Proof-of-concept of a low-dose unmodified mRNA-based rabies vaccine formulated with lipid nanoparticles in human volunteers: A phase 1 trial

May combine two claims.

Formulation of mRNA in lipid nanoparticles (LNP) protects the mRNA and enhances the immune response in animal models.

“Further preclinical research in animal models has found that formulation of the mRNA in lipid nanoparticles (LNP) protects the mRNA and enhances the immune response [9].”

• cites [9] Lutz J. Lazzaro S. Habbeddine M. Schmidt K.E. Baumhof P. Mui B.L. Unmodified mRNA in LNPs constitutes a competitive technology for prophylactic vaccines npj Vaccines 2 2017 29 29263884 PMC5648897 sourceSupported

Classified as probably not a substantial claim.

Rabies virus-specific serum neutralizing titers were measured using the WHO-recommended rapid fluorescent focus inhibition test (RFFIT) at the accredited Kansas State University Rabies Laboratory.

“Rabies virus-specific serum neutralizing titers (VNT) were measured using the WHO-recommended rapid fluorescent focus inhibition test (RFFIT) [13] at the accredited Kansas State University Rabies Laboratory.”

• cites [13] Kløverpris H.N. Akil Jackson A. Handley A. Non-immunogenicity of overlapping Gag peptides pulsed on autologous cells after vaccination of HIV infected individuals PLoS ONE 8 2013 e74389 PMC3790804 24124451 sourceCould not verify

  The Methods sections describe HIV Gag-specific IFNγ ELIspot and intracellular cytokine staining assays, not rabies-virus neutralization testing. Searches for RFFIT, rabies neutralizing titers, WHO guidance, and the Kansas State University Rabies Laboratory found no passage addressing the cited method. (LLM, conf=0.76)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Meulengracht-Gilbert Syndrome (MGS) is a benign genetic disorder present in approximately 10% of young men in Bavaria, and it affects bilirubin processing leading to elevated levels of unconjugated bilirubin in the blood.

“Meulengracht-Gilbert Syndrome (MGS), a benign genetic disorder which is present in approximately 10% of young men in Bavaria and affects bilirubin processing leading to elevated levels of unconjugated bilirubin in the blood [14], [15], [16].”

• cites [14] Sieg A. Arab L. Schlierf G. Stiehl A. Kommerell B. Die Prävalenz des Gilbert-Syndroms in Deutschland Prevalence of Gilbert's syndrome in Germany Dtsch Med Wochenschr 112 1987 1206 1208 3608845 sourceNot checked — no full text of the source
• cites [15] Strassburg C.P. Hyperbilirubinemia syndromes (Gilbert-Meulengracht, Crigler-Najjar, Dubin-Johnson, and Rotor syndrome) Best Pract Res Clin Gastroenterol 24 2010 555 571 20955959 sourceNot checked — no full text of the source
• cites [16] Wagner K.H. Shiels R.G. Lang C.A. Khoei N.S. Bulmer A.C. Diagnostic criteria and contributors to Gilbert’s syndrome Crit Rev Clin Lab Sci 55 2018 129 139 29390925 sourcePartly supported

  The ‘Bilirubin biology—An evolutionary perspective’ section describes Gilbert-Meulengracht syndrome as benign, reports a 2–10% prevalence among people of Caucasian ethnicity, and links elevated unconjugated bilirubin to genetic changes affecting its processing. It does not give a prevalence specifically for young men in Bavaria, so the claim’s population-specific figure is not supported by this source. (LLM, conf=0.89)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Recent mRNA-LNP vaccines against SARS-CoV-2 had similar rates of reactogenicity and reactogenicity noticeably increased after a second dose.

“This contrasts with recent reports of mRNA-LNP vaccines against the SARS-CoV-2 virus responsible for the COVID-19 pandemic which had similar rates of reactogenicity and in which reactogenicity noticeably increased after a second dose [17], [18].”

• cites [17] Mulligan M.J. Lyke K.E. Kitchin N. Phase I/II study of COVID-19 RNA vaccine BNT162b1 in adults Nature 586 2020 589 593 32785213 sourcePartly supported

  The Discussion says BNT162b1 had a safety and tolerability profile consistent with earlier mRNA vaccines and that reactogenicity was generally higher after the second dose at the 10 µg and 30 µg levels. The safety results (p. 3) likewise report systemic events in more participants after dose two. The paper does not establish that its reactogenicity rates were similar to those of the vaccine discussed by the citing authors. (LLM, conf=0.83)

  Experimental — accuracy not yet measured
• cites [18] Jackson L.A. Anderson E.J. Rouphael N.G. An mRNA vaccine against SARS-CoV-2 - preliminary report New Engl J Med 383 2020 1920 1931 32663912 PMC7377258 sourceSupported

May combine two claims.

In the 5 μg CV7202 group, there was a high rate of solicited systemic adverse events: 41 events reported by 9 participants, 32 (78%) mild or moderate, and 9 (22%) severe in 6 participants.

“There was a high rate of solicited systemic adverse events in this group, with 41 events reported by 9 participants, 32 (78%) of which were described as mild or moderate, but 9 (22%) of which were described as ever in 6 participants.”

May combine two claims.

In the 5 μg CV7202 group, there was only one report of any other local reaction (mild redness), with no reports of injection site swelling or itching.

“There was only one report of any other local reaction—a case of mild redness in one participant—with no reports of injection site swelling or itching.”

May combine two claims.

There have been no vaccine-related serious adverse events or adverse events of special interest throughout the study to date.

“No vaccine-related serious adverse events or withdrawals occurred.”

• Also stated in: § Safety · plain

  “there have been no vaccine-related SAEs or AESIs throughout the study to date.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

One Rabipur participant was hospitalized with appendicitis, which was not considered related to the vaccine.

“One Rabipur participant was hospitalized with appendicitis, which was not considered to be related to the vaccine.”

May combine two claims.

In the 5 μg CV7202 group, the most frequent systemic adverse events were headache, fatigue, myalgia and chills, with the majority having onset within 24 hours of vaccination on Days 1 or 2.

“The most frequent systemic AEs were headache, fatigue, myalgia and chills, the majority with onset within 24 h of vaccination on Days 1 or 2.”

May combine two claims.

In the 5 μg CV7202 group, the most frequent unsolicited adverse events were three cases of lack of appetite (all severe), three cases of night sweats (two severe), two cases of dizziness (one severe), and two cases of tachycardia (one severe).

“The most frequent of these were three cases of lack of appetite (all severe), three cases of night sweats (two severe), two cases of dizziness (one severe), and two cases of tachycardia (one severe).”

May combine two claims.

In the 5 μg CV7202 group, severe cases of fatigue, chills and myalgia became moderate or mild within 24 hours of onset, except for one case of severe fatigue lasting 29 hours and another lasting three days related to an acute gastroenteritis-like illness.

“Severe cases of fatigue, chills and myalgia which occurred became moderate or mild within 24 h of onset, except for one case of severe fatigue that lasted for 29 h, and a second case of severe fatigue lasting three days with onset on Day 5 that was related to an acute gastroenteritis-like illness with nausea and vomiting.”

May combine two claims.

In the 5 μg CV7202 group, the majority of unsolicited adverse events resolved within 24 hours of onset and the only medication used was ibuprofen by 4 of 10 (40%) participants.

“The majority of unsolicited AEs resolved within 24 h of onset and the only medication used for treatment of such AEs was ibuprofen, used by 4 of 10 (40%) participants.”

May combine two claims.

In the 5 μg CV7202 group, unsolicited adverse events were reported by 9 (90%) of 10 participants; 7 (70%) were considered related to vaccination, including 5 (50%) severe.

“Unsolicited adverse events were reported by 9 (90%) of the 10 participants; 7 (70%) of these were considered to be related to vaccination, including 5 (50%) graded as severe.”

May combine two claims.

In the 5 μg CV7202 group, all but one participant reported injection site pain, which was graded as severe in one case.

“All but one of the participants reported pain at the injection site, which was graded as severe in one case.”

May combine two claims.

GMTs were 853 U/mL (95% CI: 455-1599), 1581 U/mL (899-2780), and 2409 U/mL (1113-5215) at Day 29 after the first dose in the 1, 2, and 5 μg CV7202 groups, respectively, and these levels did not further increase in one dose groups.

“GMTs were 853 U/mL (95% CI: 455–1599), 1581 U/mL (899–2780), and 2409 U/mL (1113–5215) at Day 29 after the first dose in the 1, 2, and 5 μg CV7202 groups, respectively, and these levels did not further increase in one dose groups.”

May combine two claims.

All participants in the Rabipur group had titers ≥0.5 IU/ml by Day 15, 7 days after the second vaccination, and this 100% rate was maintained up to Day 57.

“All participants in the Rabipur group had titers ≥ 0·5 IU/mL by Day 15, 7 days after the second vaccination and this 100% rate was maintained up to Day 57.”

May combine two claims.

In the 2 μg CV7202 group, there was one (6%) report of severe injection site pain and three (19%) participants reported severe solicited systemic adverse events (chills, headache, myalgia).

“Amongst the 16 participants of the 2 μg CV7202 group there was one (6%) report of severe injection site pain and three (19%) participants reported severe solicited systemic AEs; chills (two), headache (two) and myalgia (one).”

May combine two claims.

Systemic AEs mainly consisted of transient mild or moderate headache, fatigue and chills, and any cases that were described as initially severe rapidly moderated and resolved, most within 48-72 h and all within the 7-day reporting period.

“Systemic AEs mainly consisted of transient mild or moderate headache, fatigue and chills, and any cases that were described as initially severe rapidly moderated and resolved, most within 48–72 h and all within the 7-day reporting period.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The third subject described previous clinically significant elevations which were added to their medical history.

“The third described previous clinically significant elevations which were added to their medical history.”

May combine two claims.

In the 1 μg CV7202 group, there were no severe adverse events reported, although 4 (25%) of 16 participants reported moderate adverse events.

“In the 1 μg CV7202 group there were no severe AEs reported, although 4 (25%) of the 16 participants in this group reported moderate AEs.”

May combine two claims.

In the 1 μg CV7202 group, three unsolicited adverse events were reported by two participants (one loose stool, two lower back pain) and were considered possibly related to vaccination.

“Three unsolicited AEs were reported by two participants—one had a single episode of loose stool and another had two episodes of lower back pain—that were considered to be possibly related to the vaccination.”

May combine two claims.

In the 2 μg CV7202 group, all but one of the severe reports occurred after the first dose, with onset on Days 1 or 2; all improved to mild or moderate by Day 3 within 48 hours and all but one resolved by Day 4.

“All but one of these reports occurred after the first dose, with onset on Days 1 or 2, all had improved to mild or moderate by Day 3 within 48 h and all but one had resolved by Day 4.”

May combine two claims.

In this small trial, CV7202 appeared to be safe, with no vaccine-related SAEs or withdrawals due to AEs.

“In this small trial CV7202 appeared to be safe, with no vaccine-related SAEs or withdrawals due to AEs.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Two of the five participants reported that episodic jaundice and/or bilirubin elevations had been present since youth.

“When these five participants were interviewed for more detail two reported that episodic jaundice and/or bilirubin elevations had been present ‘since youth’.”

May combine two claims.

The Rabipur GMT did not further increase following a third dose but was maintained at 9.1 IU/ml through to Day 57.

“The GMT did not further increase following a third dose of Rabipur but was maintained at 9·1 IU/mL through to Day 57.”

May combine two claims.

The bilirubin elevations were present in prevaccination (baseline) samples and post-vaccination samples in no specific pattern and with no particular association with any study vaccine.

“These were present in prevaccination (baseline) samples and post-vaccination samples in no specific pattern and with no particular association with any study vaccine.”

Probably not a substantial claim: may not pass S3 (load-bearing).

One participant had a split bilirubin typical for MGS and, in combination with a history of raised elevations, the diagnosis of MGS was marked in the medical history without genetic confirmation.

“one participant had a split bilirubin typical for MGS and in combination with a history of raised elevations the diagnosis of MGS was marked in the medical history without genetic confirmation.”

May combine two claims.

A further incremental increase to 33,373 U/mL (21236-52447) was observed after the third dose, and this level was sustained to Day 57.

“A further incremental increase to 33,373 U/mL (21236–52447) was observed after the third dose and this level was sustained to Day 57.”

May combine two claims.

After the second dose on Day 29, 5 of 8 (63%) participants who received a second dose of 1 μg and 7 of 8 (83%) participants who received a second dose of 2 μg had titers ≥0.5 IU/ml at Day 36.

“Responses were markedly increased following the second dose on Day 29 such that 5 of the 8 (63%) participants who received a second dose of 1 μg and 7 of 8 (83%) participants who received a second dose of 2 μg had titers ≥ 0·5 IU/mL at Day 36.”

May combine two claims.

Three of the five subjects had one or more bilirubin elevations that were marked as clinically significant during the conduct of the study, two of which were present at baseline.

“Three of the five had one or more bilirubin elevations that were marked as clinically significant during the conduct of the study, two of which were present at baseline.”

May combine two claims.

Following a 5 μg dose of CV7202, VNT levels ≥0.5 IU/ml were observed from Day 29 in two of nine (22%) participants, and these responses were maintained up to Day 57.

“Following a 5 μg dose of CV7202, VNT levels ≥ 0·5 IU/ml were observed from Day 29 in two of nine (22%) participants and these responses were maintained up to Day 57, the last timepoint assessed (Fig. 3 ).”

May combine two claims.

In the 2 μg group, 5 of 16 (31%) had VNT levels ≥0.5 IU/ml by Day 29, whereas no participants in the 1 μg group displayed an adequate response by Day 29 after one dose.

“These were more pronounced in the 2 μg group in which 5 of 16 (31%) had VNT levels ≥ 0·5 IU/ by Day 29, whereas no participants in the 1 μg group displayed an adequate response (0·5 IU/mL) by Day 29 after one dose (Fig. 3).”

May combine two claims. The quote only partly states this claim.

Transient lymphopenia was observed at Day 2 after vaccination in 9 of 16 and 14 of 16 in the 1 and 2 μg CV7202 groups, respectively, and at Day 30 after the second dose in 6 of 8 and 8 of 8 in those groups.

“The major finding from the laboratory safety assessments was the observation of transient lymphopenia at Day 2, the day after vaccination in 9 of 16 and 14 of 16 in the 1 and 2 μg CV7202 groups, respectively, and 6 of 8 and 8 of 8 in those groups at Day 30, one day after the second dose.”

May combine two claims.

GMTs were higher than 0.5 IU/ml at Day 36 in both groups and were further increased at Days 43 and 57.

“GMTs were higher than 0·5 IU/mL at Day 36 in both groups and were further increased at Days 43 and 57.”

May combine two claims.

Much larger increases were observed after second vaccinations, peaking at 34,186 U/mL (13253-88185) and 20,707 U/mL (5592-76678) at Day 43 in the 1 and 2 μg groups, respectively.

“Much larger increases were observed after second vaccinations, peaking at 34,186 U/mL (13253–88185) and 20,707 U/mL (5592–76678) at Day 43 in the 1 and 2 μg groups, respectively.”

May combine two claims.

An IgG response was not detected one week after the first Rabipur vaccination; GMTs were 461 and 464 at Days 1 and 8, respectively, but rapidly increased to 12,460 U/mL (95% CI: 6575-23611) at Day 15, 7 days after the second dose.

“An IgG response was not detected one week after the first Rabipur vaccination; GMTs were 461 and 464 at Days 1 and 8, respectively, but rapidly increased to 12,460 U/mL (95% CI: 6575–23611) at Day 15, 7 days after the second dose.”

May combine two claims.

Asymptomatic, isolated elevated bilirubin levels were observed in several young male participants recruited at the Munich site, and these were not temporally associated with vaccination.

“An anomaly which was not considered to be vaccine-related was the observation of asymptomatic, isolated elevated bilirubin levels in several young male participants recruited at the Munich site which were not temporally associated with vaccination.”

May combine two claims.

The 1 and 2 μg dosages were better tolerated than the 5 μg dose, with no safety concerns.

“Following observations of high reactogenicity when using the 5 μg dose of CV7202 we found 1 and 2 μg dosages were better tolerated, with no safety concerns and two doses elicited immune responses in terms of neutralizing activity and IgG antibodies that were comparable with three doses of licensed rabies vaccine.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In a second suspected MGS participant, split bilirubin was requested at a visit when total bilirubin was normal and there were no further elevations observed; because of a childhood history of intermittent icterus, suspected MGS was marked in their medical history.

“In a second suspected MGS participant split bilirubin was requested at a visit when total bilirubin was normal and there were no further elevations observed. Because of a childhood history of intermittent icterus on further questioning, suspected MGS was marked in their medical history.”

May combine two claims.

There were transient increases in IgM antibodies but not IgA after second doses of Rabipur and CV7202.

“There were also transient increases in IgM antibodies but not IgA after second doses of Rabipur and CV7202 (data not shown), but direct comparison of the kinetics of these responses is complicated by the different vaccination schedules—1 and 8 days for licensed vaccine and 1 and 29 days for CV7202—and no second 5 μg dose.”

May combine two claims.

All recipients had functional antibody responses after two 1 or 2 μg doses of CV7202, with GMTs of both rabies-specific neutralizing and RABV-G-specific IgG antibodies that were not significantly lower than those observed after three doses of licensed rabies vaccine.

“Importantly, we showed that all recipients, despite the low amount of mRNA included in the vaccine, had functional antibody responses after two 1 or 2 μg doses of CV7202, with GMTs of both rabies-specific neutralizing and RABV-G-specific IgG antibodies that were not significantly lower than those observed after three doses of licensed rabies vaccine.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The study protocol was approved by the respective Ethical Committees of the two institutions and registered on ClinicalTrials.gov (NCT03713086).

“The study protocol was approved by the respective Ethical Committees of the two institutions and registered on ClinicalTrials.gov (NCT03713086).”

Classified as probably not a substantial claim.

A rabies-specific serum virus neutralizing titer of at least 0.5 IU/mL is considered an adequate response to vaccination by the WHO.

“had VNTs ≥ 0·5 IU/mL, considered an adequate response by the WHO.”

• Also stated in: § Virus-neutralizing antibodies · plain

  “with a titer ≥ 0·5 IU/mL considered an adequate response to vaccination [11].”

• cites [11] WHO. Rabies vaccines WHO position paper. Wkly Epidemiol Rec 2007; 82:425–36. 18064757Not checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

One participant from the Rabipur control group was lost to follow up after Day 1, and one participant in the 5 μg CV7202 group withdrew consent at Day 15.

“One participant from the Rabipur control group was lost to follow up after Day 1, and one participant in the 5 μg CV7202 group withdrew consent at Day 15 for personal reasons.”

Classified as probably not a substantial claim. May combine two claims.

In this exploratory phase 1 trial, only descriptive statistics were used, with no confirmatory statistical inference planned or performed.

“In this exploratory phase 1 trial we only used descriptive statistics, with no confirmatory statistical inference planned or performed.”

Probably not a substantial claim: may not pass S3 (load-bearing).

All solicited and unsolicited adverse events were graded according to severity using the FDA toxicity grading scale.

“All solicited and unsolicited AEs were graded according to severity, using mild, moderate or severe as categories using the FDA toxicity grading scale [10].”

• cites [10] CDC. Toxicity grading scale for healthy adult and adolescent volunteers enrolled in preventive vaccine clinical trials (September 2007) Available at: https://www.fda.gov/media/73679/download Accessed 28 February 2020. 37532612 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Trial procedures were done in accordance with International Conference on Harmonization (ICH) and Good Clinical Practice guidelines, and applicable regulatory requirements.

“Trial procedures were done in accordance with International Conference on Harmonization (ICH) and Good Clinical Practice guidelines, and applicable regulatory requirements.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The remaining 51 participants completed study procedures through to the Day 57 visit.

“The remaining 51 participants completed study procedures through to the Day 57 visit.”

May combine two claims.

Lymphopenia was not observed in the 5 μg group because the first blood sampling in this group was conducted on Day 3, when lymphopenia was no longer present.

“This was not observed in the 5 μg group as the first blood sampling in this group was conducted on Day 3, rather than Day 2, when lymphopenia was no longer present.”

May combine two claims.

Two 1 μg or 2 μg doses of CV7202 were well tolerated and elicited rabies neutralizing antibody responses that met WHO criteria in all recipients.

“Two 1 μg or 2 μg doses of CV7202 were well tolerated and elicited rabies neutralizing antibody responses that met WHO criteria in all recipients”

May combine two claims.

In the third participant with clinically significant elevation of bilirubin, the split bilirubin analysis was not typical for MGS, but the participant had a recent symptomatic acute CMV illness; considering the pattern of bilirubin elevations, overall clinical picture and prevalence in Munich, MGS is still suspected per exclusionem and the participant has been referred to their GP for further测试.

“In the third participant with clinically significant elevation of bilirubin results of the split bilirubin analysis was not typical for MGS, but the participant had a recent symptomatic acute CMV illness. Considering the pattern of bilirubin elevations, overall clinical picture and prevalence in Munich, per exclusionem MGS is still suspected in this participant who has been referred to their GP”

May combine two claims.

Lipid encapsulation protects the mRNA molecule in humans and enhances the generation of protective immune responses after two doses in a similar manner to the inactivated control vaccine.

“Having previously demonstrated the concept of mRNA vaccination in humans using rabies glycoprotein as antigen we have now confirmed the preclinical observations that lipid encapsulation also protects the mRNA molecule in humans and enhances the generation of protective immune responses after two doses in a similar manner to the inactivated control vaccine.”

May combine two claims.

Initial studies of the mRNA technology using rabies mRNA, CV7201, found that there was potential for a human mRNA rabies vaccine, but the mode of delivery of the molecule was critical to elicit an adequate immune response due to its known instability in physiological conditions.

“Our initial studies of the mRNA technology using rabies mRNA, CV7201, found that there was potential for a human mRNA rabies vaccine, but the mode of delivery of the molecule was critical to elicit an adequate immune response due to its known instability in physiological conditions [8].”

• cites [8] Alberer M. Gnad-Vogt U. Hong H.S. Mehr K.T. Backert L. Finak G. Safety and immunogenicity of a mRNA rabies vaccine in healthy adults: an open-label, non-randomised, prospective, first-in-human phase 1 clinical trial Lancet 390 2017 1511 1520 28754494 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

Using rabies as a model antigen presents several advantages in this early development program, but the principles being investigated can be applied to other viral pathogens.

“As already mentioned, using rabies as a model antigen presents several advantages in this early development program, but the principles being investigated can be applied to other viral pathogens.”