FOOD AND DRUG ADMINISTRATION

	CENTER FOR BIOLOGICS EVALUATION AND RESEARCH

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	VACCINES AND RELATED BIOLOGICAL PRODUCTS
	ADVISORY COMMITTEE

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	OPEN SESSION

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	THURSDAY,
	JULY 26, 2001

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		The Committee met at 10:55 a.m. at Gaithersburg Holiday Inn, Two Montgomery Village Avenue, Gaithersburg, Maryland, Dr. Robert S. Daum, Chairman Presiding.

PRESENT:

Robert Daum, M.D.				Chairman
Nancy Cox, Ph.D.				Temporary Voting Member
Kathryn Edwards, M.D.			Temporary Voting Member
Theodore Eickhoff, M.D.			Temporary Voting Member
Walter L. Faggett, M.D.			Member
Barbara Loe Fisher				Member
Diane E. Griffin, M.D., Ph.D.		Member
Samuel L. Katz, M.D.			Member
Steven Kohl, M.D.				Member
Martin Myers, M.D.				Temporary Voting Member
Geoffrey Schild, Ph.D.			Temporary Voting Member
Dixie Snider, Jr., M.D., Ph.D.	Member
Mark Steinhoff, M.D.			Temporary Voting Member
David S. Stephens, M.D.			Member
Nancy Cherry					Executive Secretary

	C-O-N-T-E-N-T-S

	PAGE

Call to Order	3

Introduction to Session and Summary of Prior 
VRBPAC Deliberations 	8

Overview of Development of Cold Adapted,
Live Attenuated Influenza Vaccines; Basis
for Attenuation; and Potential for
Reassortment with Wild-type Viruses in
Nature	34

Q&A on Dr. Murphy's Presentation	66

Sponsor's Presentation and Q & A
	Dr. Harry Greenberg	74
	Dr. Steven Black	80
	Dr. Paul Mendelman	94
	Dr. Kristin Nichol	124
	Dr. Robert Belshe	148
	Dr. Harry Greenberg	161

FDA Presentation with Q & A	169

Adjourn	223

	P-R-O-C-E-E-D-I-N-G-S
	(10:55 a.m.)
		CHAIRMAN DAUM:  Good morning.  I'd like to welcome everyone to the continuation of our meeting this morning.  I'd like to welcome both committee members, consultants, sponsors, FDA folks and other interested parties.  I would like to ask everyone to remember that the purpose of this meeting is to hear information and discussion and allow committee members to deliberate and provide advice to the FDA.  
		In order to do that, I would very much appreciate it if cell phones, beepers and other disrupting devices be turned off now, so that we don't have to deal with them as we go along.  I think that we will now turn the floor over to Nancy Cherry who will read the committee conflict of interest statement.
		MS. CHERRY:  Well, good morning, welcome to all of you.  I think they're probably in the process of finding chairs for any of you that don't have chairs.  It looks like most of you found seats.  A couple of announcements; first of all, if there is anything we can do for particularly the committee but also for any of you, the committee management specialist who put together the meeting is sitting at the desk out front.  That's Denise Royster.  She's assisted today by Rosanna Harvey.  Tomorrow she will be assisted by Sheila Langford.  Actually, Denise is in the room at the moment, but anyway.  Now, I'll read the statement.  
		"The following announcement addresses conflicts of interest issues associated with the Vaccines and Related Biological Products Advisory Committee meeting on July 26th/27th, 2001.  Of the Advisory Committee Members, Drs. Manley, Kim and Diaz could not be with us today or tomorrow.  The Director for the Center for Bioligics Evaluation and Research has appointed Drs. Nancy Cox, Kathryn Edwards, Theodore Eickhoff, Martin Myers, Geoffrey Schild and Mark Steinhoff as temporary voting members for the discussions on Friday, July 27th regarding safety and efficacy data as well as the proposed indication for Aviron's FluMistTM.
		To determine if any conflicts existed, the Agency reviewed the submitted data and all financial interests reported by the meeting participants.  As a result of this review, the following disclosures are made regarding the discussions today and tomorrow, July 26th/27th.  Dr. Stephens and Edwards have each been granted a waiver in accordance with current statutes, which these waivers permit them to participate fully in the discussions.  In addition, Dr. Brian Murphy has been granted a limited waiver which will permit him to make a presentation and answer any questions related to that presentation.
		Doctors Daum, Goldberg, Griffin, Kim, Kohl, Snider, Stephens, Edwards, Eickhoff, Cox, Myers and Steinhoff all have associations with firms that could be or appear to be affected by the committee discussions. These involvements have been reviewed, and in accordance with current statutes, it has been determined that none of these is sufficient to warrant the need for a waiver or an exclusion.  In the event that the discussions involve specific products or firms not on the agenda and for which FDA participants have a financial interest, participants are reminded of the need to exclude themselves from the discussions.  Their refusals will be noted for the public record or their disclosures will be noted for the public record.
		With respect to all other meeting participants, we ask you in the interest of fairness, that you state your name and affiliation, any current and previous financial involvement with any firm whose products you wish to comment on.  Copies of all waivers addressed in this announcement are available by written request to the -- under the Freedom of Information Act".  And we do have one disclosure to be made today.
		DR. MINK:  I am Dr. ChrisAnna Mink.  I am the medical reviewer for this BLA.  I joined the review team in January of 2000 and would like to disclose the prior to joining the FDA, I worked as a consultant for Aviron for approximately 40 hours.  I had not performed any consulting activities for Aviron for more than one year prior to my joining your review team.
		My prior association with Aviron was disclosed to the FDA Ethics Office and their review deemed there was no conflict of interest from my participation.
		CHAIRMAN DAUM:  Thank you, Dr. Mink.
		DR. MINK: Oh, it was January of 2001 that I joined the review team.
		CHAIRMAN DAUM:  Thank you again, Dr. Mink.  I would like before we start, Dr. Patriarca's presentation to ask the committee members and consultants to briefly identify themselves.  Dr. Snider, We'll start with you and just go right around.
		DR. SNIDER:  Dixie Snider, Associate Director for Science, Centers for Disease Control and Prevention.
		DR. KOHN:  Steve Kohl, Oregon Health Science University.
		DR. FAGGETT:  Walt Faggett, Pediatrician in the National Medical Association, Pediatric Section.
		DR. GOLDBERG:  Judith Goldberg, New York University School of Medicine.  
		MS. FISHER:  Barbara Loe Fisher, President of the National Vaccine Information Center.
		DR. STEPHENS:  David Stephens, Emory University.
		DR. GRIFFIN:  Diane Griffin, Johns Hopkins.
		DR. KATZ:  Samuel Katz, Duke University.
		DR. SCHILD:  I'm Geoffrey Schild, from the U.K. National Institution for Biological Standards.
		DR. COX:  Nancy Cox, CDC.
		DR. EICKHOFF:  Ted Eickhoff, University of Colorado.
		DR. MYERS:  Martin Myers, National Vaccine Program Office.
		DR. EDWARDS:  Kathy Edwards, Vanderbilt University.
		DR. DAUM:  And I'm Robert Daum from the University of Chicago.  I'll maybe ask the FDA folks who are seated at our table extension to identify themselves also.
		DR. LEVANDOWSKI:  Roland Levandowski, I'm with the Division of Viral Products at CBER.
		DR. MINK:  Dr. Chris Mink.  I'm with DVRPA and CBER.
		DR. GEBER:  Antonia Geber, CBER.
		DR. RIDA:  Wasima Rida, Division of Vital Statistics, CBER.
		CHAIRMAN DAUM:  Thank you all very much.  AT this point I'd like to turn the floor over to Dr. Patriarca as we begin the formal part of the session and have the introduction to the session and summary of prior VRBPAC deliberations.  Peter.
		DR. PATRIARCA:  Thank you, Dr. Daum.  Good morning everyone.  Can you hear me okay?  Does this mouse work?  Okay, thank you.  
		Good morning, the topic of the meeting today and tomorrow involves FluMistTM or as generally known live, that is to say a vaccine that depends on active viral replication in order to be effective, attenuated, that is to say the production of illness on the milder end of the spectrum in comparison to the wild-type, cold-adapted and temperature sensitive which in essence means that the replication of the virus is restricted primarily to the nasopharynx, trivalent, meaning that it has three components, two Type A and one Type B, an influenza virus vaccine.  
		The vaccine is actually made by crossing what is known as a Master Donor Virus with a wild-type virus by co-infecting embryonated eggs.  The results of this, ideally, is what is known as a 6:2 reassortant, meaning that the internal genes are derives from the Master Donor which is attenuated, cold-adapted and temperature sensitive but the outer surface proteins, the hemagglutinin and the neuraminidase, which are important in immunity, are derived from the wild-type virus of interest and of epidemiologic importance.
		The vaccine, again, is a trivalent preparation.  The virus is diluted with normal allantoic fluid, that is to say more or less egg whites, and it is instilled into the nose rather than being injected as other influenza virus vaccines are.  I have three purposes this morning.  One is to orient the Committee and the audience to the presentations that will follow mine.  Secondly, I will focus on some risk/benefit considerations and in particular those that may not be emphasized later on today.  And then importantly, I'm going to review some of the deliberations that took place approximately three years ago in reference to quote, unquote, "generic" live attenuated flu vaccines, but which also included some specific discussions about FluMistTM and its predecessors.
		In talking about the potential benefits of the vaccine, this can be made fairly obvious simply by looking at the risk of wild infection.  As I believe everyone knows, influenza is the most common cause of medically attended acute respiratory illness in all age groups.  There is also a high risk of mortality and other severe complications, particularly in the elderly and other medically risk populations.  And I think very importantly there was the recent, what I term rediscovery of the clinical and public health importance of influenza in children, particularly those age zero to four years.
		There have been a number of recent studies which show that particularly among high risk children in this age group, they have a rate of about 500 excess hospitalizations per 100,000 and even healthy children have 100 excess hospitalizations per 100,000, and these are approximately four times the rate of other age groups.  So, clearly, the impact of influenza in this country and elsewhere is enormous.
		Now, it's important when we talk about  FluMistTM that there are some special challenges that pertain to this particular vaccine and vaccines like it that don't necessarily apply to other vaccines.  First of all, again, to emphasize that this involves the purposeful administration of a live replicating agent and indeed, the vaccine will not work unless it replicates.  Secondly, we're talking about an unusually large target population.  And, in fact, Aviron has requested an indication for persons age 1 to 64 years, which in this country is in excess of 200 million.
		Thirdly, annual vaccination is required.  In contrast to the other vaccines other than inactivated influenza vaccine which generally require only a few doses or a series of doses with periodic boosters, this will require annual vaccination.  Next, annual reformulation is very likely because the influenza strains, as everyone knows, tend to change over time and it's very likely that the vaccine will vary from year to year.  and then finally, there is, as everyone knows, a licensed product specifically inactivated influenza vaccine, which has been licensed in this country and used for approximately the last 50 years which does have a very long-standing history of safety and efficacy.  
		Now, talking in general terms about live virus vaccines, one can think of the risks and benefits utilizing a matrix and in this matrix on the vertical access, we have risks at the bottom, benefits at the top and then we have four components to this, each of which contribute some degree of risk and benefit.  The first are the vaccine strains and the cell substrate used to produce the vaccine.  The second component is the manufacturing process and the consistency of that process.  The third is what happens to the host, the vaccinee and then particularly with a live vaccine consideration has to be given to the potential for transmission of the vaccine to other people.  So let's take these in order.
		As far as the benefits are concerned, what this vaccine is intended to do is to provide an antigenic stimulus to the immune system to produce the appropriate immune response and with this live virus vaccine, it is intended to produce an immunity which is very similar to natural infection which, of course, goes beyond the immunity that's induced by the inactivated vaccine and this immunity ideally is both homologous, that is against the virus to which you're being immunized, but also some heterologous protection, that is to say some cross-protection with variance that might be closely related.
		Now, on the risk side, though because this is a live product, it will necessarily contain some degree of reactogenicity as you will hear later on today and importantly it also carries a risk, particularly in a live product, of carrying exogenous or endogenous adventitious agents.  And with this vaccine, it's important to point out that whereas the vaccine is produced in eggs which are known as specific pathogen free eggs, the wild virus donor is not necessarily and in most cases will not be obtained from one of these eggs.
		In other word, these isolates come from Asia and from clinics all over the world and generally the, if you will, run of the mill eggs are used for the isolation of those viruses, so there is some possibility then, that these agents could be transmitted and end up in the vaccine.  
		Now, with regard to the manufacturing process, it's particularly critical and especially for this vaccine, which has the chance of changing every year, that the purity, potency and consistency, this is sort of the triumvirate of every vaccine, are very closely maintained.  And so these three components are essential.
		On the risk side, there's always the risk of contamination during the process of manufacturing and importantly for this vaccine, one is concerned about genetic instability.  Influenza is a very highly mutable virus and if certain changes occur in the genetic constitution, it could have an adverse effect on attenuation and attenuation is a very key word that we'll talk about repeatedly today that should be kept in mind by everyone and there may also be some changes in antigenicity.
		There is also a residual cellular DNA that can come from the cell substrate, in this case the eggs and also residual egg protein to which, as everyone knows, a small percentage of the population is allergic.  In considering the  host response, I've already mentioned that influenza virus vaccine and as you will hear later today, this also applies to this vaccine, has a very large potential to substantially reduce infection, due to wild-type virus, shedding, once wild-type virus exposure occurs, and importantly, illness, complications and mortality.
		On the other hand, there are also some adverse effects that can occur with the host response.  These include both acute and delayed adverse drug reactions.  There is the potential for reversion of this virus, a change in the attenuation properties of the virus.  There's also a possibility of immune selection, that meaning that this virus may not necessarily induce heterologous protection but rather just amplify the homologous response or previous response that the recipient may have had to a prior influenza infection.  There's also the possibility of immune interference between the types of the vaccine and this will be discussed a little bit later on, and then finally there is concern about allergic reactions, again because the viruses are diluted with normal allantoic fluid that is administered intranasally.  
		The final component, transmission to contacts, it has been arguably stated with oral polio vaccine being the prototype, that immunization -- that indirect immunization is actually a positive benefit of a live virus vaccine.  But in this case, in the influenza case, this is probably not a desirable property and this is for two reasons; one, there might be a greater chance of reversion in the virus, that is to say a switch to a more virulent form once its passage in  humans, if you will, rather than eggs and there is also a possibility of reassortment with wild-type virus. 
		And these are respects and particularly genetic instability, attenuation that will be covered in detail by Dr. Murphy in a few moments.  Now, in November of 1998 this committee met and there are some persons still on the committee from that time, and we do have also some cross-overs of some of the consultants.  And in that meeting, there was a discussion about quote, unquote "generic" considerations pertaining to live attenuated influenza vaccines, not necessarily just FluMistTM and there were four main topics that were discussed.  
		One has to do with containment of the virus basically at the manufacturer's site.  Second has to do with the maintenance of attenuation of the vaccine virus, third the potential for the vaccine virus to reassort with wild-type influenza viruses and then finally the risk of allergic reactions due to primarily the administration of egg protein but also the potential risk for bacteria super-infection.  What I'd like to do now is quickly go over these four things in a slightly different order.
		The first thing I'll talk about is containment.  The issues involved here are the potential release of essentially the Master Donor Virus which is an H2N2 virus.  Some of you may remember this as a so-called Asian influenza that circulated between 1957 and 1968 and was especially virulent, also the B Master Donor Virus which also has genetic properties that are unique to that.  So what are the chances of this thing -- these viruses being released into the environment, into the general population and could that pose a problem? 
		Secondly, the issue was raised about the manufacturing of the live attenuated influenza vaccine that had a novel hemagglutinin or neuraminidase and this would be done as part of a pre-pandemic exercise where one might before the pandemic actually hit the United States, try to manufacture a vaccine for potential use.  The opinion of the committee and the consultants was that these issues were not considered to be problematic, that these viruses had been used in a number of laboratories and manufacturing facilities now for 30 plus years and that there had never been an instance where these things were released and moreover, generally, whenever one uses either these viruses or particularly viruses with novel hemagglutinin and neuraminidase, these require a very high level of biosafety that is very strictly enforced.  So containment in the opinion of the committee at that time was that this was not a problem.  
		The second issue is hypersensitivity reactions and bacterial super-infection.  The issues there, once again, are the repeated administration, the annual administration of egg protein intranasally which, as everyone knows, is not a natural root of exposure.  This pertains to the allergic component.  As far as bacterial super-infection is concerned, the concern here is that even though this is an attenuated virus, it does involve active replication.  And it was shown particularly with the H2N2 virus, the wild H2N2 virus, that this virus is prone to de-epithelialize the respiratory tract.  It can also interfere with ciliary function and importantly not only the H2N2 but other influenza viruses can interfere with the function of polymorphonuclear leukocytes which are very important in immunity against bacterial infection.  
		In the opinion of the committee at that time most people believed, although there was some question, that any egg protein administered intranasally would probably be cleared prior to the point that the virus would actually replicate so this was not seen as a problem.  And as you will hear later on this afternoon, Dr. Mink and perhaps Aviron, too, will address the issue of hypersensitivity reactions with actual clinical data.
		And the other opinion regarding bacterial infections is for a variety of reasons that the committee opined that these were probably more likely to be prevented than caused.  And again, there will be some information presented this afternoon regarding this.  There are some data that are now coming to light.  
		The third issue was introduction of new viruses into the environment in the form of live attenuated influenza vaccines.  The issues here, again, are the purposeful introduction of genetically modified influenza viruses into the general population and secondly the potential for these viruses to reassort with wild-type influenza viruses to potentially, potentially create more virulent human strains that have not circulated before.  Now, in the opinion of the committee, they determined, and you will hear information pertaining to this today that the transmission, when it occurs, appears to be very limited and as Dr. Murphy will talk about a little bit later, the progeny of that transmission, those viruses will also, very likely if not solely, be attenuated rather than more virulent.
		Secondly, Dr. Cox may want to mention this later on, but Dr. Cox and her colleagues at CDC have been involved over the years with an extensive evaluation of another live attenuated flu vaccine in Russia derived from a strain called A/Leningrad which is different from the A/Ann Arbor that we're discussing today, but nevertheless, this has been looked at repeatedly by her group and there's no evidence at least that they've been able to determine, that there's been circulation of genes derived from this vaccine in Russia, despite having been in use for many years. 
		Now, despite this positive opinion, there was the lingering concern that genetic modifications cannot be ruled out and with influenza being a very unpredictable agent, in and of itself, anything can and will go wrong.  So this still remains a concern and I believe that Dr. Murphy will probably also cover this during his presentation.  Now, Item Number 4 was the degree to which we could be assured that this vaccine would always be attenuated no matter what the conditions upon which it was made, no matter what wild-type virus was used.  
		And again, the issues are being sure that this so-called 6:2 reassortant strain, no matter what it is, is always going to be attenuated.  The second concern is that animal models, to address this, particularly the ferret, traditional animal model, has been less than ideal.  Part of the reason for this is that the ferret's body temperature is higher than the body temperature of a human and because the virus is cold-adapted then, and temperature sensitive, the ferret may not reveal all that you might like to be revealed in determining attenuation.
		And then importantly, as is true for almost all other live attenuated vaccines, the genetic basis of attenuation is generally unknown.  So n the opinion, and this is an important opinion which the committee should reconsider today, and will have the opportunity to reconsider during the discussion period, is that there was a consensus that ideally there should be annual human testing prior to widespread distribution of the vaccine.  That having been said, there was also discussion of the approach and logistics and there was some wheel-spinning and no real conclusion to this was determined during that particular meeting.  
		Now, it's important to know that in addition to these concerns, we also have some other issues involved with this vaccine.  First, as you will see later on, there is a difficulty in assessing the true reactogenicity of this vaccine, primarily because the quote, unquote "placebo" was not an inert substance.  In fact it was allantoic fluid and as you will hear later on, there was a very high degree of reactivity in the control group.  Second, we have to be concerned as we do with any vaccine, about rare and uncommon adverse events.  And these really fall into two categories that can really only be determined once the vaccine, if licensed, is used on a very large scale basis.
		One can think about a slightly more common adverse event such as pneumonia, bronchiolitis, bronchitis, croup, sinusitis and even otitis media.  But more importantly and concerning are that influenza wild-type virus infection can also lead to a series of rather severe complications.  These include toxic shock syndrome, myocarditis, pericarditis, rhabdomyolysis, encephalopathy, encephalitis, Guillane-Barre Syndrome, and there might also be the possibility of developing thrombocytopenia as has been demonstrated with MMR vaccine.  This is because the virus is grown in an egg substrate.  There might be antibodies produced against one of the surface receptors, the vitronectin receptor which can cross-react with receptors on the platlettes and thereby lead to thrombocytopenia.  So whether or not these events will occur with this attenuated, and I have to emphasize that again and again and again that this is an attenuated virus, we don't know yet.  The presumption is, is that all of these adverse events will occur at a much less frequency than it will with wild-type but that remains to be determined.  
		Another issue has to do with repeated and again annual dosing.  There are two concerns here.  One is might there be potential adverse immunologic consequences of giving a live as opposed to an inactivated virus vaccine from the standpoint of what is known as quote, unquote "original antigenic sin", also know as quote, unquote, "the Hoskins effect", which was described by a physician in England some number of years ago which basically suggested that if you repeatedly vaccinate someone that basically what might be involved is you simply reinforce the antibody response that they had to some previous infection and you don't really update their antibody very well.  
		Now, this issue has, in fact, been considered at great length by a working group by the ACIP and at least in the opinion of that group, this is only a theoretical concern and it not likely to be a real concern.  The other issue with repeated annual dosing pertains primarily to seropositive persons and especially adults and specifically as you will hear later on, this virus replicates very poorly or even not at all in persons who have previous immunity.  So the question here becomes bang for the buck.  If you vaccinate people annually, if they really don't need it, and there's no way of knowing whether they need it, there will be some proportion of people then who will not have essentially any benefit but who might also have some risk associated with that.  So this is also a general concern.  
		Two other concerns, first, as you will hear later, although the vaccine, the indication for the vaccine is for children as young as one year of age, Aviron does not yet have information on the responses when the vaccine is administered with other childhood vaccines nor to they have information on co-administration of this vaccine for travelers.  Travelers is one of the indications they've asked for.  Traveler, foreign travelers often receive other vaccines but there is no information about that at the moment that has been submitted to the FDA. 
		And then finally, an important consideration as you will hear later, is that there's very limited experience in high risk groups.  You will hear some information on HIV-infected persons. You will hear some information about small groups of asthmatics but in general there's a very limited experience in people with pre-existing medical conditions who might be more susceptible to the effects of this attenuated virus than would the normal host.  
		So in summary, I hope I've made it clear that the task before the committee is going to be very difficult, that this vaccine poses very complex benefit/risk considerations.  These complex considerations apply not only to this committee and to us at the FDA, but also recommending bodies, the ACIP, that AAP and so on.  Secondly, just to emphasize that the principal focus of today's discussion is going to involve clinical considerations and virtually all of the presentations you'll hear this afternoon will pertain to that.  
		I just want to re-emphasize that there are other important issues pertaining to this vaccine.  There are some manufacturing issues which cannot be discussed during this session, which are still under review and in consultation with Aviron.  There's the attenuation reversion problem which Dr. Murphy will cover in great detail.  I presume that he will also talk about potential for transmission and also reassortment with other viruses in nature.  And then finally, just to emphasize this again, that there's very little information about the use of this vaccine in populations that are medically high risk.  
		Now, what I wanted to do, what I've been asked to do by Dr. Midthun is before I end, is to review the questions that the committee will hear tomorrow if that's okay, unless you want to ask me questions now and then present the questions after that.
		CHAIRMAN DAUM:  I think it might be nice to hear if the committee would like clarification of points that you made first, if that's okay.
		DR. PATRIARCA:  Okay.  
		CHAIRMAN DAUM:  So why don't we open up your presentation to the committee at this point for clarifying questions, concerns, comments?  Dr. Katz?
		DR. KATZ:  I don't know if this question is best addressed to Dr. Patriarca or perhaps to Dr. Arcuri.  And you've referred several times to the fact that you're concerned about allantoic fluid which is used as a diluent.  Why it is used as a diluent?  Is it a stabilizer or does it in some way adjuvant?  What is the choice of allantoic fluid as the diluent?
		DR. PATRIARCA:  I'd like to refer that to Aviron.
		CHAIRMAN DAUM:  If we can get a response to it, that would be great.  If not, we'll defer to this afternoon.
		DR. ARCURI:  It will be a very brief response.  Basically, allantoic fluid was used as a diluent to assure a constant level of background protein so that you didn't have variation from virus formulation to virus formulation because as I said, potencies can vary, so the amount of virus you add will vary depending on the potency of the strain.
		CHAIRMAN DAUM:  Thank you.  
		DR. SCHILD:  I have a question.  In your presentation, you're making the assumption that every time you need to change the composition of the inactivated vaccine it will be necessary also to change the composition of the any live future live vaccine.  I mean, that could be a point of discussion, whether the immunological properties of a live vaccine differ significantly from those of an inactivated vaccine.
		DR. PATRIARCA:  Yes.
		DR. SCHILD:  Which suggests that you might change less frequently or more frequently or what?
		DR. PATRIARCA:  Yeah, your point is very well taken, Dr. Schild.  Yeah, that's absolutely right.  I don't think we know whether it will, in fact, in practice be necessary to change this vaccine just as we do the inactivated vaccine, a point well taken.
		CHAIRMAN DAUM:  I'd like to ask, some of the issues you raised, Peter, go to the need for ongoing interaction with the agency, the vaccine, the general public, ongoing issues but efficacy was not one of the things that you mentioned and I've actually been on my high horse a long time about what I feel is a need to have ongoing monitoring of the current influenza vaccines in terms of their annual efficacy.  How do you see this new vaccine potentially as being monitored in that regard?  Are there any concerns?
		DR. PATRIARCA:  I'll try to answer that although perhaps Nancy Cox or Dixie Snider might also want to answer that because I think this is primarily an issue which pertains mainly to CDC but the way that we've worked that with inactivated vaccine is we now have this historical data base where there have been a number of primarily ad hoc vaccine efficacy studies that have been done over time and also a number of retrospective analyses and these analyses do give us a lot of confidence that when there is a good match between the wild strain and the vaccine strain, that the vaccine -- the inactivated vaccine has a very reproducible rate of efficacy.
		The question might then be raised should another system be in place for this vaccine?  Is it considered sufficiently different, how would that be done?  Whose responsibility would it be to set up those studies and personally, I believe that those are issues that should be discussed by this committee.
		CHAIRMAN DAUM:  I would agree and maybe I will pick up the theme again when we have more general discussion.  Dr. Kohl, please.
		DR. KOHL:  I would strongly agree with that and in terms of this committee picking up that issue and this vaccine in particular, regarding the other flu vaccines in which the indication age-wise is much broader and every year when we discuss flu vaccine we talk about the lack of good studies in children, the question of efficacy in children and immunigenicity and it seems to me with essentially starting a new ball game here, that it's critical that we bring some of that stuff in at the beginning instead of next year and 10 years from not saying, "Gee, wouldn't it be nice if we had studies in pediatric populations and other high risk populations as well".
		CHAIRMAN DAUM:  Thank you, Dr. Kohl.  Other committee comments regarding clarifying points with Dr. Patriarca's presentation?  One last, Dr. Edwards.
		DR. EDWARDS:  The license application, does it state that the strain collection will be comparable to what is used in the inactivated vaccine or is that not stated in the license application in reference to your -- in reference to the comment earlier?
		DR. PATRIARCA:  I believe it says that the strains are going to depend on what this committee decides but I'll ask Roland Levandowski to be sure about that.
		DR. LEVANDOWSKI:  That's my understanding, too. I  can't quote you what is says exactly in the BLA but the intent has always been that the strains that are used in the live attenuated vaccine will reflect the hemagglutinin and the neuraminidase of the current circulating strains and that's been the strategy that's been used in producing vaccines to this point.  It doesn't necessarily mean that the strain would be identical to the one that's in the inactivated vaccine, because it wouldn't need to be but would be consistent with what the recommendations would be generally for currently circulating viruses.
		CHAIRMAN DAUM:  Very interesting potential consideration as to what this committee's discussion would look like in a live attenuated vaccine era.  Thank you very much, Dr. Patriarca, for your usual crystallizing and focusing comments.  And we'll move on now to hear from Dr. Murphy.
		DR. PATRIARCA:  Well, actually -- 
		CHAIRMAN DAUM:  Oh, I'm sorry.
		DR. PATRIARCA:  -- yeah, Dr. Midthun wanted to briefly go over the questions.
		CHAIRMAN DAUM:  Would you please do that?
		DR. PATRIARCA:  Just so everyone will keep these in mind as the presentations go forward.
		CHAIRMAN DAUM:  My mistake.
		DR. PATRIARCA:  And I'm hoping that AV guys realize that this is going to happen or supposed to happen.  
		CHAIRMAN DAUM:  That will quickly be apparent.
		DR. PATRIARCA:  Okay, so, let's see, we're still 15 minutes behind.  Sorry about that.
		CHAIRMAN DAUM:  That's okay.  It was very helpful.
		DR. PATRIARCA:  I actually don't have -- maybe I could start reading the questions until the slides come up.  I don't have a -- okay.  So what I'd like to do is just briefly go over the questions.  These have been, right, Nancy, distributed as part of the package that's available to everyone, is that correct, including the people in the audience?  Is that correct?  Okay.  
		We're going to have two questions for the committee tomorrow and we're also going to have two discussion points.  Oops, here we go.  Okay, the first question pertains to efficacy; "Are the data adequate to support efficacy of FluMistTM in pediatric and adolescent populations, that is to say 1 to 17 years of age?  If so, please discuss the appropriate schedule, i.e., one dose versus two doses.  If two doses are recommended, please discuss the age range for this regiment and the recommended timing of the doses.  That is to say the interval between doses".
		And then secondly, "The adult population defined here as age 18 to 64.  In your discussion, please address the adequacy of the challenge data submitted in support of efficacy against H1N1".  As you will hear later on this afternoon, there is no clinical data pertaining to the efficacy of H1N1 and so, you'll be hearing about some challenge data later today.  
		"If the data are not adequate for specific age ranges, please discuss what additional data should be requested".  The second question pertains to safety.  "Are the data adequate to support the safety of FluMistTM in the population in which an indication is being sought, namely 1 through 64 years of age?  Please discuss the adequacy of the data in subjects less than two years of age in the overall pediatric population, in adolescents and in adults, specifically adults greater than age 50.  If the data are not adequate for specific age ranges, please discuss what additional data should be requested".
		The third item is a discussion point not a voting point.  "Please discuss the need for data on concurrent immunizations, for example, in children and in travelers".  And then finally the fourth point, "Please discuss any additional concerns and/or data that should be requested; for example, use of this vaccine in high-risk subjects; secondly, annual re-vaccination in adults; thirdly, the assessment of attenuation; fourthly, the potential for transmission or reversion of vaccine strains and then finally, the potential for reassortment of vaccine strains with wild-type influenza viruses".  
		CHAIRMAN DAUM:  Now we'll say thank you and ask Dr. Brian Murphy if NIH to provide us with an overview of development of cold-adapted, live attenuated influenza vaccines, the basis for attenuation, potential for reassortment with wild-type viruses in nature.  Welcome, Dr. Murphy.
		DR. MURPHY:  Can you hear me?  Is this on?  Can you turn this on?  Okay, there we go.  I want to thank Peter for asking me to come and speak today.  I've worked on live attenuated influenza virus vaccines from 1970 through 1955 -- up through 1995.  I hope the rest of the talk is clearer than that particular statement.  And it's based on this experience and a lot of personal experience with the cold-adapted viruses that I'm talking today. 
		My current position is, I'm the Co-chief of the Laboratory of Infectious Diseases at NIH and we are -- we're working on other vaccines currently.  
		Now, this talk is going to be in three parts.  The first part is about a five-minute overview of the salient points of the biochemistry and biology and epidemiology of influenza viruses.  The second is I'm going to talk about the cold-adapted viruses and the third part of the talk is to address the concerns of what are the potential for rassortment of the cold-adapted virus genes with wild-type viruses, what are the potential complications of such interactions.
		So to start off with the introduction of the biology of this virus.  Influenza virus has a segmented genome.  It codes 10 proteins.  There are the polymerase proteins that are involved in transcription and replication.  Hemagglutinin protein is responsible for a binding infusion.  The NA protein is responsible for -- probably for a little bit of penetration but clearly for release.  This is part of the transcription complex and is a structural protein.
		The M1 is a membrane protein, structural protein.  The M2 is also a structural protein.  It's the ion channel that's required for successful penetration and initiation of infection.  NS1 is an interferon antagonist.  NS2 also known as the NEP or nuclear export protein, is a structural protein that's involved in getting the influenza virus replication complex out of the nucleus and into the plasma membrane where these viruses undergo assembly.
		Okay, the major property, one of the reasons we're here today, is that this virus undergoes genetic reassortment and two viruses infect a cell, it replicates and then viruses bud and they can have genes from either parent.  This is the genetic basis of the generation of the new pandemic influenza viruses.  It's also the genetic basis for the techniques that's used to make the live attenuated virus vaccines.  The influenza viruses are acute infections of man.  They grow to a pretty high titer.  We've seen titers as high as 107, in the  nasopharyngeal specimen as it comes down and antibody response, but the important thing is it's an acute infection.  It doesn't stay around very long and after day 10 to day 15, the virus is really gone from the body in contrast to herpes and HIV which have a long lasting association with humans.
		Now, this is really a crucial slide because based on a tremendous amount of work that's been done, that quantitates the amount of virus replication and the illness that's associated with that.  You can make a curve that shows that the amount of virus replication, high levels of virus replication, and here if you can't see this, this level of virus replication is 106.  People who have this amount of virus will have high fever, signs of lower and upper respiratory tract illness.   
		Okay, this is very important.  The sickest I've ever been in my life is when I had the Hong Kong flu in 1969.  I was normal at 10:00 o'clock in the morning, had a 105 fever that evening.  I would have had this amount of virus present in my nasopharynx.  Now, very importantly for the live virus vaccine is the fact that low levels of virus replication are associated with attenuation.  You can nicely infect individuals without the occurrence of significant infections.  As you'll see, the cold-adapted virus we're talking about and all the reassortants generated from it replicate in this range.  
		Wild-type viruses generally have a pattern of replication like this.  The cold-adapted vaccine in seronegative children replicates around three lives, up to around 10 days of replication.  The vaccine in seronegative adults replicates to a lower peak titer and for a shorter duration, indicating the effect of immunity, even if these volunteers are selected for lack if antibody to the hemagglutinin and they'll still have a decreased level of replication.  The CA vaccine in the elderly, this particular set of patterns of replication to some extent dictate how these vaccines can be most efficiently used, very highly immunigentic, much more so than inactivated vaccine in the seronegative child.  In the elderly they'll definitely have a role, I'll discuss that subsequently, in seronegative.  It also grows in seropositive adults and immunized seropositive adults. We'll talk about some of the results of efficacy later.
		Now, the virus undergoes two types of antigenic changes, antigenic shifts, antigenic drifts.  The antigenic shift is simply picking up a novel hemagglutinin gene from the population of birds, generally and it becomes substituted for the current influenza virus strain.  Antigenic drift is just a change in various antigenic sites that dot the hemagglutinin and generally two or three of these sites are changed every two or three years.  That's why you have the need to update the vaccine. 
		The influenza vaccine takes advantage of the -- of this ability to undergo gene reassortment, make two viruses and you isolate what we call the 6:2 reassortant.  All the genes from the attenuated donor virus, the new altered either antigenic shifted or antigenic drifted glycoproteins from the drift virus.  Now, the immunity to influenza virus is basically pretty straightforward.  It's generally antibody-mediated.  Resistance to infections antibody-mediated.  Antibodies that are -- the virus stays pretty much confined to the epithelial cells of the respiratory tract.  Antibodies have to be operative in the tracheal and lumer of respiratory tract and the role of the antibodies is to prevent infection, try and keep down the number of cells that are infected.  Antibodies that diffuse from the serum or those that are produced locally either IgG or IgA participate in this resistance.
		Extensive studies that look at it have clearly demonstrated the role for protective antibody, a protective role for antibodies directed at the HA serum, both IgA and IgG nasal washes can independently contribute to resistance NA as well, clearly a role for serum antibodies, much less is known about this.  The importance of this is that this very complicated two antigen nature of protective immunity, multiple compartments, multiple isotypes within compartments, it's almost impossible to predict by doing a simple serologic assay what factor is going to be associated with immunity. 
		Now, what I'd like to do now is to talk about the cold-adapted virus, major concepts underlying the development of this cold-adapted A or B virus.  And what I'm going to be talking about is the demonstration of the transfer of the six internal segments from the cold-adaptive virus to each new epidemic virus confirms the properties of cold-adaptation, temperature sensitivity and attenuation of genotypes, that this specifies a satisfactory level of attenuation in humans and it provides the efficacy that is necessary.  
		I believe that this -- that the amount of information that exists, the extensive study that is done with this indicates that there's enough information that's available to preclude much testing on an annual basis and that what we're really looking at is whether the licensure for this should very seriously consider licensing the process, not just the vaccines that are ultimately made.  
		Now, the derivation of the cold-adapted Ann Arbor, the A component, this was done by Dr. John Maassab and he passed the viruses at gradually lower temperatures in primary kidney (phonetic) and derived a virus, cloned it, and by passage at 25 degrees and isolated a donor virus.  This passage history about 30 passages in PCK, an it is shown to have a ts phenotype, a ca phenotype and an attenuation phenotype in ferrets.  This virus has been sequenced and compared to the sequence of the Ann Arbor 6/60 donor virus.  There's one mutation in the PB2 gene, four mutations in PB 1, three in PA, several in NP, one in the M2 gene and one in the MS1.  These are the genes that are thought to be associated with attenuation of this virus.  
		I'll provide more information on the three polymerase proteins and at least the M2 protein as well.  Now, the ts phenotype of the Ann Arbor A, HAH2 donor virus, these are the phenotypes.  If you look at the level of replication of -- level of replication at 25 degrees, the CA virus grows very efficiently at 25 degrees, wild-type virus don't.  Thirty-three degrees both viruses grow well.  The CA virus is restricted in its replication at 39 degrees.  This is the temperature sensitive phenotype.  
		The B donor virus was derived in pretty much a very similar way, passing it, lower temperatures deriving a virus at the ts/ca and attenuation phenotypes.  This virus has been sequenced.  There were an enormous number of differences between the CA and the wild-type virus from which it was derived.  So then they just compared what were the differences of the sequence of the B, the cold-adapted virus from other -- all the other wild-type B viruses that were analyzed at the time and it has a similar pattern of sequence changes.  
		This is the gene, only gene, that's unequivocally been identified to be associated with attenuation as far as I know at this point in time.  Almost certainly these other genes are involved as well.  This virus has a very similar spectrum of phenotypes as the Ann Arbor donor virus.  It is -- the wild-type virus is restricted replication at 25 degrees.  The CA virus replicates efficiently at 25 degrees, again replicating at 33, highly restricted replication of this at the -- at a restrictive temperature. 
		Now, here is some of the data from ferrets, just to give you an idea.  Here's the wild-type virus.  Here's the CA derivative of this.  It grows very nicely in the nasal turbinates, it's definitely less than the wild-type but still there, highly restricted in the lungs.  The B/Texas wild-type virus, again, replicating very nicely in the nasal turbinates, growing in the lower respiratory tract.  Here was have the CS donor virus containing the six genes from the cold-adaptive virus, glycoproteins from this, very restrictive in replication in the lungs and replicates about 10100 fold less in the upper respiratory tract.  
		Now the B virus has also been studied in hamsters and chimpanzees.  The virus is highly restrictive in replication of the lower respiratory tract of chimpanzees.  This is the B/Ann Arbor.  This is a reassortant virus.  This is very important.  People are always concerned about what will these viruses do in the lower respiratory tract of humans, et cetera.  The people have not done pulmonary lavages on individuals who have been administered the live attenuated virus vaccines, but we put both the Influenza A and the Influenza B reassortant into chimpanzees and the replication to lower respiratory tract of chimpanzees is very restricted and it's just -- it's very restricted, almost not recoverable on most of the days that were sampled.
		This is the level of attenuation of the B/Ann Arbor virus.  Oh, I think I actually -- this is a mistake.  This should be that A/Ann Arbor/6/60 viruses. It's basically identical.  The level of replications of the -- okay, I don't have the data on the -- I don't have the data on the ferret data with the A/Ann Arbor/6/60 viruses but it's identical to that what I've showed you for the B/Ann Arbor virus. 
		What I want to do now is review with you the properties of the CA reassortants in humans and the properties that have been systematically examined over a very prolonged period of time with the level of attenuation, its infectivity for humans, genetic stability, transmissibility, and efficacy.  Efficacy's been studied in individuals of different ages.  We're talking now mostly about monovalent vaccines.  None of the studies I'm going to be talking about are studies that are the formulation of the trivalent vaccine that you're considering.
		Attenuation, the summary of the results, these are highly attenuated for seronegative and seropositive individuals, you need 107 viruses to be infectious.  The ts and ca phenotypes are very stable.  The virus is poorly transmissible.  It's very immunogenic in infants and young children, much more so than the inactivated vaccine.  Young adults, live and activated vaccines look alike.  Elderly, the live is weakly antigenic but the live plus the activated is more efficacious and I'll show you some data suggesting that.
		Now, this is how we did the -- how we looked at these viruses.  We did challenge studies in adults who were selected for seronegativity to the hemagglutinin present in the cold-adapted virus.  You might not be able to see this but we looked at two influenza H3N2, two viruses and two influenza H1N1.  We looked at the wild-type virus which is this bar or the CA virus and this is the percent of the systemic illness and I think you can see in each case we were very nicely able to reduce the illness that's associated with wild-type influenza viruses by generating reassortants that contain the six transferrable genes from the A/Ann Arbor/6/60 donor virus.
		Level of replications are very similar to what I've described earlier.  Each of the wild type viruses grow four or five logs, the live attenuated, mean peak titer in seronegative adults around 1 to 2 logs.  Okay, this is really the basis of attenuation of these viruses.  They replicate less well in the respiratory tract of humans.  Similar analysis has been done for the B/Ann Arbor CA reassortment viruses.  The -- we looked at the mean peak titer replication in adults and children but the variety of the B/Texas virus, the B/Ann Arbor/60, A virus or the B/Yamagato (phonetic), these are all 6:2 B reassortants.  In each case the wild-type virus was replicated much more efficiently in the upper respiratory tract of adults and the wild-type viruses were not put in children but these levels of replication of the viruses of the cold-adapted viruses, cold-adapted B viruses that have been evaluated in children have been to the same levels of those that we've seen with the cold-adaptive influenza A virus, same levels of replication. 
		Now, what are the genes of this virus that are associated with attenuation?  The way we went about and the way this has been studied by others is you take a wild-type virus, you mate it with your cold-adapted donor virus and then you isolate reassortants.  We isolated reassortants that derived one gene from this virus, from the donor virus and the contacts of wild-type genes from the -- and this way you could describe the phenotypes of this virus to the gene derived from your cold-adapted virus.  We did this, we actually made volunteer pools up of each one of these -- each one of these preparations, put them in humans and did very careful comparisons with the wild-type virus to try and get an idea of which of the genes are associated with attenuation.  
		From this analysis, first of all we were interested in determining which of the genes were associated with ts and ca phenotypes.  And this actually -- this actually -- we got a very clean reading based on this.  The cold-adapted phenotype is specified by a single gene, a PA gene.  We will see subsequently that this also an attenuating gene.  The ts phenotype is independently specified by the PB2 gene and the PB1 gene.  Okay, so this is the genetic basis of two phenotypes which are associated with the attenuation phenotype.
		Now, these six single gene reassortments were also looked at for their level of replication in ferrets, hamsters and humans.  The level of replication in ferrets and hamsters of the two viruses bearing the ts mutations were clearly significantly restricted here.  We had a difficult time testing for significant restriction in humans but these were both lower in their level of replication.  P18 was clearly attenuated as a single gene in both the ferrets and humans.  And then the M gene was attenuated in ferrets and humans.  I think that this virus has a -- at least four genes that are associated with attenuation in humans, the three polymerase proteins and the N proteins.
		We also had the opportunity to investigate in humans a reassortment that just had this gene and this gene.  It was a non-temperature sensitive virus but it is just as attenuated as the six gene reassortant virus.  I think this virus has redundant mechanisms of attenuation that are conferred by the -- this set of ts genes and then non-ts mutations.  I think this is very important because the high level of genetic stability that's exhibited by this virus.  I don't think we've ever seen a revertant in testing this over a very long period of time attests to the fact that it has multiple genes contributing to attenuation.  When you test a virus that's just temperature sensitive, it reverts very readily. 
		It's the combination of the ts and then the non-ts mutations that contributes to the high level of genetic stability of this particular virus.  And this is true for other viruses that have been evaluated in this way.  I don't think we'll -- this just gives you a schematic look at -- you take the NR donor virus and you look at what -- these are the mutations that are present in the PB2 gene, the PB1 gene and the PA gene and the attenuations.  I also have the M gene on this.  It has mutation at M2, so there are at least four independent mutations on different genes that contribute to the attenuation phenotype for humans.  
		Which of these mutations or whether more than one or two contribute to the attenuation phenotype, which of these contribute to the CA phenotype remains to be determined.  Now, the property of infectivity, what's known about that, infectivity, you simply take a influenza virus, you dilute it out and you test the frequency of infection looking at either the shedding a virus or the antibody response.  You determine this.  You determine a human infectious dose 50 and you look at the large set of data that's been derived doing this for both the Ann Arbor/6 -- the H1N1 virus, the H3N2 and this, of course, is the A group we're looking at here.  
		In adults, the mean infectious dose 50 is around 103.5/5.7.  When you give 107 of this virus which is generally the amount of virus that's given in the vaccines, you're giving approximately 10100 human infectious dose 50 of the virus.  The infectious dose 50 in children is a little bit less and therefore 107 of the virus is -- represents around 100 to 500 human infectious dose 50's.  The same type of information exists for B CA reassortments, the adults, the human infectious dose 50.  Two studies have been done 55, 65, which is around 106.  In children it's around 103.5.  
		Safety and level of virus replication, I've talked about the level of virus replication data on genetic stability.  There are various ways of determining genetic stability.   One is you can determine the genetic basis of attenuation.  I've described some efforts to do that which has been pretty successful for the sub-group A viruses.  You can identify surrogate markets of attenuation, the ts phenotype and ca phenotype.  This has been done and this is predominantly the method that's been used to look for the viruses and characterize the viruses that have come out of infected vaccinees.  
		Let me just go back here.  Excuse me for a second.  You can also do other things.  If a vaccine actually has an altered phenotype, you can take that virus out, do some clonal analysis of it and do a variety of things to determine whether the phenotype is associated with -- has been altered following replication.  I can tell you right now that all the work that's been done and we did a lot of this, and this is actually -- this particular virus was a competitor for viruses that I was working on at the time and I'm doing all these studies with this particular virus and I've never seen an unequivocal loss of the ts and ca phenotype that went to wild-type level and any virus that has shown an alteration in its level of temperature sensitivity, when it was put back into the ferret, it maintained -- this study was done by John Maassab, it always maintained the attenuation phenotype.
		So there's never been a situation where the virus that's been given to a human has been carefully analyzed, the virus coming out that's been associated with the loss of attenuation phenotype, I believe that's the result of the fact that it has four genes independently contributing to this particular phenotype.
		The genetic stability, many studies have been done, as I say the ca and the ts phenotype is maintained in the majority of these.  This has been looked at for both H3N2, H1N1 viruses.  It's actually been done in a large number of viruses, even more than looked at here.  A similar type of analysis has been done for the 6:2 reassortants of the B/Ann Arbor/6/60 virus.  These are the reassortants and these are the numbers of isolates that have been looked at or original nasopharyngeal washes that have been characterized.  And again, a large number show the maintenance of the property of the ts and ca phenotypes.
		Since there was less information really available on the B/Texas virus, we did a study where we took the B/Ann Arbor 184 CA virus, put it into immune suppressed hamsters, isolated a virus that we got 15 days later and we made -- from six different animals and we put it back into hamsters.  I was working very hard to see if we could get revertants to do this particular study and the viruses that -- and we evaluated the passaged virus versus the unpassaged virus in the nasal turbinates and lungs of hamsters.  Wild-type virus grew well.  Attenuated unpassaged CA donor virus was restricted, as we've seen.  All of the viruses, despite extensive replication, showed and maintained the attenuation phenotype.  Again, it really gave a lot of -- it gave us a lot of assurance that this virus was -- this particular virus was highly stable.
		The conclusions on genetic stability, we think that these viruses are both phenotypically stable and that this is not a major problem, lack of genetic stability.  We don't think this will be a major problem.  Now, there have been a large number of studies that have been done, and these studies were generally done by Peter Wright.  He had three or four vaccinees, a susceptible placebo, all housed together in a little playroom setting and he looked at the ability of the viruses to spread from the vaccinees to the contacts.  In all of those studies we never saw the -- and these are the number of infected vaccinees.  These are the number of contacts.  We never saw the virus transmit to the contacts.  
		That does not -- and the importance of this is several fold.  First of all, these are seronegative vaccinees.  They're growing the virus, they're growing the virus to the highest level.  They're growing the virus at 103.5, the virus is not transmitting.  We were very interested in why.  The reason I think it's not transmitting is of you know the human infectious dose 50 for this virus, for these particular seronegative contacts, you need around, as we saw, about four, five logs approximately 104.5 logs of virus to infect 50 percent of them.  These volunteer generally shed around three logs.  So we think that they're shedding less than the human infectious dose 50.  That's one.
		These vaccinees rarely have symptoms, so they're not showing -- we think these two factors add up to a very poor and low level of transmissibility of this particular vaccine for humans.  
		Efficacy, there have been efficacy where monovalent vaccines have been studied extensively in adult wild-type challenges, pediatric subjects and then been studied also in seronegative individuals and also seropositive individuals.  And I'm not going to go through the extensive data on this.  I just wanted to indicate that these are studies that have been done with challenges of H1N1 viruses and H3N2 viruses in adult volunteers screened for susceptibility.  The wild-type virus is generally, as you saw earlier, made these volunteer sick.  Attenuated viruses infected them.  When they were challenged, I think you can see there's a high level of protection against systemic illness in the volunteers. Also, this was associated with clear and unequivocal restriction of virus application in the vaccinees, decreased number and decreased quantity of virus, the decreased number of challenged individuals infected with the wild-type, decreased number of -- decreased quantity of virus shedding.  
		The same type of thing occurs if you challenged seronegative individuals, not with the wild-type virus but with the attenuated virus.  You see a high level of protection and you see protection after a very long period of time.  Short periods of time, you have a high -- a year later you maintain at least 54 percent of the individuals are still resistant to replication of the challenge virus.
		I'm just showing this.  I know that the Aviron will discuss this, their efficacy trial.  The important point I want to make here is, is that this efficacy that they're seeing in this natural infection is very similar to what was saw in all of these challenge studies that we've done in experimental settings and not in the natural setting.  The importance of that is, is that there are multiple times when we've demonstrated efficacy against H1N1 viruses.
		I know there is some limited data with H1N1 viruses natural settings but we've seen it every time that we've looked for it in our challenge studies.  Now, here's another very interesting point and these are studies that were done by John Taeanor, three separate challenges, three separate studies that were done where they compared the efficacy in this case, against natural infection with the monovalent cold-adapted H3N2 Influenza A virus and he compared an activated group versus an activated live.  And this was the efficacy that was in addition to that conferred by the inactivated vaccine.
		And I think what we saw in this case, that there was approximately -- you can measure an efficacy of 65 -- 60 percent approximately.  That's above and beyond,  this is in elderly individuals above and beyond the protection that was afforded by the inactivated vaccine.  This was a very important lesson because what it taught was that there was certainly room for improvement of the activated vaccines.  Everybody who's used them, knows that's the case.
		This documents a way to improve that efficacy.  Although you're not considering using this -- the indication for the licensure is not for people who are older, this really indicates that the live attenuated virus vaccines will be able to supplement the efficacy of the inactivated vaccines.  And we think the reason that it does this to -- first of all the activated vaccine is much more efficient in introducing serum antibodies than the live.  
		The live, in contrast, is better in stimulating local antibody.  The sum of these two positive properties is responsible for this higher level of efficacy that is seen.  Okay.  Now, these are the properties we've talked about.  These are the number of reassortant vaccines that we studied or studied as a part of the whole NIAID, including the intramural, extramural branches.  These are the number evaluated for safety and the properties were demonstrated.
		The important thing here were that there were seven or eight other vaccines that were developed during this period of time and each one of them fell off.  Some of them were not safe.  They produced a febrile illness or too much -- most of them were satisfactorily infectious.  Some -- most of them -- most of the problems really were safety or genetic stability.  The virus with just ts mutations were not genetically stable.  The viruses that were -- we had problems with avian and human reassortants of -- viruses H3N2 viruses not being very satisfactorily attenuated, even in kids, but H1N1 viruses were not.
		So this set of properties -- the cold-adapted virus is like the energizer bunny.   It just kept going through each one of these things and doing extremely well and it went through every one of these tests and survived whereas all of the other vaccines that we tried fell off this pathway.  And that's all I wanted to say except just summarizing the possible uses.  Live virus vaccines will be very useful in seronegative individuals.  In the individuals who are between the young infants and children the elderly the live virus vaccine and the inactivated vaccine both work and they're good.  I think a lot of people would much rather have something put in their nose than a shot in their arm. 
		The elderly, I think that you're going to -- if you want to get optimum protection in this age group, you're going to have to give both.  They both give you different -- stimulates different parts of the immune system.  Those are just some thoughts for you to consider.  
		Now, I want to just address in the last five or six slides some of the problems that are associated with one of the issues regarding the introduction of the cold-adapted virus into the general population, what does this mean for a generation of reassortant viruses and what does it mean for the issues regarding unknown generation of reassortant viruses.  Now to do that, I'm just going to review briefly some of the properties of the pandemic influenza virus since 1918.  
		We had one in 1918, 1957 and 1968.  These viruses have been very carefully characterized.  In 1957 when the H2N2 virus came along, it picked up PB1 NA from an avian virus.  The reason I'm pointing this out right now is the cold-adapted virus is derived from this particular virus.  In 1968, the new virus picked up a new -- the H3N2 virus picked up a new hemagglutinin and kept the neuraminidase, picked up a new PB1.  The other virus -- this virus is circulating today.  The H1N1 virus was very similar to a strain that existed in 1950 -- the H1N1 virus present around 1950 appeared back in the population in 1970.  These two viruses circulate today.
		We'll revisit some of the issues regarding this.  What are the other examples of the introduction of animal or avian influenza viruses into the human population?  The H1N1 virus is from swine -- you all remember the swine flu.  That got into the human population and caused some problems.  The H1N1 virus from birds seems to have gotten into pigs, reassorted with pigs, generated a virus and picked up an H3N2 code, got back into humans.  This is documented in 1993.  H7N7 avian virus is from pet ducks, gotten into the humans and have caused infections.  
		H5N1, we know all about the avian bird flu from 1997.  H9N2, from market birds in 1999.   There's been a lot of introduction of genes, much more different from the genes that are present in the cold-adapted viruses.  The humans are constantly being probed by these viruses to see if they can -- just to see if the viruses can take off.  What happens is -- what's happened in these cases -- okay, this is just some of the specific examples.  The H1N1 swine flu is a introduction of the swine virus.  This is some type of reassortment with some avian genes and some human genes, got into the human population.  
		The H7N7 virus from birds, H5 from birds, H9, these are really problems -- humans are going to have problems with genes from avian viruses.  They're going to come from wild-type viruses.  They're going to come from viruses in the circuit.  They're not going to come from out cold-adapted virus and I'll give you the reasons why I believe that.  The consequences of these viruses, as you know, the 1918, '57 and '68 viruses are severe pandemic viruses.  The swine virus caused severe infections in humans but did not cause a pandemic.  Okay, this was also true of the H5N1 virus, severe infections in individuals, abortive infections in humans.  
		The H1N1 virus became epidemic.  The H7, again, was abortive, only seen in one individual.  Now, the -- the third source of these influenza genes come from laboratory studies or experimental studies.  I think many people believe the H1 virus was a 1957 strain, somebody was working with it.  It got into a laboratory worker, got into the population.  That's one scenario that's reasonable, makes sense based on the information that exists.
		H7N7, avian virus that was present in seals, got into a human, it caused conjunctivitis.  The direct inoculation, people have been administering various avian viruses to humans from time to time for the purpose of making experimental vaccines.  Now, what is known now about the interaction of viruses.  The current trivalent vaccine will have an H3N2 and an H1N1 component.  What's known about the mixture of genes from H1N1 and H3N2 virus is what has been circulating in the population together since 1957 -- 1977.   
		The various combinations have been documented by investigators and you can get reassortments.  These reassortments can be -- contain H1N1 virus, all the other genes from H3N2, various mixtures.  In fact, there are a lot of mixtures that have been identified.  You can find a variety of H1N1's, antigenic mixtures, et cetera.  The important point of this is that first of all these infections, these transfer of genes between H1N1 viruses and H3N2 viruses are going to continue as long as these viruses circulate between wild-type viruses.  
		Okay.  The important point is, is that these viruses that were identified, they cause transient circulations of the viruses in the population.  These viruses will not persist.  They will always be replaced by the H1N1 or H3N2 parent viruses.  They do not seem to be a strong selective pressure on them.  They seem to just sort of cause a little epidemic here or there and then were replaced by the other viruses.  The illnesses that were seen in individuals from whom these viruses were isolated were identical to the -- either the H3N2 or H1N1 wild-type virus.  
		Okay, I've just got one or two more slides.  Okay, so what that meant is, is that there are probably no significant consequences of mixing the H1N1 and H3N2 viruses and this will occur in the vaccinees.  I would imagine almost very vaccinee that you give an H3N3 and H1N1 component vaccine together will generate reassortant viruses.
		They all share the same six internal genes so that can undergo a significant exchange.  Now, one of the consequences of introduction of genes present in the ca virus into the human population, but can these genes -- are there any threat of getting the internal genes into the population and what are the consequences, possible consequences of reassortant of genes present in the cold-adaptive virus with those present in animal or avian viruses?  
		Okay, now just to review again, the 1960 -- the vaccine virus, the ca donor virus was derived from this H3N2 virus.  It contains genes related to the H1N1 virus as does both the H3N2 and H1N1, currently circulating H1N1 virus.   We think there are no -- you know, these are just different versions of the same gene, the same is true of the PA and the PB2 except that these genes all have attenuating mutations or most of them have attenuating mutations.  
		Only the PB1 gene differs from the currently circulating virus.  Okay, this is actually -- the ca reassortant viruses have this gene.  The currently circulating viruses have different PB1's.  So this is the only sort of novel gene, but this is not really a novel gene.  It is 97 percent related by amino acid sequence to the genes that are present in the H1N1 or the H3N2 virus.  So when you look at this, the high degree of genetic relatedness of the internal genes that are present in the ca donor virus, we not think that there should be any problem of those particular genes getting into the population, the same problem of those genes getting into the population shared by the wild-type viruses.  
		Now, this is the main -- are there unique consequences of reassortant between genes bearing new HA or NA genes from avian or animal viruses and one or more genes from the ca.  What's the chance of the ca virus picking up novel HA's or NA's and how does this differ from the wild-type virus?  We think that it will be very -- okay, I'll just -- we think it will be very unlikely for this to be a significant problem.  The ca virus is poorly transmissible.  It's almost certainly not going to get into an animal virus or a bird enabling it to undergo a combination in that host.  Therefore, there is certain -- it will likely occur in humans.  
		The ca virus is present in lower titer and for a shorter duration in vaccinees and this would decrease the opportunity with which a reassortant could occur.  At least 50 percent or even more than that of any kind of reassortant virus between a ca virus and the wild-type avian or animal virus will have ca reassortant genes.  
		This is my last slide.  This is actually a lot of -- there's a lot of information in here.  The ca vaccine at the time of the possible pandemic, if you have a ca virus vaccine available at the time of a pandemic vaccine, you'll be very lucky.  Generally, it's very difficult to isolate a new pandemic virus, make a reassortant, generate clinical lots and do studies.  So we think that this is really not an issue.  It's certainly not an issue for inter-pandemic influenza viruses.  
		Clearly, you would not -- okay, now if a -- if you did, if you were very wise and had made a whole variety of ca reassortant viruses bearing H4, H5, H6 genes and had them all ready at the time a new virus appears, you have a new virus in Asia, wants to come to the United States.  Should you be able to introduce that virus because it could undergo the combination with the H1N1 circulating viruses in the United States at the time and generate a wild-type virus.  The answer is, yes, you would probably go ahead and use it when the certainty of a pandemic virus arriving in the United States is 100 percent.
		In the case of an abortive infection, you would never use this virus, okay?  You would never use this virus and introduce it into the population where there are -- a virus bearing novel glycoproteins, ca donor viruses into an open population where wild-type viruses are circulating unless that virus -- unless the virus was -- unless the virus was a pandemic virus.  Abortive infections that occurred in 1977 and the swine -- and the swine flu or the bird flu, you would not use a cold-adaptive virus vaccine bearing those glycoproteins unless those viruses became pandemic.  
		So I don't think that people would use these viruses or consider using them at a time of a pandemic -- I think you would -- I don't think that they'll be available for the time of the pandemic in the next 10 years but if it were available, you would use them to prevent the spread but you would never use them and introduce them into a population to -- in a situation where you have an abortive epidemic.  
		That's it.
		CHAIRMAN DAUM:  Thank you very kindly, Dr. Murphy.  I hate to not provide the committee an opportunity to ask a couple questions that might be clarified regarding your presentation.  Are there a few questions from committee?  Ms. Fisher, Dr. Myers, Dr. Schild.
		MS. FISHER:  If up to 20 percent of the population every year get the flu, I believe that's the estimate, up to 20 percent of all people get the flu every year, what are the potential long term epidemiological consequences of targeting every baby, child and adult for exposure to these flu viruses albeit an attenuated form?  In other words, have you looked at the potential for mutation of the viruses into vaccine resistant forms leaving a majority of the population without true immulogoical memory and more vulnerable to future possibly more virulent flu pandemics and has there been any assessment or evaluation of the long term immunological integrity and overall health of those who are vaccinated every year with these live viruses versus those who are not?
		DR. MURPHY:  I think that's an extremely complicated question.  The important relevant experience is the experience that has been gained with a lot of live virus vaccines that have been utilized to date and generally the information from using these virus vaccines has been that the consequences of the infection fall within the range of what you'd expect with a wild-type virus except that they're highly attenuated compared to the wild-type virus.  So that you can -- if there are specific problems associated with the wild-type virus in terms of altered immunological consequences, you might see those with these live attenuated viruses but they would always be much, much less frequent because the virus is going 1,000 fold less well, et cetera.  
		The -- although 20 percent of the population develops illness, a lot more become infected.  A lot of the population becomes infected with these viruses, has illnesses that don't bring them into the physician with wild-type viruses.  We don't think that there should be anything different about these live attenuated, cold-adapted virus vaccines used as an immunogen, versus what occurs with the wild-type virus.  The wild-type virus infects a large percentage of the kids on an annual -- more than 20 percent.
		CHAIRMAN DAUM:  Three more crisp question askers and crisp answers.  Dr. Myers, please.
		DR. MYERS:  Would you build on your last comment and tell us about concern or your thoughts about the use of cold-adapted vaccine in travelers to, for example, Asia, and then just something that I wasn't clear from what you said is does productive chick embryo productive infection imply virulence for flocks?
		DR. MURPHY:  Say that once again.
		DR. MYERS:  Yeah, does the enhanced productive infection that occurs in eggs imply a virulence for flocks?
		DR. MURPHY:  No.  I mean, these viruses are -- would basically be apathogenic for a livestock, bird, et cetera.  Human virus is really -- you could -- you can't find hardly any information or literature about human viruses going into livestock and associated with lots of problems.  There's some H3N2 viruses that have been in pigs, et cetera, but if these viruses can to into livestock the wild-type viruses will be there, okay, before these cold-adapted viruses would ever be there.
		And your first question was?
		DR. MYERS:  Using the vaccine for travelers to Asia for example.
		DR. MURPHY:  Well, I don't think that would be a problem.  I mean, there shouldn't be any inherent problems of using this vaccine in travelers.  I think the concerns that were raised about their compatibility with other vaccines would be an issue, a separate issue, but in terms of generating reassortant viruses, you have to remember that the H3N2 and H1N1 viruses are widely distributed throughout the world, okay, so that, you know, they're there.  There won't be anything unique occurring, any specific problems associated with the cold-adapted vaccine.
		DR. MYERS:  I was trying to ask the question about the point that you were making at the end about never utilizing in the setting of --
		DR. MURPHY:  Let me --
		DR. MYERS:  --circulating other strains.
		DR. MURPHY:  Right, let me clarify that point.  The ca recombinants, you would not use them, you would not make a ca recombinant virus and introduce it into the human population in the setting of two -- in the settings we know about.  You would not have done that back in 1977 when the swine flu virus came along because it caused an abortive epidemic.  You would not have done this when the H5N1 virus came from birds to pigs. You would not make an H5N1 cold-adapted virus and introduce it into the population.  
		You would only use the cold-adapted virus during novel glycoprotein genes and the threat of a bona fide pandemic virus and you'd have to have a very special group of individuals who would say, yes, this is a bona fide epidemic.  That's what I was trying to make -- that point I was trying to make.
		CHAIRMAN DAUM:  Thank you.  Dr. Schild, then Dr. Griffin.
		DR. SCHILD:  Very masterly review of a very complex subject.  I believe the reappearance after 25 years of an H1N1 virus that continues to spread in co-donors is still an enigma that requires and explanation in relationship to what we do when we work influenza viruses.  Have you any reasonable hypothesis explaining how it hid for 25 years and --
		DR. MURPHY:  Well, I think it was -- I mean, I would say -- this is a little bit off the topic, but I think the virus, somebody was working with it on the bench top, somebody who was not immune to H1N1, got it in their nose, went home, brought it home to their kids and the epidemic started from that, in that way.  That to me, makes the most sense.  
		And I would share with you, and as Peter had indicated on the slide, working with viruses such as the H2N2 virus, everybody who has been born after 1968, okay, you be very careful and reassortants with this virus have to be done under -- where you can generate an H2N2 wild-type virus.  So if you're working with an H2N2 wild-type virus, I think that you have to show considerable caution in that and maybe learn from the H1N1 experience.  But I don't think that has anything to do with using the cold-adapted virus in an open population.
		CHAIRMAN DAUM:  Dr. Griffin?
		DR. GRIFFIN:  My understanding of your data comparing both replication and infectivity in adults versus children was that, first of all, it's more infectious for children than it is for adults and second of all, it replicates better and by a log approximately for each of those two.  So question number  1 is what were the ages of the children that those graphs were generally taken from?  Were those one year olds, or four year olds or eight year olds?
		DR. MURPHY:  No, no, no, the seronegative kids are all -- would generally be between six months and 36 months of age.  
		DR. GRIFFIN:  Okay, then the second question was, what do we know about those same parameters, infectivity and replication, in immuno compromised -- I know you won't have any data on immuno compromised children probably, but in immuno compromised animals, I don't know, ferrets or hamsters?  You had a little data on prolonged replication, but -- 
		DR. MURPHY:  We just did that one experiment with hamster with the B donor virus.  I have not looked at the prolonged replication of these viruses in humans.  The interesting thing about --
		DR. GRIFFIN:  And level --
		DR. MURPHY:  The interesting thing about influenza viruses in general is, is that individuals with AIDS, et cetera, they don't stand out or influenza -- or in people who are undergoing bone marrow transplant.  They don't stand out as the major problems in those settings.  RSV, PRV are the major problems in those settings indicating that there is not a lot of information out there that would suggest that influenza viruses in general or these viruses in particular would be especially problematic in immuno suppressed individuals, such as AIDS who have partial immuno suppression.
		Does that answer your questions, Diane?
		DR. GRIFFIN:  Well, I have a more elaborate -- but yeah, that gives an approximate answer.
		CHAIRMAN DAUM:  Thank you very much, Dr. Murphy.  And given that it's not an airplane day for committee members, I  think we'll take a lunch break.  It's 12:35 here in the Eastern Time Zone and we'll reconvene at 1:35, one hour from now.  Thank you.
		(Whereupon, at 12:35 p.m., a luncheon recess was taken.)

	A-F-T-E-R-N-O-O-N  S-E-S-S-I-O-N
	(1:39 p.m.)
		CHAIRMAN DAUM:  Good afternoon.  Welcome back from lunch.  The FDA staff outside the room has been kind enough to take messages for people that need to be reached here within the conference room.  You might want to check out there with the staff if you're expecting something.  We're looking for a Dr. Dominick who people apparently are trying to find and have left a message out there from this morning.  I'm sorry, Dominick Iacuzio, thank you, Dr. Bleshe.  
		We move to the afternoon's agenda now which are presentations from the sponsor and from the FDA.  Dr. Greenberg will begin the presentation and -- I did good -- and what we're going to do is to have the first two sponsor's presentations and have committee input after the second one.  We will -- the sponsor's presentation, I'm told is 90 minutes long and we will not charge them the time for the committee discussion.  So those are the ground rules that have been negotiated and so we'll have two presentations in a row and then committee discussion and then the other three, with committee discussion in between.  Without further ado, Dr. Greenberg.
		DR. GREENBERG:  Thank you, Mr. Chairman, members of the committee.  I'd like to make a brief remark before I go on and that is that this morning you heard that there are ongoing discussions between the FDA and Aviron from Dr. Patriarca and this is true and they are highly collegial and ongoing and we expect them to continue in the future and we're very appreciative of the FDA for interacting with us.  
		So this afternoon you're going to hear about the clinical spectrum with FluMistTM, the influenza vaccine for use in healthy children and adults, ages 1 to 64.  The proposed indications for this vaccine are annual immunization for prevention of influenza in healthy children 1 to 17 years of age; two doses one month apart for previously unvaccinated children less than 9 years of age and one dose for previously vaccinated children and children greater than 9 years of age, for healthy adults, 18 to 64, one dose.
		Not proposed for use in high risk children and adults, people with a history of allergy to chicken eggs, children or adolescents receiving aspirin, women who are pregnant or people concurrently being vaccinated.  Well, you've had a very brief discussion of why we're looking at vaccines for influenza and I actually mentioned this previously, but I want to bring home the message again, and that is that influenza is an equal opportunity package and by that I mean, it effects all age spectrum of the population, from our very youngest children to our elderly and it takes a big toll across the population.
		So this is data from Dr. Glezen, who may or may not be in the audience, I haven't seen him but I thought he would be here but I could have taken it from any number of people, indicating, as you heard that in the area of mortality the effect is really greatest in our elderly.  Hospitalizations, however, a type of morbidity occurs both in our elderly and in our young, children under 5 being most effected and then medically attended illness, illness that probably took Dr. Murphy to a doctor back then when he got the pandemic flu, really occurs across the population with its greatest effect on our young people.  
		There are limitations with the current influenza vaccine program.  There are 150 million healthy people currently not vaccinated.  Vaccination rates in healthy children are less than 10 percent despite this very big burden of disease.  Vaccination rates in healthy adults are less than 30 percent.  The need, current need, already outstrips supply and an annual injection is required currently and the vaccine that is currently given is not delivered at a mucosal surface where virus replicates.  
		Next slide.  So the vaccine that we're talking about and you've heard this from both Dr. Levandowski and from Dr. Murphy, is a live virus that contains that hemagglutinin and neuraminidase gene segment of the current epidemic influenza viruses and the remaining segments from the attenuated Master Donor Strain.  It's manufactured in specific pathogen-free eggs.  There's no preservative in the vaccine, no thimersol and it's stored frozen.  It's trivalent containing 107 tissue culture infectious doses of each of the strains in a half an mL and it's administered by a nasal sprayer as a large particle mist, 60 micron in average diameter and it's a quarter of an mL per nostril.
		Well, you've all gotten vaccinated and I won't belabor you with showing you what a shot looks like, but you've heard some talk about nasal sprayers and I think it would be good for you to see what vaccine administration by a nasal sprayer is.  So this is a young girl being administered a dose of FluMistTM.  As you can see FluMistTM administration is easy and well tolerated.  Next slide, please.
		You also heard about the substantial history of the investigation of this vaccine and I wanted to bring home this message, so this vaccine, live influenza vaccine milestones over the first three decades and I've given you for a reference point the presidents who were in office during that period of time.  John Maassab, who has been sick and unfortunately cannot be here today but he was the inventor of this vaccine -- the first published cold-adaptation back in 1967.  Actually, I was just leaving college at this time.  
		The first human studies carried out with 6:2 reassortants that you've heard about were in 1976, over 25 years ago.  There were lots of studies and I've only put on one here, the four -- it's actually five years, but four years of data because of wild-type circulation, the Vanderbilt Study was one of the big studies showing this vaccine, a bivalent formulation and how it worked and how safe it was and that was in the late '80's.  And Aviron entered the picture in 1995.
		By 1995 and that's when you're going to start hearing the story after I get off the podium, 19 separate influenza strains in over 8,000 people had been tested and generally, they were shown to be safe and effective.  Next slide, please.
		There are however, I just want to bring home to you some differences between the studies you're about to hear about and that historical record that is being covered.  The studies that are going to be described this afternoon are all carried out with trivalent composition vaccines.  The vaccines have been annually updated to as best as could be predicted, meet what was circulating in the community. That's not always possible, as you'll see.  Consistent doses have been given to children and adults.  A consistent 6:2 genotype has been used in all of these studies and the vaccine is administered by large particle mist.  In most of the previous studies it was administered by nasal drops.
		And finally, the data that you're going to see presented are really relatively large clinical trials and much of the historical record is smaller clinical trials.  Next slide, please.  So the way we're going to do this now is, you're going to first hear about safety and you're going to hear about a large scale safety trial carried out in Northern California Kaiser by Dr. Steve Black and that will be followed directly by safety in children by Dr. Paul Mendelman which will join all the other safety in children with the Kaiser study.  I want to remind you and the point with these safety studies is that the safety of this vaccine should be discernible to you in this very large safety data base that we're going to present in over 9,000 -- in over 18,000 healthy children, and in this Kaiser study, in over 9,000 total enrollees.
		Following the discussion of safety in children, we'll have safety in adults.  Then we'll move onto efficacy and effectiveness in adults and that will be given by Dr. Kristin Nichol from the University of Minnesota and the Minneapolis VA; then efficacy and effectiveness in children, Dr. Robert Belshe from St. Louis University medical center and I will give some brief concluding remarks.  Thank you.  Dr. Black.
		DR. BLACK:  Good afternoon.  I have the privilege now of describing to you a clinical trial that we had the opportunity to conduct in our population to evaluate the safety of the Aviron FluMistTM vaccine through medical utilization in t he clinic emergency room and hospital to assess possible occurrence of rare adverse events.  The first slide, please.
		This study was a randomized, double blind, placebo controlled clinical trial and employed a two to one randomization with twice as many children receiving the FluMistTM vaccine as placebo and occurred at essentially all of the sites within Northern California Kaiser Permanente.  The dosage scheme that we employed was similar to what was just described for two doses for healthy children 1 to 8 years of age, given at least one month apart and a single dose for healthy children 9 to 17 years of age.
		Next slide, please.  The primary objective of this study was to evaluate the safety of FluMistTM in this large cohort of children by comparing within a 42-day observation window following receipt of either FluMistTM or placebo the rates of medically attendant adverse events, in other words, clinic visits, hospitalizations, or what we'll call ED visits or emergency room visits, the rates of those events for all observed diagnosis, that is without a priori hypothesis as well as for pre-specified group diagnoses that we'll talk about a little bit later.  
		We're also comparing the occurrence of serious adverse events in the two groups as well.  Next slide, please.  The analysis format, I think, as you'll see, is this -- as we present this, but it's important to bear in mind employs a lot of different comparisons being made.  We analyzed the data by site of care, emergency, clinic, hospital or anywhere combined analysis by dose, Dose 1 or Dose 2 or regardless of dose and by as you can see, multiple age groups and for each diagnosis that was observed in each one of these analysis.  
		Overall, there are more than 1,500 different comparisons being made without statistical adjustment for the multiplicity of comparisons here and that has implications that I'll elude to as we go on.  Next slide, please.  This gives you an idea of the enrollment in the study.  There are 9,689 participants, again, to remind you of the two to one randomization.  Here there was slightly more children in the younger age group by design than in the older age group.  
		Next slide, please.  What I'm reporting on today is an interim analysis that was done as of data that was complete through the end of last year.  The study began in the fall of last year and by the end of December of 2000 enrollment was complete.  All participants had received one dose and 88 percent of the total Dose 1 follow-up time was complete.  Sixty-four percent of second doses had been administered and 43 percent of Dose 2 follow-up was complete as of the data that I'll be presenting.  And overall, 72 percent of the total follow-up time was complete.
		Next slide, please.  To give you an idea, these are all of the diagnoses that we did observe in the study.  So there really are a lot of different diagnostic comparisons that were being made.  Next slide, please.  And another way of giving you an idea of the lay of the landscape here overall is that you can see that .4 percent of FluMistTM participants and .4 percent of placebo participants experienced a hospitalization during the 42-day window.  ED visits, as you might expect, were more common, at about two percent and clinic visits and children during the winter season as all pediatricians in the audience will know, are quite a common event but there's 28 percent in each case.
		Next slide, please.  These are the four pre-specified diagnostic groups that were analyzed; acute respiratory tract events, systemic bacterial infections, acute GI tract events and rare -- potentially rare events that have been -- that are known to be potentially related to influenza infection and to summarize these results here, there is no significant risk difference in the rates between the two groups.  This shows the rate per 1,000 person months and this is the relatively risk and P-value.
		Next slide, please.  When we look at the diagnostic categories where we did not pre-specify the outcomes, this table summarizes the results that were observed and I should comment this is using a one-sided test and a P-value of .1 for significance, so it's quite conservative in terms of trying to identify events that might be associated with vaccination.  There are, as you can see here, roughly an equal number of categories of events that have decreased relative risks that are significant and those that have an increased relative risk and we're going to focus on the left-hand side of this chart for a moment and especially on the first four events where we felt, based upon what we knew about the way the vaccine was administered and influenza that these had biologic plausibility although we'll address all of these as you'll see.
		Next slide, please.  Now, in order to look at these further based upon the initial analysis, we did several things.  We did -- looked at the time course of these events, what was the time relationship between receipt of vaccine and the onset of the events.  We would anticipate for any physiologic phenomenon that there is some defined time interval between vaccination and onset.  We also looked at review of prior history which included determining whether the onset of the even pre-dated receipt of vaccine.
		We did descriptive review of individual cases from medical records to try and characterize the event and finally, for two of the outcomes where we were trying to characterize them further, we did parental interviews to determine the nature and character of these events for abdominal pain and conjunctivitis.  
		Next slide, please.  The first of these outcomes we're going to talk about is conjunctivitis.  We observed 96 events in 90 patients.  The incidents, as you can see here, was relatively uncommon with 1.1 of FluMistTM participants, .7 percent in placebo.  However, we did observe this in multiple utilization settings, multiple age group analysis and multiple dose comparisons and the fact that we observed these in multiple comparisons to out mind makes us think of them as it would be more likely to be a real phenomenon.  So these are the settings where we observed them and these are descriptive factors that we obtained in talking to the parents and reviewing the chart.  That was a concomitant diagnosis in about two-thirds of the children in both groups and prior history in about 12 to 19 percent. 
		Eye discharge appeared to be more common in the placebo group than in the FluMistTM participants and pain was quite uncommon in either group.  Next slide.  This gives you an idea of the range of the relative risk that we did observe and as you can see, these range roughly between 1.6 and almost 3 fold increase in relative risk but remember the incidents is still relatively uncommon.  You can see this occurred in both the youngest children and the middle aged children, if you will, and then the overall age group as well.
		Next slide, please.  This graph -- let me orient you to this because we'll be looking at more of these.  This shows the number of FluMistTM participants on this side and the number of placebo participants on this side and the scale is different to try and correct for the fact as you look for this visual aide that there are twice as many FluMistTM participants as there are placebo.  And in looking at this, we see that there's a clustering of these conjunctivitis events toward the beginning of the observation window.  Again, our interpretation would be giving this higher physiologic plausibility.
		Next slide, please.  So in summary, we saw a temporal association with vaccination.  These were mild and self-limited, I should say, in review of the medical records.  There was no specialty referral or any sequelae observed at all and the attributable risk depending on the setting that you look at, is somewhere between 2.8 and 11.6 cases per thousand person months.  So our conclusion, our interpretation is that there was an apparent low level increased risk of conjunctivitis with receipt of FluMistTM vaccine.
		Next slide, please.  Another outcome that we observed at increased risk as asthma.  Asthma was -- a history of asthma, according to the parent, was an exclusion criteria from participating in the trial.  Nonetheless, we observed that asthma was observed in the combined setting only for this age group only, following Dose 1 only, a very different situation than what we observed for the conjunctivitis.  There were six cases in the FluMistTM group, zero in the placebo group and the P-value here is .04.  
		Next slide.   If we'd look at the time course of these events, you can see they range from 12 to 41 days, so there isn't really any consistent time relationship.  Next slide, please.  And of these six patients with asthma, four actually had a prior history, prior to participating in the trial, two had had a history of many URIs but no prior asthma diagnosis and the onset of these two children were at the two extremes of the time window that I talked to you about.  
		So our interpretation here is that the lack of a consistent temporal relationship suggests that the increased relative risk for asthma in these young children was not related to vaccination.  Next slide.  Another outcome we observed was otitis medial with effusion.  It was also observed with increased risk.  For the non-clinicians in the audience and not to insult the clinicians, otitis media with effusion is not the same as what we normally call an ear infection.  The children, although it can be associated with ear pain, but is more of a chronic inflammatory process associated with fluid and is a chronic condition. 
		We observed this to be elevated in the clinic setting in the young children 1 to 8 years old and only after the second dose of vaccine with a 21 to 4 case point estimate for the relative risk of 2.6 and a P-value of .03.  Next slide, please.  If we look at the time course of events here, you can see that this is quite spread out.  However, we feel you'd need to interpret this with -- somewhat with caution, since this is a chronic condition and the date of onset, really is difficult to determine.  
		Next slide, please.  But in summarizing this, we did not observe a consistent temporal association.  Medical record review revealed a prior diagnosis of otitis media with effusion in three-quarters of these children roughly, whether they were in the FluMistTM or in the placebo group, so the majority these children had this prior to receipt of vaccine.  So the nature of a relationship, if any, between otitis media with effusion visits that we saw and FluMistTM following Dose 2 really we cannot determine from these data.   
		Abdominal pain was also observed in one analysis to be elevated and the emergency department only in 1 to 17 year old children for combined doses.  You can see the case split here is 11 to 1 and the ratio is 5-1/2 which is statistically significant.  So we evaluated this further again by looking at these graphs which you're probably now tired of looking at, but again, there's no consistent time association here at all, not clustering toward the vaccine or further away.  It's completely spread out.  
		Next slide, please.   And of the 11 cases and the FluMistTM recipients, specific etiology was subsequently assigned in 4 and actually confirmed in 2.  One child had pneumonia with a positive x-ray.  One child had a urinary tract infection with at positive urine culture.  The diagnosis in one child was felt to be pain secondary to ovulation due to the timing and localization and character of the pain and one was felt to be due to stress in the family, due to what was going on in the family and that child was referred to psychiatry.
		Next slide.  Additionally, if we look at abdominal pain in other settings, the clinic or combined settings, we actually see statistically significantly decreased risks of abdominal pain occurring with ratios here, as you can see varying between .33 and 4 in the clinic or combined setting in 1 to 8 year olds.  Next slide, please.  And if we look at all settings after all doses combined, all settings could include hospitalizations but there weren't any.  You can see here again that there's no statistically significant -- there's no evidence of any association between abdominal pain and receipt of FluMistTM vaccine.  
		Next slide.  If we look further, since we know that abdominal pain has been something that's been of interest to the committee recently, we look further at other events that might be associated with abdominal pain including, as you can see here, appendicitis, gastroenteritis, and rare events which include intestinal obstruction and intussusception.  There was one -- in the data that I'm reporting to you here, there was one case of appendicitis in a child in the FluMistTM group, zero in the control group.  This is slightly different than what's in the briefing book because we've had an opportunity now to include the pathology data which confirmed this child was actually having appendicitis and another child actually which was included as appendicitis is having negative pathology.  
		That's this child here and really for the other events, there was no data that would support any level for concern, vis-a-vis, these events.  Next slide, please.  So in summary for abdominal pain, in this study we saw no consistent clinical presentation or temporal relationship to vaccine.  When we interviewed the parents some of the pain was diffuse, some was dull, some was sharp, some of the pain disappeared between when the child registered in the emergency room and by the time they were seen it was gone.  Some of it lasted for days longer.  There was no consistent localization.
		There was no evidence of an association with potentially serious consequences.  The relative risks were inconsistent as I pointed out to you.  However, as Dr. Mendelman will mention in the talk that follows me, there was an increased risk of abdominal pain as ascertained through parental diaries observed in another study.  So we feel that the lack of consistent clinical presentation or temporal relationship observed in this study again suggests that abdominal pain observed in the emergency department was unrelated to FluMistTM.
		Next slide.  These are the other outcomes that we observed with increase risk and let me just point out a couple things.  One of them, speech delay was observed.  However, six of the seven children observed with this had speech delay identified prior to participation in the trial.  Enuresis, similarly again, all these children had this prior to the trial.  Benign lesion and cellulitis were observed.  These were a lot of contributing diagnoses and no consistent body site.  And the cellulitis was, again, all over the map in location in terms of where this was as well.  
		Next slide, please.   I'd like to make the committee aware, we've had an opportunity -- what I've reported to you on here is this analysis through December.  We've had an opportunity now to look over the last week at the final data set and I'd like to highlight the differences which are quite few, between the final data set and what we observed in the interim analysis.  Overall, the results are really quite consistent.  There were two diagnostic categories that were observed with an increased relative risk, elective procedures and warts, neither one of which caused us much concern because we didn't feel that there really is any possible physiologic mechanism for this.  And two, medically attended adverse events that were previously observed with an increase relative risk were no longer statistically significant, benign lesion and cellulitis, which as I pointed out, we were not very concerned about before that anyway.
		And to highlight the influence of multiple comparisons here there were eight new diagnostic categories with decreased relative risk were identified.  Next slide.  So overall we concluded that FluMistTM in this large cohort appear to be well tolerated.  There was no increased risk in the FluMistTM recipients for any of the pre-identified diagnostic groups.  Serious adverse events occurred at a low rate in both groups and in blind did an evaluation by the investigators.  None were felt to be vaccine related.  
		Several outcomes observed with elevated risk and biologic plausibility were evaluated further, as I've highlighted to you here.  Abdominal pain was not consistently observed or associated with serious sequelae.  Muscle aches and ear or eye symptoms, although we highlight them, were observed but had been reported in prior studies and are known to be associated with vaccine.  And conjunctivitis we felt was associated with receipt of vaccination and although the risk is low.  
		And finally, several biologically plausible outcomes had reduced risk, including interestingly acute GI tract events, cough, febrile illness, tonsillitis, viral syndrome, wheezing and shortness of breath.  Thank you very much.
		CHAIRMAN DAUM:  Thank you, Steve.  We'll move right onto Dr. Mendelman's presentation and then have some committee discussion.  
		DR. MENDELMAN:  Good afternoon.  My name is Paul Mendelman.  I'm Vice President of Clinical Research at Aviron.  I'm honored to be here and I'd like to thank the FDA and the committee and legion of individuals for their individual efforts and their collective efforts over the past 25 years to bring this day to fruition.  And I'd particularly like to thank Dr. Maassab and the National Institute of Health.  One housekeeping issue is that in order to stay within time and keep it off of our clock, some of the slides you got yesterday I'm not going to present but I'll take questions.  
		The first slide presents the data from '99 peer review journal articles prior to the Aviron experience.   In those articles, the 6:2 reassortant cold-adapted vaccine were studied in over 8,000 individuals and 2,743 of these individuals were children.  These were primarily monovalent or bivalent formulations and these vaccines were found to be safe and well tolerated.  The next slide presents the Aviron experience; 18,390 healthy children which includes the vaccinees in the Kaiser trial that you just heard about from Dr. Black, in 1 to 8 year olds, 12,069 in the 9 to 17 year olds, 6,321 children.  There were high risk populations that were studied and the total is 1,317.  So the overall number of children dosed with FluMistTM is 19,707.
		The next slide shows the collection of safety data in the various trials.  The methods included a symptom diary  card.  This was completed by the parent or guardian in the children trials, the monitoring of medical records by the contract research organizations and co-monitoring with Aviron personnel, telephone calls from the investigators, the investigators' staff to the participants' parents or guardians as well as health maintenance organization data base review.
		The types of events included serious adverse events. In children these were collected from day zero to day 42 and also post-vaccination reactogenicity events which in some early studies were day zero to 7 and in later studies were day zero to 10.  These were events that might be expected to be observed with viral replication or with wild-type influenza and a parent or guardian had to check a box, was it present or was it absent or did it exist.  And these were pre-specified events, nine events, which I'll go over with you shortly as well as temperature documentation with a thermometer on each of those days.  
		The parent also reported on the diary card any event that occurred within that post-vaccination period that was not pre-specified.  And they also recorded the medication use that was taken during that time interval.  The next slide presents the demographic characteristics for the children 1 to 17 years of age broken by the younger age group 1 to 8 and the older age group, 9 to 17.  On average the younger age group was 4 year of age and the older age group was 12 years of age.  There was a balance in gender between the two age groups and there was a balance in race ethnicity and the race ethnicity was similar to the general U.S. population overall.
		The next slide presents the serious adverse events in the clinical trials by age and population.  In the healthy children 1 to 8 the incidents rate was .4 percent; in the placebo recipients it was .5 percent; in the healthy 9 to 17 year olds, .3 percent in the FluMistTM recipients and .1 percent in the placebo recipients.  In general the serious adverse events were low and nearly all of these were considered by the investigator and reviewed by Aviron as being not vaccine related.  I will present in a subsequent slide the vaccine related serious adverse events that have been observed to date.
		The next slide presents the mortality in children in these over 19,000 children that have been dosed.  There was one death due to bronchopneumonia 27 days after the second dose.  This child was in a trial conducted in South Africa by Wyeth Lederle vaccines.  This child on the diary card, after the first dose, had no temperature recording on a digital thermometer that was recorded as febrile on each of those 10 days and the child did not have any other reactogenicity events which were systematically recorded.  They were all noted as not present by the parent.  
		Six weeks later the child got the second dose and again the child remained afebrile after the second dose, all 10 days of the recording, and had no events other than a runny nose on day zero and day 3.  Unfortunately, approximately 24 days after the dose, the second dose, the child had an episode of vomiting, sought medical care, got penicillin for a couple of days and had a rapid respiratory death, very soon after hospitalization.  
		The other death was a child with a brain tumor and complication of malignant hyperthermia, 145 days after dosing in a second season.  This was also not considered vaccine related.  The next slide presents the vaccine related serious adverse events.  There were two in vaccinees.  This was in a study in children initially enrolled at 12 to 15 months of age.  A child came in what wheezing six days following the second dose.  The investigator felt it was medically important and therefore, was serious.  And another child 14 months of age with bronchiolitis 21 days following the second dose.   We've had a third vaccine related serious adverse event that we were told about yesterday after you got your briefing document slides.
		This child was also in this study, was 16 months of age.  The child had gastroenteritis and croup 10 days after receipt of the second dose and was hospitalized overnight.  There actually were two vaccine related serious adverse events prior to unblinding.  The investigators determined this and then subsequent unblinding they were noted to be placebo recipients.  One was a case of laryngitis in an 18-month old three days following the first dose and the other was a case of croup four days following the first dose in a 21-month old child.
		The next slide presents the review of the systematically collected reactogenicity events following the first dose and this varies somewhat from your briefing document that we provided in that in the briefing document we provided all children integrated, regardless of whether they were placebo controlled trials or not and in the data I will go through with you here these are in placebo controlled trials so we can provide statistical analysis on which events were statistically significant in a correct statistical fashion.  
		This slide shows after Dose 1 the nine events that were systematically collected as well as temperature and what is observed that runny nose, nasal congestion is higher in the FluMistTM recipients than in the placebo recipients.  Muscle aches was also increased and the low grade temperature of an oral temperature of 100 degrees Fahrenheit was increased statistically over the placebo recipients looking at a temperature of 102 there was no difference statistically between the two treatment groups.  
		The one event, just to highlight to you here, vomiting, is our GI event or gastrointestinal event within the reactogenicity period and you can see there's no difference looking at all the placebo controlled trials and that may be seen somewhat as a surrogate for abdominal pain.  The next slide presents the by day of occurrence analysis for the temperature analysis.  And there's a peak on day 2 and there's a statistical significant increase on day 2 and day 3 in the FluMistTM recipients compared to the placebo recipients.
		The next slide presents the data after dose 2 in the same season and for all of the events, there's no statistical difference between FluMistTM and placebo following the second dose of FluMistTM.  The next slide presents an analysis that we conducted with a complex of these illness events.  The analysis uses the Center for Disease Control influenza like illness definition which is published in the literature in the MMWR and other publications and used the definition of a temperature of greater than or equal to 100 degrees Fahrenheit with cough or sore throat.  
		And there was no difference after dose 1 or dose 2 in the CDCILI definition.  As we know, fever is the hallmark of influenza and systematically based on the temperature recordings by the parent/guardians, we evaluated these temperatures and the one temperature that's statistically significant higher in the FluMistTM recipients which is about four percent significant after the first dose, not after the second dose, and the higher temperatures are not significantly -- there's on significant difference after dose 1 or dose 2 in the higher temperatures evaluated.
		The next slide presents the medication use during the reactogenicity period are recorded by the parent/guardian.  There was one event or one medication used category antipyretics/analgesics which is statistically significant, the difference of about five percent between FluMistTM and placebo recipients.  It's not significantly different after the second dose.  The other three categories, antibiotics, antihistamines, beta agonist use, whether it was dose 1 or dose 2, there is no significant difference.  
		The next slide presents the data for numbers of children dosed after and/or repetitive dosing and subsequent seasons; 4,771 children had been dosed for a second season, nearly 2,000 for a third season and 549 children have been evaluated over four consecutive seasons showed under initially in the AV006 efficacy trial.  It was a two-year trial and then followed for an open label study in year 3, revaccination and 4 purposely to evaluate safety on repetitive dosing.  
		The next slide presents the reactogenicity profile across the four years.  This is runny nose, nasal congestion which was collected in children as a single event.  This is dose 1 and year 1 followed by the subsequent seasons where it's reduced.  There was no pattern of increasing reactogenicity for any of the events evaluated in the subsequent seasons in these children.  
		The next slide presents selected events based on what you've heard from Dr. Black in the Kaiser trial and the conducted with Dr. Shinefield and also our own evaluations.  These are placebo controlled trials that did not include the Kaiser trial.  The Kaiser trial was medically attended events within 42 days.  So they had to seek medical attention to be on the data base tapes.  These are what the parent dealt with in the reactogenicity period and then recorded by them.  
		For conjunctivitis, the incidents rate is low and similar between the FluMistTM and the placebo recipients after dose 1 or dose 2 in the placebo controlled trials.  For abdominal pain, in the FluMistTM recipients, 1.5 percent compared to .7 percent in the placebo recipients and .8 versus .4 percent after the second dose.  I'll discuss this further on a subsequent slide but let me just note, lower respiratory illness, similar incidents after either dose in the two treatment groups which were not significant and otitis media, which was similar and not significant after either dose. 
		For lower respiratory illness, the categories that were included in there were pneumonia, bronchitis, bronchiolitis, asthma, wheezing, croup, et cetera.  I will note that on abdominal pain, there was one study noted here, Study AV006 where we did have higher incidents of abdominal pain in the vaccinees compared to the placebo recipients.  Next slide, please.
		Shown here is the 1.5 versus .7 percent.  The age in these children with abdominal pain is identical to what you'd expect for the children enrolled in this age group.  They were approximately four to five years of age.  The abdominal pain was two to three days.  Three of the 25 children's parents sought medical attention for the abdominal pain.  Where severity was measured, most were mild.  One was noted to be severe and this was a serious adverse event.  The child developed the abdominal pain on day 9 after vaccination, was admitted for an overnight stay in the hospital and was discharged the next day without abdominal pain. 
		Most of these abdominal pains are recorded on the diary card as tummy ache or stomach ache by the parent.  In evaluating the data that you heard from Dr. Black on the next slide we wanted to do an analysis of appendicitis.  As you heard from Dr. Black there were two cases that went to appendectomy of the 6,473 vaccinees.  That incident is 1.5 per 10,000 person months.  It's lower if we remove the child who had a histologically normal appendix and it's even lower than that if we remove the child who had appendiceal abscess who had abdominal pain prior to being dosed with FluMistTM. 
		But we also looked at our other large HMO trial being conducted by the Baylor College of Medicine group under an NIH grant which has currently been a three-year trial.  There are no cases of appendicitis among over 4,000 individuals in the first year of that trial.  There was one in the over 5,000 vaccinated children in the second year of that trial, but there were three in the third year of that trial in 5,000 vaccinees.  If we total those numbers at six, then we see that the incidents rate here is 1.3.  Just to note the time sequence on these cases, that the appendiceal abscess which the dosing was on day -- the diagnosis and hospitalization was day 11 after dosing.
		The event in year 1 in Texas on day 12.  The other four events that occurred in the Texas trial of appendicitis  occurred on day 30 or beyond after vaccination which would be outside biologic plausibility and again this trial is not a placebo-controlled trial, it's open-label.   So we took published literature that we could find and local data from both Northern California Kaiser and Scott & White HMO controlled communities in Temple, Texas.  You can see the rate incidents is between .6 and 1.2 which is consistent with the overall 1.3 including all six cases.  
		The next slide presents data specifically on pneumonia in the Kaiser trial -- no, sorry, I'm off a slide.  This is data on AV006, the two years of the trial on pneumonia within 42 days of vaccination and presents those pneumonia reported when -- day 0 to 10 based on the AE case report form from the parent filling out the diary. There were four cases in FluMistTM and none in the placebo group.  These were not statistically different.  In the second dose, the split was 01 but then the 11 to 42 days on these illness events report forms which you'll hear from Dr. Belshe is how we surveyed the children for influenza like illness to obtain a culture.  There were eight events and three events after the first dose in the placebo group.  The total 1.1 percent and .6 percent and .4 versus .7 percent after the second dose.  
		The next slide, please.  Another comment on the pneumonia, that several of these pneumonia events upon review of the case records and noted in the briefing package from the FDA are still under review by the FDA, several of these children, three, had pre-existing symptoms, including cough prior to vaccination with FluMistTM.  The data from the Kaiser trial on pneumonia and it wasn't presented to you by Dr. Black, is it wasn't increased and it wasn't decreased, but we can look at this placebo controlled trial to look at the incidents rate; 14 cases of pneumonia among the 6,000 vaccinees, 10 among the 3,000 placebo recipients for a relative risk that's .7, that's not statistically different and based on the final data analysis set just recently conducted, these numbers are 28 and 17, so the increase is concordant with the -- in both groups the relative risk is .82 and therefore, remains non-significant.
		The next slide is a change from talking about these post-vaccination events that have occurred to data that has been generated on transmission, which is important to understand and has been noted in the briefing document.  In November 1998 Dr. Peter Wright presented data different than what Dr. Murphy presented on the published data with Dr. Wright and himself.   In the day care setting where transmission didn't occur, Dr. Wright noted to the committee that there were two children among 40 placebo recipients that he noted to the committee were potential placebo recipients that had received vaccine virus and were shedding that virus.  He also noted that these two children, based on their serology did not seroconvert to serum HAI and that these 40 children were exposed to over 100 children who were vaccinees and approximately 80 percent of those vaccinees shed in that daycare setting at Vanderbilt.
		Now, as was noted earlier by Dr. Murphy, transmission may be expected to occur at a very low rate.  In the trial conducted by Wyeth-Lederle vaccines is noted here.  These are children 8 to 36 months of age, which would be very young seronegative children in a daycare setting in daycare groups.  This was a double blind, placebo controlled trial, randomized one to one.  Ninety-eight children received FluMistTM and 99 who were atomized received placebo and nasal cultures obtained systematically three times per week for the following three weeks.
		And the next slide presents the data from this study. Eighty percent of the vaccinees showed vaccine virus.  One placebo child showed the Type B vaccine virus on a signal day, day 15, during the 21-day period and this child was exposed to two vaccinees in their daycare group who shed vaccine virus Type B on day 7.  The symptoms in this child were similar to other participants in the trial regardless of whether they were FluMistTM or placebo mist recipients and the vaccine virus retained the cold-adapted and the temperature sensitive phenotype.
		The calculated transmission attack rate is 1.75 percent and with an upper bound on the confidence interval of 8 percent and the transmission probability is .9 percent.  In conclusion on the next slide, FluMistTM was safe and well tolerated in children 1 to 17 years of age, over 30,000 doses have been administered to over 18,000 healthy children.  There were mild self-limited reactogenicity events observed and a low risk of other adverse events.
		Thank you.
		CHAIRMAN DAUM:  Thank you very much, Dr. Mendelman.  We will take advantage of this opportunity now to invite committee discussion of the data you've been hearing for the last 49 minutes.  Dr. Kohl?
		DR. KOHL:  A question and a comment, Steve -- first of all, I enjoyed the presentations from everybody.  Steve, in any of the children with conjunctivitis, were viral cultures obtained by chance?
		DR. BLACK:  No.
		DR. KOHL:  No.  So we don't know if that's an irritative phenomenon or an infectious phenomenon.
		DR. BLACK:  No, because that was not a prospectively identified outcome and wasn't identified till we looked at the data and by that time the events were passed, so we didn't have the opportunity to collect a --
		DR. KOHL:  I'm shocked that you guys at Kaiser don't get viral cultures on your kids with conjunctivitis.  One concern I have and I'm not exactly sure how we're going to address it as a committee, but where all the adverse events results are compared to placebo and this was raised before but I want to reinforce that question again.  Since the placebo was a very proteinaceous material, one would wonder if the baseline adverse events in the placebo group were really adverse events and weren't what we think of as placebo nothings sort of.
		And that's just something I think we're going to have to deal with and I'm not exactly sure how we're going to deal with that.  
		DR. BLACK:  Let me just make one comment, is we did note for conjunctivitis where we hypothesized this is by topical inoculation of rubbing the nose and then the eye which adults do often enough but kids surely do more often, that there was a clustering of those events in the placebo group as well toward the front of the time window.  So I think for that event, as distinct from the other events that we're talking about in terms of rare events, we could hypothesize that there was an irritant effect in both groups.
		CHAIRMAN DAUM:  Dr. Snider and Ms. Fisher and Dr. Edwards.
		DR. SNIDER:  Yes, in looking at the data the way you have which is appropriate, I didn't get a hint from the slide presentations of how many children actually had events, because you're, you know, counting events independently.  So were there children that -- I mean, did a lot of these events tend to cluster in a smaller group of children or not?
		DR. BLACK:  We did not report here, but we looked at these results in two ways, the results that I reported but the binomial relative risk actually count the first event per child, so that each child only contributes one event per diagnosis to each analysis.  We did also do this in another comparison using a passon (phonetic) regression that did account multiple events per child and that's in the briefing book.  It really did not identify different events but the time graphs that I showed you do not account for more than one event per child because we think that with the relatively small numbers we have here, one child with four or five visits to the doctor, could basically dominate the entire analysis and make it difficult to interpret.
		CHAIRMAN DAUM:  Thank you.  Ms. Fisher, Dr. Edwards, Dr. Steinhoff.
		MS. FISHER:  One would perhaps expect that in the vaccinated group there would be a much lower rate of pneumonia and in fact, the rate was somewhat elevated in the vaccinated group but not statistically significant.  But I'm interested in your dismissal of the several cases of pneumonia that occurred in the vaccinated group in children who you said had a cough or symptoms prior to vaccination when I noted that in the exclusion criteria no children with upper respiratory symptoms within one week were supposed to be vaccinated and I was wondering in the trials was it kind of not -- was the criteria not exactly adhered to or -- I mean, because writing those cases off as not related because they had symptoms prior seems to be somewhat cavalier.
		DR. MENDELMAN:  In general, the trials were that an acute respiratory infection within 72 hours was an exclusion criteria.  The two children that had cough, one had a cough for a month and one had a cough for a week and so those were more chronic conditions so they met the inclusion criteria because they didn't have an acute febrileness and I think we followed in general, in our protocols the recommendations for vaccinating healthy children and many children have runny nose and a cough.  And we wanted to make sure there wasn't a new febrile illness at the time that they were being administered FluMistTM or placebo.
		MS. FISHER:  Well, in the FDA summary, though, it says that the exclusion was specifically upper respiratory symptoms within one week.  So in other words, it was within 72 hours and it had to be febrile was actually the exclusion criteria?
		DR. MENDELMAN:  It's -- we'd have to do it per protocol, but in general it was within 72 hours, correct.
		CHAIRMAN DAUM:  Thank you very much.  Dr. Edwards and Dr. Steinhoff.
		DR. EDWARDS:  Did you have the opportunity to measure serologic responses in the single patient who shed Flu B and did you think it was interesting that they only shed for a single day or was that just that they weren't shedding when they were checked again in three days?
		DR. MENDELMAN:  The answer is that we did not get serology on the child and the answer is also that the next culture date, which would have been three days hence, day 18, the child was not shedding virus.
		CHAIRMAN DAUM:  Dr. Steinhoff?
		DR. STEINHOFF:  I was going to get back to the conjunctivitis question because in the two studies we heard, there was an association in one study, one apparent association, and not in the other.  And it occurs to me we've already asked about other causes of conjunctivitis, the conjunctivitis can either be caused directly by the virus administered to the children or it could be irritative which you've talked about or it could be another virus and this virus somehow working together.  And I don't know if you've looked at that or looked at patterns of what was circulating at the time you did the study in the two different sites.  It's a complex question but --
		DR. MENDELMAN:  Steve, that question is for you.
		DR. BLACK:  Yeah, I had trouble hearing what you were saying but I'll try and answer what I heard.
		DR. STEINHOFF:  The real question is if you have any knowledge about other circulating causes of conjunctivitis at the same time.
		DR. BLACK:  Yeah, we did look and there's a backup slide on conjunctivitis I can look for here.  But some of these children did have antibiotics.  Yeah, let's see, it's number -- starting with number 9, I think,  Yeah, okay.  This is our attempt to further characterize this.  Again, we -- because we were doing this after the fact, we don't -- if cultures would have been done we could have looked at them, but since there weren't we really can't but this sort of characterizes the two groups of children in terms of other diagnoses that were present, whether they had cough, whether they had other conditions.  
		Next slide, if I could.  Yeah, and this, again, in terms of clinical features, you can see that some of the children had the conjunctivitis or evidence of conjunctivitis prior to vaccination or at least had a history of a visit within several weeks prior.  They may not have had it at the time that they were vaccinated.  And you can see that whether topical or systemic therapy was prescribed, was pretty similar in the two groups.  I think that's really all I can say.  We don't have any other information.
		DR. STEINHOFF:  I presume you did these studies in the summer.  The immunization took place in the summer or not?
		DR. BLACK:  This follow-up time that we're -- you can turn that slide off.  The follow-up time reporting on took place between October and the end of the year, so it's the fall.
		CHAIRMAN DAUM:  Thank you, Dr. Eickhoff, please and then perhaps we'll go on and hear the rest of the sponsor's presentation.
		DR. EICKHOFF:  A question for Dr. Mendelman; I believe it was page 4 or your fourth slide, you outlined the methods used to collect safety data on these 19,000 and some children.  Could you expand on those methods just a little bit?  How often were diary cards collected and filled out and how often were telephone cards made to participants and did all of the studies utilize those same identical methods of safety data collection?
		DR. MENDELMAN:  It varied by study.  For example, in the large trial that was conducted at Northern Kaiser in 9,000 individuals, it was based solely on data base review of the Kaiser health care records, so there was no diary card.   In the large study conducted by Dr. Glezen and his colleagues, in the first year of that trial in the Scott & White Health Plan, the children are insured, everybody got a phone call on day 42 or thereafter that non-insured health plan members who came into the Scott & White Clinic and enrolled in the trial, got a postcard.  They then returned the postcard.  They got a registered letter. 
		In the second year, the health plan was very solid in terms of being able to get that data out of the data base so all the non-health plan members got a phone call and not a postcard in the year 2 of that trial. In the other trials, in general the placebo controlled all had a symptom diary card that was taken by the parent and then brought into our own data base, including the efficacy trial you'll hear about.
		CHAIRMAN DAUM:  Thank you very much.  Okay, Dr. Cox, then Dr. Kohl, but then we're really going to go on.
		DR. COX:  I'd just like to go back to the pneumonia cases reported within 42 days.  You have that broken down after dose 1 by says zero to 10 and 11 to 42.  Was there any temporal clustering, in other words, for most of the cases around two weeks or --
		DR. MENDELMAN:  Okay, I think the easy one to go to, Dr. Cox, is the backup slide from the Kaiser trial, which is slide number 15, slide number 15, slide 15, 1-5 in the back-up children's safety.  
		DR. BLACK:  Sometimes the technology overwhelms you. This is a similar graph to the ones we talked about before and looks at the distribution of pneumonia in the two groups, the FluMistTM again in blue and the placebo in gray or whatever color that appears to you at the back of the room.  As you can see, there really is not again, a consistent association or a clustering here.  Perhaps there -- well, we haven't analyzed this statistically for trend but there's no evident clustering of pneumonia events.
		CHAIRMAN DAUM:  Thank you.  Dr. Kohl.
		DR. KOHL:  Can you show us specific data on safety -- adverse events in the first year age, 12 months to 24 months and was there an increase in any events in that time period and how many children received vaccine at 12 to 24 months?
		DR. MENDELMAN:  Medically attended events?
		DR. KOHL:  Anything, anything you've got on that age group. 
		DR. MENDELMAN:  In the briefing document that we provided there is a reactogenicity by age, broken by year and what you can see going from 12 to 23 months to the end of that spectrum is that decreased activity and irritability tend to decrease and then as the children maybe become more verbal, the incidents of headache and sore throat tends to increase.  That's also true in the placebo group as well.
		CHAIRMAN DAUM:  Thank you very much.  I'd like to ask the sponsor's presentation to give us the slightly less than second half of their performance and then we'll hear some more committee input.  Dr. Goldberg, there are others that wish to speak and I'd really like to go on now.  Is this urgent and quick.
		DR. GOLDBERG:  You described on the Kaiser trial and if I heard you correctly, that the surveillance for the non-insured subjects was different than for the insured members of the plan.
		DR. MENDELMAN:  Not in the Kaiser trial.  In the Texas Scott & White trial.
		DR. GOLDBERG:  Did you analyze the data or just look at it descriptively to see whether there was any influence on the reporting whether you -- did you analyze it in the two stratas then of insured and non-insured patients?
		DR. MENDELMAN:  Right.  There are analyses ongoing between the health plan and the overall clinic population.  Primarily this is a large scale trial and to evaluate serious adverse events but the investigators and Dr. Glezen is in the audience, maybe later can comment about the other analyses as they are ongoing.
		CHAIRMAN DAUM:  Thank you.  Now we'd like to sort of go on.  Dr. Mendelman, please.
		DR. MENDELMAN:  Thank you.  The first slide again shows the historical experience; 5,348 adults were dosed with previous formulations of the 6:2 reassortants in the peer review journal articles that we reviewed, and the following slide presents the Aviron experience with FluMistTM.  Three thousand, nine hundred and forty-seven healthy adults received FluMistTM and 1,303 high risk adults received FluMistTM.  The total is 5,250, thus over 10,000 adults have received vaccine derived from the Mr. Maassab Master Donor Virus Strains. 
		The next slide is similar to the collection of safety for the pediatric trials except that the serious adverse events in adults were collected for day zero to 28 and in the children it was day zero to 42 and the post-vaccination reactogenicity events were collected for day zero to 7, in contrast to the children day zero to 10.  
		The next slide, please.  The serious adverse events in healthy adults are shown on this slide, a one percent incidents in the FluMistTM recipients and a 1.4 percent incidents in the placebo recipients.  I will go over some of these other events in the high risk population as we move forward in the remaining slides.  Next slide, please.  These were balanced as noted on that prior slide.
		This slide shows the all-cause mortality in adults.  There's one healthy adult who died 16 days after administration of FluMistTM from an accidental drowning.  The alcohol level was .32.  There were 64 deaths in adults in the VA cooperative studies program trial.  All of these adults had to have chronic obstructive pulmonary disease.  They all received licensed inactivated trivalent vaccine on the same day.  Eleven hundred and seven received FluMistTM and 1108 received placebo.  There were 34 FluMistTM recipients, 3.1 percent and 30 placebo recipients, 2.7 percent who died some time during this trial.  Three deaths occurred within 28 days in the FluMistTM recipients; five deaths occurred within 28 days in the placebo recipients.  
		There was one considered vaccine related because of the lack of causality being provided by the investigator.  Therefore, it's considered unknown and defaults to related.  that occurred 218 days after vaccination.  And the three deaths that were considered vaccine related, the two at day 78 and day 158 also did not have causality, were considered unknown and were put in this category and the one on day 3 -- and all of these adults with chronic obstructive pulmonary disease obviously had respiratory events.
		The next slide presents the vaccine related serious adverse events in the healthy adults.  There have been one reported and again, in the VA trial there were nine for a .8 percent incidents in the vaccinees, 22 in the placebo recipients for an incident of 2 percent, these being given by the investigator prior to unblinding.
		The next slide presents the demographic characteristics of adults and this is study AV009 which you'll hear the effectiveness data from Dr. Nichol.  The reason to present this study is a single study, again, it's placebo controlled and provides the proper statistics and 3,041 of the 3,947 adults that received FluMistTM were in this study.  The average age is 38.  It's well-balanced in gender and race and ethnicity between the two treatment groups.  
		And the next slide presents the day zero to seven reactogenicity events, these seven events plus temperature taken.  Pre-specified in the protocol was an event that was clinically significant, considered greater than 10 percent difference between FluMistTM and placebo mist.  That was met for sore throat and for runny nose.  Other events that were statistically significant during that time were cough, chills and tired/weak and these differences because of the large size of the trial, were statistically significant but the difference between FluMistTM and placebo were 2 to 4 percent.  
		The next slide presents the data for the CDC influenza-like illness definition.  No difference and also temperature greater than 100 an equal number presenting with fever in the seven-day period after being dosed with FluMistTM or placebo mist in the healthy adult trial.  The next slide presents the analysis on medication use.  None of the four categories had a statistically significant difference, antibiotics, analgesics, antihistamines or beta agonist use.
		The next slide, again to look at some of the events that we talked about in children, conjunctivitis, abdominal pain, lower respiratory illness, these are sub-sets of lower respiratory illness as the wheezing and pneumonia and none of these are statistically significant between the two groups and neither was otitis media within that week following dosing.
		The next slide in conclusion, FluMistTM was safe and well-tolerated in healthy adults 18 to 64 years of age. Three thousand nine hundred and forty-seven healthy adults have received FluMistTM.  There were mild self-limited reactogenicity events observed and a low risk of other adverse events. Thank you.
		CHAIRMAN DAUM:  How would it be if we heard from Dr. Nicol next and then had committee input after the two?  
		DR. NICHOL:  Good afternoon.  Can people hear me?  I'll take that as a yes. In the next few minutes, I'm going to be presenting data on the efficacy and clinical effectiveness of Aviron's live attenuated influenza virus vaccine in healthy adults.  I will be reviewing data from two trials, AV003, a trial conducted by Dr. John Treanor and colleagues that assessed the efficacy of this vaccine in a wild-type virus challenge trial.  I will also discuss data from a large field trial, AV009, that was designed to assess the clinical effectiveness of this vaccine in healthy adults.
		First, AV003, the challenge trial; this was a randomized double blind placebo controlled trial.  Participants were between the ages of 18 and 41 years.  All had to be serosusceptible, that is have a serum HAI titer less than or equal to 1 to 8 to at least one of the wild-type viral antigens included in the challenge study, that is either to H1N1, H3N2 or to the B strain.
		Randomization occurred in equal proportions; FluMistTM the trivalent inactivated vaccine or placebo.  All participants received both an internasal mist as well as an inter-muscular injection.  On day 28 participants were challenged with a well-matched wild-type virus.  Next slide.  The primary end point for this trial was protection against laboratory documented illness after challenge.  Laboratory documentation was defined either as evidence of viral shedding or evidence of a four-fold serum antibody rise.
		Next slide.  In this schematic, we have summarized the dosing schedule for this trial.  I'll figure this out soon here.  Here we go.   Three hundred and eighty-two healthy adults were screen for serosusceptibility.  Of these 382 volunteers, 135 were found to be serosusceptible to at least one of the three viral antigens; 70 to H1N1, 54 to H3N2 and 32 to the B virus.  One hundred and three of these volunteers were actually randomized to be immunized and 92 of them remained in the trial and were challenged with either the H1N1, H3N2 or B viruses.
		As I mentioned the primary end point was protection against laboratory documented illness.  Forty-five percent of placebo recipients developed laboratory documented influenza illness; 7 percent of the FluMistTM recipients and 13 percent of the inactivative vaccine recipients developed laboratory documented illness.   This was consistent with an 85 percent efficacy for FluMistTM and a 71 percent efficacy for the inactivated vaccine.  These levels of efficacy were not different between the two vaccines.
		In addition to collecting data on the primary end point, the investigators also collected data on the immunogenicity of the vaccines as well as strain-specific efficacy.  I've summarized on this slide data for both for you.  As you can see, immunogenicity as defined by evidence of a four-fold serum antibody response, was modest in the  FluMistTM group, with 10 percent of participants mounting a four-fold antibody rise to the B strain, 29 percent to the H1N1, 39 percent to the H3N2.  
		In contrast, the serum antibody response to the inactivated vaccine was demonstrated by more than 90 percent of the participants in each group.  Despite the relatively modest serum antibody response, efficacy as defined by protection against clinical illness, was very high in the FluMistTM group as well, as in the activated vaccine group, and therefore, there was very little correlation for recipients of the FluMistTM vaccine between the serum antibody response and efficacy, again, with very high levels of efficacy being observed despite the low serum antibody response in each of the strains.
		Next slide.  In conclusion, therefore, from the challenge trial, AV003, FluMistTM was highly efficacious providing 85 percent protection and prevention against laboratory documented illness in healthy adults when they were challenged with the wild-type viral strains and this efficacy was observed despite the low serum antibody response.
		I'd now like to move on to the large clinical effectiveness field trial.  This was a multi-site trial conducted in 13 centers across the United States during the 1997/'98 season.  This was also a randomized double-blind placebo controlled trial.  Participants were between the ages of 18 and 64 years and all of them were working at least 30 hours per week.  As has already been mentioned, over 4,000 people were randomized in this trial.  The randomization scheme was 2 to 1 with twice as many participants receiving live attenuated vaccine as placebo.
		I will note that during the 1997/'98 season the predominant circulating virus, the H3N2 A/Sydney virus was poorly matched to the vaccine strain A/Wuhan that was included for that year.  This was a single dose regiment as would be the case for adults and we defined the outcome period according to community and national surveillance data that were available.  We looked at a variety of effectiveness outcomes in order to achieve a fairly broad assessment of the impact of influenza and its prevention in this population.  We looked at the proportion of people with influenza like illness, numbers of illnesses, days of illness, work loss and health care use.  
		We ascertained outcomes through the use of symptom cards that were completed on a daily basis for each month, November through March of the study year.  Participants received twice monthly telephone reminders to encourage them to complete and return the cards.  As mentioned previously, the outcome periods were based on local and national influenza surveillance data.  We looked at both site-specific peak outbreak periods because these were expected to provide the most specific or precise estimates of vaccine effectiveness.  We also looked at a pooled 14-week total outbreak period.
		The site-specific periods were defined based on a pre-specified computer algorithm centered on the modal week for the local geographic area designed to capture at least 80 percent of influenza activity for that season.  The total operating period is defined by an expert panel.  As has been mentioned previously, for the study participants in this trial, baseline characteristics were well-balanced between the two groups.
		In this slide I have summarized for you the influenza surveillance data both for the study sites pool in the red line as well as national data for the season in the vertical bars.  As you can see, the experience in the study sites closely mirrored that of the United States for that season.  The median duration of the peak outbreak periods was seven weeks.  Symptom completion card rates were excellent in this trial.  As you can see, they were similar between the vaccine and placebo groups across the five months of the outcome data gathering period.  Ninety-seven percent of participants returned at least one of the five symptom cards and 88 percent returned four or more.
		The illness definitions presented something of a challenge for us in this trial.  There is no or historically  has been no gold standard for the definition of clinical influenza-like illness.  Accordingly we considered trade-offs between sensitivity and specificity as we considered illness definitions.  A sensitive illness definition was expected to provide us with the most comprehensive assessment of the impact of influenza benefits of vaccination in the population which was particularly relevant from a health economic point of view.
		On the other hand, a more specific illness definition would be expected to provide perhaps a more accurate estimate of whether or not the vaccine actually works, that is, is it efficacious.  For the primary outcome illness definition we selected the most sensitive and least specific outcome illness, that is any febrile illness with a definition listed here, a febrile illness of at least two day's duration with at least two symptoms as listed over here.  
		The more specific illness definitions that we included in our pre-specified data planning included severe febrile illness that is a febrile illness lasting at least three days with symptoms on all three days as well febrile upper respiratory illness, that is febrile illness of at least two day's duration but with the requirement that participants actually have respiratory symptoms during the illness.  I would say that this illness definition, febrile upper respiratory illness, most closely mirrors the CDC's surveillance definition for influenza-like illness as can be seen here.  
		And this slide and then the next few slides, I will be summarizing some of the clinical effectiveness results of this trial for the peak outbreak period.  Here we have shown the proportion of participants experiencing any illness during the peak outbreak period for the primary end point any febrile illness as well as for severe febrile illness, febrile respiratory illness.  We have also included for your information, information on outcomes using the CDC surveillance definition for ILI.  As can be seen, there was a reduction in illness events across all the definitions.  
		However, for the primary end point the reduction did not reach statistical significance.  Not unexpectedly, as we look at the more specific illness definitions, the reduction was larger and we appeared to achieve somewhat more precision in the estimate.  Well, in addition to looking at the proportion of participants experiencing an outcome, we also tried to -- we also measured the outcomes looking at event rates.  Why did we do that?  Because some participants had more than one event and when we looked just a proportions, we actually failed to look at all of the information that was available.  
		For example, if someone had two or three febrile illnesses and with vaccination would have had only one illness, we would have picked that up when looking at event rates, but not when looking a proportions.  When looking at event rates, that is the number of illness episodes, one sees somewhat similar kinds of reductions across all of the illness definitions; again, any febrile illness, severe febrile, febrile upper respiratory illness and the CDC surveillance definition.  However, again, the estimates appear to have achieved somewhat greater precision.
		We also looked at numbers of days of illness as another parameter, measuring burden of disease.  And in each case, there were substantial reductions in the numbers of days of illness.  I mentioned that this was a clinical effectiveness trial.  We were interested in a very broad assessment on the impact of vaccination or the prevention of influenza, not only on illness but also on other healthy economic parameters including missed work, health care use and I have summarized the data here for any febrile illness.  You can see the reductions we've observed.  And likewise, reductions with febrile upper respiratory illness somewhat more impressive reductions with more precision and also with CDC's surveillance definition for influenza-like illness.
		In conclusion, FluMistTM was shown to be highly effective in reducing illness, missed work and health care use and this effectiveness was observed during a year when the predominant circulating virus strain was poorly matched to the vaccine.  Thank you.
		CHAIRMAN DAUM:  Thank you, Dr. Nichol.  We'd now like to take the two presentations together that dealt with adult issues and have some committee discussion about them.  Dr. Katz and then Dr. Schild.
		DR. KATZ:  Kristin, I wondered in the first study, the challenge study with the rather modest antibody increase but the very significant protection against illness with challenge.  Do you attribute that to local nasal antibody?  Did anyone measure that or to cell-mediated immunity?  What do you look to as the mechanism there?
		DR. NICHOL:  Local antibody responses in nasal wash were also assayed in the trial.  And in both groups of vaccine recipients, there was some evidence of antibody response that was higher than in placebo.  There was no significant difference between inactivated vaccine and the live attenuated vaccine.  I think it's the million dollar question, how do we identify the immune correlates with protection.  Clearly serum antibody response is not sufficient to explain the immune response that people obviously are having.
		DR. KATZ:  My second question, it can go to Harry or Paul or anyone which is obviously, you've excluded the major group for whom influenza vaccine is recommended, people over 65 years of age.  Is this because you anticipate the vaccine isn't as effective or your -- what was your reason for using 64 years as your cut-off?
		DR. MENDELMAN:  Mostly Dr. Katz, it's an IRB issue. You're doing an efficacy trial, you can't give placebo to people where the vaccine that's currently licensed is indicated.  And you can do large safety trials comparative to the inactivated vaccine but it won't provide the end point that you need for registration.
		DR. KATZ:  Thank you.  
		CHAIRMAN DAUM:  Dr. Schild, please.  Dr. Schild, could you press that button for us?
		DR. SCHILD: Mine is a similar point to Dr. Katz;   you're getting better protection in your challenge study with a live vaccine than with an inactivated vaccine and yet you have much lower antibody responses.  Therefore HAI antibody is not a very good indicator of protection and whether you attempt to do further studies to really try to find surrogate markers for protection in the live vaccine situation, for example, neutralizing antibody.
		DR. ARCURI:  We did perform nasal wash IgA antibodies on that test and I won't bother to call up the slide but I could if you want to look at it, but it's a negative result in that there was no difference between placebo and  FluMistTM recipients or between ITV and placebo in nasal wash IgA titers.  Now, remember, this is a small study so we don't have large numbers.
		DR. SCHILD:  Oh, yes.
		DR. ARCURI:  One could spend several days on immunity of influenza after TIV and live virus and I think work needs to be ongoing on markers of protection, but it's been a gnarly problem for a long time.
		DR. SCHILD:  Thank you.
		DR. NICHOL:  Might I also just follow up?  I showed plate estimates there but if you'll recall confidence interval around the estimates of efficacy actually the live attenuated and inactivated vaccines, we cannot distinguish between those levels of efficacy.
		DR. SCHILD:  They were small numbers, yes.
		DR. NICHOL: So that we would say they were equivalent in this trial.
		CHAIRMAN DAUM:  Dr. Steinhoff, please.
		DR. STEINHOFF:  This is a question about the challenge model in the adults.  I'm just wondering how you would reflect on the issue that in the placebo recipients. 45 percent of the subjects developed your end point that you were measuring.  Do you think that if you had a different kind of a challenge with a higher illness rate among the placebo recipients, you'd find a different protective response?  You may not be able to answer that, but the -- how would you reflect on that question?
		DR. NICHOL:  You know, I suspect that if there had been a higher illness rate among the placebo recipients, that we might have seen a higher level of efficacy, but, you know, it's my understanding in challenge trials and this was a study conducted by John Treanor and colleagues, that illness rates of 50 to 60 or 70 percent are not uncommonly seen.  We saw an illness rate of 45 percent, so whether or not that was much different from what one might expect in other challenge trials, perhaps others would like to comment.
		CHAIRMAN DAUM:  Dr. Goldberg, then Dr. Stephens.
		DR. GOLDBERG:  On the challenge trial, if I understand it correctly from your slides -- 
		CHAIRMAN DAUM:  Could you speak directly into the mike, Dr. Goldberg?
		DR. GOLDBERG:  If I understand your slides correctly, it looks like you stratified in the randomization by the susceptible strain.  When I add back up the numbers, you've lost the most -- you've got 29 subjects who actually did the challenge in the FluMistTM group, 10, 9 and 10, out of the 36, so that's the group where you lost more subjects for the challenged.  Can you explain that?  You randomized 33, 36 and 34 and you had 32, 29, 31 who actually -- you reporting challenge data on. Could someone address that?
		DR. MENDELMAN:  As an aside, it just showed up.  It's really the susceptible B's that drove the sample size because they're multiple -- the adults, you know, are susceptible to, you know, more than one strain, and then at the time of the randomization and the challenge, it was also based on how many people could be housed after the challenge.  There were logistical, practical issues.
		DR. GOLDBERG:  I just wanted to -- my question really addresses the fact that it looks a little differential with regard to not being challenged by strain and I wondered if that meant anything here.  There's a differential in the challenge group.  Do you want to address that?
		DR. MENDELMAN:  I'm not hearing the question or understanding it.  Sorry.
		DR. GOLDBERG:  You have 36 subjects in the  FluMistTM
group, but when you do the challenge, you have 29, so you've lost 7 subjects in --
		DR. MENDELMAN:  Right, right, there was --
		DR. GOLDBERG:  -- and that's more proportionately than in the other groups.  Is there anything that went on there?  Is there any reason for that or is it related to the susceptibility or the FluMistTM itself?
		DR. MENDELMAN:  No, the reason was practical in how many people could be challenged and housed for the next seven days.
		DR. GOLDBERG:  It was supposedly blinded, I would think.  So did they drop out because they didn't want to be on -- you know, because -- was here anything that went on that might make you -- I mean, I don't know if this would effect the result or not, but I think it is a differential.
		CHAIRMAN DAUM:  Did someone on the sponsor group want to make a comment because you can't make it from your seat?
		DR. ARCURI:  The people -- the randomization occurred, a subset were challenged, but the randomization occurred -- was blinded.
		DR. GOLDBERG:  No, I would expect that.  I mean, the only question is, is there something associated with the FluMistTM group that led them not to be challenged?  That's really the essence of my --
		DR. MENDELMAN:  There has not been any, Dr. Goldberg.  We could, if it's okay, Dr. Daum, ask Dr. Wittes to comment, who was involved in the analysis.
		CHAIRMAN DAUM:  Who is Dr. Wittes?
		DR. MENDELMAN:  Dr. Wittes is a consultant and she is the --
		CHAIRMAN DAUM:  Sure.
		DR. MENDELMAN:  -- head of Statistics Collaborative.
		DR. WITTES:  But she doesn't talk very well.  Obviously, Judy, we looked at that, I mean, because you wonder when you see something.  There was nothing that we could see.  It was a small group, so -- okay.
		CHAIRMAN DAUM:  Poor Dr. Wittes.  Dr. Goldberg, I think we're done with this issue.  We're not going to get any further with it, I guarantee you.  Dr. Stephens, Ms. Fisher and someone here, Dr. Steinhoff, thank you, and then Dr. Schild.
		DR. STEPHENS:  The efficacy data you presented, studies, the healthy adult study was effective -- pretty impressive for the H3N2 virus and the challenge study looked like there was protection, albeit without antibody for the H1N1.  Do you have any other data on H1N1, which I think is at least a concern that I have that you're going to share with us? Maybe you're going to share it later.
		DR. MENDELMAN:  George, could you call up slide number 10 and 11 under backup's to Dr. Belshe's presentation? So these are the historical data for trials primarily conducted by National Institute of Health and if we could -- can we focus this, George?  You can see the range of efficacy, depending on here's H1N1, 79 percent, 29 percent, H1N1, 100 percent, 67 percent, H1N1, 188, H3N2, 172, H3N2, 100/100, H3 -- B's those are all 100.  So high efficacy, albeit, these are small trials and challenges, high efficacy overall against the challenge.
		The next slide should be the field trials, whether it's H1 or H3, including Dr. Edwards' trial at Vanderbilt, and the efficacies range from 36 percent to it's hard to see, 76 percent.
		CHAIRMAN DAUM:  Imagine how we feel.  
		DR. STEPHENS:  I'm sorry, just to clarify, I'm asking about FluMistTM specifically.
		DR. MENDELMAN:  Well, these are the same Master Donor Viruses, that's either a monovalent or a bivalent, that were derived by Dr. Maassab.  They're not Aviron trials.  They were conducted prior to Aviron, prior to the current trivalent formulation that we are proposing for licensure.
		CHAIRMAN DAUM:  Thank you.  Ms. Fisher, then Dr. Steinhoff and Schild.
		MS. FISHER:  Okay, I just want to make sure I understand.  With FluMistTM you get a between 10 percent and approximately 25 percent reduction in any febrile illness, severe febrile illness, febrile upper respiratory illness and days of missed work between 10 and 25 percent on average.  It's different for different categories.  Were you, perhaps, expecting a larger reduction?  I mean, is that a healthy reduction in terms of placebo and --
		DR. NICHOL:  It's not a paltry reduction.  It's absolutely what one would expect understanding that even with our more specific illness definitions, not all of the outcomes were influenza related and so to see a 25 percent reduction in febrile respiratory illness, for example, might correlate with if one had laboratory confirmation of only those illnesses that are influenza related, might correlate with an 85 or 90 percent reduction in the influenza related illness.
		I have a slide here.  I've been, over about 5 or 6 years experimenting with ways to address that point specifically, the difference between efficacy and clinical effectiveness.  These are data not from the AV009 trial because we didn't have laboratory confirmation of influenza documented illness, but these are data that I have adapted actually from the CDC trial conducted over two seasons in Michigan and from the second year of the trial, they looked at influenza-like illness and had laboratory confirmation for approximately 35 to 40 percent of the people who had influenza like illness so only about 30 percent of the influenza like illnesses were actually influenza if you add laboratory confirmation.
		If you looked at the difference between placebo and vaccine, you saw a 34 percent reduction in all influenza-like illness but if you looked at the subset of laboratory confirmed, you saw an efficacy of 89 percent.  Does that help?  So when we see a 25 percent reduction in febrile upper respiratory illness or whatever the numbers exactly are, that perfectly well correlates with some level of efficacy that's the underlying efficacy is much higher.
		MS. FISHER:  So we really don't know in these cases how many of them were actually influenza.
		DR. NICHOL:  That's right, they were only clinically defined.  We did not have laboratory confirmation.  This was a clinical effectiveness trial.  In the challenge trial, we had laboratory confirmation.  They were very different kinds of trials, different outcomes and in many ways, different purposes.  What the physician sees in the office is influenza-like illness.  They see this and when I immunize my population of patients, what I see is in this case, a 34 percent reduction.  
		If I'd only teased out influenza illness by laboratory confirmation, I would have been able to say that there was an 89 percent reduction in this case, using this example in what was only influenza related.  Yeah, it's the difference between influenza attributable or caused specific versus all cause outcomes.
		CHAIRMAN DAUM:  Thank you very much.  Dr. Steinhoff, then Dr. Schild, then I think Dr. Faggett and then we'll go back and finish the sponsor's presentation.
		DR. STEINHOFF:  This is another question for Kristin on the challenge study.  We already talked about the laboratory documented illness rates and they were similar between the two vaccine groups.  Could you tell us the infection rates in the subjects in that study?
		DR. NICHOL: Yes, I believe that I have those numbers immediately here for you.  I do not believe that I have a slide for you but let me read you the wild-type infection rates by strain and vaccine.  For placebo, the wild-type infection rates were 58 percent for H1N1, 50 percent for H3N2, 55 percent for B.  For the live attenuated vaccine, they were respectively 30 percent, 44 percent, 20 percent.  For inactivated vaccine, they were respectively H1N1, 20 percent, H3N2, 30 percent and B zero percent.
		CHAIRMAN DAUM:  Thank you very much.  Dr. Schild, then Dr. Faggett.
		DR. SCHILD:  It's really a technical question.  It's been shown that on occasion when you isolate influenza viruses from the human specimen from the throat in eggs, you select variants that are antigenically somewhat different from the actual human virus in the throat.  This has been shown in several laboratories.  The question I have in relationship to the challenge studies is whether the virus you used in challenge was actually cultivated in eggs, and just to comment it might not effect the issue very much but it has been shown in laboratory studies that it can make a significant difference in terms of protection of immunized animals whether the viruses you're using compared in eggs mammalian cells or whether the virus is directly from human specimens from the throat.
		DR. GREENBERG:  All the challenge studies that you see -- that you were just presented and that you will be presented the challenge pools were grown in eggs and I think in the historical record that we eluded to previously, that is also the case.
		CHAIRMAN DAUM:  For the last word of this session, we'll go to Dr. Faggett, please.
		DR. FAGGETT:  Just a quick question; it would appear that there's quite a bit of allergic rhinitis present in this population manifest post-FluMistTM.  Do you have any feel for what the pre-FluMistTM incidents of allergic rhinitis was and would this have any impact in terms of antibody response because of the condition of nasal mucosa?
		DR. GREENBERG:  Dr. Faggett, could you just restate that question.
		DR. FAGGETT:  Well, you know, you talk about a lot of runny noses but that's usually just either perennially or allergic rhinitis but it could have some impact in terms of --
		DR. GREENBERG:  You're talking about in Dr. Mendelman's safety study.
		DR. FAGGETT:  Right, right.
		DR. GREENBERG:  Can we pull up the slide of --
		DR. MENDELMAN:  Is it no a particular slide or is it a different question?
		DR. FAGGETT:  There was a 20 percent incidents of -- you say runny nose but I'm just trying to get a feel for what the population was -- looked like.
		DR. MENDELMAN:  This is in children or adults?
		DR. FAGGETT:  That was adults.
		DR. MENDELMAN:  That's an 18 percent difference between FluMistTM and placebo recipients, within the seven days, any time within the seven days.  We've also done a by day analysis and that's in the slides as well as number of days.  Most -- well, more placebo recipients than FluMistTM recipients have no days of runny nose and then there's a distribution on one of those slides that shows that.  
		CHAIRMAN DAUM:  Thank you very much.
		DR. FAGGETT:  That's all, thanks.
		CHAIRMAN DAUM:  I'd like to move on now to the last leg of the sponsor's presentation, Dr. Belshe, with a few parting remarks from Dr. Greenberg.
		While you're setting up, could I ask folks who want to take photographs of the proceedings to please not use their flash.  It's really somewhat disruptive to the overall proceedings.  Photographs are okay, flash is not.  Thank you very much.  
		DR. BELSHE:  Thank you very much.  I'm delighted to have an opportunity to present the effectiveness and efficacy field trial that was jointed conducted by the NIAID and Aviron  in children.  I'm going to summarize the study in four parts.  This was a two-year efficacy field trial.  I'm going to first describe the results of year 1 in which both Influenza A and Influenza B circulated and those strains were well matched to the strains contained in the vaccine.  
		Then I'll turn and talk about efficacy in year 2 which was an H3N2 outbreak.  This was the first year that Influenza A/Sydney appeared and the vaccine was not well-matched to the epidemic strain.  Then I'll turn and talk about the analysis of combined efficacy for both years and then summarize the challenge trial we did with H1N1 vaccine strain to obtain surrogate data on efficacy against this virus.
		This clinical trial was governed by a steering committee that consisted of the principal investigators shown here on this slide.  Many of them are here in the audience today.  The steering committee also consisted of representatives from the two sponsors, NIAID and Aviron and we had the benefit of biostatistical expertise from actually four sources.  Both sponsors and then contractors to both sponsors provided substantial input into the design conduct and analysis of the trial.  
		Now, this figure summarizes the design of the study.  This was a double blind, placebo controlled study, randomized 2 to 1, FluMistTM to placebo.  Healthy children were enrolled at age 15 to 71 months.  The regiment consisted primarily of two doses of vaccine in year 1.  At two centers, however, by design only one dose of vaccine or placebo was given and that gave us an opportunity to assess one-dose efficacy as well. 
		In year 2, subjects where not re-randomized.  They remained blinded and were revaccinated according to the initial randomization with either the vaccine or placebo with a single dose revaccination.  The primary end point of this study was protection against culture confirmed influenza among the children who had received two doses of vaccine.  
		Now, we performed active surveillance during the post-vaccination period for adverse events.  All parents were called on day 4 and again on day 10 after each dose of vaccine and then between the vaccination doses, parents were called at two to three weekly intervals to inquire about the health of the child.  And before -- after dose 2 and before influenza season began, parents received additional calls at 2 to 3-week intervals to determine safety information.  
		Now, once influenza season began, which in year 1 was mid-November, we called the families approximately every week, to remind them to report any evidence of influenza and based on what we heard over the phone, we would decide then whether or not to visit the children and culture them for influenza.  And we set our sensitivity extremely sensitive, that is a runny nose and a cough was sufficient to trigger a culture for viruses.
		Enrollment into the trial is summarized on this slid for year 1.  One thousand and seventy children were randomized to receive FluMistTM and 532 were randomized to receive placebo.  Most of the children were randomized to receive two doses of FluMistTM or two doses of placebo.  Now, the occurrence of influenza in the total study population, that is both placebo subjects and vaccination subjects, is summarized in this figure.  In year 1 we had initially a H3N2 outbreak that was influenza A/Wuhan like and this was followed very shortly by an influenza B outbreak, that was influenza B/Harbin-like and this was similar to what was in the vaccine.  And I'll turn and talk about year 2 in a minute.
		Now, when we analyze the occurrence of influenza according to a study group, there were only 14 cases of culture confirmed influenza in the FluMistTM group for an attack rate of just over one percent.  Seven of those were influenza A and seven of those were influenza B cases.  However, among the 532 placebo subjects, there were 63 children with culture confirmed influenza A for an attack rate of almost 12 percent, 37 children had influenza B for an attack rate of 7 percent.  Now, that's 100 cases.
		Those 100 cases occurred in 94 children because 6 of the children had two illnesses one with influenza A and another with influenza B.  Overall the attack rate in year 1 in the placebo group was 17.7 percent.  Now, when we do the efficacy calculation against the primary end point, that is children who received 2 doses of vaccine, we get a point estimate of 93 percent efficacy against culture confirmed flu with relatively -- a very narrow confidence intervals.  One dose was also effective.  It was almost 89 percent protective against culture confirmed flu and an intent to treat analysis revealed 92.6 percent efficacy against influenza.  
		Vaccine was also protective against significant clinical illnesses associated with influenza and this particular analysis looks at febrile illnesses and otitis media.  For culture confirmed febrile illness, there were only eight cases among the 1,070 FluMistTM recipients.  In contrast there were 80 cases among the 532 placebo subjects for 95 percent efficacy against febrile influenza.  
		Now otitis media is a common complication of influenza and we observed 20 cases of otitis media among those children in the placebo group who had culture confirmed flu and only one case of otitis media in the children in the vaccined group with culture confirmed flu and so that's 97-1/2 percent efficacy against influenza associated otitis media.  
		Now, in addition, among the FluMistTM recipients who developed breakthrough influenza, the disease appeared to be more mild at least as indicated by duration of fever.  As shown here in the footnote, FluMistTM recipients who had flu, had an average or 2.4 days of fever.  In contrast, placebo recipients who had fever -- who had flu had 4.1 days of fever.  
		Now, in year 2, 85 percent of the children re-enrolled in the study, 917 were in the FluMistTM group and 441 were in the placebo group and they received a single re-immunization according to their original randomization.  Influenza A occurred in year 2.  It was the first year that influenza A/Sydney occurred, it's shown here in the red line and there was a single case of influenza B.  Now, when we look at the breakdown of those cases according to the treatment group, there were 15 cases among the 917 placebo recipients but 56 cases among the 441 placebo recipients.  
		Now, the outbreak of influenza A that year was primarily influenza A/Sydney but there was some influenza A/Wuhan or vaccine-like viruses circulating in the community.  So we strain typed each of those viruses and this particular slide illustrates the efficacy according to the strain specificity.  So the vaccine contained A/Wuhan and then we had wild-type A/Wuhan occurring in a few of the patients.  There were four such cases and then there was a single B/Harbin occurring.  So I've lumped together in this analysis the vaccine-like viruses and vaccine then was 100 percent effective because these five occurred all within the placebo group and there were none in the vaccine group.
		Most of the viruses were A/Sydney-like, 15 of those occurred in the FluMistTM group and 51 occurred in the placebo group which gives us a point estimate of about 86 percent efficacy.  Overall, for all cases of flu in year 2, vaccine was 87 percent protective.  Now, in order to understand this high efficacy of the live attenuated vaccine against a significantly drifted virus, a subset of children who were initially seronegative and received two doses of vaccine in year 1, were analyzed for HAI antibody against the vaccine strain shown here in the first column, which is the percent of children with four-fold rise, and a variety of related H3N2 viruses using antigens provided by the FDA.  
		And so this is the proportion of children with four-fold antibody rise to vaccine and the next column is influenza A/Sydney and then the other viruses here are A/Thessalonika '95, Russia '95 and Johannesburg '94.  And so there appeared to be a very broad reacting antibodies directed against H3N2 viruses after vaccination with FluMistTM. 
		We also had an opportunity to look at protective effect of natural infection in year 1 with A/Wuhan upon the A/Sydney outbreak in placebo children.  So what I've got here is the 441 placebo recipients broken down by group according to whether or not they had culture confirmed influenza A/Wuhan in year 1.  And there were 52 placebo subjects in whom we had isolate A/Wuhan in year 1 and only one of those had A/Sydney in year 2.
		In contrast, there were 389 placebo children without culture confirmed H3N2 in year 1 and we had 54 had culture confirmed influenza A/Sydney H3N2 in the second year.  And so this gives us an efficacy rate then of 86 percent which is the same point estimate we get for vaccine.  So to turn that around a little bit, it appears that live attenuated vaccine was just as effective as a recent natural infection with a related but significantly drifted H3N2 virus.
		In year 2 we also observed significant benefit against clinical disease associated with culture confirmed influenza.  This is the same analysis for year 2 as I showed you earlier for year 1.  Febrile illness associated with culture confirmed flu, there were only 12 cases in the 927 FluMistTM recipients, but there were 54 cases among the 441 placebo recipients.  That's an efficacy of 89 percent against febrile influenza and similar to year 1, there were a lot of case of otitis media associated with influenza.  In the placebo group there were 17 case, in contrast there were only two cases of influenza associated otitis in the FluMistTM group which is 94 percent protective.
		And finally we also observed in year 2 FluMistTM was protective, seemed to reduce the severity of illness against A/Sydney.  The duration of fever in the breakthrough cases in the FluMistTM group was only 2.1 days in year 2.  In contrast, the duration of fever in the placebo recipients was 4.9 days and that was a significant difference.
		Now, to do an analysis of 2-year efficacy we did a Kaplan-Meier analysis and the display of this data is shown as acquisition of influenza in the placebo group shown in the top part here with 95 percent confidence intervals versus the vaccine group and this is over the time in the study.  So that initially children start out, they've not had flu and they're being vaccinated and then at this point, we had the H3N2 outbreak in year 1 and these curves very quickly diverge as placebo children acquired H3N2.  
		And at this point, the slope changes and this is the influenza B outbreak in year 1 as children acquire influenza B.  And then we get to the intervening summer months when there is no flu and children are revaccinated in the fall and then at this point, there's the outbreak of influenza A, H3N2 Sydney and at the end of two years, a third of the children in the placebo group have had culture confirmed flu.   In contrast, only about 2-1/2 percent of vaccinated children had culture confirmed flu.  And there's a 92 percent reduction then from this point to this point and the 2-year protection against influenza.
		Vaccine was also protective against lower respiratory disease associated with influenza.  And this analysis looks at year 1, year 2, and the 2 years combined.  In year 1 there were four cases of lower respiratory disease, 3 of them occurred associated with culture confirmed flu.  Three of them occurred in the placebo group, only 1 in the FluMistTM group, that's 83 percent efficacy but the confidence interval includes zero.  However, in year 2, influenza A/Sydney was a particular virulent virus.  There were eight cases of lower respiratory disease, all of them in the placebo group or 100 percent efficacy.  Lower bound on the confidence level is 77 percent.
		Overall in the two years of study there was 95 percent protection against lower respiratory illness associated with influenza.  Now, this is a similar display as we just discussed for adults which illustrates the difference in efficacy and what we mean by effectiveness.  And in this particular data I'm showing you is the -- represents -- the height of the bar represents the attack rate of all febrile illness that we observed in the 2 years of study in this clinical trial, and the left-hand bar is the placebo group, and the right-hand bar is the vaccine group.
		Now so far we've been talking about efficacy which looks then only at the laboratory documented influenza which is a portion of this bar because clearly there are many other causes of fever and we don't expect the vaccine to have efficacy against other causes of fever and so what we've been looking at is, is this portion of the bar versus this portion of the bar in vaccinated subjects and we get efficacy of 94 percent against febrile influenza.  
		If we now turn and look at what's the benefit of the vaccine on the overall health of the child, we then say, okay, let's look at the total height of the bar in the placebo group versus the total height of the bar in the vaccine group and we get effectiveness of 18 percent. So we can expect vaccine to reduce all febrile illness but about 18 percent.  So with that as an introduction, let's look at several other effectiveness measures from this trial and I'm showing you the overall 2-year effectiveness.  
		The vaccine reduced febrile illness associated with antibiotics by 23 percent and that was statistically significant.  Vaccine reduced febrile otitis media with antibiotics by 30 percent and that was statistically significant.  Vaccine reduced the days that children missed daycare by 12 percent and similarly parents didn't have to lose as much work by 12 percent.  Those two measures did not quite achieve statistical significance.  
		However, there was a significant reduction in the number of health care provider visits in the vaccine group.  There was an overall 11 percent reduction in visits to the doctor.  So by a number of measures, FluMistTM improved the health and well-being of children.  Now during the two years of this field trial, H1N1 viruses did not circulate and therefore, the steering committee got together and designed a follow-on study where a subset of children were asked to be challenged with H1N1 vaccine strain.  The challenge was a high dose 107 given by the spray device and children were challenged 5 to 8 months following the second year of study.
		One hundred forty-four children had received prior FluMistTM and 78 children had received prior placebo.  The primary end point of this study was protection against viral shedding H1N1 vaccine virus.  Now, before we did this challenge, we obtained serum for HAI antibody and nasal washes for IgA so that we could determine correlates of protection and we assessed a viral shedding on days 1 through 4.
		A summary of the viral shedding is illustrated here.  Of 142 prior FluMistTM recipients who had viral shedding tested, only 6 shed virus.  In contrast, of 77 tested placebo recipients, 19 shed vaccine virus on days 1 through -- on any day 1 through 4 which gives an efficacy, a point estimate of efficacy of about 83 percent.  The analysis of the correlates of protection is long and complex and I'd be happy to discuss that with you, but just to summarize those results here, we demonstrated that overall any serum HAI antibody was associated with a 93 percent reduction in the attack rate of viral shedding.  Any nasal wash IgA antibody was associated with an 85 percent reduction in attack rate of viral shedding.  In addition to that, there were a subset of children in the  FluMistTM group who had neither HAI antibody nor nasal wash IgA and simply having a history of receiving vaccine correlated with protection against viral shedding.
		So we conclude then, that FluMistTM provided a very high degree of protection against culture confirmed influenza during two seasons of this efficacy field trial.  FluMistTM provided a high degree of protection in year 2 against a significantly drifted H3N2 virus and FluMistTM protected against significant influenza associated clinical illnesses, including otitis media febrile illness and lower respiratory infection.  Thank you.
		CHAIRMAN DAUM:  Bob, thank you very much for a very clear presentation.  I think what I'd like to do is, Dr. Greenberg, it looks like your final comments will be quite brief.
		DR. GREENBERG:  Mercifully.
		CHAIRMAN DAUM:  Mercifully, no, that's your word.  And so could we hear them and then have a few minutes of committee discussion.  We will then take a short break and then have the FDA presentation.
		DR. GREENBERG:  Just out of curiosity, where are we with our 90 minutes?
		CHAIRMAN DAUM:  You are at 91 minutes, so you're actually at minus 1 but I presume you're only going to take 2 or 3 and we can tolerate that.
		DR. GREENBERG:  Thank you.  I'd like to thank all of you for being so attentive and I'm not just going to very briefly summarize what you've heard.  I think from the data you've just listened to you would agree with me that FluMistTM is safe, well-tolerated, effective and efficacious in healthy children and adults 1 to 64 years of age.  The efficacy was shown in four different trials both challenged trials and field trials and I want to remind you that the efficacy we showed is consistent with the efficacy that Dr. Murphy talked about in all the historical record with multiple trials of this vaccine over many years.  So the efficacy really is a continuum and we've shown it again.
		FluMistTM protected against disease due to antigenically well-matched influenza viruses and against an antigenically drifted strain in both children and adults.  And FluMistTM was effective in reducing antibiotic usage, health care provider visits and days of lost work.  Next slide, please.  Well, so FluMistTM is safe and effective and that's  highly important because we're going to prevent a disease that causes a lot of problems for everybody and I know I'm boring you but that's the mission of this vaccine.  FluMistTM will provide an additional vaccine supply in a situation where vaccine is limited and the need is great.  It has an ease of administration which you all are aware of and most importantly, I think prevention of influenza -- it will prevent influenza  in healthy children and adults and I want to emphasize the children because as we said at the beginning of this presentation, children are really under-served, vis-a-vis, vaccination at the present time.  Less than 10 percent of children are vaccinated and there's a tremendous burden of disease on those children and they represent a potential nidus of infection to the rest of the community.
		Next slide, please.  As you are all aware, the story of this vaccine is a very long one and many, many people have contributed to it and I couldn't put all the names on a single slide.  I'd like to simply remind you that Dr. John Maassab, who cannot be here today, was the originator of this vaccine and has really been involved with it over a 30-year period.  The National Institute of Health and more specifically the National Institute of Allergy and Infectious Disease and even  more specifically, that's intramural, even more specifically the vaccine treatment evaluation units have played a very big role in the development of this vaccine.  Numerous clinical investigators outside of those groups have been involved and finally my colleagues at Wyeth Lederle Vaccines have also helped.  Thank you.
		CHAIRMAN DAUM:  I'd like to thank the sponsor for essentially adhering to our constraints and providing us with a stimulating set of data to consider and I'd like to have some questions on Dr. Belshe and Dr. Greenberg's presentations before break.  Dr. Kohl, Dr. Griffin and Dr. Katz.
		DR. KOHL:  Dr. Belshe, 2 questions.  You may not have the numbers because it's a sub-group, but do you have specific protection numbers age 12 to 24 months.
		DR. BELSHE:  Yes, that is in fact in the FDA briefing booklet.
		DR. KOHL:  I didn't see it.
		DR. GEBER:  It's 15 months.
		DR. BELSHE:  It's months, yes.
		DR. KOHL:  Okay, 15 to whatever.
		CHAIRMAN DAUM:  It's just being called up.
		DR. KOHL:  Okay, and then while we're calling that up, in the children who were challenged in the H1N1 challenge of the FluMistTM recipients who did not shed the virus, a fairly large number, did they have an antibody response?  Did you get sera on them to see if even though they didn't shed, whether you could boost their immune response with a challenge?
		DR. BELSHE:  We didn't go post-challenge sera in these children.  They'd been manipulated a lot in 2 years and in order to be practical and bring this data to an end, we did not do that.
		DR. KOHL:  It's too bad because the question comes up will the immune response be blunted or whatever by multiple episodes of immunization and that would have been a neat chance to see if they continue not to response.
		CHAIRMAN DAUM:  Thank you.  Dr. Griffin.
		DR. GRIFFIN:  Since the efficacy was actually pretty similar for whether you got 1 dose or 2 doses, I was wondering what the reasoning is behind recommending 2 doses for the youngest children.
		DR. BELSHE:  There's a long history of studying multiple doses by the NIAID as well as more recently by Aviron and what we've seen is that H3N2 and B very reliably give a vigorous antibody response it seronegative children and appear to in some -- what we've called, the investigators have called interference reduce the response anyway to H1N1 with the first dose.  And that this is overcome by just repeating the vaccination 30 to 60 days later.
		DR. GRIFFIN:  Is that unique then to the youngest children?
		DR. BELSHE:  Well, it's only observed in triply seronegative individuals and that -- it really means young kids.
		CHAIRMAN DAUM:  Thank you.  I think three committee members wanted to ask the same question at once, so we'll go on to Dr. Katz and then Dr. Edwards.
		DR. KATZ:  With permission, my question is for Nancy Cox.  Every year you show us studies at ACID of ferret anti-sera and various cross reactivities.  What's the difference in your studies between Wuhan and Sydney?  I mean, how far apart are they?
		DR. COX:  There were very consistent 4-fold to 8-fold differences using post infection ferret sera and there were -- I don't remember if -- they were in both directions but I can't remember if it was greater in one direction than the other, but there was what we would consider to be a significant difference and the vaccine strain was updated in the next year.
		DR. KATZ:  Thank you.  
		CHAIRMAN DAUM:  Dr. Edwards and Dr. Daum.
		DR. EDWARDS:  That actually is a nice prelude to my question.  Are you suggesting that the cold-adapted vaccine is unique in it's heterotypic protection compared to the inactivated vaccine from your suggestions?
		DR. GREENBERG:  No.
		DR. EDWARDS:  Thank you.
		CHAIRMAN DAUM:  I'm wondering about children or adults for that matter who fail vaccine and I know that certainly in other settings particularly bacterial infections when you have a child that fails a vaccine during a trial where you sort of run around and study every possible thing about that person.  What do we know about the people who fail trials, trials like we've heard today?  Have we made any attempt to look and see if there's anything special with their exposure, their clinical situation, their immunity, their ability to be a good host?
		DR. BELSHE:  Well, the problem, of course, with studying a vaccine that has 94 percent efficacy is that you get very few failures and so we just do not have the pre-immunization and post immunization immunologic assessments on enough children to make any comments about why is it that small subset fails.
		CHAIRMAN DAUM:  Ms. Fisher and then I think we'll break.
		MS. FISHER:  So if HAI -- serum HAI antibody is not a correlate for immunity then the only way to measure it is through challenge?  In other words, you measure efficacy by direct challenge.
		DR. BELSHE:  No, serum HAI antibody is clearly a correlative protection but it's not the only correlative protection.  IgA antibody in the nose is also an important correlative protection. So we clearly have shown that in children.  We have two good correlative protection but there is something beyond that.  There is something beyond that because a subset of children without HAI antibody and without IgA antibody are still protected.
		MS. FISHER:  So you just don't know the mechanism.
		DR. BELSHE: That's correct, not in that subset.
		CHAIRMAN DAUM:  Okay.  Again, we thank the sponsor for a great deal of data and food for thought so to speak.  It's now 4:00 o'clock.  We will begin the FDA presentation promptly at 4:15.
		(A brief recess was taken.)
		CHAIRMAN DAUM:  We'll now continue, please, if everyone will take their seats.  We'll turn the floor over to Dr. Mink, ChrisAnna Mink, from the FDA to initiate the FDA presentation.
		DR. MINK:  Can you hear me okay?  I will present the clinical summary from FDA on the Aviron cold-adapted, live attenuated influenza virus vaccine FluMistTM.  Let me re-emphasize what Dr. Levandowski stated this morning that this BLA was submitted on October 31st, 2000.  Our review is ongoing and many of the data have not been submitted or have not yet been submitted in final format.  I also need to give my eternal gratefulness to my clinical review team, and my supervisor, Dr. Geber and our statistician, Dr. Wasima Rida.  I hear an echo, do you?
		CHAIRMAN DAUM:  There is an echo in this room.  The sound bounces around and comes back.  I don't know what to do about it.  
		DR. MINK: That's okay, just so it's inside my head.  
		CHAIRMAN DAUM:  Can people in the back -- we can't rule that out unfortunately.  We can rule that out.  Would everybody please turn their cell phones and beepers off.  If anyone needs any help, as someone told me this morning, shutting it off, let me know.  Dr. Mink.
		DR. MINK:  The indication sought is active immunization for the prevention of influenza in children, adolescents and adults from 1 to 64 years of age.  Two-dose regiment at least 30 days about is being requested for the first 10 years in 1 to 9-year old subjects, less than 9 years and one-dose regiment for those over 9 years to 64 years of age also for immunization of travelers to areas where influenza viruses are circulating.  
		In this section, I will discuss studies in support of efficacy. You've heard a little about most of these already, the pediatric efficacy trial, AV006.  AV011 is the efficacy against shedding a vaccine strain H1N1 following -- AV009 is efficacy against illness during influenza outbreak periods in adults 18 to 64 and AV003 is efficacy against challenge with wild-type virus.   In this section I will also review studies submitted in support of consistency of manufacturing; AV007, which is a lot consistency trial and AV014 which is bridging of FluMistTM blended and filled at 2 different facilities.
		To begin, I'll start with AV006.  As described to you, this is a U.S. multi-center 2-year trial prospective double blind randomized in 2 to 1 ratio in healthy children 15 to 71 months of age. It was initiated for the 1996/'97 influenza season and evaluated by a 1-dose or a 2-dose regiment which was separated by 60 days.  FluMistTM was delivered via AccuSprayTM device of .5 mL dose.   The type that's shown here in the year 1 was A/Texas H1N1, year 2 was A/Shenzhen of H1N1 and both years the H3N2 A/Wuhan and the B was Harbin '94-like.  As has been said there, the placebo was normal allantoic fluid, which I'll abbreviate as NAF, stabilized with SPG.
		Monitoring for efficacy was performed by active surveillance with phone calls every two to three weeks starting on day 11 post-vaccination.  Calls were increased to every 7 to 10 days with influenza outbreaks.  Parents were to call if their child had any illness consistent with influenza.  Pre-defined criteria for obtaining influenza cultures or at the investigator's discretion were reasons for the subjects coming in for cultures.  This was after day 11.  Per protocol, to minimize risk of unblinding, cultures of subjects was discouraged in the first 10 days post-vaccination.  
		The end points were -- the first episode of culture confirmed influenza illness any time on the day of or after receipt of the second dose of vaccine was the primary end point.  Secondary end points included first episode of first culture confirmed influenza illness occurring at least 15 days after the first dose of vaccine and the subject after receipt of 1 or 2 doses both those enrolled to receive 2 doses and those enrolled to receive 1 dose.
		To briefly review, the enrollment of the subjects for both the 1 and 2-dose regiments were comparable demographics, for mean age, ethnicity, gender and for those subjects about 50 percent of the study group had a primary caretaker who was working outside of the home.  
		The number of cultures obtained is shown in this slide.  There were 139 cultures that were positive for an influenza virus out of the 3,127 cultures obtained.  Of the -- 18 cultures were obtained within the first 14 days, which I will discuss in a moment.  Seven cultures are not included because they were lost or could not be confirmed or had other procedural problems.  Six placebo subjects had cultures positive for H3N2 and then subsequently for Type B.  This left a total of 114 influenza positive cultures from 108 subjects that were included in the efficacy analysis.
		As has been stated, there was H1N1 circulating in year 1 and thus, I do not have field efficacy data to present for this strain.  This is a busy slide that shows the efficacy against culture confirmed influenza illness and so this would be those who received 2 doses and those with 1 dose and then all regimentized participants.  These are the number of positive subjects and the estimated efficacy was 95 percent confidence levels.  As stated by the sponsor, a high degree of efficacy was noted for those who received 2 doses which shows the --
		There was also an efficacy stated for those who received 1 dose but because of the small number confidence levels were wider.  And again, for all randomized participants, efficacy was demonstrated.  The sponsor also provided efficacy analysis for age, gender and ethnicity. This shows results by age.  For those less than 24 months which would be 15 to 24 months, the middle age groups and the highest were those over 60 months to 71 months.  As you can see, the numbers are smaller but there's efficacy demonstrated and again some of the confidence levels are wider. 
		On the next slide, it shows efficacy by gender and ethnicity.  There was no difference appreciated against any strain for subjects enrolled in 2 doses between male and female and between Caucasian and non-Caucasian.  As mentioned earlier, culturing in ill subjects was discouraged in the immediate post-vaccination period.  However, as shown on this slide, some cultures were obtained.  A total of 116 subjects who were ill, had 117 cultures obtained in the first 14 days post-vaccination.  Of these 116, 38 were placebo recipients, 16 of those had cultures after day 11 which is per protocol.  Twenty-two had cultures between days 2 and 10 and zero of those were positive for an influenza vaccine strain.
		Seventy-eight of the subjects were FluMistTM recipients, 66 were cultured after day 11 and 17 were obtained between days 2 and 10 which grew 18 cold-adapted incidents of virus strains.  As I mentioned, of these 17 FluMistTM there were 18 cultures, they grew 20 CAIV isolates.  There were 11 that grew Type B, five Type A and two that grew A and B.  I do not have the growth of other viruses at this time but I'm sure this analysis is available from the sponsor or will be soon.  
		Of note, 16 of the 17 subjects with positive cultures were from the Houston site.  As background for the audience, culturing was performed in a total of 31 out of the 144 of the FluMistTM recipients, which was 21 percent and 18 percent of the placebo recipients at that site had cultures obtained within the first 14 days.  The illness profiles of these subjects is shown on this slide.  I have presented here the placebos that were culture negative for CAIV, that's 36.  There are two that I'm not sure of the culture results, so it's presumably negative for CAIV.  Seventeen who were positive for CAIV and there were 60 subjects that were negative.  As you can see, any illness event, a reactogenicity event or adverse events was identified in 100 percent of the subjects who were culture positive.  
		More than three events were identified, which is .6 percent which is compared to 41 percent of the negative subjects for our CAIV strain.  Forty-one percent compared to 13 percent of the FluMistTM recipients who grew vaccine virus met criteria for CDO influenza-like illness and finally fever occurred in 70.6 of these positive subjects compared to 23 percent of the negative and 23 percent of the placebo subjects.  Thus, this would suggest that children who grew a cold-adapted influenza virus strain were ill.
		There is some suggestion that HAI titers greater than 1:32 have been associated with protection after natural influenza and after inactivated vaccine.  In AVO06 a subset of subjects had serum HAI and serum IgG and nasal IgA, anti-HA antibodies measured.  I will briefly discuss the HAI results.  The pre-vaccine titers are shown for this category and in that protocol seronegative was defined as less than 14.  For H1N1 the GMT was 5.4.  The geometric mean titer for H3N2 was 9.5 and for B it was 4.  Post-dose 1 was increased modestly for H1N1 and there was a notable increase for H3N2 and for Type B. 
		Post-dose 2, H1N1 had a rise to 18.8, H3N2, 43.8 and B to 25.8.  Please note that the placebo post-dose 2 were comparable to the pre-vaccine titers of the FluMistTM group.  This slide presents similar data but shown as geometric mean fold rise.  Post dose 1 to H1N1 was an 8.7 rise and there is at least a 4-fold rise for both H3N2 and B and post-dose 2, an increase of 3.4 from baseline for H1N1 and increase of up to 6.3 GMFR was noted for Type B.  There we go.  I'm okay, I think I've got it.  Thank you very much.  
		In year 2 approximately 87 percent of the subjects returned for participation.  In this protocol the subjects received 1 dose of the same study vaccine that they had received in year 1, that is they were not rerandomized.  The primary end point was efficacy against the first episode of culture confirmed influenza illness caused by a sub-type antigenically similar to the vaccine strain.  Antigenically  similar was not pre-defined in the protocol.  The circulating H3N2 as previously described was A/Sydney as was noted to be a variant from the vaccine strain A/Wuhan.  Again there was no H1N1 circulating in year 2.  
		The efficacy in year 1 as shown on this slide for all year 2 participants against all community acquired strains, the efficacy was approximately 87 percent with rarely -- fairly narrow confidence intervals.  For the missed strain the asterisk as A/Wuhan and B the efficacy was 100 percent but there are a few cases and we have wide confidence intervals.  And for the variants, the efficacy was 85.9 percent.  In the H1N1 challenge study, because there was no field efficacy available for H1N1, a challenge study was performed with the primary objective to compare viral shedding of vaccine strain, cold-adapted influenza monovalent or H1N1, and previous FluMistTM compared to previous placebo recipients. 
		A subset of AV006 subjects approximately 220 of them, about 20 per site, were challenged with vaccine strain H1N1 and then viral shedding was assessed as a surrogate for vaccine efficacy.  In this study design on day zero the subjects were challenged with .5 107 TCID50 of the vaccine monovalent A/Shenzhen.  This was the same lot as H1N1 as used in the FluMistTM for the 1997/'98 season, the year 2 of AV006.  The challenge was performed about 5 to 8 months after the year 2 dose.  On days 1 through 4 the subjects had nasopharyngeal cultures obtained.  
		Efficacy against vaccine shedding is shown on this slide.  Shedding on any day, frequency denoted by K, occurred in 4 percent of prior FluMistTM recipients compared to 25 percent of prior placebo recipients for an efficacy of 82.9 percent against shedding of monovalent vaccine H1N1.  Percent shedding is shown on this part of the graph and as you can see, on days 2, 3, and 4, there was significantly more shedding noted in the placebo recipient, prior placebo recipients than in the prior FluMistTM recipients.
		Please also note that shedding still occurred on day 4 for 8 percent of the subjects in the placebo group.  There were no subsequent cultures obtained and the total duration of shedding cannot be determined.  For adult experience, an effectiveness trial was performed, AV009, as presented earlier.  This study involved healthy working adults from 18 to 64 years of age, randomized 2 to 1 FluMistTM to placebo.  The subjects received one dose of the vaccine for 1997/'98 composition of A/Shenzhen for H1N1, A/Wuhan and B/Harbin-like.  
		In this trial vaccines could be self-administered or delivered by study personnel.  The primary objectives were to show safety and tolerability of the FluMistTM and placebo the normal allantoic fluid preparations and to show smaller proportions of FluMistTM recipients had any febrile illness during influenza outbreaks.  There were several secondary objectives as described by Dr. Nichol.  
		The effectiveness results are shown in this slide.  Any febrile illness occurred in 13.2 percent of FluMistTM recipients compared to 14.6 percent with a reduction of 9.7 percent, with these CBER-generated confidence intervals provided.  The p-value, unadjusted for multiple comparisons was not statistically significant for this primary end point.  Effectiveness was demonstrated for severe febrile illness, reduction of 17.4 percent, febrile URI reduction of about 22 percent and for the post-analysis of the CDC influenza-like illness and the Department of Defense influenza-like illness with these p-values are shown.
		The rate of AFI or any febrile illness associated events is shown on this slide and as described earlier, these were the number of days or the number of events per 1,000 subjects, per 7-week outbreak period.  There were statistically significant decreases for days of over the counter medication use and days of antibiotic use.  But the decreases were not statistically significant for days with health care provider visits and missed work days.  
		In the next slide I will describe study AV003 which was presented to you earlier.  Though this is a small study and was performed early in the clinical development of FluMistTM, it provides useful information and that is the only data available in adults with culture results for influenza virus.  The goal of this study was to assess the efficacy post-challenge with wild-type influenza against laboratory documented illness is subjects 18 to 42 years of age.
		FluMistTM was compared to placebo and FluMistTM was also compared to the trivalent in activated vaccine.  The other goal was to assess safety and tolerability of FluMistTM in adults who were serosusceptible to at least one of the strains in the vaccine.  Study definitions are reviewed briefly here and that symptoms of influenza -- for laboratory documented illness, symptoms of influenza with shedding of wild-type influenza on one or more days and/or a greater than or equal to 4-fold rise in HAI antibody titers to the challenge virus from days 28 to 56.  
		Illness was defined as two consecutive days of at least one respiratory symptom of moderate or greater severity or two symptoms of any severity.  The strains used were A/Texas for the H1N1, A/Shendong for H3N2 and B/Panama for the Type B.  These were contained in the 1994 strains for FluMistTM, also in the licensed TIV produced by Evand Medeva and in the challenge strains which were described by Dr. Greenberg.
		Placebo included an intranasal challenge -- I'm sorry, intranasal dose of normal allantoic fluids with SPG as described earlier and the injection with a saline with .01 percent thimerosal.  Efficacy against laboratory documented illness, any strain, is shown here.  In the FluMistTM subjects this occurred in 7 percent with compared to placebo an efficacy of 85 percent, competence intervals for 28 and 100.  For the inactivated licensed vaccine, laboratory documented illness occurred in 13 percent, also compared to 45 percent in the placebo group with an efficacy of 71 percent.  The efficacy estimates for the FluMistTM and the TIV were not statistically different.
		Next, I'd like to briefly review the lot consistency trial.  This is performed to -- to compare the safety tolerability and immunogenicity of 2 doses given 28 to 60 days part of 3 consistency lots of FluMistTM performed in healthy children 12 to 36 months of age.  There were approximately 100 subjects per each study group.  And lot consistency was to be declared if they could rule out a greater than 4-fold range in post-dose strain specific HAI geometric mean titers across lots with 95 percent confidence.  
		This slide shows the ratio of GMTs were all less than the pre-defined criteria of 4-fold, the largest difference being noted for lot 2 to 3 of 2.12 with these confidence intervals.  The manufacturing bridging study AVO14 was performed as a prospective randomized 3 to 2 ratio of FluMistTM to placebo.  Double blind trials compared the safety and tolerability of vaccine blend and filled at two facilities, Medeva and Aviron-PA.  The Medeva facility was used for vaccine production and all of the -- for all of the vaccines in clinical trials.
		The two primary -- two co-primary objectives are seroconversion rate in seronegative subjects should differ by no more than 20 percent and that 90 percent confidence intervals for the GMT ratios were within 1/4 and 4.  In this study, 2 doses 28 to 40 days apart were given to healthy children, 12 to 42 months of age and this study was performed in Australia, to limit interference by circulated influenza in the Northern Hemisphere.
		Post-dose 2, the baseline percents for conversion are shown on this slide.  For H3N2 and Type B there was zero percent difference and for the H1N1 there was 16 percent difference.  
		So in conclusion, for efficacy, efficacy was demonstrated against culture confirmed influenza after 1 or 2 doses in healthy children from 15 to 71 months of age in year 1 and again, after revaccination in year 2.  Influenza-like illnesses occurred in children who shed CAIV vaccine strain virus post-vaccination.  In adults there was no significant decrease in AFI during influenza outbreak periods.  And at this time we have no field efficacy data for H1N1.  
		Next I'd like to review the safety summary.  Safety monitoring categories generally are shown in this slide included reactogenicity events, REs, which were solicited post-vaccination events generally monitored for 10 days in pediatric trials and seven days in the adult trials.  The list of these REs were provided by Dr. Mendelman.  
		Other adverse events, abbreviated as other AEs, were unsolicited AEs also captured in the post-vaccination period. Serious adverse events were consistently defined in the protocols with the Code of Federal Regulations.   Generally, these were captured for 42 days post-vaccination in the studies where they were monitored.  Not all studies had active monitoring for all categories of adverse events. 
		The studies that I will briefly review include the safety data from the efficacy trial AV006 and also in pediatric trial of AV012 mentioned this morning, the herd immunity trial performed primarily in an HMO in Texas and then the Kaiser trial AVO19 where they captured medically attended events and SAEs in children 1 to 17 years of age.  
		Studies submitted in support of safety in adults included effectiveness trial, AV009.  Additional studies which I will not discuss today include Phase 1 and Phase 2 trials as well as the safety in AV003.  And then because of the chance of inadvertent exposure for at-risk subjects, studies for safety profiles in asthmatics, 9 to 17 year old, also asthma subjects in AV012 and then an NIH trial which evaluated the safety profiles of FluMistTM and HIV-infected subjects will briefly be reviewed.  
		I mentioned earlier that the review is ongoing.  The sponsor has presented larger numbers for total exposure than we have completed review in the FDA data base.  And our data base as of April 30th, 2001, there are 20,046 subjects who have had their first time exposure to FluMistTM.  Please note that this includes 511 subjects from 50 to 64.9 years of age and 1254 were those subjects between 1 and 2 years of age.  First I will begin with the adult experience with the representative trial being AV009, the healthy adult effectiveness trial.	
		A total of 3,041 FluMistTM recipients and 1520 placebo recipients were in this trial.  REs and unsolicited adverse events were captured for seven days with 98 percent of subjects returning a diary card.  SAEs were actively monitored with a phone call at 28 days post-vaccination.  In addition, the sponsor collected any passive reported events after 28 days because, as you recall, there was a 5-month illness surveillance in the study.  This shows selected RE events by group, 3041 subjects with this number returning the diary card.
		Both the FluMistTM and the placebo groups experienced at least one reactogenicity event, 70.9 percent in the FluMistTM group and about 62 percent in the normal allantoic fluid recipients.  Runny nose and nasal congestion was the most frequent and recorded the greater than 10 percent difference between the groups.  Sore throat was next, headache also occurred frequently though it's not on the trial. 
		And please note that the rate of fever was about 1 percent in both groups.  Unsolicited or other adverse events are shown on this slide.  Again, both the FluMistTM and placebo group were reactogenitic with any adverse event being reported in the 30 percent of the FluMistTM recipients and about 21.5 percent of the normal allantoic fluid recipients.  Respiratory events occurred in 18.1 percent of FluMistTM and 7.5 percent of placebo.  Allergic reactions, which had been a concern, were infrequently observed in either group.  
		And digestive events were also comparable between the groups.  The only statistically significantly difference noted here was the occurrence of any adverse event.  In study AV009, there were 46 subjects with asthma who were inadvertently enrolled with 23 of them being FluMistTM.  Though the numbers are small, there was an increase in REs noted in the FluMistTM and the placebo recipients who were asthmatics.  For any adverse event for the placebo group, the rate was about 84 percent.  
		There were also 7 pregnancies noted in this trial.  Five of them were FluMistTM recipients.  There were 5 exposures in the first trimester which all led to full term live births, though I have no additional information for these pregnancies.  There were also two spontaneous abortions, one each in the  FluMistTM and the placebo group.  
		For the pediatrics safety monitoring I present AV006 years 1, 2 and 3.  The REs were captured in this trial on diary cards for 10 days after each vaccination.  Other adverse events were also collected for 10 days.  SAEs were not actively monitored post-vaccination, though there were illness calls -- there were phone calls performed for illness surveillance.  SAEs were not specifically queried.  Selected REs are shown by group and by dose on this slide.  As described earlier both the FluMistTM and placebo recipients experienced significant adverse -- any reactogenicity event occurring 74 percent of FluMistTM and 66 in placebo and 69 and 62 post-dose 2.  Both of these were statistically significant with a p-value of less than .05.
		Runny nose and nasal congestion was still the most frequent followed by vomiting and also we have myalgias and fever greater than 100.6 rectally.  The sponsor presented 100 today but that was orally.  This is the same fever categories.  This was statistically different after dose 1 but not after dose 2. 
		This slide shows selected other adverse events by group and by dose.  And adverse event was experienced by 18 percent of FluMistTM and 15 percent of placebo and a comparable rate after dose 1 and dose 2 and there was no difference between the study groups.  Statistical difference were noted with abdominal pain occurring more frequently in the FluMistTM group after dose 1 and this was not seen after dose 2.  Rash described as macular papular rash occurred more in the placebo recipients after dose 1 and it was infrequent after dose 2.
		Again, allergic reactions was recorded and occurred infrequently after all doses in both groups.  And respiratory events, which Dr. Mendelman listed today including pneumonia, bronchitis, sinusitis, otitis, et cetera, were comparable between the groups in this display.  In year 2 the reactogenicity events were shown to be similar in the subjects who had received 1 or 2 doses in year 1 after their re-vaccination in this year.  Also there was no statistically significant difference for REs between the FluMistTM and normal allantoic fluid recipients.  Both groups experienced -- 58 percent of both groups experienced at least one RE.  And again, runny nose and nasal congestion was the most frequent, occurring in about 42 percent of both groups, followed by cough occurring in about one-quarter of both groups.  
		Of note, one 6-year old with a history of allergic reactions had hives and angioedema 30 minutes post-receipt of normal allantoic fluid, the placebo vaccine.  
		Safety monitoring was performed in the third year for these subjects called AV015.  The subject who had completed years 1 and 2 were eligible for year 3 participation which was open-labeled administration of FluMistTM.  The subjects could have also participated in AV001, which means they may have previously received 1 to 4 doses of FluMistTM.  In this year the prior  FluMistTM recipients were given one dose of vaccine and prior placebo recipients could receive 1 or 2 doses separated by 28 to 60 days.  There was day 42 phone calls to collect SAEs in this trial.  
		The reactogenicity events between the groups again, for runny nose and nasal congestion have the largest difference and as you can see, this occurred in 49 percent of prior placebo recipients compared to 37 percent of prior FluMistTM recipients after dose 1, which is essentially their first dose of receiving FluMistTM vaccine.  No other differences and REs rates were greater than 10 percent.  In looking at REs across 3 years of FluMistTM, in year 1 approximately 73 percent of subjects experienced any RE.  This decreased to approximately 56 to 58 percent in year 2 and year 3.  Thus, there was no increase in REs observed with subsequent doses.  
		The sponsor also has continued to follow these subjects for a fourth year and those data are to be submitted to the BLA.  During CBER's review of this file, pneumonia cases were identified and, thus, a search of all available data was performed.  In year 1 looking at pneumonia within 21 days of vaccination, there were 6 FluMistTM and 1 placebo recipient which led to a relative risk of 2.98 with confidence intervals of .36 and 24.72. 
		For all cases not temporally limited, there were 8  FluMistTM and 2 placebo recipient for a relative risk of 1.99, confidence intervals of .42 and 93.  Please note that one subject at Houston, who was diagnosed with pneumonia also had a culture positive for CAIV strain.  In year 2, there were 2 FluMistTM subjects with pneumonia and these cases occurred at 15 and 68 days post-vaccination.  
		In the next study for safety, I will review the Kaiser trial briefly because it was presented in detail this morning.  I will again emphasize that this is an ongoing review.  In this trial SAEs and MAEs were monitored in 9689 healthy children from 1 to 17 years of age.  The trial began in October of 2000.  FluMistTM versus placebo in a 2 to 1 ratio was the design.  Two doses separated by 28 to 42 days was for children from 1 to less than 9 years of age and one dose was for children 9 to 17 years of age.  The data base was searched for MAEs and SAEs for 42 days after each dose.   
		And the data base was locked on December 31st for interim analysis for safety.  At that time, which is the data that we have available at the CBER, approximately 89 percent of the 9 to 17-year olds had completed their post-dose monitoring and 68 percent of the 1 to 8  year olds had completed their monitoring.  The data was submitted to CBER on April 30th, 2001.  The interim analysis included multiple comparisons as presented by Dr. Black.  There were four clinical events that were pre-specified.  These included acute respiratory events, systemic bacterial infections, acute gastrointestinal events and rare potential -- rare events potentially related to influenza.  
		The utilization setting was hospital, outpatient clinic, emergency department and combined and there was also stratification for age with these age groups of all 9 to 17, 1 to 8, 18 to less than 36 months and then 12 to 18 months.  As mentioned, a total of 1500 statistical comparisons were performed without adjustments for multiple comparisons. Because of the large number there are some relationships that show differences that could have been due to chance.
		From the interim analysis, 20 SAEs within 42 days were reported through April 15th of 2001.  Thirteen of these are included in the FluMistTM group and 4 were within 14 days.  This included hemolytic uremic, HUS syndrome in a 12-month old, acute gastroenteritis, AGE in a 14-month old, abdominal gynecological pain in the 16-year old female and appendicitis in a 15-year old male.  All if these events occurred on day 11.
		In the placebo group there were 7 SAEs, 3 of them within 14 days.  There was one croup in a 17-month old female that the sponsor coded as possibly vaccine related.  Trauma in a 17-month old and a psychiatric disorder in a 12-year old and all of these occurred on day 4 plus vaccination.  For MAEs within 42 days as of December 31st, 2000, 50 events were reported.  These were not presented to you by study group.  There were 20 percent that were coded as well-child or reassurance, 11 percent at URI and 7 percent for otitis media, trauma and psychiatric disorders.  These codes are what's provided by the Kaiser provider on the sheets at discharge.  
		For interim analysis of pneumonia in 1 to 17-year olds, less than 21 days post-vaccination, interim there were 10 FluMistTM group and 6 in the placebo group for relative risk of .83 with these confidence intervals of .3 and 2.28.  For all cases identified the sponsor presented 14 FluMistTM and 10 placebo with a relative risk of 0.7 with confidence intervals of 0.3 and 1.57.  
		As you recall in AV006, the subjects were 15 to 71 months of age.  An analysis in this study by age group is ongoing.  The sponsor reviewed these this morning so I will briefly point out MAEs that they have assessed as plausibly related biologically to FluMistTM with an increase in the FluMistTM group compared to placebo.  Conjunctivitis that has been described increased in 1 to 17-year olds, 1 to 8-year olds and 18 to 36-months old and seem to have a temporal relationship.  
		URIs were also increased from 1 to 17-year olds.  Abdominal pain, musculoskeletal pain was also increased in 1 to 8-year olds and the 18 to 36-month old.  Asthma in 18 to 36 months was 7.75 events compared to zero events per 1,000 person months in the placebo group and the otitis media with effusion in 1 to 8-year olds in the clinical setting post-dose 2 as described by Dr. Black this morning or earlier this afternoon.
		They have also -- it seems like this morning, I agree.  A long day.  In the Texas community study, AV012 trial, this is a 1-dose of FluMistTM given to children 18 months to 18 years primarily performed in Scott and White HMO in Temple/Belton, Texas to assess effectiveness against medically attended acute respiratory infection.  For this BLA, SAEs within 42 days were reported.  Reporting methods included postcard reporting with reminder calls and also there were data base searches performed for 79 percent of the subjects who had their primary health care at Scott and White.  
		There is also a collection of passive reports from the parents of the subjects of any concerning adverse events to them.  There were 531 of 4298 subjects identified to have asthma, reactive airway disease or wheezing which was not an exclusion in this community trial.  The SAEs and captured other AEs are shown on this slide.  There were 8 SAEs with 6 of them occurring more than 21 days post-vaccination.  There were 149 out of the 40,063 subjects who had 42 data available that reported onset of at least one new illness. 
		Eighty-seven of these events and 78 subjects were judged by study personnel to be clinically significant.  After being considered clinically significant they were recorded on a case report form and entered into the data base.   On FDA review of these 9 listings 65 were respiratory events and 10 diagnosis of pneumonia and/or bronchitis were identified.  This also is an ongoing analysis and the full data set has not yet been presented to CBER, including the analysis on asthmatic subjects.
		For the subjects that had completed the trial, I believe it was 409 asthma subjects, there was not an increase in medically attended respiratory events.  These are preliminary data.   As I mentioned, because of the risk of inadvertent exposure in high risk subjects, some studies have been done, including AV010, which was the asthmatic trial.  Forty-eight subjects with 24 FluMistTM and 24 placebo recipients, 9 to 17-years of age with moderate to severe asthma were given one dose of study vaccine.  The subjects were monitored for safety, tolerability and asthma stability for 35 days, including 7 days pre-vaccine to establish their baseline and 28 days post-vaccination.
		This shows the adverse event profiles of the subjects and, again, please note the both the FluMistTM and normal allantoic fluid were reactogenitic with 91 percent of both groups experiencing at least one RE.  Runny nose was the most common with 75 percent and 56 percent of the groups.  Cough occurred in about 40 to 45 percent.  Fever was more frequent in the placebo recipients.  Two subjects or 8.3 percent experienced an asthma exacerbation meaning a required increase in medication or therapeutic intervention but none of these required hospitalization and there are no SAEs reported in this trial.  
		Briefly, I will review the HIV trial.  There were 57 HIV infected subjects and 54 HIV negative subjects who received FluMistTM or placebo vaccine in a 1 to 1 ratio.  There was one HIV subject who shed cold-adapted influenza virus, Type 9 on day 5 post-vaccination but was culture negative on day 7.  AEs were comparable in the two groups, occurring in 12 to 16 percent of HIV positive and HIV negative subjects.  
		CV4 counts decreased 8 percent in the HIV positive FluMistTM recipients transiently at day 28 and had increased by day 90.  There was no increase in viral load post-vaccination and these subjects were followed for 6 months.
		A Veterans Administration Study was performed and the study synopsis is provided in the BLA.  In this study, they evaluated 22015 adults more than 50 years of age with chronic obstructive pulmonary disease.  The subjects received 1 dose of FluMistTM or placebo in a 1 to 1 ratio given concurrently with TIV.   Only SAEs were reported in March of 2001 which included 63 deaths in this trial, 34 in FluMistTM and 29 in placebo recipients.  Approximately 8 deaths, four in each group, occurred within 28 days of vaccination.  As I mentioned earlier, an increase in pneumonia was noted in AV006 and so we searched all available data at CBER for pneumonia cases.  These are CBER generated data and include review of inspection reports, data base, line listings and any SAE reports from the sponsor.
		I have not totalled this column on purpose because there are varying follow-ups and varying dosing regiments and varying capturing for AEs.  To date we have identified 37 pediatric cases after FluMistTM of pneumonia.  Actually, we have 2 additional ones since I prepared this slide and also 12 cases of placebo -- 12 cases of pneumonia identified in placebo.  The data that's most useful are in studies AV006 and AV019 where there are denominators.  However, AV019 is an interim analysis and the final data set has not yet been analyzed.
		In AV006, as I presented earlier, for pneumonia less than 21 days the relative risk was 2.98 but there was not an increase in relative risk noticed in study AV019 in 1 to 17-year olds.  So in CBER review of pneumonia, the things that we would like you to note is that there was one death that occurred in pneumonia as described by Dr. Mendelman.  Symptoms began 23 days after the second dose of FluMistTM in an 18-month old boy in a live sponsored trial in South Africa.  
		There was also one pneumonia case identified by CBER inspectors which occurred 15 days post-dose 3 in a four and a half year old in year 2 of AV006.  The parents reported this to the study site a year after it occurred and there was one case of pneumonia that was associated with culture positive CAIV.   For deaths, there was 65 deaths reported, actually it was 66 because I have left off the one child who died of a brain tumor as described earlier.  The one pneumonia case -- there was one adult who died from accidental drowning associated with alcohol intoxication and there were 63 deaths in the VA study which I cannot describe in more detail.  
		So our conclusions is our review is ongoing.  Our review of respiratory events, including pneumonia and search for a diagnosis of bronchitis and bronchiolitis is not complete.  FluMistTM and the normal allantoic fluid placebo are reactogenitic.  Most of the safety data in this BLA have been generated in trials of healthy subject.  There have been a few high risk subjects evaluated and there is a suggestion of increased REs and asthmatics.  There was no increase in REs noted with annual dosing of children and also there were a few subjects evaluated at either end of the age spectrum.  
		Additional concerns are concurrent immunization.  At this time, there are no data for safety or efficacy with concomitant immunization, including traveler's vaccine available in any age group.  For transmissibility, the Finnish trial has been presented but the full data set has not yet been reviewed but there was note of one subject who was a placebo recipient that shed vaccine virus.  
		And also we have no data for the annual revaccination of adults.  Thank you.
		CHAIRMAN DAUM:  Thank you very much, Dr. Mink.  
		DR. MINK:  And since it's late, no questions.
		CHAIRMAN DAUM:  And since it's late -- no, wait a minute.  I'd like to open the floor now to committee for questions and clarification of Dr. Mink's presentation.  Dr. Eickhoff, then Dr. Edwards.
		DR. EICKHOFF:  Dr. Mink, you described very nicely the curious events in Houston with positive cultures for CAIV in those first 10 days with a curious association with illness, both fever and CDC-ILI.  But you refrain from speculating as to what might be going on here.  Would you speculate at this time?
		DR. MINK:  I'm not allowed to speculate.  Actually, we can ask the sponsor if they'd like to comment if there was a difference in Houston compared to the other sites.
		CHAIRMAN DAUM:  Could we get this mike on, please?
		DR. BELSHE:  I just wanted to comment, actually, as well, on slide 18, but in that particular analysis, only ill subjects were cultured, whether they were in the vaccine or placebo group and then we divided the ill vaccinated subjects to whether they had positive cultures or negative cultures and concluded that the vaccine virus shedding was associated with illness but that's a self-fulfilling prophecy, because only ill subjects were cultured.  
		And I think that a better way to -- if you shed more virus, are you more likely to have illness associated with  FluMistTM?  We've addressed this formally in the NIE studies using monovalent vaccine in which all subjects were cultured on a daily basis and the virus shedding pattern described and in fact, in one study, I believe Ed Anderson's study of H3N2 vaccine we can show a decrease in symptoms associated with a virus setting suggesting that there were inner current things actually suppressing replication of the vaccine virus.  And so I would suggest what this analysis really needs is to look at the positive culture rate in a similar cohort because this is only 20 percent of the children shedding and I would expect on any given day that 50 percent would be shedding virus in the vaccine group and you're actually showing a decrease in shedding here.  
		DR. MINK:  Actually, I think that's probably a different analysis.  What this was looking at was the subjects who were cultured who were ill in the first 14 days, which was not specified in the protocol.  And in these groups what we looked at with the assistance of the sponsor was of those subjects who were ill with cold-adapted virus versus subjects who were ill that were culture negative potentially due to other viruses, we saw a difference in the illness profile.  These numbers are small and they haven't been statistically analyzed to see if the differences are significant.  
		CHAIRMAN DAUM:  Thank you very much.  Dr. Eickhoff. 
		DR. MINK:  I don't think I answered Dr. Eickhoff's question about what was unique.  
		CHAIRMAN DAUM:  Does anyone want to attempt to answer that question?
		DR. MENDELMAN:  Paul Mendelman.  I think the -- if we could put a slide up the --
		DR. MINK:  My side?
		DR. MENDELMAN:  One that we have on the computer here. 
		DR. MINK:  Okay.
		DR. MENDELMAN:  The data Dr. Mink is quoting is correct and we did this analysis at CBER's request.  It's important to note that there may be case ascertainment bias and it's a non-randomized comparison because you're looking at children who are all FluMistTM recipients and a subset who are sick, cultured and you're looking at the positive versus the negative.  In the randomized comparison shown on this slide, would be all the 116 plus children in the 2 to 1 randomization, so it's the randomized comparison.  
		Whatever brought them into the clinic at the investigator sites agreed most of the cultures were done at Houston but there were other representative sites in this analysis, so looking at the 77 FluMistTM recipients on this slide compared to the 38 placebo recipients and if we look down the case definitions that CBER asked us to do or looking at the reactogenicity that were collected, you can see that the differences here noted on the culture positive versus culture negative FluMistTM recipients really are significantly reduced in this analysis which was also presented to the agency.  So I think that's one way the committee to clarify what was going on in the 14 days after vaccination at these sites.
		DR. MINK:  Again, I think that this is a little bit different because these are 78 FluMistTM and as I stated at least 66 of those were after day 11 and there's probably a temporal difference and that the first 14 days post was when there were more subjects that were culture positive for cold-adapted influenza.  But I will give you that the analysis is still ongoing.
		CHAIRMAN DAUM:  Dr. Eickhoff, are you comfortable with the answer here?  I don't know if --
		DR. EICKHOFF:  No, but there may not be an immediate answer.  
		CHAIRMAN DAUM:  Okay, thank you.  Let's go on to Dr. Edwards.
		DR. EDWARDS:  I think one of the issues surrounding the pneumonia question is the very well-known fact that when you're hurrying to get people immunized for the influenza  season that you also have a contending problem of RSV that is co-circulating at that same time.  So is there any data from the sponsor that looks at these children that had respiratory illnesses, had pneumonia for the presence of RSV?
		DR. MINK:  I can tell you that the AV006 began from August and went through November, so most of that enrollment and follow-up was before RSV season although subjects toward the end were entering into RSV season just, you know, based on usual circulation of RSV.  However, I'm sure the sponsor has this data about what other viruses were cultured but that's not yet been submitted either.  Do you guys want to comment?
		DR. MENDELMAN:  Paul Mendelman.  The investigator sites routine cultured on RMK cells and that would have been grown in order to optimize the growth of influenza.  Certain cell lines that are more permissive to RSV were not inoculated and there wasn't a question of this study what other viruses, respiratory viruses might be present.  It was really trying to answer the question about influenza efficacy and trying to limit the amount of reagents that the investigators were needing to do and the number of cultures they needed to do.
		DR. MINK:  So like we just have seasonality, I guess.
		CHAIRMAN DAUM:  Dr. Katz and Ms. Fisher.
		DR. KATZ:  Dr. Mink, you cited one study of HIV infected adults.
		DR. MINK:  Right.
		DR. KATZ:  And I really had three questions really.  One, how were they selected as far as where they were in their illness, two, did anyone study their antibody response and three, you said that they had no increase in virus load and I wonder when that was assayed.
		DR. MINK:  Okay, it is actually a very complex thoughtful study design in that the enrollment was staged at initially subjects who had CD4 counts greater than 500 who had been clinically well and either not on anti-retroviral therapy or on a stable regiment for at least six weeks were enrolled and the next phase the CD4 count was lowered to 200.  I'm sorry, I don't remember that ends in each of those phases.  
		The viral load was followed actually, I think -- I can't remember and hopefully the sponsor can help me out, at zero and an interim period of either 7 or 12 days, at 28 days, at 3 months, at 6 months. Even though it's a small study, it was comprehensive.
		DR. KATZ:  And did they demonstrate any rise in antibody?
		DR. MINK:  Serology was performed on these subjects.  I don't remember if it's in their briefing documents.  If it's not, if the sponsor can't provide it to you, I can provide it to you.  And actually there wasn't a noticeable difference between the HIV positive and the HIV negative subjects for the immune responses for the different sero-types.
		DR. KATZ:  Thank you. 
		CHAIRMAN DAUM:  Ms. Fisher, then Dr. Edwards.
		MS. FISHER:  Thank you for a very excellent presentation.  You emphasized several times that the FDA's review is ongoing, particularly for evaluation of pneumonia and bronchitis after vaccination, the increased reactions in asthmatics.  Does the FDA staff feel comfortable about the amount of data they have so far in terms of our voting on this issue tomorrow, or do you believe we need more information?
		CHAIRMAN DAUM:  Can I interrupt as a matter of order here?  It seems to me that FDA is asking our advice on that very question.  So to ask them to advise us to advise them doesn't compute.
		MS. FISHER:  No, I think it's very important when you have a presentation by industry and presentation by FDA staff and when you have several times being stated that the FDA review is ongoing, that we need to know whether or not there's enough data here in their opinion, in their expert opinion for us to be voting tomorrow.
		DR. MINK:  I can give you an easy answer.  We are required to discuss and BLAs with the advisory committee and there on a 10-month clock.  So we come to you in July because of our 10-month clock and we are mandated to discuss products with you before a complete response is provided to the sponsor.
		MS. FISHER:  Perhaps I can clarify.
		CHAIRMAN DAUM:  Dr. Geber, do you wish to comment on this question?
		DR. GEBER:  Yes.  I think that we have received -- we received the BLA in October of last year and we have by and large completed our review of those data that were received at that time.  The sponsor has requested that we present that information to you today and we're doing so.  We have subsequently received additional information from the sponsor.  Some of those data include the Kaiser Permanente study which Dr. Mink eluded to were submitted to us at the end of April in an unblinded fashion and so the review of those data from our perspective are ongoing.  
		And the sponsor has committed to submitting a complete data set from that study.  In discussing the respiratory events that Dr. Mink has discussed, what we say about our review being ongoing that in the study reports that we've received, we did not have summaries of pneumonias, of bronchitis, of bronchiolitis.  So in order for us to analyze this data, we've had to go back and search the data bases. 
		And it's a multitude of factors that lead us to the statement that our review is ongoing.  I think that's where we're at.
		MS. FISHER:  Thank you.
		CHAIRMAN DAUM:  Thank you very much. Dr. Edwards is next.
		DR EDWARDS:  Could you comment a little bit on the cultures that were taken within the first 14 days, those were performed at the laboratories of the investigators and then were the investigators told what was isolated which would subsequently unblind them or did they all go to a central place or how was that managed?
		DR. MINK:  That's correct, they were performed at the site and then sent off to Aviron labs for confirmation.
		CHAIRMAN DAUM:  Dr. Stephens.
		DR. STEPHENS:  This is a specific question regarding AV014, which is the bridging study.  And you have a statement in your handout that says that the study did not achieve the goal of demonstrating equivalence between the two manufacturing facilities.  Can you comment on that statement?
		DR. MINK:  You should have received an amended handout.  Those criteria of 20 percent were accepted by CBER.
		DR. GEBER:  There was some confusion as to whether we had accepted the 20 percent point estimate or whether we accepted the confidence interval but the sponsor has pointed out to us and correctly so that what they had proposed was a point estimate and that apparently is what we accepted.
		CHAIRMAN DAUM:  Dr. Snider?
		DR. SNIDER:  A couple of questions that perhaps can't be satisfactorily answered but I'll ask them anyway.  One has to do with the fact that this vaccine, I guess not in trivalent form but in monovalent and/or bivalent form was administered at one time as drops as opposed to the nasal spray.  And I was wondering if there had been any observations at that time of lower respiratory infections and -- in the same 21-day interval after administration.  
		And the other is whether in earlier studies of the vaccine, whether there had been a different control, normal saline or some non-protein containing substance that was administered at the same time that would give us a better handle on -- because as you point out, both the placebo and the vaccine are reactogenitic.  I was just wondering what baseline data there may be for getting some sense of what is caused by the vaccine with all of its constituents versus having nothing or having normal saline sprayed into your nose.
		DR. MINK:  Would you like to answer Aviron?
		DR. MENDELMAN:  Paul Mendelman.  Our review of all the literature shows that all the prior studies conducted by the NIH were with egg allantoic fluid that we could review.  Obviously, the importance of having a placebo controlled that visually and indistinguishable and taste, smell and every other way is important to limit a lot of bias that can go into a randomized placebo controlled trial.  
		So we've also used allantoic fluid for that reason.  I'm sorry, Dr. Snider, what was your first question?  Oh, I remember.  AV001, the very first trial conducted by Aviron with the NIH in adults looked at FluMistTM delivered by drops versus FluMistTM delivered by spray and there was no difference in the safety profile in that study or in the immune responses.  The second trial conducted, AV002, with the NIH looked at drops versus spray in children, and again, no difference in the immune response and the safety profile.
		And then subsequent, starting with study AV003, and on all sprayers were used.
		CHAIRMAN DAUM:  Thank you for clarifying.  Dr. Griffin and Dr. Schild.
		DR. GRIFFIN:  I'm not sure who this is a question for, maybe it's for Brian Murphy or maybe it's for somebody from Aviron but I was just wondering if it was -- how much we know about the neurovirulence of these viruses.  Influenza in general is not a neurovirulent virus but we are giving it intranasally and I would just be interested in knowing what kind of information we have on that question.
		I notice that meningitis and encephalitis, that sort of thing were not monitored events but I assume that they would clearly have been picked, you know, as adverse events in the Kaiser study, et cetera.
		DR. MINK:  They were monitored, like in the Kaiser trial, the CNS was one of the long laundry list of --
		DR. GRIFFIN:  I just looked through that laundry list and I didn't find it, but maybe CNS I looked for, yeah.
		DR. COELINGH:  I don't have much to add.  I would agree with you that influenza is not either neurovirulent or neurotropic, the wild-type influenza even and for that reason we have not performed neurovirulent studies.
		DR. GRIFFIN:  I mean, there are neurovirulent strains for animals that are well studied.  I just -- I don't have a good idea of how they fit into these categories.
		DR. COELINGH:  Those strains have -- we've had to passage those in animal strains multiple times in order to pick out variants that become neurovirulent so as far as I'm aware and anyone can correct me, I'm not aware of any naturally occurring neurovirulent human strains.
		CHAIRMAN DAUM:  Dr. Schild is next and Dr. Kohl, Edward and Eickhoff.
		DR. SCHILD:  The clinical effectiveness of this vaccine is highly dose dependent it seems and I just wonder, it's well known, of course that sensitivity of egg assays or cell culture assays vary from time to time and between laboratories.  I just wonder what is being done to validate and standardize those assays for infectivity.  Is there actually a reference preparation that you use in every assay?
		DR. GREENBERG:  As was discussed earlier this morning, there is a very well validated potency assay that has high levels of reproducability.
		DR. SCHILD:  But does that include the use of the same material in every assay so that you could look at changes in sensitivity?  Thank you.
		CHAIRMAN DAUM:  The answer was yes.  Let the record show that Dr. Greenberg nodded his head.  Dr. Kohl.
		DR. KOHL:  FDA, since we've heard data that there is a limited by finite risk of transmission of this virus, as shown in both the Peter Wright studies and the daycare center studies, I'm a little concerned about transmission of the virus to high risk hosts who are contacts living in families, HIV infected people, kids with immuno deficiencies, et cetera.  Other than the HIV data that we've heard which are fairly healthy HIV folks, are there any other data on high risk hosts or are there any forthcoming?
		DR. MINK:  For shedding in high risk subjects?
		DR. KOHL:  No, for serious illness in high risk subjects or unusual adverse events in high risk subjects.
		DR. MINK:  I think Aviron wants to answer this, too.  There was also an HIV pediatric trial that has been performed.  I don't know in what stage that is and there's still some asthma subjects to be evaluated.  What else do you have?
		DR. MENDELMAN:  Paul Mendelman. You're correct.  The pediatric HIV trial also, these are children infected with HIV, not AIDS subjects and the control, similar to the adult trial, were non-infected children with HIV.  And those data will be available for CBER and if there's a particular question, the lead investigator, Dr. Jim King, is in the room that can address the question about either the adult HIV or the pediatric HIV trial, if there's a specific question that Dr. Daum would like addressed to Dr. King.
		CHAIRMAN DAUM:  Thank you, Dr. Mendelman.  Dr. Edwards, please.
		DR. EDWARDS:  I just did want to add that there have been increasing reports from Japan about encephalitis associated with wild-type influenza strains.  So I thing that that is a very reasonable question that Dr. Griffin raised. 
		DR. MINK:  In the data base there was one diagnosis of aseptic meningitis in AV012, the Texas community trial.  In the Kaiser study, I believe it was on the list of queries and there wasn't an increase in CNS events to the data base so far.  If you want to add more, go for it.
		DR. BELSHE:  We did, as part of potentially influenza related rare events look at encephalitis and aseptic meningitis and did not identify any case of either in the interim analysis or in the final data set.
		CHAIRMAN DAUM:  Thank you.  We're going to go on for about five more minutes here.  We'll have time tomorrow morning to return to things that people would like to reraise and we'll have both FDA and the sponsor here to provide additional clarification.  So I have Dr. Eickhoff, Steinhoff, Daum and Cox.  Dr. Eickhoff, please.
		DR. EICKHOFF:  My query has been answered.
		CHAIRMAN DAUM:  Dr. Steinhoff.
		DR. STEINHOFF:  One of the things we've been hearing about and one of the questions we're supposed to answer is the issue of reassortants and reversion in these viruses.  And listening today we've seen lots of information about examining phenotype and genotype of the seed viruses and of the reassortants that have been tested.  I may have missed something but I don't think I've seen any data on more than there was some information about phenotyping of the viruses that come out of the vaccinated kids.  We've seen a fair amount of information.  These kids do shed virus. They shed it up to 7 to 8 days, may or may not be associated with symptoms.  
		We are usually told that it's phenotypically stable.  But it would seem to me that if the data is available, we should get that information on the characterization of the viruses from vaccinated kids.  We've seen some.  I'm not saying I haven't seen any.  We've seen some data but here's what I'm curious about.  If you take 100 kids or 1,000 kids and give them this virus and if half of them shed, what do we know about the viruses that they're shedding?  I would guess there must be some finite rate of change.  It may be the same as the master strain, but it would seem to me this would be important data to have, to be able to characterize the variability of the vaccine strains.
		CHAIRMAN DAUM:  It's a thoughtful comment, Mark, and it goes very nicely with what we're going to be discussing tomorrow morning.  We'll see if Dr. Mink wants to comment on it from the point of view of the FDA's perspective this afternoon.
		DR. MINK:  Good idea.
		CHAIRMAN DAUM:  Thank you very much.  
		DR. STEINHOFF:  The point is though, there may  not be data right now, so that we need to think about what kind of data do we want or are we interested in.
		CHAIRMAN DAUM:  And I think I would like you to reraise this tomorrow at the right moment.  I think it's an important point.  Dr. Greenberg.
		DR. GREENBERG:  I think the sponsor will be able to help in that discussion tomorrow morning.
		CHAIRMAN DAUM:  We will be grateful for that help.  Dr. Mink, I'd like to ask you a question that shows how little I know about influenza but you indicate that there were several kinds of adverse events that were biologically plausible and mentioned abdominal pain among those.  I need a little bit of help with that.  How does influenza cause abdominal pain?  What kind of abdominal pain are we talking about?
		DR. MINK:  Actually, the biological plausibility was assigned by the sponsor for those categories.  You could postulate and this is postulation, that the virus that's sprayed in the nose could be swallowed and potentially you could have some sort of response that way but natural influenza, a lot of times the kids will have abdominal discomfort or GI discomfort associated with the illness.
		CHAIRMAN DAUM:  Dr. Greenberg, do you want to speak to this very issue?
		DR. GREENBERG:  I think the biologic plausibility was based on the well documented association of wild-type influenza with abdominal pain.  So it was sort of biologic epidemiologic plausibility as opposed to strict pathophysiologic plausibility.
		CHAIRMAN DAUM:  Thank you very much.  Dr. Cox.
		DR. COX:  Yeah, I think this is actually more of a comment than it is a question.  I don't quite know how to formulate the question.  But I keep going back to the pneumonias that might possibly be associated with FluMistTM administration and back to the particle size and knowing that the small particles could possibly be deposited in the lungs, and obviously, we know that the live attenuated vaccine should not replicate in the lungs so therefore, you should not -- because it's temperature sensitive, so you should not have disease caused but I'm just interested in what comments the sponsor might have with regard to these comments.
		CHAIRMAN DAUM:  All right, it's late in the day.  Let's hear your comments, sir.
		DR. MENDELMAN:  Paul Mendelman.  The one case that Dr. Mink has talked about is when cold-adapted vaccine was isolated from a child on day 3 after vaccination, a Type A virus vaccine and on day 8 was a Type B virus.  On day 3 the child was see when a culture was taken and by chest x-ray, and by the documentation and the records that are under review, the investigator noted that the chest x-ray showed a consolidated bacterial process pneumonia.  
		And I think that my estimation on that one, Dr. Cox, is that the child was dosed with FluMistTM, so likely the child is going to be culture positive for FluMistTM if you culture the child and happen to have another co-infection that was brewing prior to the vaccination, I think that from a pediatric infectious disease is to rapid to have a consolidated pneumonia.  If Dr. Daum, I could have a slide put up to maybe clarify the pneumonia question for Dr. Cox and for Dr. Snider. 
		The comparison in an open label trial, Dr. Glezen's trial, a community protection trial in Temple, Texas and this was brought up by Dr. Mink, these are data that have not been submitted to the agency but in part have been presented at national meetings.  And this is year 1 and year 2 of the trial for the children and in this analysis looking at medically attended acute respiratory illness, the child is his or her own control.  So this is looking at 14 days after being vaccinated, compared to the reference period, which is in the data base states prior to enrollment in the study, and day 15 and beyond, so it's a rolling type of analysis that many of you are aware of, then I guess I would just show you the last line, LRI on the slide in year 1 and year 2 and the relative risk column on the second to last column, actually there's a reduction.  The relative risk is .5 and .6.
		Comparing the child to himself, albeit the bias is in a non-placebo controlled trial, but given that we're probing placebo controlled trials for is it egg allantoic fluid reactogenitic, here is the kind of trial one could do without a placebo control and there does not appear to be pneumonia or bronchitis any other lower respiratory events excluding asthma events and albeit the agency hasn't seen these for their own analysis.
		CHAIRMAN DAUM:  Thank you very much, Dr. Mendelman.  Dr. Greenberg, the last word.
		DR. GREENBERG:  I just wanted to clarify very briefly the issue of lung deposition of infectious agents and particle size.  I think, Dr. Daum, you probably remember the publications better than I do but I had forgotten but actually Dr. Gordon Douglas is in the audience reminded me that the association of increased infectivity and infection dose50 with particle size is really carried out with a specific nebulizer that made 1 micron particles and that's what the data is.
		DR. MINK:  Actually, can I have one last comment?
		CHAIRMAN DAUM:  Yes.
		DR. MINK:  Remember that you get pneumonia after influenza with it only ever getting in your nasopharynx.
		CHAIRMAN DAUM:  Okay, now we have Dr. Geber stepping up.  This will be the last.
		DR. GEBER:  You know, I think the FDA has presented data on pneumonia that we have not -- we've received case report forms within the last week, so we haven't reviewed them all.  We have some suggestion of a point estimate relative risk being increased in the first year of 006 but the confidence interval overlaps 1 and so we are just presenting the data as we know them now and we have not finished our review of 019, but you have heard from the sponsor that no increase was seen in their review of those data and I think that that's where we're at and that's the only point we're trying to make.
		CHAIRMAN DAUM:  Thank you, Dr. Geber.  Committee members, we are not at all sure that this room will be locked overnight, so we ask you to take your materials with you.  We will reassemble promptly tomorrow morning at 8:30.
		(Whereupon, at 5;41 p.m. the above-entitled matter recessed to reconvene at 8:30 a.m. on July 27, 2001.)