PREVENTION OF PNEUMONIA CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of priority of US Provisional

Application No. 62/183,888, filed June 24, 2015, which is incorporated by reference in its entirety for any purpose.

FIELD

[001] This application relates to compositions and methods for preventing pneumonia.

INTRODUCTION AND SUMMARY

[002] Pneumonia is an infection of one or both of a patient's lungs that can be caused by a number of different pathogens, including viruses, bacteria, and fungi. Symptoms of pneumonia include cough, chest pain, fever, and difficulty breathing. Serious complications of pneumonia can include respiratory failure, sepsis, and lung abscesses. When a patient develops pneumonia outside of a hospital without having had recent contact with a healthcare facility (like a hospital, long-term care facility, or dialysis center), it is termed community- acquired pneumonia (CAP). When a patient develops pneumonia following a stay in a healthcare facility, it is termed healthcare-associated pneumonia. The infectious agents that cause CAP and healthcare-associated pneumonia are often different.

[003] Respiratory viruses are recognized as common causes of CAP, particularly among children and the elderly (see PaviaAT (2013) Infect Dis Clin North A 27(1): 157— 175). Additionally, respiratory viruses are an important cause of severe pneumonia and respiratory failure in immunocompromised patients. In patients with CAP, respiratory viruses can be the sole cause of viral pneumonia (i.e., primary viral pneumonia), can be present as a co-infection with a bacteria or another virus (i.e., viral-bacterial pneumonia or viral-viral pneumonia), or can act as predisposing factors to facilitate or worsen bacterial pneumonia.

[004] Influenza virus can cause primary viral pneumonia or predispose a patient to bacterial pneumonia. Influenza is a common cause of pneumonia particularly among young children, the elderly, pregnant women, those with chronic health conditions, and those who live in a nursing home. Radiographic pneumonia can be confirmed in approximately 16%-55% of patients hospitali2ed for influen2a. Patients with influen2a who are admitted to the hospital are more likely to die or be admitted to the ICU if they also have pneumonia. The

American Lung Association reports that flu and pneumonia was the ninth leading cause of death in the United States in 2010 and the seventh leading cause of death among individuals 65 years of age and older.

[005] Many different types of bacteria can also cause pneumonia. The most common cause of bacterial pneumonia in adults is Streptococcus pneumoniae (pneumococcus). Available vaccines have decreased the prevalence of

pneumococcal diseases, including pneumonia caused by Streptococcus pneumoniae (CDC: Pneumococcal vaccination) .

[006] The Centers for Disease Control estimates that one million people per year are hospitali2ed with pneumonia in the US, and approximately 50,000 people die from pneumonia (CDC: Pneumonia Prevention). Most hospitali2ations and deaths from pneumonia in the US are in adults. Globally, pneumonia causes nearly one million deaths in children under 5 years of age, which is greater than that from any other infectious agent, including HIV infection, malaria, or tuberculosis. While certain vaccinations and preventative practices can decrease its risk, pneumonia remains a significant healthcare concern in the US and globally.

[007] The inventors have discovered that when influen2a vaccine is administered at a higher than normal dose, it can prevent pneumonia in addition to preventing influen2a. In one embodiment, the influen2a vaccine's effect on pneumonia is mediated directly through cross-pathogen immune responses. In another embodiment, the influen2a vaccine's effect on pneumonia is mediated indirectly through alterations of the nasopharyngeal microbiome. In another embodiment, the influen2a vaccine's effect on pneumonia is mediated through a combination of effects.

[008] In one embodiment, the influen2a vaccine exerts an effect on pneumonia protection that is independent from its prevention of influen2a infection or its corresponding disease modulation. In other embodiments, the influen2a vaccine elicits an immune response that prevents pneumonia caused by non-influen2a pathogens, like, for example, Streptococcus pneumoniae.

[009] In accordance with the description, methods for preventing pneumonia comprising administering an influen2a vaccine or a component or components of an influen2a vaccine are encompassed. In some embodiments, use of an influen2a vaccine or a component or components of an influen2a vaccine for preventing pneumonia is provided. In some embodiments, use of an influen2a vaccine or a component or components of an influen2a vaccine for the manufacture of a medicament for the prevention of pneumonia is provided. In some embodiments, an influen2a vaccine or a component or components of an influen2a vaccine for use in the prevention of pneumonia is provided.

[0010] In some embodiments, the dose of the influen2a vaccine

administered to a subject is higher than a standard dose influen2a vaccine. In some embodiments, the subject is provided with a greater volume of a standard dose vaccine, thereby providing the subject with a higher dose. In other embodiments, the influen2a vaccine is formulated to contain a higher dose. In other embodiments, the influen2a vaccine has a higher neuraminidase (NA) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher haemagglutinin (HA) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher matrix 1 (Ml) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher matrix 2 (M2) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher polymerase basic 1 (PB1) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher polymerase basic 2 (PB2) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher polymerase acidic (PA) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher non-structural 1 (NS1) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher non- structural 2 (NS2) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher nucleoprotein (NP) content when compared to standard dose vaccines. In other embodiments, the influen2a vaccine has a higher amount of any combination of one or more of the influen2a virus proteins HA, NA, Ml, M2, PB1, PB2, PA, NS1, NS2, and NP when compared to standard dose vaccines.

[0011] In some embodiments, the pneumonia is caused by a virus, bacteria, or fungi. In some embodiments, the pneumonia is caused by a virus selected from influen2a virus, respiratory syncytial virus (RSV), metapneumovirus, adenovirus, rhinovirus, coronavirus varicella-2oster virus, and parainfluen2a virus. In some embodiments, the pneumonia is caused by a bacteria selected from the group consisting of Streptococcus pneumonia, Staphylococcus aureus, Neisseria meningitides, Mycoplasma pneumonia, Haemophilus influenza, Legionelk pneumonia, Legionelk spp., Chlamydia spp., including Chlamydia pneumonia, and Chlamydia psittaci, Moraxella spp., including Moraxella catarrhalis, Streptococcus pyogenes, including Streptococcus pyogenes (Group A), Pseudomonas aeruginosa, gram-negative enteric bacilli, methicillin-susceptible S. aureus, methicillin-resistant S. aureus, Haemophilus parahaeoyl ticus, Pseudomonas alcaligenes, Citrobacter freundii, Staphylococci haemoyl ticus, Clostridium perfringens, anaerobes, including Fusobacterium sp., Prevotella sp., Gemella morbillorum, Peptostreptococcus prevotii, and Veillonella sp., nocardia sp., coagulase- negative Staphylococci, and Acinetobacter baumannii. In some embodiments, the pneumonia is caused by a fungus associated with at least one of histoplasmosis, coccidioidomycosis, blastomycosis, Pneumocystis pneumonia, sporotrichosis, cryptococcosis, aspergillosis, candidiasis, and scedoporiosis. In some

embodiments, the pneumonia is caused by a virus and a bacterium.

[0012] In some embodiments, the pneumonia is a community-acquired pneumonia (CAP). In some embodiments, the pneumonia is a healthcare- associated pneumonia.

[0013] In some embodiments, the pneumonia is caused by infection with influeu2a virus. In some embodiments, the pneumonia is not preceded by influeu2a. In some embodiments, the pneumonia is preceded by, or concurrent with influen2a.

[0014] In some embodiments, the vaccine is administered to a subject at a dose that is higher than that in a standard-dose influen2a vaccine. In some embodiments, the vaccine administered to a subject has a hemaeglutinin (HA) content that is higher than the HA content of a standard-dose influen2a vaccine. In some embodiments, the vaccine administered to a subject has a neuraminidiase (NA) content that is higher than the NA content of a standard-dose influen2a vaccine. In some embodiments, the vaccine administered to the subject has a content of one or more influen2a proteins that is higher than the content in a standard-dose influen2a vaccine, wherein said influen2a protein(s) is selected from HA, NA, Ml, M2, PB1, PB2, PA, NS1, NS2, and NP.

[0015] In some embodiments, the influen2a vaccine is a trivalent vaccine. In some embodiments, the influen2a vaccine is a quadrivalent vaccine.

[0016] In some embodiments, the vaccine is produced in avian eggs. In some embodiments, the vaccine is not produced in avian eggs. In some embodiments, the vaccine is made by recombinant DNA techniques. In some embodiments, the vaccine is inactivated or live attenuated.

[0017] In some embodiments, the vaccine is administered intradermally, intramuscularly, or intranasally.

[0018] In some embodiments, the vaccine contains adjuvant. In some embodiments, the vaccine does not contain adjuvant.

[0019] In some embodiments, the vaccine is selected from Flu2one (Trivalent or Quadrivalent; Sanofi Pasteur), Fluarix (Trivalent or Quadrivalent; intradermal; GlaxoSmithKline), FluLaval (Trivalent or Quadrivalent; ID

Biomedical Corporation of Quebec; distributed by GlaxoSmithKline), Alfluria (bioCSL), Fluvirin (Novartis Vaccines and Diagnostics), Flucelvax (Novartis Vaccines and Diagnostics), FluMist (Medlmmune), and FluBlok (Protein

Sciences). In some embodiments, the vaccine is a reformulated version of a vaccine selected from the group consisting of Flu2one (Trivalent or Quadrivalent; Sanofi Pasteur), Fluarix (Trivalent or Quadrivalent; intradermal;

GlaxoSmithKline), FluLaval (Trivalent or Quadrivalent; ID Biomedical

Corporation of Quebec; distributed by GlaxoSmithKline), Alfluria (bioCSL), Fluvirin (Novartis Vaccines and Diagnostics), Flucelvax (Novartis Vaccines and Diagnostics), FluMist (Medlmmune), and FluBlok (Protein Sciences), wherein the reformulated vaccine has a higher dose than the standard dose version. [0020] In some embodiments, the influen2a vaccine is marketed as a high- dose influen2a vaccine.

[0021] In some embodiments, a dose is considered high if the dose provided to the subject for prevention of pneumonia is increased as compared to the dose in a standard-dose influen2a vaccine.

[0022] In some embodiments, the vaccine is Flu2one High-Dose, which contains 60 micrograms HA per strain per dose (0.5 mL).

[0023] In some embodiments, the vaccine is an inactivated or recombinant vaccine.

[0024] In some embodiments, the vaccine has an HA content that is higher than 15 micrograms of HA per strain per each 0.5 mL. In some embodiments, the vaccme is higher than about 15, 20, 24, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 micrograms of HA per strain for each 0.5 mL.

[0025] In some embodiments, the vaccine is similar to Flu2one ID except that its HA content is higher than about 9, 10, 15, 20, 24, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 micrograms of HA per strain for each 0.1 mL. In some embodiments, the vaccine is similar to Flublok except that its HA content is higher than about 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 micrograms of HA per strain for each 0.5 mL. In some embodiments, the vaccine that is administered to a subject for the prevention of influen2a is formulated to have a higher HA content than the HA content of a standard dose vaccine. In some embodiments, the vaccine that is administered to a subject for the prevention of influen2a is formulated to have a higher NA content than the NA content of a standard dose vaccine.

[0026] In some embodiments, the vaccine is a live-attenuated vaccine.

[0027] In some embodiments, the vaccine is similar to Flumist except that it contains more than about 10 ⁶ - ⁵ -10 ⁷ - ⁵ FFU (fluorescent focus units) of live attenuated influen2a virus reassortants.

[0028] In some embodiments, the subject is elderly. In some

embodiments, the subject is older than about 65 years. In some embodiments, the subject is an adult that is older than about 18 years and younger than about 65 years. In some embodiments, the subject is a child that is younger than about 18 years. In some embodiments, the subject is younger than 5 years, 4 years, 3 years, 2 years, 1 year, or 6 months. In some embodiments, the subject is immune- compromised. In some embodiments, the subject is a pregnant woman.

[0029] In some embodiments, the subject has asthma, diabetes, heart disease, HIV, AIDS, or cancer. In some embodiments, the subject had asthma, diabetes, heart disease, HIV, AIDS, or cancer.

[0030] In some embodiments, the subject is non-human. In some embodiments, the subject is a horse, poultry, pig, dog, or cat.

[0031] Headings are provided in this description for organi2ational purposes and as an aid to the reader only and are not to be construed as limiting the disclosure in any way.

BRIEF DESCRIPTION OF THE DRAWINGS

[0032] Figure 1 shows the trial design of the FIM12 study. FIM12 compared two influen2a vaccines, standard-dose inactivated influen2a vaccine IIV-SD (Flu2one ^® ) and high-dose inactivated influen2a vaccine IIV-HD (Flu2one High-Dose ^® ), over two influen2a seasons. This randomi2ed-controlled trial (RCT) enrolled patients 65 years of age or older.

[0033] Figures 2A and 2B shows the comparison of risk ratio for pneumonia within 30 days of respiratory illness (Pneumonia 30D, Figure 2A) and serious pneumonia (Figure 2B) in Trial FIM12 for IIV-SD (labeled as Flu2one ^® ) and IIV-HD (labeled as Flu2one ^® High-Dose). Analysis was done by year (Yl = year 1; Y2 = year 2), and total data for both years are also shown. Heterogeneity is a test of whether the risk ratios are the same in Yl and Y2; for both pneumonia 30D and serious pneumonia the p-values do not indicate statistically significant differences between the years in this respect, and one therefore concludes there is no strong evidence for a difference in the effect in the two years. CI = confidence interval; M-H = Mantel-Haens2el.

[0034] Figure 3 shows the relative vaccine efficacy of IIV-HD against pneumonia relative to IIV-SD. Pneumonia classification were pneumonia occurring within 30 days of lab-confirmed influen2a, pneumonia occurring with 30 days of respiratory illness (RI) regardless of influen2a confirmation, and serious pneumonia regardless of influen2a confirmation. Efficacy data are presented as % (95% confidence interval).

[0035] Figure 4 presents pneumococcus vaccination rates prior to FIM12 randomi2ation and during the trial for IIV-HD and IIV-SD for Yl, Y2, and combined (Y1 +Y2).

[0036] Figure 5 presents data on the number of serious pneumonia events and the rate of these events following vaccination with IIV-HD or IIV-SD based on the timing of events in relation to the defined level of influen2a incidence for the week based on the number of laboratory-confirmed influen2a illness observed in the trial. The categories of high, moderate, and low influen2a incidence are described in the footnotes.

[0037] Figure 6 presents rates of all-cause hospitali2ation and serious cardio-respiratory events possibly related to influen2a within the intent-to-treat population for IIV-HD and IIV-SD for Yl, Y2, and combined (Y1 +Y2) combined analysis.

[0038] Figure 7 presents the relative vaccine effectiveness (rVE) of IIV- HD compared with IIV-SD in preventing all-cause hospitali2ation and serious cardio-respiratory events possibly related to influen2a within the intent-to-treat population for Yl, Y2, and combined (Y1+Y2) analysis.

[0039] Figure 8 shows the rate ratios (IIV-HD /IIV-SD) for all-cause hospitali2ation and serious cardio-respiratory events possibly related to influen2a (intent-to-treat analysis). Each hori2ontal line represents the 95% confidence interval of the rate ratio for each comparison, with the center being the corresponding point estimate. The vertical line represents the null value of 1. Hori2ontal lines that do not intersect with the vertical line are statistically significant. Point estimates to the left of vertical line favor IIV-HD, and those to the right favor IIV-SD. "Influen2a Events" refer to serious laboratory-confirmed influen2a diagnosed outside study procedures by a participant's health-care provider.

[0040] Figure 9 shows the etiology of the "Serious Pneumonia" narrated in the FIM12 study, based on SAE narratives. Note that for one event, S.

pneumonia was isolated from blood cultures, and respiratory cultures revealed E. colt, Pseudomonas, and Group C streptococci (only S. pneumonia counted in the table for this event).

DESCRIPTION OF CERTAIN EMBODIMENTS

Influenza Vaccine for Preventing Pneumonia

[0041] The invention comprises vaccine compositions useful in preventing influen2a and pneumonia, regardless of the cause of pneumonia.

[0042] In one embodiment, a method of preventing pneumonia in a subject comprising administering an influen2a vaccine to a subject, wherein the dose of the influen2a vaccine is higher than a standard dose influen2a vaccine, is encompassed. In one embodiment, use of an influen2a vaccine for preventing pneumonia in a subject, wherein the dose of the influen2a vaccine is higher than a standard dose influen2a vaccine, is encompassed. In one embodiment, use of an influen2a vaccine for the manufacture of a medicament for preventing pneumonia in a subject, wherein the dose of the influen2a vaccine is higher than a standard dose influen2a vaccine, is encompassed. In one embodiment, an influen2a vaccine for use in preventing pneumonia in a subject, wherein the dose of the influen2a vaccine is higher than a standard dose influen2a vaccine, is encompassed.

[0043] In one embodiment, a method of preventing pneumonia in a subject comprising administering an influen2a vaccine to a subject, wherein the influen2a vaccine provides the subject with a higher level of antigen than a standard dose influen2a vaccine, is encompassed. In one embodiment, use of an influen2a vaccine for preventing pneumonia in a subject, wherein the influen2a vaccine provides the subject with a higher level of antigen than a standard dose influen2a vaccine, is encompassed. In one embodiment, use of an influen2a vaccine for the manufacture of a medicament for preventing pneumonia in a subject, wherein the influen2a vaccine provides the subject with a higher level of antigen than a standard dose influen2a vaccine, is encompassed. In one embodiment, an influen2a vaccine for use in preventing pneumonia in a subject, wherein the influen2a vaccine provides the subject with a higher level of antigen than a standard dose influen2a vaccine, is encompassed. [0044] In other embodiments, methods of preventing pneumonia in a subject comprising administering an influen2a vaccine to a subject, wherein the neuraminidase (NA) content of the influen2a vaccine is higher than the NA content of a standard dose influen2a vaccine is encompassed. In one embodiment, use of an influen2a vaccine for preventing pneumonia in a subject, wherein the NA content of the influen2a vaccine is higher than the NA content of a standard dose influeu2a vaccine, is encompassed. In one embodiment, use of an influeu2a vaccine for the manufacture of a medicament for preventing pneumonia in a subject, wherein the NA content of the influen2a vaccine is higher than the NA content of a standard dose influen2a vaccine, is encompassed. In one

embodiment, an influen2a vaccine for use in preventing pneumonia in a subject, wherein the NA content of the influen2a vaccine is higher than the NA content of a standard dose influen2a vaccine, is encompassed.

[0045] In other embodiments, a method of preventing pneumonia in a subject comprising administering an influen2a vaccine to a subject, wherein the haemagglutinin (HA) content of the influen2a vaccine is higher than the HA content of a standard dose influen2a, is encompassed. In one embodiment, use of an influen2a vaccine for preventing pneumonia in a subject, wherein the HA content of the influen2a vaccine is higher than the HA content of a standard dose influeu2a vaccine, is encompassed. In one embodiment, use of an influeu2a vaccine for the manufacture of a medicament for preventing pneumonia in a subject, wherein the HA content of the influen2a vaccine is higher than the HA content of a standard dose influen2a vaccine, is encompassed. In one

embodiment, an influen2a vaccine for use in preventing pneumonia in a subject, wherein the HA content of the influen2a vaccine is higher than the HA content of a standard dose influen2a vaccine, is encompassed.

[0046] The description below applies to the methods, uses, and products disclosed herein. Terms such as "administering," e.g., with respect to doses, particular subjects, etc., encompass products and uses of products "to be administered" at the indicated doses and/ or to the indicated subjects, etc. [0047] In other embodiments, the influen2a vaccine has a higher amount of one or more of the influen2a virus proteins (HA, NA, Ml, M2, PBl, PB2, PA, NS1, NS2, and/ or NP) when compared to standard dose vaccines.

Types of Pneumonia

[0048] In one embodiment the pneumonia is caused by a virus, bacteria, or fungi. In the case of viral pneumonia, the virus may be any virus known to cause pneumonia, including an influen2a virus, a respiratory syncytial virus (RSV), a metapneumovirus, an adenovirus, a rhinovirus, a coronavirus, a varicella-2oster virus, and a parainfluen2a virus.

[0049] In the case of bacterial pneumonia, the bacteria may be any bacteria known to cause pneumonia, including Streptococcus pneumonia, Staphylococcus aureus, Neisseria meningitides, Mycoplasma pneumonia, Haemophilus influenza, Legionelk pneumonia, L·egionella spp., Chlamydia spp., including Chlamydia pneumonia, and

Chlamydia psittaci, Moraxella spp., including Moracella catarrh alis, Streptococcus pyogenes, including Streptococcus pyogenes (Group A), Pseudomonas aeruginosa, gram-negative enteric bacilli, methicillin-susceptible S. aureus, methicillin-resistant S. aureus, Haemophilus Haemophilus parahaeoyl ticus, Pseudomonas alcaligenes, Citrobacter freundii, Staphylococcu haemoyl ticus, Clostridium perfringens, anaerobes, including Yusobacterium sp., Prevotella sp., Gemella morbillorum, Peptostreptococcus prevotii, and Veillonella sp., nocardia sp., coagulase-negative Staphylococci, and Acinetobacter baumannii.

[0050] In the case of fungal pneumonia, the fungus may be any fungus known to cause pneumonia, including a fungus responsible for any of

histoplasmosis, coccidioidomycosis, blastomycosis, Pneumocystis pneumonia, sporotrichosis, cryptococcosis, aspergillosis, candidiasis, or scedoporiosis.

[0051] In some embodiments, the cause of the pneumonia is unknown. In other embodiments, the cause of the pneumonia is determined to be viral and bacterial.

[0052] In one embodiment the pneumonia is characteri2ed as community- acquired pneumonia (CAP). In other embodiments the pneumonia is a healthcare- associated pneumonia, which is a pneumonia that develops following a stay in a healthcare facility, including a hospital, long-term care facility, or dialysis center. [0053] In some embodiments, the pneumonia to be prevented by the methods, uses, and products of the invention is not preceded by influeu2a.

Influenza Vaccines

[0054] The influen2a vaccine composition, as well as the influen2a vaccine used in accordance with the invention, may be any influen2a vaccine approved by a body that governs the type of vaccines that may be administered to the public. In certain embodiments, a high-dose vaccine contains high levels of one or more influen2a protem(s) (HA, NA, Ml, M2, PB1, PB2, PA, NS1, NS2, and/or NP).

[0055] In one embodiment, the influen2a vaccine is a trivalent vaccine. In another embodiment, the influen2a is a quadrivalent vaccine.

[0056] The trivalent or quadrivalent vaccine may be produced in avian eggs or may be "egg- free" or "recombinant".

[0057] The trivalent or quadrivalent vaccine may be inactivated or live attenuated.

[0058] The trivalent or quadrivalent vaccine may be administered intradermally, intramuscularly, or intranasally.

[0059] The trivalent or quadrivalent vaccine may be adjuvanted or non- adjuvanted.

[0060] The trivalent or quadravalent vaccine may be selected from the group consisting of Flu2one ^® (Trivalent or Quadrivalent; Sanofi Pastuer), Fluarix (Trivalent or Quadrivalent; intradermal; GlaxoSmithKline), FluLaval (Trivalent or Quadrivalent; ID Biomedical Corporation of Quebec; distributed by

GlaxoSmithKline), Alfluria (bioCSL), Fluvirin (Novartis Vaccines and

Diagnostics), Flucelvax (Novartis Vaccines and Diagnostics), FluMist

(Medlmmune), and FluBlok (Protein Sciences).

Dosages

[0061] In one embodiment, the influen2a vaccine composition of the invention, as well as the influen2a vaccine for use in accordance with the invention, are high-dose. A dose of an influen2a vaccine is considered high if the amount of antigen provided to the subject is increased as compared to the amount of antigen in a standard dose influen2a vaccine. The dose may be increased by administering a greater volume of a vaccine formulated in a standard dosage or by specifically formulating a higher dose vaccine.

[0062] Dosages are typically based on HA content. For example, the only high-dose influen2a vaccine on the market as of the filing date is Flu2one High- Dose, which contains 60 micrograms HA per strain per dose (0.5 mL). All other currently approved influen2a vaccines are considered standard dose. Flu2one High-Dose is contemplated for use in accordance with this invention.

[0063] For inactivated and recombinant vaccines (all vaccines named above except Flumist) the HA content is typically 15 micrograms of HA per strain for each 0.5 mL. Thus, in one embodiment, the influen2a vaccine of this invention has an HA content that is higher than 15 micrograms of HA per strain per each 0.5 mL. In one embodiment, the influen2a vaccine of the invention has an HA content that is higher than about 15, 20, 24, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 micrograms of HA per strain for each 0.5 mL.

[0064] Standard dose Flu2one ID has an HA content of about 9 micrograms per strain per dose (0.1 mL). For Flu2one ID to be used in the present invention, it must have an HA content that is higher than about 9, 10, 15, 20, 24, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 micrograms of HA per strain for each 0.1 mL.

[0065] Standard dose Flublok has an HA content of about 45 micrograms per strain per dose (0.5 mL). Despite the higher HA content as compared to other vaccines, Flublok is not considered a "high-dose" vaccine by the FDA because of the lack of comparative clinical trial data for it against standard-dose influen2a vaccines. In one embodiment, Flublok is considered a high dose vaccine capable of being used in accordance with the invention. In other embodiments, for Flublok to be used in the present invention, it must have an HA content that is higher than about 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 micrograms of HA per strain for each 0.5 mL.

[0066] Thus, the standard dose vaccines described herein and known to those of skill in the art (those today marketed and those marketed in the future) may be used in accordance with the invention to prevent pneumonia as long as they are reformulated to have a higher HA content than the HA content of a standard-dose influen2a vaccine.

[0067] Flumist is a live-attenuated vaccine that is administered intranasally. Each 0.2 mL dose of Flumist contains about 10E6.5-7.5 FFU (fluorescent focus units) of live attenuated influen2a virus reassortants. For Flumist to be used in the present invention, it must have an FFU content that is higher than about 10E6.5- 7.5 FFU per live attenuated influen2a virus reassortants.

[0068] In some embodiments of the present invention, the influen2a virus used in preventing pneumonia have an increased neuraminidase (NA) content as compared to a standard-dose influen2a vaccine.

[0069] The NA content of the high-dose Flu2one ^® is also increased versus the standard-dose vaccine. An NA activity assay (optical density [O.D] obtained with a microplate reader assay) determined that the mean NA activity in standard dose influen2a vaccine was 23,373. In comparison, the mean NA activity in the high-dose influen2a vaccine was 179,454, representing approximately 7.7 times the NA activity in the standard dose influen2a vaccine (Cate TR et al. Vaccine 2010; 28:2076-2079).

[0070] Thus, in one embodiment, the influen2a vaccine of this invention has a NA content that is higher than the NA content of a standard dose influen2a vaccine. In one embodiment, the influen2a vaccine of the invention has a NA content that has an O.D. higher than about 23,000, 23,373, 23,500, 24,000, 25,000, 30,000, 35,000, 40,000, 45,000, 50,000, 55,000, 60,000, 65,000, 70,000, 75,000, 80,000, 85,000, 90,000, 95,000, 100,000, 105,000, 110,000, 115,000, 120,000, 125,000, 130,000, 135,000, 140,000, 145,000, 150,000, 155,000, 160,000, 165,000, 170,000, and 175,000.

[0071] In some embodiments of the present invention, the influeu2a vaccine used in preventing pneumonia have an increased HA, NA, Ml, M2, PB1, PB2, PA, NS1, NS2, and/ or NP content as compared to a standard dose vaccine. Treatment Groups

[0072] Subjects to be treated by the methods, products, and uses of the invention include any subject capable of receiving an influen2a vaccine. In one embodiment, the subject is considered elderly. An elderly human subject is older than about 65 years. In other embodiments, the subject is a healthy adult (older than 18 years), a healthy child (younger than 18 years), an immune-compromised adult or child, a pregnant woman, or an adult or child with asthma, diabetes, heart disease, HIV, AIDS, or cancer. The subject may also be a child younger than 5 years, 4 years, 3 years, 2 years, 1 year, and 6 months.

[0073] In other embodiments, the subjects to be treated by the methods, products, and uses of the invention are non-human, including horses, poultry, pigs, dogs, and cats.

Combination Therapy

[0074] The high-dose influen2a vaccine used in accordance with the invention may be administered alone, or co-administered with at least one additional therapeutic or prophylactic agent. In one embodiment, the at least one additional therapeutic or prophylactic agent is a pneumonia vaccine. Thus, methods of preventing pneumonia, or methods of preventing pneumonia and influen2a, comprising co-administering a high-dose influen2a vaccine and a pneumonia vaccine are encompassed. Uses of a high-dose influen2a vaccine and a pneumonia vaccine for preventing pneumonia, or preventing pneumonia and influen2a, wherein the influen2a vaccine and pneumonia vaccine are coadministered, are also encompassed. A high-dose influen2a vaccine and a pneumonia vaccine for use in preventing pneumonia, or preventing pneumonia and influen2a, wherein the influen2a vaccine and pneumonia vaccine are coadministered, are also encompassed. Uses of a high-dose influen2a vaccine and a pneumonia vaccine for the manufacture of a medicament for preventing pneumonia, or preventing pneumonia and influen2a, wherein the influen2a vaccine and pneumonia vaccine are co-administered, are also encompassed. The co-administration may be concurrent or sequential. The sequential administration may occur on the same day or on different days. As described herein, the high- dose influen2a vaccine may contain more than one influen2a protein including combinations of HA, NA, Ml, M2, PB1, PB2, PA, NS1, NS2, and/or NP, and any one or all of these proteins may be present at a higher level than in a standard- dose vaccine. Thus, in one embodiment the high-dose influen2a vaccine used in accordance with the invention has high HA, NA, Ml, M2, PB1, PB2, PA, NS1, NS2, and/ or NP, and is given in combination with at least one additional therapeutic or prophylactic agent, such as a pneumonia vaccine.

EXAMPLES

Example 1. Efficacy of vaccination with high-dose inactivated influenza vaccine versus standard dose in prevention of pneumonia in elderly patients.

[0075] A high-dose inactivated influenza vaccine (IIV-HD) has been shown to produce more robust antibody responses and improves protection against influenza illness compared to a standard-dose vaccine (IIV-SD) in elderly patients. In this study, IIV-HD was 24.2% more efficacious than IIV-SD in preventing laboratory-confirmed symptomatic influenza in elderly patients.

CA, et al. N Engl J Med (2014) 371 (7 ):635 -645). Herein, IIV-HD was compared with IIV-SD in regards to the ability to decrease the risk of pneumonia, a common and dangerous sequelae or complication to influenza, and also a common and very burdensome infectious illness that can be caused by many other microorganisms in addition to influenza.

[0076] The FIM12 study was a double-blind, randomized, active- controlled, multicenter trial that enrolled adults≥65 years. Participants were randomized to receive either IIV-HD or IIV-SD and were followed for 6-8 months post-vaccination for the occurrence of influenza, pneumonia, and serious adverse events (SAEs). SAEs were defined as events leading to death or hospitalization (or its prolongation); considered as life-threatening or medically important; or resulting in disability. The trial was conducted during the 2011-2012 (Year 1) and 2012-2013 (Year 2) influenza seasons. The trial compared IIV-HD (containing 60 micrograms of hemagglutinin per vaccine strain, Fluzone ^® High- Dose) versus IIV-SD (containing 15 micrograms of hemagglutinin per vaccine strain, Fluzone ^® ).

[0077] The FIM12 trial (NCT01427309) included 31,989 participants with 15,991 participants randomized to IIV-HD and 15,998 participants randomized to IIV-SD. The design of the FIM12 trial is presented in Figure 1; note that the actual numbers of patients enrolled in the trial differ slightly from the projected design. Participants were vaccinated in September-October of each season (i.e., Year 1 and Year 2), and participants were followed for 6-8 months post- vaccination (until April 30 ^th , which would be past the normal end of annual influen2a season) for the occurrence of influen2a, pneumonia, and SAEs.

Results

[0078] To determine whether IIV-HD protects against pneumonia, the number of pneumonia events occurring within 30 days of a respiratory illness (Pneumonia 30D) for Yl and Y2 was evaluated, with results shown in Figure 2A. In combined data from Yl and Y2, there were 169 events of Pneumonia 30D in the IIV-HD (i.e., Flu2one® High-Dose) and 232 events in the IIV-SD (i.e., Flu2one®). These combined data indicated a relative risk of 0.72 for IIV-HD versus IIV-SD for pneumonia within 30 days of a respiratory illness. As shown in Figure 3, this corresponds with a 27% relative vaccine efficacy/ effectiveness (i.e., 27% reduction in relative risk) in preventing pneumonia within 30 days of a respiratory infection (labeled RI) for IIV-HD versus IIV-SD. Statistical analysis shown in Figure 2A indicates that this reduction in pneumonia within 30 days of a respiratory infection was statistically significant for IIV-HD versus IIV-SD (P = 0.05, test for overall effect). The significance of the finding is further confirmed by the confidence intervals of the vaccine effectiveness estimate (Figure 3), which indicated a lower bound of the 95% confidence interval of 11%, well above the null value of 0.

[0079] The number of cases of serious pneumonia (irrespective of confirmed influen2a infection) was also evaluated. Serious pneumonia was defined as events of pneumonia resulting in death or hospitali2ation, considered life- threatening or medically important, or resulting in disability. As shown in Figure 2B, there were a total of 71 events of serious pneumonia in the IIV-HD group compared to 118 events in the IIV-SD group in combined data for Yl and Y2. These combined data indicated a relative risk of 0.60 for IIV-HD versus IIV-SD for serious pneumonia. As shown in Figure 3, this corresponded to a relative vaccine efficacy/ effectiveness of 40% (i.e., 40% reduction in relative risk) of serious pneumonia for IIV-HD versus IIV-SD. Results shown in Figure 2B indicate that the efficacy in preventing serious pneumonia was statistically significant for IIV-HD versus IIV-SD (P = 0.0007, test for overall effect). The significance of the finding is further confirmed by the confidence intervals of the vaccine effectiveness estimate (Figure 3), which indicated a lower bound of the 95% confidence interval of 19%, well above the null value of 0.

[0080] The relative reduction in pneumonia within 30 days of lab- confirmed influen2a was also evaluated. As shown in Figure 3, there was a 60% relative vaccine efficacy (i.e. reduction in relative risk) of IIV-HD versus IIV-SD for prevention of pneumonia within 30 days of lab-confirmed influen2a.

However, given the low number of cases, the estimate did not reach statistical significance.

[0081] The potential for pneumococcal vaccination rates to have impacted efficacy measurements of pneumonia prevention for IIV-HD versus IIV-SD was also evaluated, as pneumococcal vaccination is suggested for patients 65 years of age or older and can reduce the risk of pneumonia (see CDC: Prevention of

Pneumonia). As shown in Figure 4, vaccination rates for the IIV-HD and IIV-SD groups were essentially the same, indicating that differences in pneumococcal vaccination rates cannot explain the differences in efficacy/ effectiveness in preventing pneumonia for IIV-HD versus IIV-SD.

[0082] The relative vaccine efficacy of IIV-HD versus IIV-SD was determined based on differences in the rate of incidence of influen2a at the time when the pneumonia event occurred. The actual FIM12 study influen2a incidence data was used to determine periods of high, moderate, and low incidence of influen2a, as described in Figure 5. Data confirmed that IIV-HD had greater relative vaccine efficacy compared with IIV-SD for periods of high, moderate, and low incidence. Therefore, the higher relative vaccine efficacy of IIV-HD versus IIV-SD was consistent during all incidence periods.

[0083] The data presented in Figures 1-5 indicated significant reductions in the incidence of pneumonia, including serious pneumonia, following vaccination with IIV-HD compared with IIV-SD. As data from the same trial indicated that IIV-HD was 24.2% more efficacious than IIV-SD in preventing laboratory- confirmed symptomatic influen2a in elderly patients, the data on reduction of risk of pneumonia shown in Figures 2 and 3 support an unexpectedly large effect of IIV-HD to reduce pneumonia compared with IIV-SD. The efficacy of IIV-HD significantly reduced the risk of serious pneumonia (relative vaccine efficacy of 40%, see Figure 3). These data support the use of high-dose influen2a vaccine, including IIV-HD, to reduce the risk of pneumonia. These data also support the use of high-dose influen2a vaccine, including IIV-HD, to reduce the risk of pneumonia in elderly patients who have increased risk of pneumonia and complications resulting from pneumonia.

[0084] The FIM12 study was charactered by intensive surveillance for detection of influen2a respiratory illness. The study surveillance included active surveillance, by which a call-center called all study participants twice weekly (during periods of high influen2a activity) or weekly (at other times during the influen2a season) to inquire about the occurrence of any new or exacerbated respiratory illnesses. If a new or exacerbated illness was reported, the study sites were to collect a nasopharyngeal sample within 5 days of the illness start for influen2a testing and detection. We therefore believe that the study had the appropriate design to detect most of the illnesses due to influen2a infection occurring in the study participants. This provides an opportunity to evaluate how likely is to attribute the pneumonias reported during the study to influen2a (directly as "influen2a pneumonias" or indirectly as pneumonias complicating influen2a illness). To evaluate this, we ascertained how many of the Pneumonia 30D and serious pneumonias reported in the study occurred within 30 days of laboratory-confirmed influen2a. It turns out that only 14 of the 401 reported Pneumonia 30D (3.5%) occurred within 30 days after laboratory-confirmed influen2a illness. For the Pneumonias 30D that occurred after a respiratory illness that was not confirmed to be influen2a by laboratory methods, the relative vaccine efficacy/ effectiveness was 26% and still statistically significant. Similarly and even more importantly, only 4 of the 189 reported Serious Pneumonias (2.1%) occurred within 30 days after laboratory-confirmed influen2a illness (with 3 of these confirmations occurring outside of study procedures). For the Serious Pneumonias reported at any time during study surveillance that did not occurred within 30 days of laboratory-confirmed influen2a, the relative vaccine

efficacy/effectiveness was 38% and highly statistically significant. Therefore, the high-dose influen2a vaccine is showing an effect in preventing pneumonia for pneumonias that cannot be classified as related to laboratory-confirmed influen2a illness. This indicates that even if the study missed some laboratory-confirmed influen2a infections, the high-dose influen2a vaccine is very likely having an important preventive effect on pneumonia etiologies other than influen2a.

Example 2. Reductions in hospitalizations and serious adverse events following administration of IIV-HD versus IIV-SD

[0085] Based on results on the reduction in risk of pneumonia, the efficacy of IIV-HD versus IIV-SD was also determined for the potential to reduce all-cause hospitali2ation and serious cardio-respiratory events for the 6-8 month post- vaccination period of the trial (as described in Figure 1). SAEs were defined as events that lead to death or hospitali2ation (or its prolongation); that are considered as life-threatening or medically important; or that result in disability. Based on available medical information, the diagnoses associated with all SAEs were reported.

[0086] As shown in Figure 6, there were a total of 3,173 all-cause hospitali2ation events with a combined rate (events per 1,000 participant-seasons for Y1 +Y2) of 95.68 for IIV-HD and 102.73 for IIV-SD. Figure 7 shows the relative vaccine efficacy of IIV-HD versus IIV-SD for Yl, Y2, and combined data for all-cause hospitali2ation. Data indicated that while there was very little difference between the rates for Yl, there was a 13.6% relative vaccine efficacy for the all-cause hospitali2ation rates for IIV-HD versus IIV-SD in Y2. The greater relative vaccine efficacy seen in Y2 may be due to the higher influen2a virulence and the greater mismatch between the strains in the vaccine in Y2 versus the predominant circulating strains in that influen2a season (as previousyl discussed in Dia^Granados 2014).

[0087] Serious adverse events were also assessed in the FIM12 trial. A total of 1,347 SAE preferred terms in the trial for Yl and Y2 were independently reviewed by two physicians (blinded to the participant's treatment group) using the Medical Dictionary for Regulatory Activities versions 14.0 (for Year 1) and 15.0 (for Year 2) (see Brown EG, et al. (1999) Drug Saf. 20(2):109-17). A total of 948 serious cardio-respiratory events were adjudicated as possibly related to influen2a. Rates of serious cardio-respiratory events for IIV-HD and IIV-SD are shown in Figure 6; note that the data on serious pneumonia events were also presented in Figure 3. The rates of influen2a in Figure 6 correspond to serious laboratory- confirmed influen2a diagnosed outside study procedures by a participant's healthcare provider; therefore, these are different values than those that were used to determine efficacy of the vaccine.

[0088] The relative vaccine efficacy (rVE) to reduce serious cardiorespiratory events of IIV-HD compared with IIV-SD is shown in Figure 7. Rates of serious cardiorespiratory events were lower for IIV-HD than for IIV-SD in both Yl and Y2 for the events of pneumonia, other selected respiratory events, and heart failure, as evidenced by an rVE greater than 30% for the combined data of Yl and Y2 for IIV-HD versus IIV-SD. Also the aggregate occurrence of any serious cardio-respiratory event possibly related to influen2a was also lower for IIV-HD versus IIV-SD with an rVE of 17.7% for combined data from Yl and Y2.

[0089] The data in Figures 6 and 7 support the greater relative efficacy of high-dose influen2a vaccine, including IIV-HD, versus IIV-SD for reducing all- cause hospitali2ation and some serious cardio-pulmonary events in elderly patients. Compared with IIV-SD, IIV-HD produced greater reduction in all-cause hospitali2ation and pneumonia, other selected respiratory events, and heart failure over two influen2a seasons.

EQUIVALENTS

[0090] The foregoing written specification is considered to be sufficient to enable one skilled in the art to practice the embodiments. The foregoing description and Examples detail certain embodiments and describes the best mode contemplated by the inventors. It will be appreciated, however, that no matter how detailed the foregoing may appear in text, the embodiment may be practiced in many ways and should be construed in accordance with the appended claims and any equivalents thereof.

[0091] As used herein, the term about refers to a numeric value, including, for example, whole numbers, fractions, and percentages, whether or not explicitly indicated. The term about generally refers to a range of numerical values (e.g., +/ - 5-10% of the recited range) that one of ordinary skill in the art would consider equivalent to the recited value (e.g., having the same function or result). In some instances, the term about may include numerical values that are rounded to the nearest significant figure.