Annegret Van der Aa, Claire Crimi, Scott D. Power, Sidharta Murthy, Alessandro Sette, Lydie Meheus, Jonathan Krakover, Carol Dahlberg, Scott Southwood, Erik Depla, Koen Allosery, Veronique De Brabandere, Manley Huang, Brian D. Livingston, Lilia Maria Babe, Denise M. McKinney, Mark Newman, and Ramilla Philip
Chronic hepatitis B virus (HBV) infection, which occurs in 1 to 5% of adult infections and up to 30% of pediatric infections, is characterized by high levels of viral replication averaging a daily production of about 1011 viral particles, hepatic inflammation, necrosis, and ultimately liver failure (36). An estimated 350 million individuals are classified as chronically HBV infected, with the highest concentrations of infection occurring in large parts of Asia and Africa (23). Chronic HBV can be treated with nucleoside analogues that inhibit polymerase activity. Lamivudine was the first licensed polymerase inhibitor, and it results in significant suppression of HBV DNA levels. However, this response, similar to the loss of hepatitis B virus e antigen, is often not sustained upon discontinuation of treatment (11, 28). The emergence of viral resistance in 15 to 20% of treated patients per year clearly pinpoints the limitations of this treatment. Newer drugs such as adefovir dipivoxil, entecavir, and telbivudine can result in less resistance, increased suppression of DNA levels, or in somewhat higher levels of hepatitis B virus e antigen loss. Real long-term treatment data with these drugs are, however, limited, and it is unclear how well these responses would be sustained if therapy were withdrawn. Higher levels of sustained response after the cessation of therapy have been documented for treatment with alpha interferon (IFN-α) and even more so for its pegylated form. This higher efficacy may be related to the fact that interferon has not only an antiviral but also an immunomodulatory function. However, drug cost and toxicities often restrict the use of IFN (11, 28). Thus, the development of supplemental therapies, especially those aiming at an improved immune response, remain a priority, particularly as a combination of lamivudine and IFN failed to improve sustained response rates (19). In acute HBV infection, cellular immune responses are well characterized and temporally associated with the clearance of infection. The HBV-specific cytotoxic T-lymphocyte (CTL) and helper T-lymphocyte (HTL) responses present during and immediately following resolution of acute infections are readily detected and often broadly specific, targeting epitopes from numerous viral gene products (13, 17). Chronic HBV infection is, however, only rarely resolved by the immune system. When this occurs, viral clearance is associated with increased CTL activity and increased levels of alanine transaminase (ALT), referred to as ALT flares, caused by the destruction of infected hepatocytes by the immune system (40). Viral clearance also can be induced in a significant proportion (10 to 15%) of individuals receiving IFN-α, and, similar to the effect of spontaneous clearance, the effect is correlated with increased CTL and HTL responses. Antiviral effects can be mediated through the action of cytokines, such as IFN-γ, which depress viral replication or inactivate virus particles without killing HBV-infected cells (15, 16). Similarly, in persistent HBV infection, the presence of HBV-specific CTL is associated with lower viral loads, independent from liver damage, further confirming the noncytolytic antiviral activity of CTL (4, 29). Successful vaccine immunotherapy in chronically infected individuals is expected to be characterized by similar CTL and HTL responses. However, in the presence of active HBV replication, the immune system of chronically infected individuals no longer responds vigorously to viral epitopes. The high levels of HBV particles and HBV proteins in the circulation are thought to be responsible for this immune suppression (12, 43). This effect can be so pronounced that it develops into a generalized imbalance of HTL type 1 and 2 responses (Th1/Th2), which manifests as general peripheral tolerance (42). The rare spontaneous resolution of chronic HBV infection and the immune responses observed during IFN-α or lamivudine treatment, in which viral replication is significantly reduced, indicates that deletion of HBV-specific CTL precursors does not occur and that the disease state of immune system tolerance is reversible (7, 8). So far, therapeutic vaccine candidates (6, 20, 25, 38, 44) for HBV have focused on the use of HBsAg and core proteins or parts thereof. However, cellular immune responses to these antigens probably are most prone to suppression, tolerance, or other dysfunctions, since these proteins circulate in very high levels in the infected host (21, 41). This was effectively demonstrated by a single core epitope lipopeptide vaccine candidate, which successfully induced CTL responses in healthy volunteers but failed to do so in chronic HBV patients (24, 25). Even under effective antiviral treatment with polymerase inhibitors or IFN-α, the levels of circulating HBsAg remain very high, possibly pointing to an explanation of why combinations of lamivudine and therapeutic vaccines based on HBsAg so far have failed to show a benefit (44). On the other hand, the polymerase antigen so far has not been as thoroughly investigated as therapeutic vaccine candidate, although the immune system may be more likely to respond to this antigen, which is produced only in minute amounts compared to production of the HBsAg and core antigen. Importantly, polymerase-specific CTL and HTL responses can be readily detected in persons resolving HBV infection (33). The induction of broadly specific CTL and HTL responses against various HBV antigens including the polymerase thus would be a new approach to improve the efficacy of a candidate therapeutic vaccine. Such a vaccine, designed for use in the general population, needs to be based on numerous epitopes restricted by multiple HLA types in order to provide acceptable levels of population coverage. The use of synthetic peptides to deliver large numbers of CTL and HTL epitopes is not feasible, but the technology to design and synthesize genes encoding multiple epitopes for use in DNA plasmid vaccines and in viral vectors is well suited (26, 27). The utility of using genetic constructs, such as DNA vaccines, to deliver multiple epitopes was demonstrated through the development of a vaccine product designed primarily for use with human immunodeficiency virus (HIV)-infected patients (56). This vaccine, which is designated EP HIV-1090, was successfully evaluated for safety and immunogenicity in two phase-1 clinical trials. This first-generation product proved to be safe at the dose levels tested, but immunogenicity was limited. The combined use of DNA vaccines with viral vectors in a heterologous prime-boost sequential immunization format has proved useful for augmenting response levels and rates in some clinical studies. Thus, it was decided that the combined use of DNA and modified vaccinia Ankara (MVA)-vectored vaccines encoding CTL and HTL epitopes warranted investigation. This report describes the design, synthesis, and characterization of a multiepitope-based HBV candidate therapeutic vaccine composed of a plasmid DNA (pDNA) construct (INX102-3697) and a recombinant MVA viral vector (INX102-0557) that each contain a single gene encoding 30 HBV-derived CTL epitopes, 16 HBV-derived HTL epitopes, and the universal pan-DR epitope (PADRE) HTL epitope. These two products are designed for sequential administration using a heterologous prime-boost immunization format to maximize the cellular immune responses induced.