key: cord-1024968-7gui1sou
authors: Asano, Michiko; Okada, Hiroshi; Itoh, Yohji; Hirata, Hajime; Ishikawa, Kensuke; Yoshida, Erika; Matsui, Akiko; Kelly, Elizabeth J.; Shoemaker, Kathryn; Olsson, Urban; Vekemans, Johan
title: Immunogenicity and safety of AZD1222 (ChAdOx1 nCoV-19) against SARS-CoV-2 in Japan: A double-blind, randomized controlled phase 1/2 trial
date: 2021-10-22
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2021.10.030
sha: 3ea80a675284478d09d989a94fd28b62cbbfd630
doc_id: 1024968
cord_uid: 7gui1sou

Background Immunogenicity and safety of the AZD1222 (ChAdOx1 nCoV-19) vaccine was evaluated in Japanese adults in an ongoing phase 1/2, randomized, double-blind, parallel-group, placebo-controlled, multicenter trial (NCT04568031). Methods Adults (N=256; age ≥18 years) seronegative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were stratified by age into 18–55- (n=128), 56–69- (n=86), and ≥70-year-old cohorts (n=42), then randomized 3:1 to receive AZD1222 or placebo (2 intramuscular injections 4 weeks apart). Immunogenicity and safety were coprimary endpoints. Data collected up to Day 57 are reported. Results Positive seroresponses to SARS-CoV-2 spike and receptor-binding domain antigens were seen in all 174 participants who received 2 doses of AZD1222. Neutralizing antibody seroresponses were seen in 67.5%, 60.3%, and 50.0% of participants receiving AZD1222 aged 18–55, 56–69, and ≥70 years, respectively. Solicited adverse events (AEs) were typically mild/moderate in severity and included injection site pain and tenderness, malaise, fatigue, muscle pains, and headache. Common unsolicited AEs included injection site pain and tenderness, fatigue, and elevated body temperature. No vaccine-related serious AEs or deaths were reported. Conclusions AZD1222 elicited a strong humoral immune response against SARS-CoV-2 and was well tolerated in Japanese participants, including elderly participants.

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in widespread morbidity and mortality, prompting the most extensive and rapid global vaccine development program in history (World Health Organization 2020a). Accelerated development and approval has been crucial to providing effective, well-tolerated vaccines against symptomatic SARS-CoV-2 infection . By the end of 2020, several vaccines had reached their phase 3 efficacy milestones and received emergency authorization for use (Polack et al., 2020; Baden et al., 2021; Voysey et al., 2021b; Voysey et al., 2021a) .

As of September 21, 2021, there have been 1,679,116 confirmed cases of COVID-19 and 17,233 deaths related to the disease reported in Japan, with greater numbers seen in older age groups (World Health Organization 2020b; National Institute of Population and Social Security Research 2021). In 2019, people aged ≥65 years accounted for 28.4% of the Japanese population (Statistics Bureau of Japan 2021). Age is a prominent risk factor for COVID-19 morbidity and mortality, with adults aged ≥70 years at greater risk of severe disease and death than younger age groups (Wu et al., 2020; Chen et al., 2021) . Risk of severe disease is also increased by the presence of comorbidities, including hypertension, cardiovascular disease, diabetes, and obesity (Wu et al., 2020) . The rapid approval of COVID-19 vaccines in Japan is therefore crucial to help protect an aging population.

The AZD1222 (ChAdOx1 nCoV-19) vaccine is a replication-deficient simian adenovirus-vectored vaccine encoding the full-length SARS-CoV-2 spike protein (Folegatti et al., 2020) . The immunogenicity, safety, and efficacy of AZD1222 is being assessed globally in randomized controlled trials (Folegatti et al., 2020;  AstraZeneca 2021; Barrett et al., 2021; Ewer et al., 2021; Ramasamy et al., 2021; Voysey et al., 2021b; Voysey et al., 2021a) . In a pooled analysis of 4 trials conducted in the UK (phase 1/2 and 2/3), Brazil (phase 3) and South Africa (phase 1/2), AZD1222 exhibited an acceptable safety profile and an overall vaccine efficacy of 66.7% (95% confidence interval [CI] , 57.4, 74.0) against COVID-19 more than 14 days after the second dose (Voysey et al., 2021a) . A single dose of AZD1222 induced spike and receptor-binding domain (RBD) antibodies as well as neutralizing antibody (nAb) titers against SARS-CoV-2, which were substantially increased after a second dose 28 days later (Folegatti et al., 2020; Barrett et al., 2021; Ewer et al., 2021; Ramasamy et al., 2021) .

A growing number of studies suggest that seroresponse and presence of nAbs may indicate protection against COVID-19 (Addetia et al., 2020; Folegatti et al., 2020; Robbiani et al., 2020; Wang et al., 2020; Hall et al., 2021; Hansen et al., 2021; Harvey et al., 2021; Krammer 2021; Pilz et al., 2021) . For the development of a vaccine, presence of an immune response can provide a reasonable indication of efficacy, and immunogenic assessments can be made in a shorter time and with smaller sample sizes compared with efficacy assessments.

Here we report immunogenicity and safety results from a randomized, placebocontrolled, phase 1/2 trial of AZD1222 in Japanese adults. To our knowledge, this is the first randomized, double-blind, placebo-controlled study to evaluate immunogenicity and safety of a replication-deficient simian adenovirus-vectored vaccine in an East Asian country.

This phase 1/2, randomized, double-blind, parallel-group, placebo-controlled trial (ClinicalTrials.gov identifier: NCT04568031) is being conducted at 5 centers in Japan, with a planned study duration of 1 year following dosing for each participant.

Safety and immunogenicity data up to Day 57 from all enrolled participants are reported here.

The study is being conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. The protocol, including amendments and consent form, were approved by an institutional review board prior to study initiation.

All participants provided written informed consent before enrollment.

Adults aged ≥18 years, seronegative to SARS-CoV-2 at screening, and with a negative reverse-transcriptase polymerase chain reaction test for SARS-CoV-2 were eligible for inclusion. Participants with a history of laboratory-confirmed SARS-CoV-2 infection; pregnant women; a new onset of fever; any confirmed or suspected immunodeficient state; receipt of any vaccine within 30 days before and after each study dose; or prior or planned receipt of an investigational or licensed vaccine or product that may impact interpretation of trial data (e.g., adenovirus-vectored vaccines or coronavirus vaccines) were excluded. Participants with severe and/or uncontrolled cardiovascular, respiratory, gastrointestinal, hepatic, or renal disease, endocrine disorder, or neurologic illness were also excluded; mild/moderate, wellcontrolled comorbidities were allowed.

Participants were stratified between 2 age cohorts: 18-55 years and ≥56 years. The ≥56-year cohort was further divided into subcohorts aged 56-69 years and ≥70

years. Approximately 30% of participants in ≥56-year-old cohort had been secured for participants ≥70 years of age. Participants in each cohort were randomized (3:1) to receive either AZD1222 or placebo (saline) using a centralized Interactive

Response Technology system. AZD1222 and placebo were prepared by an unblinded pharmacist, in accordance with local and institutional regulations at each site. Participants, clinical investigators, and sponsor staff were blinded to the study vaccination received until completion of safety data lock up to Day 57.

AZD1222 was manufactured in accordance with current Good Manufacturing Practice guidelines (AstraZeneca K.K., Osaka, Japan; MedImmune Pharma BV, Nijmegen, Netherlands). Participants received 2 doses of AZD1222 (5×10 10 viral particles/dose) or placebo (saline; 0.9% weight/volume) on study Days 1 and 29, administered as intramuscular injections into the deltoid muscle.

Blood samples for immunogenicity assessments were collected before and after each dose (serology: Days 1, 15, 29, 43, and 57; nAb: Days 1, 29, and 57). Humoral responses at baseline and after dosing were assessed using a validated, multiplex, electrochemiluminescent immunoassay against the SARS-CoV-2 spike, RBD, and nucleocapsid (PPD Vaccines, Richmond, Virginia, USA), and a validated HIV-1based pseudo-virus neutralization assay (Monogram Biosciences, South San Francisco, California, USA).

Participants were monitored for 30 minutes after dosing to assess for adverse events (AE). Solicited AEs were predefined as local (injection site pain, tenderness, redness, swelling, and induration) or systemic (fever, chills, muscle pains, fatigue, headache, malaise, nausea, and vomiting) and were collected by participants using an electronic diary for 6 days after each dose (Days 1-7 and Days 29-35).

Unsolicited AEs were recorded for 28 days following each dose (Days 1-29 and Days 29-57).

Blood samples were collected at Days 1, 8, 29, 36, and 57 for determination of clinical laboratory safety, including assessment of hemoglobin concentration, leukocyte counts, platelet counts, and clinical chemistry.

Severity of safety endpoints was assessed according to toxicity grading scales adapted from Food and Drug Administration (FDA) grading guidance.

The coprimary endpoints were immunogenicity, measured by anti-SARS-CoV-2 spike seroresponse (≥4-fold rise in titers from Day 1 baseline value)(European Medicines Agency 2018) at Day 57 following vaccination with AZD1222, and safety, measured by occurrence of solicited local and systemic reactogenicity signs/symptoms in the 6 days after each dose; occurrence of unsolicited AEs, serious AEs (SAEs), and AEs of special interest (AESIs) for 28 days after each dose;

and change from baseline in safety laboratory measures.

Secondary endpoints included proportion of participants with a seroresponse for the RBD antigen and SARS-CoV-2 nAb at 28 days after second dose of AZD1222 (Day 57); geometric mean titer (GMT) and geometric mean fold rise of immunogenicity against SARS-CoV-2 spike and RBD antigens and SARS-CoV-2 nAb at each time point up to Day 365; and occurrence of SAEs and AESIs up to Day 365.

A sample size of 128 participants (96 and 32 randomized to AZD1222 or placebo, respectively) in each cohort was determined mainly for evaluation of safety and based on feasibility. With a sample size of 96 participants in the AZD1222 arm for each cohort, ≥1 participant with an AE at an incidence of 2.5% could be detected with a probability of ~90%.

The proportions of participants with a seroresponse for the SARS-CoV-2 spike and RBD antigens, as well as for nAb, were compared between AZD1222 and placebo using Fisher's exact test at the 2-sided 5% alpha level for each cohort. Two-sided 95% CIs were calculated using the Clopper-Pearson method for proportions within each cohort/subcohort. Given the exploratory nature of the study, no adjustment for multiple comparisons and multiplicity was performed; only nominal P values were provided for immunogenicity endpoints. All statistical analyses were conducted using SAS version 9.4.

Assessments of immunogenicity were performed on the fully vaccinated analysis set (FVS), which included all participants who received 2 study doses, had no protocol deviations judged to potentially interfere with generation/interpretation of immune responses, and did not exhibit a seroresponse (≥4-fold rise in titers from the Day 1 baseline value) to nucleocapsid antibodies by Meso Scale Discovery serology assay up to Day 57. Safety analyses (unless otherwise stated) were performed on the total vaccinated analysis set (TVS), which included all participants who received ≥1 dose of study intervention. Data are summarized by descriptive statistics.

Participants were recruited from August 2020 (final data lock: February 24, 2021), with follow-up scheduled for ~1 year after first dose. This study was temporarily interrupted by the safety data review on the occurrence of SAEs outside Japan.

Participant disposition is outlined in Figure 1 . All screen failures that were categorized as "Sponsor decision" were associated with this interruption and a consequent pause in enrollment (Figure 1 ).

Demographic and other participant baseline characteristics were well balanced between AZD1222 and placebo in the TVS (Table 1) . At baseline, the prevalence of comorbidities associated with higher risk of severe COVID-19 was 27.0%, 4.3%, 1.6%, 1.6% and 0.4% for hypertension, obesity (body mass index ≥30 kg/m 2 ), cardiac disorder, type 2 and type 1 diabetes, respectively. All participants were Japanese (Asian), and 32.8% (42/128) of participants in the ≥56-year-old cohort were ≥70 years.

Seroresponses to the SARS-CoV-2 spike antigen in the FVS on Day 57 were exhibited by 100% (174) of participants who received AZD1222 and 0% (60) of participants who received placebo (P<0.001 AZD1222 vs placebo for both cohorts).

In participants who received AZD1222, antibody titers for SARS-CoV-2 spike antigen increased substantially after the first dose and increased further after the second dose across all age cohorts/subcohorts in the FVS. Titers peaked on Day 43 and remained above pre-dose Day 29 levels up to Day 57 (Figure 2) .

Results for SARS-CoV-2 RBD antigen were similar to those for the spike antigen (Figure 3) . A seroresponse to the SARS-CoV-2 RBD antigen was observed in 100% (174) of participants who received AZD1222 and 0% (60) By contrast, no nAb response was observed among any participant receiving placebo. The difference in nAb responses between AZD1222 and placebo was statistically significant in each age cohort (P<0.001). Titers for nAb increased in a similar manner to anti-spike and anti-RBD antibodies, remaining above pre-dose Day 29 levels up to Day 57 (Figure 4) . For participants in the 18-55-year cohort, and 56-69-year, and ≥70-year age subcohorts, peak nAb GMTs (95% CI) on Day 57 were 107.3 (84.2, 136.7), 101.5 (74.3, 138.5), and 70.2 (45.6, 108.1), respectively. In the placebo groups, there was no change from baseline in antibody titers for the SARS-CoV-2 spike and RBD antigens, and the nAb for any age cohort.

Incidences of solicited local and systemic AEs in the first 6 days are reported in (Table S1 ). In participants who received AZD1222, solicited AEs were milder and reported less frequently in those aged ≥70 years, compared with those in the 18-55-year cohort and 56-69-year subcohort.

Unsolicited AEs (28 days following each dose) for AZD1222 and placebo, respectively, were reported by 28.1% (27/96) and 9.4% (3/32) of participants in the 18-55-year cohort, 21.5 % (14/65) and 28.6% (6/21) in the 56-69-year subcohort, and 22.6% (7/31) and 27.3% (3/11) in the ≥70-year subcohort. The majority were of mild or moderate severity. Severe unsolicited AEs occurred in 4.2% (4/96) of participants in the 18-55-year age cohort receiving AZD1222, and 3.1% (2/65) and 9.5% (2/21) of participants in the 56-69-year subcohort receiving AZD1222 or placebo, respectively. The most common unsolicited AEs were consistent with AEs commonly observed following vaccination, including injection site pain, injection site tenderness, fatigue, and body temperature increase (Table S2 ). There were no notable imbalances between AZD1222 and placebo for AEs that were not commonly associated with vaccination. In participants who received AZD1222, unsolicited AEs were milder and reported less frequently in those aged ≥56 years, compared with those in the 18-55-year cohort.

No deaths, SAEs, or AESIs were reported among participants receiving AZD1222.

Among participants receiving placebo, 1 SAE of cervical intraepithelial neoplasia (grade 3) occurred in a 69-year-old female after the first dose. This SAE was considered unrelated to placebo and the participant received their second dose as planned.

No clinically significant differences in hematologic and clinical chemistry parameters were observed in both AZD1222 and placebo groups over time. Isolated increases from baseline in FDA toxicity grades were observed for hematology/chemistry parameters in a minority of participants, but it was not considered clinically significant. A temporary decrease in neutrophils with 1 male participant was reported in the AZD1222 group as an unsolicited AE (grade 3) and recovered to the normal range within 3 weeks after each vaccination. There was no clinically relevant change in average platelet counts in the AZD1222 group compared with placebo (Table S3,   Table S4 ).

The coprimary objectives of this randomized, placebo-controlled trial were to assess immunogenicity and safety of AZD1222 in a Japanese population.

All measures of immunogenicity indicated a strong humoral response to AZD1222 on Day 57, irrespective of participant age. All participants who received both doses of AZD1222 had seroresponses against the SARS-CoV-2 spike and RBD antigens on Day 57. nAb response rates were 62.0% among participants who received two doses of AZD1222, ranging from 50.0% in the ≥70-year age subcohort to 67.5% in the 18-55-year age cohort. Titer values of anti-spike antibodies, anti-RBD antibodies, and nAb substantially increased after first dose of AZD1222 (Day 29), increasing further after the second dose (Day 57).

Seroresponse rates against SARS-CoV-2 spike and RBD antigens were almost identical to those reported in a pooled analysis of trials conducted in the UK, Brazil and South Africa, in which the majority of participants were white (seroresponse rates of ~100%) (Voysey et al., 2021a) , although the respective titer values in this study were less than previously reported (Voysey et al., 2021a) . nAb response rates and titers were also numerically lower than observed in the pooled analysis, though this is likely owing to differences in intervals between first and second dose (4 weeks ±2 days in this study compared with 3-26 weeks for the pooled analysis) (Voysey et al., 2021a) . However, nAb titers observed in this study (overall GMT, 97.96) were comparable with those in clinical trials conducted in the UK (GMT, 97.43) and Brazil (GMT, 110.96) , which employed similar dosing intervals (4-8 weeks) to this study (Pharmaceuticals and Medical Devices Agency (PMDA) 2021). Furthermore, the GMTs observed for anti-spike antibodies, anti-RBD antibodies, and nAb after the first dose of AZD1222 were comparable between Japanese and non-Japanese participants (Voysey et al., 2021a) .

In this study, there was a decreasing trend in anti-spike antibodies, anti-RBD antibodies, and nAb titers with increasing age, although large variability was observed among individual titers with wide, overlapping CIs between age cohorts.

These data align with the reduced humoral responses observed in older adults in the previous pooled analysis (Voysey et al., 2021a) . However, given the robust vaccine efficacy of AZD1222 previously observed in adults aged >65 years (Voysey et al., 2021a) , these numerically reduced responses may not be clinically meaningful.

Correlates of protection have not yet been established for SARS-CoV-2 in humans, although nAb titers have been correlated with protection in nonhuman primates (Deng et al., 2020; van Doremalen et al., 2020a; van Doremalen et al., 2020b; Yu et al., 2020; McMahan et al., 2021) . In addition, several studies suggest presence of nAb is associated with protection in humans (Addetia et al., 2020; Robbiani et al., 2020; Wang et al., 2020; Hall et al., 2021; Hansen et al., 2021; Harvey et al., 2021; Krammer 2021; Pilz et al., 2021) . In this study, AZD1222 elicited a strong humoral immune response against SARS-CoV-2 in Japanese adults, irrespective of age. This suggests AZD1222 may provide effective protection against COVID-19 in this population, extrapolated from immunogenicity and efficacy results observed in the previous pooled analysis (Voysey et al., 2021b; Voysey et al., 2021a) .

AZD1222 was well tolerated in Japanese adults across all age groups, and the safety profile was similar to that observed in previous clinical trials (Folegatti et al., 2020; Ramasamy et al., 2021) . The most frequently occurring AEs were consistent with previous studies of AZD1222 and included pain and tenderness at the site of injection, malaise, fatigue, muscle pains, and headache. Up to Day 57, no vaccinerelated SAEs were reported, and no deaths have been reported in the trial to date.

Extremely rare cases of thrombosis with thrombocytopenia syndrome (TTS) have been observed following vaccination with AZD1222 during postauthorization use.

While no cases of TTS were observed in this study, given the rarity of TTS, no events would be expected in a clinical trial setting such as this; in other studies of the large AZD1222 clinical trial program no cases were observed among ~30,000 participants who received AZD1222 (Falsey 2021; Voysey et al., 2021a) . Limitations of this study include the small sample size and short duration of follow-up reported (~8 weeks after first dose). Pregnant women, individuals with immunodeficiency and those with severe or uncontrolled underlying disease were excluded from this study and results may not be generalized to these populations.

Long-term follow-up of this study (Day 365 after first dose), other ongoing clinical studies and emerging real-world evidence will provide further data to characterize the safety, immunogenicity and efficacy of AZD1222. Although correlates of protection against SARS-Cov-2 remain undefined, it is thought that both humoral and cellular immune responses play a protective role (Ewer et al., 2021) . Cellular immunity was not investigated within this study, which focused on the humoral immune response. However, data from a previous phase 1/2 trial in UK adults (18-55 years) demonstrated that AZD1222 induced a T-helper 1-biased CD4+ effector response and cytotoxic CD8+ T cell response (Ewer et al., 2021) . Finally, this study was not designed to evaluate AZD1222 efficacy, and we cannot definitively conclude that the immune responses observed correlate with protection.

AZD1222 elicited a strong humoral immune response against SARS-CoV-2 regardless of age and was well tolerated with an acceptable safety profile in Japanese adult participants, including the elderly and those with controlled underlying diseases. Results were comparable with data from clinical trials conducted in the UK and Brazil that employed a similar dosing interval to this study, suggesting that AZD1222 can confer effective protection against COVID-19 in the Japanese population. 

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The authors thank the participants, their families, and all investigators (Akiyoshi Uchiyama, Tokyo Asbo Clinic, formerly Shinagawa East One Medical Clinic, Tokyo, Japan; Atsuko Abe, Seikoukai New Medical Research System Clinic, Hachioji City, Tokyo, Japan; Takuma Yonemura, Souseikai Sumida Hospital, Sumida City, Tokyo, Japan; Kenjiro Nakamura, Tenjin Sogo Clinic, Fukuoka City, Fukuoka, Japan; Akira Numata, Ikebukuro Metropolitan Clinic, Toshima City, Tokyo, Japan), Tatsuya Nakamura (study leader, AstraZeneca K.K.), clinical site staffs and all relevant