
were observed for 30 minutes after each vaccination in Year 1 and 15
minutes in Years 2 and 3.

The three categories of AEs (REs, other AEs and SAEs) were monitored
during all three years of the study. Parents/guardians were given
digital thermometers and asked to maintain a diary card for 10 days
post-vaccination for each dose for pre-defined RE's. These events
included: temperature cough, runny nose/nasal congestion, sore throat,
irritability, headache, chills, vomiting, muscle aches, and decreased
activity. Study personnel contacted the parents on \~ days 4 and 10 to
remind them to complete the diary cards and to return them to the study
site.

The final study report indicated that all SAEs were to be reported if
they occurred within 42 days of each study vaccination. After 42 days
until the end of the influenza season in each year, any SAEs judged to
be "related to vaccine" was to be reported to the study personnel. There
is no monitoring plan specified in the protocol for the collection of
SAEs either within the first 42 days post-vaccination or after that time
period. In response to an FDA question, the sponsor submitted
information to the BLA on 6/1/2001 stating that there had been no active
monitoring specifically to capture SAEs.

**RESULTS -- Year 1**

A total of 1070 subjects received at least 1 dose of FluMist and 532
received at least one dose of placebo. Eight hundred and eighty-one
subjects received 2 doses of FluMist and 433 subjects received 2 doses
placebo.

AV006 -- Year 1 Solicited Reactogenicity Events with Onset Day 0 to 10
by Dose and Treatment Group

+---------------+------------+------------+------------+------------+
|               | #          |            | #          |            |
|               | ### Dose 1 |            | ### Dose 2 |            |
+---------------+------------+------------+------------+------------+
|               | ### FluMi  | **Placebo, | **FluMist, | **Placebo, |
|               | st, N {#fl | N**        | N**        | N**        |
|               | umist-n .u |            |            |            |
|               | nnumbered} |            |            |            |
+---------------+------------+------------+------------+------------+
| Randomized    | 1070       | 532        | 881        | 433        |
+---------------+------------+------------+------------+------------+
| Valid Diary   | 1056       | 530        | 850        | 415        |
| Card          |            |            |            |            |
+---------------+------------+------------+------------+------------+
|               | \%         | \%         | \%         | \%         |
+---------------+------------+------------+------------+------------+
| Cough         | 28         | 29         | 36         | 33         |
+---------------+------------+------------+------------+------------+
| Runny         | 59         | 48\*       | 51         | 46         |
| nose/nasal    |            |            |            |            |
| congestion    |            |            |            |            |
+---------------+------------+------------+------------+------------+
| Sore Throat   | 10         | 8          | 6          | 7          |
+---------------+------------+------------+------------+------------+
| Irritability  | 26         | 26         | 17         | 19         |
+---------------+------------+------------+------------+------------+
| Headache      | 8          | 6          | 5          | 6          |
+---------------+------------+------------+------------+------------+
| Chills        | 4          | 3          | 3          | 3          |
+---------------+------------+------------+------------+------------+
| Vomiting      | 6          | 4\*        | 7          | 5          |
+---------------+------------+------------+------------+------------+
| Muscle Aches  | 5          | 3\*        | 3          | 2          |
+---------------+------------+------------+------------+------------+
| Decreased     | 16         | 13         | 13         | 13         |
| Activity      |            |            |            |            |
+---------------+------------+------------+------------+------------+
| Fever         |            |            |            |            |
+---------------+------------+------------+------------+------------+
| Fever 1       | 16         | 12\*       | 11         | 11         |
+---------------+------------+------------+------------+------------+
| Fever 2       | 7          | 6          | 5          | 6          |
+---------------+------------+------------+------------+------------+
| Fever 3       | 2          | 4          | 2          | 4          |
+---------------+------------+------------+------------+------------+
| Fever 4       | 0.9        | 1          | 0.7        | 1          |
+---------------+------------+------------+------------+------------+
| Fever 5       | 0.1        | 0.2        | 0.1        | 0.5        |
+---------------+------------+------------+------------+------------+
| Any Event     | 74         | 66\*       | 69         | 62\*       |
+---------------+------------+------------+------------+------------+

Fever 1 -- Oral \> 100.0°F, rectal \> 100.6°F, axillary/missing method
\>99.6°F

Fever 2 -- Oral \> 101.0°F, rectal \> 101.6°F, axillary/missing method
\>100.6°F

Fever 3 -- Oral \> 102.0°F, rectal \> 102.6°F, axillary/missing method
\>101.6°F

Fever 4 -- Oral \> 103.0°F, rectal \> 103.6°F, axillary/missing method
\>102.6°F

Fever 5 -- Oral \> 104.0°F, rectal \> 104.6°F, axillary/missing method
\>103.6°F

78% of subjects (parents) had axillary , 4% rectal, 10% oral
temperatures, 8% the method of measurement was missing.

\*p-value \<0.05 based of Fisher's exact test.

Post-dose one, statistically significant differences between FluMist and
placebo groups were noted for runny nose/congestion (59% vs. 48%),
vomiting (6% vs 4%) and muscle aches (5% vs 3%). Runny nose/nasal
congestion was also significantly different between FluMist and placebo
groups after either dose (72% vs. 64%) and after both doses (35% vs
26%), but not after Dose 2. "Any RE" was reported more in FluMist than
placebo groups post-dose 1, post-dose 2, after either and after both
doses.

**AV006 -- Year 1. Selected "Other Adverse Events" with Onset Day 0 to
10 by Dose and Treatment Group**

+--------------+-------------+-------------+-------------+-------------+
|              | #### Dose 1 |             | #### Dose 2 |             |
+--------------+-------------+-------------+-------------+-------------+
|              | ###         | **Placebo** | **FluMist** | **Placebo** |
|              |  FluMist {# |             |             |             |
|              | flumist-1 . |             |             |             |
|              | unnumbered} |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| *            | 1070        | 532         | 881         | 433         |
| *Randomized, |             |             |             |             |
| N**          |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
|              | **%**       | **%**       | **%**       | **%**       |
+--------------+-------------+-------------+-------------+-------------+
| **Any AE**   | 18          | 15          | 14          | 15          |
+--------------+-------------+-------------+-------------+-------------+
| **Allergic   | 1           | 0.6         | 0           | 0           |
| reaction**   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Flu        | 0.1         | 0           | 0.1         | 0.5         |
| syndrome**   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Edema,     | 0           | 0.2         | 0           | 0           |
| face**       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Abdominal  | 2           | 0.2\*       | 0.8         | 0.5         |
| pain**       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Anorexia** | 1           | 0.6         | 0.9         | 0.7         |
+--------------+-------------+-------------+-------------+-------------+
| **Diarrhea** | 4           | 3.2         | 2           | 2           |
+--------------+-------------+-------------+-------------+-------------+
| **Rash**     | 0.1         | 0.8\*       | 0.2         | 0           |
+--------------+-------------+-------------+-------------+-------------+
| **Conj       | 0.5         | 0.4         | 0.6         | 0.7         |
| unctivitis** |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Otitis     | 2           | 1           | 3           | 2           |
| media**      |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Asthma**   | 0.6         | 0.4         | 0.5         | 0.5         |
+--------------+-------------+-------------+-------------+-------------+
| **           | 0.1         | 0.2         | 0.6         | 0.7         |
| Bronchitis** |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| *            | 0.4         | 0           | 0           | 0.2         |
| *Pneumonia** |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| *            | 0.2         | 0.4         | 0.4         | 0.5         |
| *Sinusitis** |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Total      | 2.3         | 1.5         | 2.8         | 3.1         |
| r            |             |             |             |             |
| espiratory** |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| **Febrile    | 0           | 0           | 0           | 0.2         |
| seizure**    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+

\*p\<0.05 by Fisher's exact test.

Unsolicited AEs reported within 10 days of vaccination were coded by
Body System (modified COSTART), and statistically significant
differences were noted post-dose 1 for abdominal pain (FluMist 2% vs.
placebo 0.2%) and rash (FluMist 0.4% vs. placebo 2.1%.) For respiratory
system, events included asthma, bronchitis, dyspnea, epistaxis,
laryngitis, lung disease, pneumonia, sinusitis, stridor and altered
voice (otitis media was included in "special senses" category).

**Serious Adverse Events**

As noted under trial design, there was no active monitoring plan for
collecting SAEs. Five SAEs were reported within 42 days of vaccination
of either dose 1 or 2. All of these were hospitalizations and occurred
in FluMist recipients. All but one was judged as definitely not vaccine
related. There was 1 subject with abdominal trauma from a motor vehicle
accident; 1 with dehydration 23 days post-dose 1; 1 Staph infection of
the foot, 16 days post-dose 2; 1 abdominal pain rule-out appendicitis 9
days post-dose 1 (this was judged probably not related *\[As noted
above, abdominal pain occurred significantly more often in FluMist than
placebo recipients.\]*); and 1 subject with hydrocephalus with VP shunt
placement 34 days post-dose 1. Also, 1 FluMist recipient had new onset
of juvenile-onset rheumatoid arthritis (JRA) within 42 days, which was
not attributed to vaccination, and the sponsor did not code as an SAE.

There were 5 SAEs and significant adverse events more than 42 days
post-vaccination. Three of these were in the FluMist group (1 pneumonia
3 ½ months post-dose 2, 1 Henoch Schonlein Purpura (\~ 3 months post
dose 2), 1 dehydration (\~ 3 months post-dose 2). In the placebo group
there was 1 case of pneumonia \~ 2 months post-dose 1 and 1 case of
croup \~1 ½ months post dose 2.

## RESULTS YEAR 2

## Safety 

Solicited reactions were reported by vaccine group and by Year one
regimen (one-dose vs. 2 doses in year one). Reaction rates in the
FluMist group in Year two were similar whether subjects had received one
or two doses of vaccine in Year 1. Reaction rates for all FluMist
recipients and for all placebo recipients in Year 2 (i.e., regardless of
dosing regimen in Year 1) are shown in the table below. There were no
significant differences in reaction rates between the vaccine and
placebo recipients.

## AV006 -- Year 2 Percent of Subjects with Post-Vaccination RE's with Onset from Day 0 to 10 in Year Two by Treatment Group

+--------------------------+---------------------+---------------------+
|                          | ### FluMist {#flu   | **Placebo**         |
|                          | mist-2 .unnumbered} |                     |
+--------------------------+---------------------+---------------------+
| ####### Randomized, N    | 917                 | 441                 |
+--------------------------+---------------------+---------------------+
| **Valid Diary Card, N**  | 912                 | 441                 |
+--------------------------+---------------------+---------------------+
|                          | \%                  | \%                  |
+--------------------------+---------------------+---------------------+
| **Cough**                | 24                  | 25                  |
+--------------------------+---------------------+---------------------+
| **Runny nose/nasal       | 42                  | 42                  |
| congestion**             |                     |                     |
+--------------------------+---------------------+---------------------+
| **Sore throat**          | 10                  | 8                   |
+--------------------------+---------------------+---------------------+
| **Irritability**         | 14                  | 16                  |
+--------------------------+---------------------+---------------------+
| **Headache**             | 9                   | 7                   |
+--------------------------+---------------------+---------------------+
| **Chills**               | 3                   | 3                   |
+--------------------------+---------------------+---------------------+
| **Vomiting**             | 5                   | 4                   |
+--------------------------+---------------------+---------------------+
| **Muscle aches**         | 3                   | 4                   |
+--------------------------+---------------------+---------------------+
| **Decreased activity**   | 11                  | 13                  |
+--------------------------+---------------------+---------------------+
| **Fever\***              |                     |                     |
+--------------------------+---------------------+---------------------+
| **Fever 1**              | 11                  | 10                  |
+--------------------------+---------------------+---------------------+
| **Fever 2**              | 6                   | 3                   |
+--------------------------+---------------------+---------------------+
| **Fever 3**              | 3                   | 2                   |
+--------------------------+---------------------+---------------------+
| **Fever 4**              | 1                   | 0.2                 |
+--------------------------+---------------------+---------------------+
| **Fever 5**              | 0.2                 | 0                   |
+--------------------------+---------------------+---------------------+
| **Any event**            | 58                  | 58                  |
+--------------------------+---------------------+---------------------+
|                          |                     |                     |
+--------------------------+---------------------+---------------------+

> \*The same definitions for fever as used in Year 1 were used in Year
> 2.
>
> 75% of subjects had axillary, 0.1% rectal, 1.7% oral, 5% the method
> was missing.

**AV006- Year 2 Percent of Subjects with Selected Unsolicited Adverse
Events with Onset Day 0 to 10 by Dose and Treatment Group**

+-------------------------+---------------------+---------------------+
|                         | ### FluMist {#flu   | **Placebo**         |
|                         | mist-3 .unnumbered} |                     |
+-------------------------+---------------------+---------------------+
| **Randomized, N**       | 917                 | 441                 |
+-------------------------+---------------------+---------------------+
|                         | **%**               | **%**               |
+-------------------------+---------------------+---------------------+
| **Any AE**              | 13                  | 14                  |
+-------------------------+---------------------+---------------------+
| **Allergic reaction**   | 1                   | 2                   |
+-------------------------+---------------------+---------------------+
| **Edema, face**         | 0.3                 | 0.2                 |
+-------------------------+---------------------+---------------------+
| **Anorexia**            | 0.2                 | 0.5                 |
+-------------------------+---------------------+---------------------+
| **Diarrhea**            | 1                   | 3                   |
+-------------------------+---------------------+---------------------+
| **Rash**                | 1                   | 0.9                 |
+-------------------------+---------------------+---------------------+
| **Conjunctivitis**      | 0.1                 | 1\*                 |
+-------------------------+---------------------+---------------------+
| **Otitis media**        | 2                   | 1                   |
+-------------------------+---------------------+---------------------+
| **Asthma**              | 0.3                 | 0.5                 |
+-------------------------+---------------------+---------------------+
| **Bronchitis**          | 0.1                 | 0                   |
+-------------------------+---------------------+---------------------+
| **Sinusitis**           | 0.2                 | 0.5                 |
+-------------------------+---------------------+---------------------+
| **Total respiratory**   | 1.7                 | 2.7                 |
+-------------------------+---------------------+---------------------+
| **Febrile seizure**     | 0                   | 0                   |
+-------------------------+---------------------+---------------------+

\*p\<0.05 by Fisher's exact test.

For unsolicited adverse events, the only event that occurred at
significantly different rates between groups (p\<0.05) was
conjunctivitis, which occurred in 1% of placebo and 0.01% FluMist
recipients.

One 6 year old girl (with a history of allergies and chronic rhinitis)
developed angioedema and urticaria within 30 min of vaccination with
placebo. She was treated with Benadryl and oral prednisone, and the
symptoms resolved overnight. On the next day when visited by study
personnel, she was noted to have multiple pustules c/w ant bites. She
was evaluated for egg allergy with scratch tests (for allantoid
elements) and TIV which were negative, however intradermal testing was
refused. The sponsor did not code this event as an SAE.

## Serious Adverse Events

As noted, there was no active monitoring plan for capturing SAEs. Two
participants (1 each FluMist and placebo) experienced an SAE within 42
days of re-vaccination in Year 2. One FluMist recipient, with a history
of asthma, had onset of wheezing on day 9 post-vaccination and required
hospitalization for status asthmaticus. This was judged to be
"probably-not" vaccine-related by the investigator. The other event was
*Salmonella* enterocolitis on day 15 post-vaccination with placebo, and
this was judged as not vaccine related. Two additional SAEs occurred
more than 42 days post-vaccination. These SAEs included one child who
died from a malignant brain mass and malignant hyperthermia and another
child who was hospitalized for pneumonia and hypoxia 5 months
post-vaccination. Two other events (one child with a bee sting and
another child with a lip laceration requiring an ER visit) also occurred
within 10 days of vaccination.

One SAE was not reported to the investigator until 9/29/99 (the database
was locked on 7/15/98). In Year 2, this subject received the third dose
of FluMist on 10/14/97, and 15 days later on 10/29/97, he developed a
fever of 103^o^F. He was taken to the emergency room, diagnosed with
clinical pneumonia and treated with antibiotics for ten days. The event
is not included in the sponsor's report of SAEs in Year 2, and was not
identified to CBER until completion of the inspection of the clinical
site in April 2001.

# **AV015 Study (Year 3 of AV006)**

## Design

As noted above vaccine was administered in an open label fashion to
AV006 study participants who had completed years 1 and 2. Subjects, who
had participated in study AV011 (challenge with CAIV-monovalent H1N1)
following Year 2 of AV006, were also eligible for enrollment.

In AV015, prior vaccine recipients were to receive one dose of FluMist
and previous placebo recipients were to receive one or 2 doses of
FluMist. Thus, subjects in AV015 might have received anywhere from a
total of 1-5 doses of FluMist. For subjects in the two-dose regimen of
AV015, the 2^nd^ dose was given 28-60 days post-dose 1. The choice of
one or two dose regimen for prior placebo recipients was based upon
primary dosing regimen (Houston was designated as a 1-dose site) or
investigator/parent choice (e.g., for convenience of one dose regimen).
Safety monitoring was conducted in the same manner as for the first two
years. Additionally, this protocol specified that study personnel were
to conduct a phone call on Day 42 to obtain any follow-up information
and to inquire about SAEs. There was no placebo arm in this year of the
study, and descriptive results of safety were provided.

# **RESULTS YEAR 3**

## Enrollment and Demographics

A total of 949 participants enrolled (650 prior FluMist and 299 prior
placebo recipients). This represented 62% of AV006 participants who
completed Year 1 and 71% of those who completed Year 2. Year 3
participants were more likely to be white/Caucasian as compared to
non-participants (91% vs. 75%) which may have been partly attributed to
the fact that the AV006 UCLA site, which had enrolled a predominance of
Hispanics, did not participate in Year 3.

## Protocol compliance

Eight subjects, all prior placebo recipients, did not complete the
study. None withdrew due to an adverse event.

## AV015 (AV006-Year 3) Reactogenicity Events with Onset Day 10 Post-FluMist in Year 3 by Treatment Group 

+-------------------+----------------+----------------+----------------+
|                   | ###            | **Prior        |                |
|                   | Prior FluMist  | Placebo\***    |                |
|                   | {#prior-flumis |                |                |
|                   | t .unnumbered} |                |                |
+-------------------+----------------+----------------+----------------+
|                   | ### FluM       | **1^st^ Dose** | **2^nd^ Dose** |
|                   | ist {#flumist- |                |                |
|                   | 4 .unnumbered} |                |                |
+-------------------+----------------+----------------+----------------+
| **Vaccinated, N** | 650            | 192            | 186            |
+-------------------+----------------+----------------+----------------+
| **Valid Diary     | 649            | 192            | 186            |
| Card, N**         |                |                |                |
+-------------------+----------------+----------------+----------------+
|                   | \%             | \%             | \%             |
+-------------------+----------------+----------------+----------------+
| **Cough**         | 27             | 24             | 19             |
+-------------------+----------------+----------------+----------------+
| **Runny           | 37             | 49             | 30             |
| nose/nasal        |                |                |                |
| congestion**      |                |                |                |
+-------------------+----------------+----------------+----------------+
| **Sore throat**   | 8              | 11             | 9              |
+-------------------+----------------+----------------+----------------+
| **Irritability**  | 10             | 11             | 11             |
+-------------------+----------------+----------------+----------------+
| **Headache**      | 10             | 14             | 11             |
+-------------------+----------------+----------------+----------------+
| **Chills**        | 2              | 3              | 5              |
+-------------------+----------------+----------------+----------------+
| **Vomiting**      | 5              | 7              | 6              |
+-------------------+----------------+----------------+----------------+
| **Muscle aches**  | 3              | 5              | 4              |
+-------------------+----------------+----------------+----------------+
| **Decreased       | 10             | 13             | 12             |
| activity**        |                |                |                |
+-------------------+----------------+----------------+----------------+
| **Fever**         |                |                |                |
+-------------------+----------------+----------------+----------------+
| **Fever 1**       | 8              | 9              | 12             |
+-------------------+----------------+----------------+----------------+
| **Fever 2**       | 3              | 4              | 8              |
+-------------------+----------------+----------------+----------------+
| **Fever 3**       | 1              | 1              | 3              |
+-------------------+----------------+----------------+----------------+
| **Fever 4**       | 1              | 0              | 1              |
+-------------------+----------------+----------------+----------------+
| **Fever 5**       | 0              | 0              | 0              |
+-------------------+----------------+----------------+----------------+
| **Any event**     | 55             | 61             | 48             |
+-------------------+----------------+----------------+----------------+

> \*For prior placebo recipients only those subjects who did not
> participate in Study AV011 are included i.e., only subjects who had
> never received a dose of CAIV.)
>
> Fever definitions were the same as used for AV006 Years 1 and 2:
>
> Fever 1 -- Oral \> 100.0°F, rectal \> 100.6°F, axillary/missing method
> \>99.6°F
>
> Fever 2 -- Oral \> 101.0°F, rectal \> 101.6°F, axillary/missing method
> \>100.6°F
>
> Fever 3 -- Oral \> 102.0°F, rectal \> 102.6°F, axillary/missing method
> \>101.6°F
>
> Fever 4 -- Oral \> 103.0°F, rectal \> 103.6°F, axillary/missing method
> \>102.6°F
>
> Fever 5 -- Oral \> 104.0°F, rectal \> 104.6°F, axillary/missing method
> \>103.6°F
>
> 75% of subjects (parents) had axillary, 0.1% rectal, 1.7% oral, 5% the
> method of measurement was missing.

The largest difference in adverse events following the first dose
between prior FluMist and prior placebo recipients was for runny nose
(37% vs. 49%).

Reactogenicity event rates were also reported for FluMist recipients
across three year of vaccination, results are shown on the table below.

## AV015 - Reactogenicity Events Across Three Years in Prior FluMist Recipients (Two-Doses in AV006 Year One) Excluding Those Who Participated in AV011 (H1N1 Challenge) by Year and by Dose. 

+----------------+-----------+-----------+-------------+-------------+
|                | **1^st^   |           | **2^nd^     | **3^rd^     |
|                | Year      |           | Year        | Year        |
|                | (AV006)** |           | (AV006)**   | (AV015)**   |
+----------------+-----------+-----------+-------------+-------------+
|                | #         | **2^nd^   | **1^st^     | **1^st^     |
|                | ## 1^st^  | Dose**    | Dose**      | Dose**      |
|                | Dose {#st |           |             |             |
|                | -dose .un |           |             |             |
|                | numbered} |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **Vaccinated,  | 461       | 457       | 455         | 461         |
| N**            |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **Valid Diary  | 459       | 456       | 455         | 461         |
| Card, N**      |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
|                | \%        | \%        | \%          | \%          |
+----------------+-----------+-----------+-------------+-------------+
| **Cough**      | 25        | 36        | 25          | 26          |
+----------------+-----------+-----------+-------------+-------------+
| **Runny        | 57        | 52        | 40          | 37          |
| nose/nasal     |           |           |             |             |
| congestion**   |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **Sore         | 7         | 6         | 8           | 8           |
| Throat**       |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **             | 24        | 16        | 15          | 9           |
| Irritability** |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **Headache**   | 7         | 6         | 7           | 10          |
+----------------+-----------+-----------+-------------+-------------+
| **Chills**     | 2         | 2         | 2           | 2           |
+----------------+-----------+-----------+-------------+-------------+
| **Vomiting**   | 5         | 7         | 4           | 6           |
+----------------+-----------+-----------+-------------+-------------+
| **Muscle       | 4         | 3         | 2           | 4           |
| Aches**        |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **Decreased    | 14        | 12        | 11          | 10          |
| Activity**     |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **Fever**      |           |           |             |             |
+----------------+-----------+-----------+-------------+-------------+
| **Fever 1**    | 14        | 10        | 11          | 8           |
+----------------+-----------+-----------+-------------+-------------+
| **Fever 2**    | 5         | 4         | 5           | 2           |
+----------------+-----------+-----------+-------------+-------------+
| **Fever 3**    | 2         | 2         | 3           | 1           |
+----------------+-----------+-----------+-------------+-------------+
| **Fever 4**    | 1         | \<1       | 2           | 1           |
+----------------+-----------+-----------+-------------+-------------+
| **Fever 5**    | 0         | 0         | \<1         | 0           |
+----------------+-----------+-----------+-------------+-------------+
| **Any Event**  | 73        | 70        | 56          | 56          |
+----------------+-----------+-----------+-------------+-------------+

Fever definitions were the same as used for AV006 Years 1 and 2, as
noted in the table above.

## Other Adverse Events

For unsolicited AE's, 14% of FluMist and 17% of prior placebo recipients
(combined 1^st^ dose) experienced one or more other AE.

## Serious Adverse Events

Only one SAE was reported 43 days post-vaccination in a subject who
underwent outpatient surgery for tonsillectomy and adenoidectomy but
required hospitalization due to a prolonged response to anesthesia.

**STUDIES AV007 AND AV014**

The safety monitoring for these two pediatric trials was nearly
identical as that performed for AV006. Active monitoring for SAEs ( a
study nurse called the participants 42 days post-dose 2 to question
about the occurrence of SAEs) is described for AV014, but not for AV007.
The results for safety, including reactogencity profile, occurrence of
"other AEs" and SAEs were also similar to those reported for AV006 Year
1.

## Safety Results for AV007 (Lot Consistency Study)

A total of 500 subjects were enrolled, and 499/500 subjects returned the
diary card post-dose 1, and all 474 subjects who received Dose 2
returned the diary card. After Dose 2, 285/300 participants in the
consistency lots returned the diary card

After Dose 1, 76% of Flumist vaccine groups (3 consistency lots and
FM-AV006) and 63% of placebo recipients had at least 1 RE (p value not
given). These rates decreased after Dose 2 to 48% in both the Flumist
and placebo groups. Compared to placebo, the vaccine groups had higher
rates of runny nose/nasal congestion after Dose 1 (65% vs. 49%, p \<
0.003) and chills after Dose 2 (5% Flumist vs. 0% placebo, p \< 0.002).

## SAE's

Two SAE's were reported. A 32 month old girl with a history of seizures
had a seizure following a blow to the head, 23 days after receipt of the
2^nd^ dose of FM-AV006 vaccine. This was judged not to be vaccine
related. The second SAE was liver laceration post- MVA that occurred in
a 25 month old female which occurred 24 days after receipt of Dose 1 of
a consistency lot #2 vaccine, which was judged not to be vaccine
related.

## AV014

A total of 225 subjects received Dose 1 and 222 subjects received Dose
2. The sponsor did not state the number of diary cards that were
returned. Seventy six percent (76%) of Aviron-PA and 71% of Medeva
Flumist recipients experienced at least 1 RE after Dose 1. The most
common RE's were runny nose/nasal congestion (57% Aviron-PA and 58%
Medeva) and irritability (41% Aviron-PA and 37% Medeva). After Dose 1, a
10% \[90% CI: -18.2, -1.8\] difference in rate was only observed for
vomiting (3% Aviron-PA vs. 13% Medeva).

After Dose 2, 55% of Aviron-PA and 53% of Medeva Flumist recipients
experienced at least 1 RE, and again runny nose/nasal congestion (38%
vs. 35%) and irritability (26% vs. 17%) Aviron-PA vs. Medeva were most
common. For irritability, the difference was 9% (-1.3, 20.8). For fever-
grade 1 (defined below) the rates were 6.3% (-15.7, 3.1) different,
occurring in 9% of Aviron-PA and 15% of Medeva Flumist recipients.

The 90% CI for difference in event rates post-dose 1 exceeded 10% for
"any RE", cough, runny nose/nasal congestion, sore throat, irritability,
headache, vomiting, lethargy, fever --grade 1(oral \>100.0^o^F, rectal
or ear 100.6 ^o^F, or axillary \> 99.6 ^o^F) and fever-grade 2 (oral
\>101.0^o^F, rectal or ear 101.6 ^o^F, or axillary \> 100.6 ^o^F).
Similar findings were seen post-dose 2. No statistical analyses were
provided.

## SAE's

No deaths occurred in the study. 3 SAE's were reported, and all were in
the Aviron-PA group. These events included: 1) a subject with a fall
requiring an ER observation, occurred on 1 day post-dose 1 and was not
vaccine-related, 2) a subject with a febrile illness with dehydration
which required hospitalization, occurred 31 days post-dose 2 and was
determined as "probably not" vaccine-related, and 3) a subject with
diagnosis of Perthes disease 38 days after Dose 1, which was judged as
not vaccine related.

**Study AV012**

**TITLE**: **Study of Influenza Virus Vaccine, Trivalent, Types A&B,
Live, Cold-Adapted**

**(CAIV-T) in a Community-Based, Non-Randomized, Open-Label Trial in
Children to**

**Assess the Safety and Herd Immunity for the Control of Epidemic
Influenza.**

LOCATION: Scott & White HMO, Temple, TX - multi-center; CRADA with NIH

STUDY PERIOD: 3 Years; Year 1 -- 1998-99 (1^st^ enrolled 8/17/98 --
ended 4/30/99)

PIVOTAL TRIAL: Yes, Phase 3.

POPULATION: Children, ages 18 months -- 18 years (not had their 19^th^
birthday)

SAMPLE SIZE: Total planned in 3 years -- 15, 000; Year 1- Flumist n=4298

At the time of submission of the BLA, the study report was an interim
report for Year 1, and all

analyses were not complete.

**Design**

In this 3 year trial, a subject may be enrolled in Year 1, 2, 3
[or]{.underline} any combination of years. The study is to be conducted
during influenza season (August through April) of 3 consecutive years.
Participants will receive 1 dose of vaccine for each year they enroll
(separate CF for each year of enrollment). Children 18 mo through 18
years (before their 19^th^ birthday) were eligible.

This is open-label, non-randomized clinical trial. Subjects residing in
Temple-Belton Texas area or receiving the medical care at Scott & White
(S&W) HMO were invited to participate. Unvaccinated children at S&W were
used as a comparison group. The goal of the study was to enroll 50% of
the 4700 children ages 18 mo -- 4 years and 85% of \~15,000 children
ages 5 through 18 years living in the study area. Two other populations
were used for comparisons: patients at PCA (now Humana) HMO in Austin,
TX and patients at S&W in Bryan-College Station TX. The sponsor did not
obtain consent from the subjects in the control populations, but state
that they requested IRB approval for the database searches.

## Objective

## Primary

The primary objective was to assess the total effectiveness of
immunization of preschool and school children 18 mo -- 18 yrs with
Flumist (medically attended acute respiratory infection, MAARI, in
vaccinated children compared to unvaccinated children in each control
community with adjustments for potential co-variates.) Assessing the
general safety of FluMist (essentially only SAE's were captured) was one
of the secondary study objectives. Only the safety data were submitted
to the BLA safety database.

## VACCINES

Flumist -- Each 0.5 ml dose contained 10^7^ TCID~50~ of each strain of
virus (2 type A and 1 type B) in normal allantoic fluid (NAF) containing
sucrose-phosphate-glutamate (SPG.) 1998-99 influenza strains were
A/Beijing/262/95 (H1N1), A/Sydney/5/97 (H3N2) and B/Harbin/7/94-like.
The chosen strains were representative of the FDA recommended strains
for 1998-99. The filled trivalent lot numbers (CAF1003 and CAF 1004)
were used in this trial.

A single dose regimen was chosen for this protocol (in contrast to the
2-dose regimen used in AV006, the Pediatric Efficacy Trial) based upon
logistics for performing the study. The sponsor states that in AV006,
the 1-dose regimen was efficacious.

**Safety Monitoring**

Subjects stayed in the clinic for 15 minutes post-vaccination to monitor
for immediate reactions. Parents/guardians were given a laminated parent
information card, which contained the study site's phone number, and
instructions to call if the subject was hospitalized, developed a
serious condition, or became pregnant. They were also given a
refrigerator magnet (with study information) and a Day 42 health report
card (which was to be completed, signed and returned to the study center
after Day 42). To be valid, the Day 42 report card had to be signed and
dated later than the 42 days post-vaccination [and]{.underline} have 1
check box completed to indicate whether or not the subject had a new
significant health problem between vaccination and Day 42. Subjects at
S&W were to receive an automated "reminder call" generated by the
Integrated Clinical Encounter System (ICES) on Day 42 to remind the
parent to call the investigator about new health problems and to return
the Day 42 report postcard.

The study site contacted parents/guardians of those subjects who were
identified as having a new significant health event to determine if the
event met the definition of an SAE. For subjects who did not return
their Day 42 postcard or the card was not valid, study personnel tried
to contact the parent/guardians by telephone. If they were unreachable
by phone, a registered letter was sent with a postcard. SAEs were
identified by searching S&W SMS database and through reporting by
postcard or by telephone.

##### [Database Searches]{.underline} {#database-searches .unnumbered}

Searches of the S&W database were performed every 30 days to confirm
ascertainment of all SAEs. The search checked for any hospitalization in
study subjects. These searches did not capture events for subjects who
did not receive their care at S&W. In the Temple-Belton area, \~20% of
the local physicians do not participate in S&W HMO, and these physicians
were also informed about the study and requested to help identify SAEs
that may be related to study vaccination.

SAEs were defined as in AV006, consistent with CFR. Investigators were
to follow all SAEs until resolution. Any SAE occurring within 42 days of
vaccination were to be reported to Aviron and IRB within 1 day of
notification. After 42 days, only SAEs that were "vaccine-related" were
to be reported.

Vaccine-relatedness of an adverse event was to be based upon the type of
event, the temporal relationship of the event and vaccine
administration, the known biology of the vaccine viruses, and the
medical judgement of the investigator. The investigator may contact the
Medical Monitor at Aviron, the Study Chair, or the DSMB chair, as
needed. Categories of relationship were definitely not, probably not,
possibly, probably, and definitely related. Vaccine related refers to an
AE that is either possible, probably or definitely related to
administration of vaccine.

## Enrollment

4298 participants were enrolled between 8/17/98 and 12/19/98. 53% of
participants reported that they were members of S&W HMO and 79% stated
that S&W was their primary health care facility (e.g., some subjects had
more than 1 insurer). Eleven percent (11%) had Medicaid. The mean age
was 8.6 years (range 18 mo -- 18 years) and 55% were 18mo -- 9 yrs, 44%
9-17 yrs and 1% was 18 yrs old. 3 subjects, ages 1.4-1.5 years, were
enrolled. Caucasians accounted for 71%, Hispanics 17% and Blacks 7% of
enrollees. There were equal numbers of males (50.4%) and females
(49.5%).

[Subjects with Asthma]{.underline}

531 of 4298 subjects (12.4%) gave some history of asthma, reactive
airway disease (RAD) or wheezing. 156 were identified through review of
the eligibility questionnaire only, 232 through review of S&W database
only, and 143 by both methods.

Of 4298 participants, 4063 either returned a valid postcard or received
a successful Day 42 phone contact, for a follow-up rate of 94.5%. 3056
(71.1%) returned a valid postcard. 1006 (81%) of 1242 subjects who did
not return a valid postcard had successful Day 42 phone contacts. 235
(5.4%) subjects were lost to follow-up. Of the 235 lost to follow-up, 82
were self-identified as members of S&W. So with these 82, 4145 (96%)
were evaluable for safety based upon the Shared Management System (SMS)
database for self-identified S&W members, postcards and/or telephone
calls.

**SAEs**

8 SAEs were identified, and none were considered to be definitely or
possibly vaccine-related. 2 of the SAEs occurred in the subjects with a
history of wheezing -- one was a groin abscess and one was a MVA. The
other 6 SAEs included fever with hip pain, vomiting, fever and vomiting,
croup, and aseptic meningitis, all of which occurred 21 or more days
post-vaccination. 1 subject had onset of depression at 3 days
post-vaccination considered as definitely not vaccine-related. No deaths
occurred.

# **Other AE's**

149 of 4063 subjects (3.7%) with Day 42 data reported onset of a 1 or
more significant new health problem. All problems reported by the
parents and new problems identified through S&W database search were
evaluated by study staff for clinical significance, and if judged
significant, they were recorded on the CRF. 87 such events occurred for
78 subjects, and though exact numbers are not available, most were
respiratory (URI, sinusitis, OM, bronchitis, asthma exacerbation and
pneumonia). These events were not presented in tabular form, but as
narratives in a line listing.

##  

# **STUDY AVO19** 

**TITLE:** **A Prospective, Double-blind, Randomized, Placebo-Controlled
Trial to Assess the**

**Safety of Frozen FluMist in Health Children and Adolescents.**

LOCATION: United States, Northern California Kaiser Permanente

STUDY PERIOD: 10/2/00 - ongoing

PIVOTAL TRIAL: No, supportive for safety

POPULATION: Healthy children, age 18 months to 17 years (before their
18^th^ birthday)

SAMPLE SIZE: Total, originally planned 15,000; at the time of
submission, n=9689 with FluMist n=6473 and placebo n=3216

### DESIGN {#design-4 .unnumbered}

AV019 is an ongoing study intended to provide additional safety data
with FluMist in children. The study is being performed in 32 outpatient
clinics in the Northern California Kaiser Permanente (NCKP) system. In a
double-blind fashion, children ages 18 months to 18 years were
randomized in a 2:1 ratio to receive FluMist or placebo. Healthy
children less than 9 years of age received 2 doses of study vaccine
(28-42 days later) and children 9-17 years of age received one dose of
study vaccine. Medically-attended events (MAEs) and serious adverse
events (SAEs) were monitored by database searches. There was no active
monitoring for post-vaccination solicited reactogenicity events by the
participants.

This report contains the results from a planned interim analysis
performed to present preliminary data to CBER and the advisory
committee. The preliminary report was provide to CBER on 4/30/01, and
the review is ongoing.

### OBJECTIVES {#objectives-4 .unnumbered}

## Primary

To estimate the rates of MAEs, including SAEs and selected groups of
MAEs, following the administration of FluMist compared to placebo.

## VACCINES 

1.  FluMist -- Each 0.5 ml dose contained 10^7^ TCID~50~ of each strain
    of virus (2 type A and 1 type B) in normal allantoic fluid (NAF)
    containing sucrose-phosphate-glutamate (SPG). The strains used were
    the 1999/2000 strains, A/Beijing/262/95 (H1N1), A/Sydney/05/95
    (H3N2) and B/Yamanashi/166/98. For 2000-2001, the B strains were the
    same; however, the recommended strains for 2000-2001 were different
    from the ones used for both of the type A strains.

2.  Placebo -- NAF in SPG was used.

## PROCEDURES

The procedures for this study for enrollment, inclusion and exclusion
criteria, and dosing interval (28-42 days) were similar to AV007, except
a dosing interval of 28-60 days was used in AV007.

Concomitant Immunizations and Medications

No concomitant immunizations, aspirin-containing meds or nasal
medications (for 7 days post-vaccination and post-challenge) were
permitted.

Monitoring

All subjects were considered evaluable for safety unless they withdrew
informed consent. The safety assessment period for each participant
began at the time of 1^st^ dose (Day 0) and ended on date of 2^nd^ dose
of vaccine (for 2-dose regimen) or 42 days after vaccination, whichever
came earlier. The primary method of ascertainment of safety outcomes was
extraction of records from the KP computerized health care utilization
databases. Outcomes were also collected via spontaneous reporting of
parents/guardians. The database is managed and analyzed by the
investigation team at the KP Vaccine Study Center. One or more MAEs may
be assigned for a single encounter.

SAEs were defined as in AV006, 007 and other Aviron studies. The SAEs
were captured by extraction of KP database, spontaneous reporting and by
review of the State of California mortality tapes. MAEs were defined as
an encounter with a health care provider, especially a visit to a
medical clinic or emergency department, or a hospital admission. These
events were also captured by extraction from the computerized databases
or spontaneous reports of parents/guardians. The MAEs reflect the coded
diagnoses assigned by the health care provider who saw the child at
presentation, as recorded onto the standardized NCKP encounter forms.

About 2-5% NCKP members discontinue their healthcare coverage annually.
Although infrequent, participants who discontinue KP coverage may not be
identified until several months later, and the exact date of termination
may not be known.

Statistical Methods

Relative risk estimates and confidence intervals (CI) were the primary
method of evaluating outcomes. No formal hypothesis testing was planned.

MAEs were analyzed by individual coded diagnosis within the following
four pre-specified classes of events: acute respiratory events, systemic
bacterial infections, acute gastrointestinal events and rare,
potentially wild type influenza-related events.

The sponsor states that because of the large sample size and range of
potential MAEs, expect many observed MAEs. Therefore, a two-stage
approach was used for the analysis of MAEs:

a)  Binomial screening -- in this analysis, participants experiencing
    multiple encounters for the same MAE will be counted once. The
    relative risk (RR) with 2-sided 90% CI will be presented. RR= rate
    in FluMist / rate in placebo, and the CI were constructed using
    mid-probability binomial method, adjusted for follow-up time. If the
    lower bound is greater than 1, further statistical evaluation
    (Poisson regression) and medical review will be performed.

b)  Poisson regression - for all MAEs with lower bound of the 90% CI
    exceeds 1 (as above) Poisson regression will be performed. The
    number of encounters per participant for each MAE will be modeled as
    a Poisson random variable with treatment group, age category
    (1-17years, 3-8 years, 18 to \< 36 months and 12 to \< 18 months),
    gender and race included as classification variables. The RR for
    treatment group with 90% CI will be calculated. If the lower bound
    exceeds 1, additional statistical and medical investigation was
    planned. Results are present separately for clinic visits, ED
    visits, and hospitalizations.

The sponsor states that due to the exploratory nature of the study and
lack of formal hypotheses testing, a large number of CI will be
constructed without multiplicity adjustments.

RESULTS

Enrollment and Demographics

Between 10/2/00 and 12/22/00, 9734 participants were enrolled and 9689
(FluMist n=6473 and placebo n=3216) were evaluable for safety. One
subject, between the ages of 1 and 8 years, was lost to follow-up, and
due to an administrative error could not be identified. Also, 44
subjects could not be included in the analysis because the study vaccine
given at dose one was uncertain due to "dosing discrepancies," which
were not described. Post-dose 2 data for 47 subjects were not included
because the study vaccine received at dose 2 was different than at
dose 1. Of the enrollees, 5637 were from 1-8 years and 4052 were from
9-17 years old. Originally, the study enrollment was planned for
\~15,000 subjects.

The database was locked on 12/31/00 for the interim report. As of that
date, all subjects had received at least 1 dose of study vaccine and 64%
of subjects in the 2-dose regimen had received both doses of study
vaccine. Approximately 72% of total expected follow-up for the study and
\~43% of post-dose 2 follow-up was complete by 12/31/00.

For both the 1-8 year age group and 9-17 year age groups, the study
population was equally distributed by gender and ethnicity; \~55% of
subjects were Caucasian, 20% Hispanic, 10% Asian or Pacific Islander, 6%
African American, 4.5% multiethnic and 4% other. At enrollment, 261 (3%)
of subjects were 12 to \<18 mo, 1097 (11%) were 18 to \< 36 mo, 4279
(44%) were 36 mo to 8 years, and 4052 were 9-17years of age.

SAEs

There were 20 SAEs reported through April 15, 2001, the time of
submission to CBER. No deaths were reported. Thirteen SAEs occurred in
the FluMist group and seven SAEs occurred in the placebo group. The
relationship to which vaccine doses (i.e., 1st or 2nd) is not reported.
Four SAEs in the FluMist group occurred within 14 days of vaccination
and included: hemolytic uremic syndrome, onset 11 days post-vaccination
in a 12 month old; acute gastroenteritis, onset 11 days post-
vaccination in a 14 month old; abdominal pain/gyn disorder onset 11 days
post-dose in a 16 year old; and an appendiceal abscess, onset 11 days
post-dose in a 15 yo male. The other nine SAEs had onset after day 15
and included benign foot lesion, post-extubation airway obstruction
(reason for intubation not stated), testicular torsion, synovial
carcinoma, appendicitis (onset Day 42 in 12 year old) and 4 subjects
with diagnoses of psychiatric disorders. None of these SAEs were coded
as vaccine related by study investigators.

In the placebo recipients, the three SAEs in the 1^st^ 14 days
post-vaccination included: croup, onset day 4 post-dose in a 17 mo
female -- coded as "possibly related" to vaccine by the investigator;
trauma onset day 4 post-dose in a 17 mo female; and a psychiatric
disorder onset day 4 post-vaccination in a 12 year old. The SAEs with
onset after day 15 included: diabetes onset day 25 post-vaccination in a
5 year old; suicide ideation, onset on day 29 in an 8 year old;
cellulitis and fractured clavicle, onset day 37 post-vaccination in a \~
5year old, and dehydration with onset on day 39 in a 6 ¾ year old.
Besides the croup event, none of the SAEs were coded as related to
vaccination by the investigators.

MAEs

A total of 5,850 MAEs were reported through December 31, 2000. Twenty
percent (20%) of MAEs were coded as Well care/reassurance visits, 11%
were URI, 7% were otitis media, 7% trauma, and 6% were psychiatric
disorders. These event codes were not reported by study group.

None of the four pre-specified group diagnoses (defined above in
Statistical Methods) were associated with a statistically significant
increased RR in the FluMist group after Dose 1, Dose 2, or any dose in
any utilization setting (clinic, ED or hospitalization) for any age
group.

Increases in the rates of individual MAEs for which the sponsor stated
that a relationship to FluMist was biological-plausible were observed in
the clinic or ED (not hospital setting) for:

-   Conjunctivitis in subject 1-17 years, 1-8 years and 18 to \< 36
    months (FluMist 6.6 -- 14.52 and placebo 0 -- 5.17 per 100 person
    months),

-   URI in participants 1 to 17 years of age (FluMist 1.24-1.76 and
    placebo 0 per 1000 person months),

-   Abdominal pain in participants 1 to 17 years of age (FluMist 1.19
    and placebo 0.22 per 100 person months),

-   Musculoskeletal pain in subjects 1-8 years and 18 to \< 36 months
    (FluMist 4.39 -- 9.04 and placebo 0 -- 1.7 per 1000 person months),
    and

-   Asthma in subjects 18 to \< 36 months (FluMist 7.75 and placebo 0
    per 1000 person months).

Otitis media with effusion in the clinic setting was associated with a
statistically significant increase in FluMist than placebo recipients,
FluMist rate 10.79 and placebo 4.09 per 1000 person months, Poisson RR
3.43 (1.64, 7.24).

There were also some MAEs that were associated with decreased rate in
FluMist compared to placebo recipients, some of which were respiratory
symptoms and possibly due to protection from FluMist against natural
influenza. However, these decreased events could also have been due to
chance alone because of the large number of comparisons performed.

# **TRIALS IN SUPPORT OF SAFETY IN ADULTS**

# **STUDY AV009** 

**TITLE**: **A Prospective, Randomized, Double-blind,
Placebo-controlled, Trial to Assess the**

**Safety, Tolerability, and Effectiveness of Influenza Virus Vaccine,
Trivalent, Types A and**

**B, Live, Cold-Adapted (CAIV-T) in Healthy working Adults to Reduce
Influenza-Like**

**Illness,** **Absenteeism from Work and Health Care Costs during
Influenza Outbreaks.**

LOCATION: United States, multi-center -- 13 sites; CRADA with NIAID

STUDY PERIOD: Sept. 18, 1997 -- Mar. 31, 1998

PIVOTAL TRIAL: Yes, Phase 3 Trial

POPULATION: Healthy working adults ages 18-64 years (not had 65^th^
birthday).

SAMPLE SIZE: Original n=3600, increased to 4,200.

Final enrollment, n=4561 (FluMist n= 3041 and placebo n=1520).

## Safety 

Subjects were observed for 15 minutes after vaccination to monitor for
immediate adverse events (AEs). Subjects were given thermometers and
asked to maintain a diary card for 7 days post-vaccination for
pre-defined RE's, which included oral temperature \> 100^o^F, cough,
runny nose or congestion, sore throat, headache, chills, muscle aches,
and weak/tired. Study personnel contacted the subjects on Day 7 to
remind them to complete and mail in the diary card. Unsolicited AEs and
medications were coded for consistency using the COSTART Preferred Term
and the Anatomic Therapeutic Class, respectively. All SAE's were
collected for the first 28 days post-vaccination and phone contact was
made at day 28 post-vaccination to query about SAEs. SAEs occurring
after the 28-day safety phase were not actively collected; however, any
SAEs reported during the study period were summarized in the study
report.

**Statistical Methods**

All subjects who were randomized were evaluable for any safety data
obtained. The proportion of solicited AEs between FluMist and placebo
recipients was compared using exact two-sided 95% confidence intervals.
FluMist was judged to be equivalent to placebo if the upper limit of the
95% CI for the difference in rates was no more than 5% for fever and 10%
for other solicited events. The number of days with solicited AEs with
onset in the first seven days-post vaccination were compared by
examining distributions in the two groups. Unsolicited AEs and SAEs were
tabulated by treatment group. A subgroup analysis of safety was to be
performed to assess safety (RE and SAEs) in participants with asthma who
were inadvertently enrolled.

**RESULTS**

A total of 4,561 subjects received 1 dose of study vaccine (FluMist =
3041, placebo = 1490.) 4,475 of 4,561 subjects (98%, FluMist n=2985 and
placebo n=1490) were evaluable for safety and tolerability, i.e.,
returned the diary card.

## Compliance

Of 4561 subjects, 98% of each treatment group returned the 7 day diary
card, and 97.5% provided safety information for the 1^st^ 28 day
monitoring period. There were 116 subjects for whom safety data was not
completed for the Day 0-28 post-vaccination period (FluMist 78, Placebo
38). The most common reason for not completing the 28 day period
follow-up was lost-to-follow-up \[FluMist n=65 placebo n=31\]. Two
subjects in the FluMist group and 1 in the placebo group withdrew for
adverse events during this period (see below).

AV009 - Solicited Reactogenicity Events (REs) by Treatment Group (onset
Day 0-7)

+---------------+------------+------------+------------+------------+
|               | ### Fl     | *          | **         | **95% CI   |
|               | uMist {#fl | *Placebo** | Difference | for        |
|               | umist-5 .u |            | in         | differ     |
|               | nnumbered} |            | Percent**  | ence\*\*** |
+---------------+------------+------------+------------+------------+
| #######       | 3041       | 1520       |            |            |
| Randomized, N |            |            |            |            |
+---------------+------------+------------+------------+------------+
| **Returned    | 2985       | 1490       |            |            |
| Diary Card**  |            |            |            |            |
+---------------+------------+------------+------------+------------+
| *             | **%**      | **%**      | **%**      | **%**      |
| *Experiencing |            |            |            |            |
| RE\***        |            |            |            |            |
+---------------+------------+------------+------------+------------+
| ####### Fever |            |            |            |            |
+---------------+------------+------------+------------+------------+
| **Oral T \>   | 1.34       | 1.34       | -0.00      | (-0.00,    |
| 100°F**       |            |            |            | 0.010)     |
+---------------+------------+------------+------------+------------+
| **Oral T      | 0.44       | 0.60       | -0.00      | (-0.01,    |
| \>101.2°F**   |            |            |            | 0.00)      |
+---------------+------------+------------+------------+------------+
| **Oral T      | 0.77       | 0.13       | -0.00      | (-0.01,    |
| \>102.0°F**   |            |            |            | 0.00)      |
+---------------+------------+------------+------------+------------+
| **Oral T \>   | 0          | 0          | 0.00       | (-0.00,    |
| 103.0°F**     |            |            |            | 0.00)      |
+---------------+------------+------------+------------+------------+
| **Runny       | 44.32      | 26.64      | 0.18       | (0.15,     |
| nose**        |            |            |            | 0.21)      |
+---------------+------------+------------+------------+------------+
| **Sore        | 26.57      | 16.31      | 0.10       | (0.08,     |
| throat**      |            |            |            | 0.13)      |
+---------------+------------+------------+------------+------------+
| **Cough**     | 13.64      | 10.20      | 0.03       | (0.01,     |
|               |            |            |            | 0.06)      |
+---------------+------------+------------+------------+------------+
| **Headache**  | 39.26      | 37.25      | 0.02       | (-0.01,    |
|               |            |            |            | 0.05)      |
+---------------+------------+------------+------------+------------+
| **Muscle      | 16.11      | 14.50      | 0.02       | (-0.00,    |
| aches**       |            |            |            | 0.04)      |
+---------------+------------+------------+------------+------------+
| **Chills**    | 8.28       | 6.11       | 0.02       | (0.00,     |
|               |            |            |            | 0.04)      |
+---------------+------------+------------+------------+------------+
| *             | 24.56      | 20.54      | 0.04       | (0.01,     |
| *Tired/weak** |            |            |            | 0.07)      |
+---------------+------------+------------+------------+------------+
| **Any RE**    | 70.92      | 61.88      | 0.09       | (0.06,     |
|               |            |            |            | 0.12)      |
+---------------+------------+------------+------------+------------+

\*Participants are counted if they experience an event at least once
within 7 days following vaccination.

\*\* CIs for the difference in proportions are based on an exact method.

Two RE's failed to meet the pre-specified equivalence criteria, those
being runny nose (FluMist -- 44.3% and placebo -- 26.6%) and sore throat
(FluMist -- 26.6% and placebo -- 16.3%.) Duration of runny
nose/congestion was 1-2 days for 22.6% of FluMist and 14.5% of placebo
recipients, but occurred in \> 5 days for 9.3% of FluMist and 7.1% of
placebo recipients. The peak difference between the groups occurred on
Day 2. A similar time pattern was observed for sore throat and headache.
Healthcare utilization and missed workdays were not monitored for the
1^st^ 7 days post-vaccination.

AV009 -- Solicited Reactogencity Events by Treatment Group for
Participants with Asthma (Onset Day 0-7)

+--------------------------+---------------------+---------------------+
|                          | ### FluMist {#flu   | **Placebo**         |
|                          | mist-6 .unnumbered} |                     |
+--------------------------+---------------------+---------------------+
| ####### Randomized, N    | 23                  | 13                  |
+--------------------------+---------------------+---------------------+
| **Returned Diary Card**  | 23                  | 13                  |
+--------------------------+---------------------+---------------------+
| **Experiencing RE\***    | **%**               | **%**               |
+--------------------------+---------------------+---------------------+
| ####### Fever            |                     |                     |
+--------------------------+---------------------+---------------------+
| **Oral T \> 100°F**      | 0                   | 0                   |
+--------------------------+---------------------+---------------------+
| **Runny nose**           | 43.5                | 23.1                |
+--------------------------+---------------------+---------------------+
| **Sore throat**          | 30.4                | 30.8                |
+--------------------------+---------------------+---------------------+
| **Cough**                | 21.7                | 30.8                |
+--------------------------+---------------------+---------------------+
| **Headache**             | 30.4                | 53.8                |
+--------------------------+---------------------+---------------------+
| **Muscle aches**         | 30.4                | 7.7                 |
+--------------------------+---------------------+---------------------+
| **Chills**               | 17.4                | 7.7                 |
+--------------------------+---------------------+---------------------+
| **Tired/weak**           | 39.1                | 15.4                |
+--------------------------+---------------------+---------------------+
| **Any RE**               | 73.9                | 84.6                |
+--------------------------+---------------------+---------------------+

No statistical comparisons were reported.

The number of participants with asthma who were inadvertently enrolled
was too small to make definitive conclusions about tolerability in this
subset. Although the number is small, there was an increase in "any REs"
for asthma participants (Flumist - 73.9%, placebo -- 84.6%), as compared
to the entire study cohort (Flumist -- 70.9%, placebo -- 61.7%).

**Other Adverse Events**

Unsolicited AEs occurring during the first seven days following
vaccination were summarized by COSTART body system and preferred term.

AV009 -- Percent of Subjects Experiencing Selected "Other Adverse
Events" with Onset from Day 0 to 7, by Treatment Group

+--------------------------+---------------------+---------------------+
|                          | ### FluMist {#flu   | **Placebo**         |
|                          | mist-7 .unnumbered} |                     |
+--------------------------+---------------------+---------------------+
| ####### Randomized, N    | 3041                | 1520                |
+--------------------------+---------------------+---------------------+
| **Returned Diary Card**  | 2985                | 1490                |
+--------------------------+---------------------+---------------------+
| **Experiencing**         | **%**               | **%**               |
|                          |                     |                     |
| **"other AE"**           |                     |                     |
+--------------------------+---------------------+---------------------+
| ####### Any AE           | 30.2%               | 21.5%               |
+--------------------------+---------------------+---------------------+
| **Respiratory system**   | 18.1%               | 7.5%                |
+--------------------------+---------------------+---------------------+
| **Nasal congestion**     | 9.1%                | 2.3%                |
+--------------------------+---------------------+---------------------+
| **Rhinitis**             | 6.1%                | 3.1%                |
+--------------------------+---------------------+---------------------+
| **Sinusitis**            | 4.0%                | 2.1%                |
+--------------------------+---------------------+---------------------+

Overall, there were more unsolicited AEs in the FluMist group *vs.* the
placebo group (respectively 30.2% vs. 21.5%, p\< 0.001) and the
difference was due primarily to respiratory system AEs (FluMist - 18.1%,
placebo - 7.5%). Rates of digestive system AEs were similar in the
FluMist group and placebo group both for overall events (5.59% FluMist;
6.118% placebo) and for specific events (abdominal pain, diarrhea,
nausea, vomiting). Statistical comparisons were not provided.

There were 7 pregnancies (Flumist n=5) in the study. Five resulted in
live full-term (FT) infants, and there were 2 spontaneous abortions (1
each in Flumist and placebo recipient). Five vaccine exposures were in
the 1^st^ trimester, all resulted in FT infants.

There were 16 vaccine sprayer deviations, mostly due to use off site
causing use out sequence. 71% of the vaccines were self-administered
with 3.8% of subjects having some problem (no details provided). Of the
29% administered by study personnel, 2.5% reported some problem (1.84%
for Flumist and 3.85% for placebo).

**Adverse Events Leading to Withdrawal from the Study**

There were 3 AEs that led to withdrawal from the study (2 FluMist; 1
placebo). One of the FluMist subjects withdrew due to Crohn's Disease
with abdominal pain and vomiting with onset 2 days post-vaccination and
then diarrhea 7 days post-vaccination, which was recorded as "probably
not" vaccine-related. The other FluMist subject was withdrawn due to
accidental death 16 days post-vaccination. The placebo subject withdrew
due to a diagnosis of personality disorder, noted 17 days
post-vaccination.

**Serious Adverse Events**

There were 9 serious AEs within the 28-day post-vaccination period
(FluMist, n=5 and placebo, n=4). In the FluMist group these AEs were; 1
abdominal pain and cramping which led to hospitalization in a subject
with Crohn's disease with onset 2 days post-vaccination; 1 hysterectomy
due to severe adenomyosis/dysmenorrhea 12 days post-vaccination; 1 fatal
drowning 16 days post-vaccination; 1 torn knee cartilage 18 days
post-vaccination; 1 anaphylactic reaction to oral Septra 26 days
post-vaccination. In the placebo group there was: 1 knee ligament repair
6 days post-vaccination; 1 hemorrhagic cystitis 8 days post-vaccination;
1 hospitalization for an AE to Tylenol and Verapamil 13 days
post-vaccination; and 1 psychiatric hospitalization 17 days
post-vaccination.

An additional 51 SAEs were passively reported during the remainder of
the study period (FluMist, n = 30 and placebo, n=21). In the FluMist
group, there were 8 injuries and/or orthopedic surgery; 1 elective jaw
surgery; 3 acute tracheobronchitis/bronchitis; 1 flu; 1 renal calculus;
1 ureteral obstruction; 1 optic neuritis/cat scratch fever; 1
undiagnosed neuropathy; 1 possible panic attack; 2 hysterectomy; 4
cholecystectomy; 1 gallbladder infection; 2 leg thrombosis; 2 pancreatic
cancer; 1 goiterous mass. In the placebo group there were: 7 injury
and/or orthopedic surgery; 1 bacterial infection; 1 ovarian cystectomy;
2 renal calculus; 2 hysterectomy; 3 cholecystectomy; 1 appendicitis; 1
inguinal hernia repair; 1 breast cancer; and 1 fatal drug overdose.

**STUDIES SUBMITTED FOR SAFETY IN HIGH RISK GROUPS**

# 

# **STUDY -- AV010** 

**TITLE:** **A Randomized, Prospective, Double-Blind, Placebo-Controlled
Trial to Assess the**

**Safety and Tolerability of Influenza Virus Vaccine, Trivalent, Types A
and B, Live, Cold-**

**Adapted (Flumist) in Patients with Moderate to Severe Asthma between
the Ages of Nine**

**and Seventeen Years.**

LOCATION: United States, multi-center; CRADA with NIAID

STUDY PERIOD: 10/3/97 -- 12/4/97

PIVOTAL TRIAL: No, supportive for safety

POPULATION: Children with asthma, ages 9-17 years old

SAMPLE SIZE: Total - 48; FluMist -- n= 24; Placebo -- n=24

## OBJECTIVE

To investigate the safety and tolerability of FluMist compared to
placebo when administered intranasally to children and adolescents with
moderate to severe asthma.

### DESIGN {#design-5 .unnumbered}

The study was randomized, double-blind, prospective, placebo-controlled
to assess safety and tolerability of FluMist in 9-17 year olds with
moderate to severe asthma, as defined by National Heart, Blood and Lung
Institute (NHBLI). According to the NHBLI Expert Panel Report II:
Guidelines for the diagnosis and management of asthma: *Asthma is a
chronic disorder of the airways that causes recurrent episodes of
wheezing, breathlessness, chest tightness and coughing, particularly at
night or in the early morning. These episodes are usually associated
with widespread but variable airflow obstruction that is often
reversible whether spontaneously or with treatment* (NHBLI, 1997).
However, the sponsor did not provide specific definitions for "moderate"
and "severe."

Subjects were randomized 1:1 to receive FluMist or placebo. Subjects
were assigned to the next available sequential identification number,
affixed on each vaccine sprayer. The sponsor, study personnel, and
participants remained blinded to the treatment group assignments until
the study was completed. The total study duration was 35 days (from 7
days prior to 28 days post-vaccination). No immunogenicity evaluations
were performed.

**VACCINES**

1.  FluMist -- Each 0.5 ml dose contained 10^7^ TCID~50~ of each strain
    (2 type A and type B) of virus in NAF containing SPG. The 1997-98
    strains were A/Shenzhen/227/95 (H1N1, lot CAE036), A/Wuhan/359/95
    (H3N2, lot CAE033) and B/Harbin/7/94-like (lot CAE 029.) Filled
    trivalent lot CAF026 with NAF lot CAE023 was used. The lots are the
    same as those in CAF020, which was Lot #3 in the Lot Consistency
    trial (AV007).

2.  Placebo -- NAF in SPG, lot CAE019 was used.

3.  Inactivated influenza vaccine (TIV) -- This was optional for
    participants, and was administered according to the manufacturer
    guidelines. This was offered to subjects at any time after
    completion of the 10 day post-vaccination monitoring period or
    sooner, if culture-confirmed cases were identified in the community.

**Procedures**

## Schedules

Informed consent was obtained at Visit 1 (Day minus 7) and eligibility
criteria were reviewed. A brief PE was performed and the subjects had to
demonstrate a forced expiratory volume in 1 second (FEV~1~) \< 80% of
predicted after having withheld albuterol for 8 hours with reversibility
of \> 12% within 30 minutes after 2 administrations (180 μg) of
albuterol MDI. Subjects who met this criteria were given a diary card
and a peak flow meter and asked to record their peak expiratory flow
rates each morning at about the same time and before bronchodilator
treatment.

Daily asthma scores, nighttime awakening scores, use of rescue
medication (albuterol MDI) and all medications taken (including OTC
meds) from Day minus 7 to Day 0 were recorded. Participants returned on
Day 0 for repeat pulmonary function tests (PFT's) and, if they had not
experienced an asthma exacerbation during the week of screening, they
were then randomized for vaccination (FluMist or placebo).

After vaccination, participants were given a thermometer and a diary
card. They were asked to record daily temps and the daily asthma
assessments as done from Day --7 to Day 0. Subjects were also asked to
record reactogenicity events (RE's) similar to other Aviron trials,
including cough, sore throat, runny nose, headache, chills, muscle
aches, and tiredness, as well as the occurrence of any other adverse
events (AEs).

During the 35 day study, the subjects were asked to complete 4 diary
cards, one for each of these time periods:

-   Visit 1 to Visit 2 (Day --7 to Day 0)

-   Visit 2 to Visit 3 (Day 0 to Day 2-5)

-   Visit 3 to Visit 4 (Day 2-5 to Day 10-14)

-   Visit 4 to Visit 5 (Day 10-14 to Day 28-30).

Study personnel telephoned the participants (on Days 2-3, 7-8, and
21-23) to remind them to complete the diary cards and to bring them to
the next visit. However, the timing for the phone calls was not
consistent with the timing for completing the diary cards.

##### Inclusion Criteria {#inclusion-criteria-3 .unnumbered}

a.  9-17 years of age, inclusive.

b.  Male or non-pregnant female. Females had to have used a form of
    birth control considered acceptable to the investigator (not
    defined).

c.  Diagnosis of asthma in accordance with NHBLI, 1997.

d.  Demonstrated (FEV~1~) \< 80% of predicted at Day minus 7 (Visit 1)
    after withholding albuterol MDI for 8 hours and, if applicable,
    salmeterol xinafoate (Serevent) for 24 hours. Predicted FEV~1~
    values were obtained using normal equations of Polgar (ages 9-17
    years).

e.  Demonstrated reversibility defined as an increase in FEV~1~
    [\>]{.underline} 12% within 30 min following administration of 2
    administrations (180 μg) of albuterol MDI.

f.  Stable asthma defined as:

-   No asthma exacerbations in the prior 4 weeks. An exacerbation was
    defined as a worsening of asthma that was not controlled by a
    maximum of 6 puffs of albuterol MDI over 8 hours and/or required
    additional therapy such as oral steroids or additional nebulized
    bronchodilators.

-   No hospitalization, ER visits or unscheduled medically attended
    visit for the treatment of asthma in the prior 4 weeks.

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```
-   No use of an oral steroid burst for the treatment of asthma in the
    prior 4 weeks.

g.  On a fixed dosage maintenance regimen of asthma medications during
    the prior 4 weeks.

h.  A non-smoker who had not used any tobacco products on a regular
    basis within the prior 6 months.

i.  Able to perform spirometry effectively (assessed by the maximum
    respiratory flow volume loop curves) and peak flow measurements
    (assessed visually by observation of peak expiratory flow technique)
    and able to comply with the accurate completion of diary cards.

###### **Exclusion criteria**

a\. Hx of hypersensitivity to eggs or egg protein.

b\. An acute febrile illness within 1 week prior to vaccination.

c\. Current upper respiratory illness, including the common cold or
nasal congestion within 72 hours.

d\. Hx of previous CAIV.

e\. Receipt of an investigational drug within 1 month of vaccination.

f\. Signs or syxs of immunosuppression or immunodeficiency.

g\. Clinically significant hx or current evidence of bronchiectasis, CF,
bronchiolitis, or other obstructive pulmonary disease other than asthma.

h\. Receipt of any live virus vaccine within 1 month prior to study
vaccine.

i\. Receipt of any inactivated vaccine within 2 weeks prior to study
vaccine.

j\. Receipt of any blood products, including immunoglobulin in the prior
6 months.

k\. Concurrent need for nasal steroids for the 1^st^ 10 days
post-vaccination.

l\. Underlying condition in the investigators opinion might interfere
with evaluation of the vaccine.

m\. Presence of nasal polyps.

n\. Use of any anti-viral drug in the 2 weeks before or during the
clinical trial, including Amantadine, Rimantadine, Acyclovir,
Ganciclovir, and Famcyclovir.

## Concomitant Vaccinations and Medications

No concurrent immunizations were permitted in this trial. Participants
were asked to record all medications taken, including non-prescription
meds, on the diary cards for the entire study duration (Day --7 to Day
28). The protocol states that use of nasal steroids was not permitted in
the 10 day post-vaccination period.

## Vaccine Administration

Subjects received 0.5 ml of study vaccine (0.25 ml in each nostril) by
intranasal spray while in the seated position. Vaccine administration
could be by self-administration under observation, by parents/guardians
under observation, or by the study personnel. Subjects remained seated
for 30 seconds, and remained at the clinical site for 15 minutes to
observe for immediate reactions.

## Monitoring

Vaccine safety was monitored for the duration of the study. Safety and
tolerability measurements included asthma stability, REs, other AEs
(unsolicited AEs) and SAEs.

**[Asthma Stability]{.underline}**

a.  The primary measure of asthma stability was the mean percent change
    in percent predicted FEV~1~ from baseline to post-vaccination.

b.  Other measures of asthma stability included:

-   Mean percent change from baseline in forced vital capacity (FVC),
    FEV~1~/FVC, and forced expiratory flow during the middle half of FVC
    (FEF~25%-75%~).

-   Proportion of participants with more than a 15% absolute decrease in
    FEV~1~

-   Mean number of days with a decrease in PEFR [\>]{.underline} 30% or
    [\>]{.underline} 2 SD from the baseline mean.

-   Proportion of subjects with a decrease in PEFR [\>]{.underline} 30%
    or [\>]{.underline} 2 SD from the baseline mean.

-   Mean number of days with a decrease in PEFR [\>]{.underline} 15% or
    [\>]{.underline} 2 SD from the baseline mean.

-   Proportion of subjects with a decrease in PEFR [\>]{.underline} 15%
    or [\>]{.underline} 2 SD from the baseline mean.

-   Daily asthma scores.

-   Nighttime awakening scores.

-   Change from baseline in daily use of albuterol MDI.

-   Proportion of subjects with at least 1 asthma exacerbation.

**[Asthma stability measure definitions]{.underline}**:

-   **Spirometry**

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-   Performed according to American Thoracic Society standards.

-   Maneuvers were performed at the clinical site in the morning, before
    bronchodilator treatment, during the same 2 hour window to minimize
    diurnal variation in PFT's. Triplicate blows were performed, and
    spirometric results were deemed acceptable if the FEV~1~ values were
    within 10% of one another. The same spirometer was used for each
    subject for all 3 study visits.

-   FEV~1~ percent predicted: During Visit 1, subjects had to
    demonstrate FEV~1~ of \< 80% predicted based upon age, sex, and
    height (no adjustment for race.) It was calculated using the highest
    FEV~1~:

> \% Predicted = 100 x [Highest FEV~1~]{.underline}
>
> Predicted FEV~1~

-   Reversibility definition: At Visit 1, each subject had to
    demonstrate an increase in FEV~1~ of [\>]{.underline} 12% within 30
    minutes of 2 administrations (180 μg) of albuterol MDI.

> Percent reversibility was calculated using the highest FEV~1~ before
> and after morning bronchodilator treatment:
>
> 100 x [\[highest FEV~1~ after albuterol MDI -- (highest FEV~1~ before
> albuterol MDI)\]]{.underline}
>
> highest FEV~1~ before albuterol MDI

-   **PEFR**

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```
-   Each morning prior to taking any asthma meds, subjects obtained 3
    PEFR readings (flow meters were provided, Personal Best.) The
    highest of the 3 values was recorded on the diary card.

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```
-   **Asthma Symptom Scores**

> Scores were assessed in the evenings before going to sleep, using the
> following scale:
>
> 0=no asthma syxs
>
> 1=occassional asthma syxs
>
> 2=frequent asthma syxs
>
> 3=continuous asthma syxs

-   **Nighttime Awakenings**

Scores were assessed in the mornings for the previous nighttime
awakenings:

0=fine

1=slept well, slight wheeze or cough

2=awake 2-3 times, wheeze or cough

3=bad night, awake most of the time

-   **Use of Rescue Medications**

Prior to going to sleep, subjects recorded the number of puffs of
albuterol MDI used in the previous 24 hours.

-   **Asthma Exacerbations**

This was defined as a worsening of asthma that was not controlled by a
maximum of 6 puffs of albuterol MDI over 8 hours and that required
additional therapy such as oral steroids or additional nebulized
bronchodilators.

**[Reactogenicity Events, AEs and SAEs]{.underline}**

In the 1^st^ 10 days post-vaccination, the solicited REs included
temperature ([\>]{.underline} 100.4^o^F), decreased activity,
irritability, runny nose, sore throat, cough, headache (H/A), chills,
tiredness and muscle aches (similar to those in AV006 and 007, except
nasal congestion was not listed with runny nose and vomiting was not
included). Definitions for other AEs, "vaccine-relatedness" (decided by
the investigator) and SAEs similar to AV006 are provided. SAEs were
reportable for the entire duration of the study.

On the routinely schedule phone calls during the 10 day monitoring
period, study personnel were to ask about AEs. It is not stated that
inquiries about SAEs were to be performed on the day 21-23 phone call,
but study personnel were to query for SAEs at the Day 28 visit.

### RESULTS {#results-5 .unnumbered}

## Enrollment and Demographics

48 subjects were enrolled, 24 in each study group. No explanation is
provided for the study enrollment below expected.

Differences in the groups were noted for age (13.1 vs. 11.7 years),
ethnicity (Caucasian 96% vs. 75%) and gender (males 58% vs. 50%) for the
FluMist vs. placebo groups, respectively. No statistical analyses were
provided. The ethnicity of the enrollees for FluMist were: 96% Caucasian
and 4% Hispanic and for the placebo group: 75% Caucasian, 8% Black, 8%
Asian, 4% Hispanic, and 4% Native American.

## Protocol Compliance

All randomized subjects completed study follow-up. Study vaccine was
self-administered by 71% of subjects, and the remainder was administered
by study personnel.

Six deviations were noted for Inc/Exc criteria: 1 child had a stuffy
nose at baseline, 3 deviations concerned screening FEV1 not being \<80%
(80%, 81% and 80%), 2 deviations concerned reversibility (1 child
reversed at 11.6% and 1 child reversed at \>12% but at 42 minutes, not
within the 30 min specified in the protocol).

##### Receipt of TIV {#receipt-of-tiv .unnumbered}

12 subjects in each group (total n=24) received the TIV, 23/24 were
after the 10 day RE monitoring. 1 subject received TIV on Day 10. Of
note, only 13 of the 48 subjects (FluMist n=6 and placebo n=7) had
received TIV in the previous 5 years.

## Asthma Stability

##### Screening Measurements {#screening-measurements .unnumbered}

29/48 subjects (60%, FluMist-n=14 and placebo-n=15) were on a
maintenance dose of inhaled steroids at Visit 1 (Day --7) and had been
on the regimen for the previous 4 weeks. The FluMist and placebo groups
had comparable PFTs at Visit 1. The mean [+]{.underline} SD percent
predicted FEV~1~ for FluMist = 73.3 [+]{.underline} 6.8 and placebo =
72.9 [+]{.underline} 5.7. The mean [+]{.underline} SD percent FEV~1~
reversibility for FluMist = 23.8 [+]{.underline} 12 and placebo = 21.2
[+]{.underline} 9.9.

##### Primary Measure of Asthma Stability {#primary-measure-of-asthma-stability .unnumbered}

The FluMist and placebo groups had similar baseline FEV~1~ and percent
change in FEV~1~ from baseline (mean of predicted values obtained at Day
--7 and Day 0) to Visit 3.

## AV010 -- Change in Spirometry FEV~1~ from Baseline to Visit 3

  ----------- ---------- ---------- ---------- ---------- ---------- ----------
              Baseline              Visit 3               Percent    
                                                          Change     

  FEV~1,~ %   FluMist    Placebo    FluMist    Placebo    FluMist    Placebo
  Predicted                                                          

  N           24         24         24         24         24         24

  Mean        74.7       76         75.3       76.4       0.2        0.4\*

  SD          8.7        7.6        16.8       12.2       17.9       12
  ----------- ---------- ---------- ---------- ---------- ---------- ----------

\* p =0.78

##### Secondary Measures of Asthma Stability {#secondary-measures-of-asthma-stability .unnumbered}

There were no differences between the groups in the secondary measures
of spirometry (FVC, FEV~1~ /FVC, and FEF~25%-75%~) at baseline, or in
the mean percent change from baseline to Visit 3.

3 subjects \[FluMist n=2 (8.3%), placebo n=1(4.2%)\] had \>15% decrease
in percent predicted FEV~1~ from baseline to Visit 3. Difference in
proportions was 0.042 (--0.214, 0.298).

There were no significant differences between the study groups for any
of the analyses of PEFR (proportion with PEFR [\>]{.underline}30%,
[\>]{.underline}2SD, [\>]{.underline}30% or [\>]{.underline}2SD below
the baseline OR the number of days with PEFR [\>]{.underline}30% or
[\>]{.underline}2SD below baseline). Of note, over the entire
post-vaccination period (Day 1-28), 17/24 (71%) of FluMist and 12/24
(50%) of placebo recipients had a decrease in PEFR [\>]{.underline} 30%
or [\>]{.underline} 2 SD below baseline. For similar analyses performed
for decreases [\>]{.underline} 15% or [\>]{.underline} 2 SD below
baseline, 20/24 (83.3%) of FluMist and 13/24 (56.5%) of placebo
recipients had decreases, Fishers Exact test p =0.06.

Asthma exacerbations occurred in [2 of the 24 FluMist recipients and 0
placebo recipients]{.underline}, and both exacerbations were temporally
associated with receipt of study vaccine. For 1 FluMist subject, the
exacerbation occurred on Day 3 post-vaccination and was associated with
sinusitis. For the other subject, the exacerbation occurred on Day 2 and
was associated with runny nose and cough (reported as REs on the diary
card).

In this very small study sample, there were no differences between the
groups for any of the secondary measures of asthma stability, including
PEFR, daily asthma scores, nighttime awakenings, daily use of rescue
medications or asthma exacerbations.

## REs

All 24 of FluMist recipients and 23/24 placebo recipients returned the
diary card. No subjects withdrew due to an AE. Overall, 22/24 (91.6%) of
FluMist and 21/24 (87.5%) of placebo recipients experienced at least 1
RE. Runny nose was the most frequently reported RE (FluMist -- 75% and
placebo -- 54%.) No statistically significant differences were noted
between the groups, however the rates of RE's (other than fever and
chills) were \> 20% in each group.

## 

## 

## AV010 -- Selected Reactogenicity Events by Treatment Group, Post-Vaccination Day 0-10

+-----------------------------+-------------------+-------------------+
| #                           | **FluMist**       | **Placebo**       |
| ###### Reactogenicity Event |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Randomized,**             | N= 24             | N= 24             |
+-----------------------------+-------------------+-------------------+
| **Returned Diary Card,**    | N= 24             | N= 23             |
+-----------------------------+-------------------+-------------------+
|                             | \%                | \%                |
+-----------------------------+-------------------+-------------------+
| **Fever**                   | 0                 | 17.4              |
|                             |                   |                   |
| **Oral temp \> 100^o^F**    | 0                 | 8.7               |
|                             |                   |                   |
| **Oral temp \> 101 ^o^F**   | 0                 | 1                 |
|                             |                   |                   |
| **Oral temp \> 102          |                   |                   |
| [\<]{.underline} 103 ^o^F** |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Cough**                   | 45.8              | 43.5              |
+-----------------------------+-------------------+-------------------+
| **Sore throat**             | 41.7              | 56.5              |
+-----------------------------+-------------------+-------------------+
| **Runny nose**              | 75                | 56.5              |
+-----------------------------+-------------------+-------------------+
| **Muscle aches**            | 20.8              | 34.8              |
+-----------------------------+-------------------+-------------------+
| **Tiredness**               | 33.3              | 43.5              |
+-----------------------------+-------------------+-------------------+
| **Any RE**                  | 91.7              | 91.3              |
+-----------------------------+-------------------+-------------------+

There were no statistically significant differences between the groups
for REs.

**Other AEs**

Three (12.5%) FluMist recipients reported other AEs in the 10 day
post-vaccination period. 1 subject had 3 AEs (epistaxis, sinusitis, and
gastralgia), 1 subject had URI and 1 subject had gingivitis. Five
(20.8%) placebo subjects experienced 1 AE, including URI, nasal
congestion, allergic conjunctivitis, ear infection and dizziness. The
day of occurrence post-vaccination was not provided. The AEs of
epistaxis post-FluMist and URI post-placebo were deemed by the
investigator as possibly vaccine-related. This placebo recipient
developed fever of 101.1^o^F on day 5 (associated with cough, runny
nose, headache chills and muscle aches), and a viral culture was
obtained, which was negative for viruses, including influenza.

**SAE's**

No SAEs were reported in this trial.

### This small study demonstrated the FluMist and placebo vaccines were reactogenic in subjects with moderate to severe asthma, in that 91.6% of FluMist and 87.5% of placebo recipients experienced at least 1 RE. For asthma stability, 8% of FluMist recipients had \> 15% in FEV~1~ decrease from baseline to Visit 3, and 71% of FluMist and 50% of placebo recipients had a decrease in PEFR [\>]{.underline} 30% or [\>]{.underline} 2 SD below baseline. Also, 2 of 24 FluMist subjects had asthma exacerbations within 3 days of receipt of vaccine. {#this-small-study-demonstrated-the-flumist-and-placebo-vaccines-were-reactogenic-in-subjects-with-moderate-to-severe-asthma-in-that-91.6-of-flumist-and-87.5-of-placebo-recipients-experienced-at-least-1-re.-for-asthma-stability-8-of-flumist-recipients-had-15-in-fev1-decrease-from-baseline-to-visit-3-and-71-of-flumist-and-50-of-placebo-recipients-had-a-decrease-in-pefr-30-or-2-sd-below-baseline.-also-2-of-24-flumist-subjects-had-asthma-exacerbations-within-3-days-of-receipt-of-vaccine. .unnumbered}

# **STUDY DMID #98-005** 

**TITLE: Comparison of the Safety, Vaccine Virus Shedding, and
Immunogenicity of the**

**Influenza Virus Vaccine, Trivalent, Types A & B, Cold-Adapted (CAIV-T)
Administered**

**to HIV-Infected and Non-HIV-Infected Adults.**

LOCATION: United States, two-sites; CRADA with NIAID

STUDY PERIOD: 8/21/98 -- 12/7/99

PIVOTAL TRIAL: No, Phase 2 exploratory

POPULATION: Adults, 18-50 years with HIV infection and HIV negative

SAMPLE SIZE: Planned n=140; Enrolled 57 HIV-infected and 54 HIV negative
adults

## INTRODUCTION/DESIGN

The target population for FluMist, a live viral vaccine, is healthy
children and adults; however, some asymptomatic or mildly symptomatic
HIV-infected individuals may inadvertently receive the vaccine. Thus,
information about the safety and tolerability of the vaccine, as well as
effect on HIV replication is needed. The study was performed at
University of Maryland and University of Rochester. This was a
randomized, double-blind, placebo-controlled trial performed to compare
the safety profile of FluMist *vs*. placebo when administered to
HIV-infected adults and HIV negative adults.

## OBJECTIVES 

## Primary

To evaluate the reactogenicity profile of FluMist compared to placebo in
HIV-infected adults with asymptomatic or mildly symptomatic HIV disease
(CDC Class A1-2).

## Secondary

To compare the reactogenicity profile of FluMist between HIV-infected
adults with asymptomatic or mildly symptomatic HIV disease (CDC Class
A1-2) with HIV-negative adults.

Additional secondary objectives included evaluating: shedding of vaccine
virus, effects on HIV RNA levels in plasma, CD4 counts, and
immunogenicity in the HIV-infected and HIV negative study groups.

## VACCINES 

3.  FluMist -- Each 0.5 ml dose contained 10^7^ TCID~50~ of each strain
    of virus (2 type A and 1 type B) in normal allantoic fluid (NAF)
    containing sucrose-phosphate-glutamate (SPG). The recommended
    1997-98 strains used were A/Shenzhen/227/95 (H1N1), A/Wuhan/395/95
    (H3N2) and B/Harbin/7/94-like. Filled trivalent lot #CAF021 was
    used.

4.  Placebo -- NAF in SPG, lot CAF025 was used.

## PROCEDURES

HIV-infected subjects had to have CD4 counts \> 200 cells/mm^3^, and be
on stable anti-retroviral (ARV) therapy for six weeks [or]{.underline}
stable without ARV (stable was not defined). Pre-enrollment HIV RNA
levels had to be \< 10,000. Subjects were randomized within HIV stratum
in a 1:1 ratio to receive FluMist or placebo. Subjects received one 0.5
ml intranasal dose of study vaccine on Day 0, and were followed for
28-35 days post-vaccination for clinical and laboratory observations.
HIV-infected subjects had 2 additional visits, at 3 and 6 months
post-vaccination to obtain HIV RNA and CD4 lab studies.

Monitoring

## Subjects maintained diary card for REs for 10 days post-vaccination. Solicited REs included malaise, runny nose/nasal congestion, sore throat, cough, muscle aches, nausea/vomiting, decreased appetite, abdominal pain, and headache. Other AEs were also recorded for 10 days post-vaccination. All SAEs were to be reported through Day 28 and "vaccine-related" SAEs were to be reported for the entire study duration, but mechanisms for capture are not stated.

## 

## The subjects were evaluated at the clinical site again on Days 3-5, 7-10 and 28-35 for review of diary cards, and an interval medical history and physical exam were performed. Nose and throat swabs were obtained on these visits for influenza cultures. HIV labs (viral RNA and CD4 counts) were measured at Day 0, 7-10 (viral RNA only), Day 28-35, 3mo and 6 mo.

Concomitant Immunizations and Medications

No concomitant immunizations were permitted. HIV infected subjects were
to be on stable ARV for six weeks, unless they had CD4 counts \> 500
cells/mm^3^.

## 

## Statistical Methods

This was an exploratory study. No adjustments were made for multiple
comparisons. The planned enrollment was 140 subjects, with 70
HIV-infected and 70 HIV negative participants. Reactogenicity events
(REs) were calculated by the proportion of FluMist and placebo subjects
who experienced each event or any event using a Fisher's Exact test and
exact 95% confidence intervals. Logistic regression was used to asses
the effect of FluMist on the occurrence of each RE between HIV-infected
and HIV negative participants. Linear models were used to compare log
change in HIV RNA in HIV-infected subjects receiving FluMist or placebo.

## RESULTS

## Enrollment and Demographics

A total of 111 subjects, 57 HIV-infected and 54 HIV negative adults were
enrolled. Demographic characteristics were different between the
HIV-infected and HIV negative, more were African-American (74% vs. 22%)
and older (40 vs. 34.5 years) subjects were in the HIV-infected group.
All of the HIV negative subjects completed the study (through Day 28-35)
and 79% of HIV-infected subjects completed the study through the 6 month
visit. Twelve HIV-infected subjects withdrew, and seven of the 12 were
voluntary withdrawals.

## Safety

## All subjects with available data were considered evaluable for safety. For RE's, the only statistically significant difference (unadjusted p \<0.05) between FluMist and placebo recipients occurred for runny nose/nasal congestion in both the HIV-infected subjects (respectively 61% vs. 31%), and HIV negative groups (78% *vs*. 44%). For all study participants, regardless of HIV status, all of the solicited REs occurred at [\>]{.underline}5% rate, except fever \> 100.0^o^F in HIV negative FluMist recipients which occurred in zero subjects.

Fifteen unsolicited events (other AEs) occurred in 13 subjects, with a
rate of 9/57 (15.8%) in HIV-infected and 6/54 (11.1%) in HIV negative
subjects. In HIV-infected subjects, 4 FluMist subjects reported 5 AEs
and 4/29 (14%) of placebo subjects reported other AEs. Five events
occurred in HIV negative subjects. Four events were respiratory and
considered as possibly related to vaccination; 2 events (wheezing and
sinusitis) occurred in HIV-infected FluMist recipients. One HIV-infected
placebo recipient had unilateral wheezing, and one HIV negative placebo
recipient had bronchitis.

## SAEs

One SAE occurred during the study, which was not vaccine related.
Twenty-eight days after vaccination with placebo, an HIV-infected
subject who routinely used an indwelling urinary catheter was
hospitalized for an urinary tract infection. No deaths occurred in the
study.

## Viral Shedding

One HIV-infected subject shed vaccine virus (type B) on sampling on Day
5, but he had 2 subsequent negative cultures at Day 7-10 and Day 28-35.
This subject had type B specific HAI titer \< 1:4 prior to vaccination.
The virus was not quantified because there was no growth on subsequent
culture.

## HIV Viral Load and CD4+ cell counts. 

HIV viral load did not increase post-vaccination. Mean CD4+ cell counts
decreased from 598/mm^3^ to 550 mm 28 days post-vaccination in the
Flumist group and from 498/mm^3^ to 490/mm^3^ in the placebo group. The
geometric mean CD4 count declined in the placebo recipients (36
cells/mm^3^), and increased slightly (17 cells/mm^3^) in the FluMist
recipients from Day 28-35 to 3 months. It rose slightly in both groups
between 3 and 6 months.

## STUDY VA #448

This Veterans' Administration study evaluated the safety and efficacy
against laboratory-documented influenza following one dose of FluMist or
placebo, when given with TIV, in adults [\>]{.underline} 50 years of age
with chronic obstructive pulmonary disease (COPD) with a planned
enrollment of 4000 subjects. Enrollment was in a 1:1 ratio. The safety
monitoring included post-vaccination REs for 7 days, other AEs and SAEs
for the study duration. At 20 VA Medical Centers, a total of 2215
subjects were enrolled, 1107 received FluMist and 1108 received placebo.
The mean age was 68 years, 98% were male and the 83% were Caucasian.

This study was ongoing at the time of submission of the BLA and was not
included in the original October 30, 2000 submission. In March 2001 a
Safety Update Report was submitted to the BLA which included a synopsis
of this study. Line listings of the SAE data from the study were
provided. A summary of the line listings of the deaths is provided
below.

## DEATHS IN ALL TRIALS INCLUDED IN BLA

A total of 64 deaths occurred in protocols performed with FluMist, and
63 (34 in FluMist recipients and 29 in placebo recipients) of these
occurred in the VA study. A line listing of the deaths was provided in
the March report. Eight of the 64 deaths in male subjects occurred
within 28 days of receipt of study vaccine (FluMist, n=4 and placebo,
n=4). The FluMist subjects included one child (described in the next
paragraph), a 63 year old with respiratory arrest 9 days post-vaccine, a
72 year old who died 13 days post-vaccination due to pneumonia and lung
cancer, and a 61 year old who died due to an accident 4 days
post-vaccination. In the placebo group the 4 deaths included: an 73 year
old who died due to tracheobronchitis on day 3 post-vaccine, 76 year old
with respiratory failure on day 25 post-vaccine, a 59 year old with an
MI 7 days post-vaccination and an 83 year old who died on day 2
post-vaccination (cause not stated).

There was one death due to bronchopneumonia in an 18 mo old African
American boy, who had received frozen FluMist (same preparation as the
FluMist within the BLA) in a Wyeth-Lederle-sponsored trial performed to
compare frozen and liquid FluMist formulations. A full study report for
this trial was not submitted to the BLA. The child received the 2^nd^
dose of FluMist on 5/5/00, and experienced RE of runny nose for 3 days
post-vaccination. Also on the 5/5/00 visit, chronic otitis media was
noted and treatment with Allergex was recommended. In the CRF, this
medication was recorded as starting on 5/9/00. According to the CRF, the
child was clinically well until 5/28/00 when he had onset of vomiting
and fever. On 5/29/00, he was taken to the clinic and was diagnosed with
bronchopneumonia, received treatment with antibiotics (Pen VK) and
decongestants. On 5/31/00 he had respiratory difficulties, was taken to
the ER where he received IV antibiotics (ampicillin and gentamicin) and
he died on 6/1/00.

## 

Question #3. Are there adequate data to support efficacy and safety of
FluMist when administered with concomitant immunizations?

No data for efficacy or safety of FluMist with concomitant immunizations
in any age group have been submitted.

No data have been submitted in support of efficacy or safety for
concomitant use with vaccines recommended for international travelers.

## Discussion point #4. What additional information in support of safety and efficacy of FluMist vaccine should be requested?