Document text
C4591001
CONFIDENTIAL16.1.11 PUBLICATIONS BASED ON THE STUDY
1.Mulligan MJ, L yke KE, Kitchin N, et al. Phase 1/2 study of COVI D-19 RNA vaccine
BNT162b1 in adults. Nature. 2020;10.1038/s41586 -020-2639 -4.
2.Walsh EE, Frenck FW, Falsey AR, et al. Safety and immunogenicity of two RNA -based
Covid -19 vaccine candidates. N Engl J Med 2020; DOI : 10.1056/NEJMoa2027906.
3. Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA
Covid -19 Vaccine. N Engl J Med. 2020;383(27):2603 -2615. doi:10.1056/NEJMoa2034577
4.Xie X, Liu Y, Liu J, et al. Neutralization of SARS -CoV -2 spike 69/70 deletion, E484K and
N501Y variants by BNT162b2 vaccine -elicited sera [published online ahead of print, 2021 Feb
8]. Nat Med. 2021;10.1038/s41591 -021-01270 -4. doi:10.1038/s41591-021-01270-4
5.Liu Y, L iu J, Xia H, et al. Neutralizing Activity of BNT16 2b2-Elicited Serum - Preliminary
Report [published online ahead of print, 2021 Feb 17]. N Engl J Med.
2021;10.1056/NEJMc2102017. doi:10.1056/NEJMc2102017
090177e19679d0b2\Approved\Approved On: 17-Mar-2021 02:29 (GMT)
Page 1
FDA-CBER-2022-5812-0231600
Phase 1/2 study of COVID-19 RNA vaccine
BNT162b1 in adults
Mark J. Mulligan, Kirsten E. Lyke, Nicholas Kitchin, Judith Absalon, Alejandra Gu tman,
Stephen Lockhart, Kathleen Neuzil, Vanessa Raabe, Ruth Bailey, Kena A. Swanson, Ping Li, Kenneth Koury, Warren Kalina, David Cooper, Camila Fontes-Garfias Pei-Yong Shi,
Özlem Türeci, Kristin R. Tompkins, Edward E. Walsh, Robert Frenck Ann R Falsey,
Philip R. Dormitzer, William C. Gruber, Uğur Şahin & Kathrin U Jansen
This is a PDF file of a peer-reviewed paper that has been accepted for publication.
Although unedited, the content has been subjected to preliminary formatting. Nature is providing this early version of the typese paper as a service to our authors and readers. The text and figures will undergo copyediting and a proof review before the paper is published in its final form Please note that during the production process errors may be discovered which ould affect the content, and all legal disclaimers apply.Received: 29 June 2020
Accepted: 4 August 2020Accelerated Article Preview Published
online 12 August 2020
Cite this article as: Mulligan, M. J. et al.
Phase 1/2 study of COVID-19 RNA vaccine BNT162b1 in adults. Nature https://doi.
org/10.1038/s41586-020-2639-4 (2020).https://doi.org/10.1038/s41586-020-2639-4
Nature | www.nature.com
Accelerated Article Preview
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 2
FDA-CBER-2022-5812-0231601
Nature | www.nature.com | 1
ArticlePhase 1/2 study of COVID-19 RNA vaccine
BNT162b1 in adults
Mark J. Mulligan1,2,12, Kirsten E. Lyke3,12, Nicholas Kitchin4,12, Judith Absalon5 ✉,
Alejandra Gurtman5, Stephen Lockhart4, Kathleen Neuzil3, Vanessa Raabe1,2, Ruth Bailey4,
Kena A. Swanson5, Ping Li6, Kenneth Koury5, Warren Kalina5, David Cooper5,
Camila Fontes-Garfias7, Pei-Yong Shi7, Özlem Türeci8, Kristin R. Tompkins5,
Edward E. Walsh9,10, Robert Frenck11, Ann R. Falsey9,10, Philip R. Dormitzer5, William C. Gruber5,
Uğur Şahin8 & Kathrin U. Jansen5
In March 2020, the World Health Organization (WHO) declared a pandemic of
coronavirus disease 2019 (COVID-19), due to severe acute respi atory syndrome coronavirus 2 (SARS-CoV-2)
1. With rapidly accumulating cases and deaths reported
globally2, a vaccine is urgently needed. We report the a ailable safety, tolerability, and
immunogenicity data from an ongoing placebo-controlled, observer-blinded dose escalation study among 45 healthy adults, 8 to 55 years of age, randomized to receive 2 doses, separated by 21 days, of 10 µg, 30 µg, or 100 µg of BNT162b1, a lipid nanoparticle-formulated, nucleoside-modified mRNA vaccine that encodes trimerized SARS-CoV-2 spike glycoprotein eceptor-binding domain (RBD). Local reactions and systemic events were dose-dependent, generally mild to moderate, and transient. A second vaccination with 100 µg was not administered due to increased reactogenicity and a lack of meaningfully increased immunogenicity after a single dose compared to the 30
µg dose. RBD-binding IgG concentrations and SARS-CoV-2
neutralizing titers in era increased with dose level and after a second dose. Geometric mean neutral zing titers reached 1.9- t
o 4.6-fold that of a panel of COVID-19
convalescent human sera at least 14 days after a positive SARS-CoV-2 PCR. These results support further evaluation of this mRNA vaccine candidate. (ClinicalTrials.gov identifier: NCT04368728).
In December 2019, a pneumonia outbreak f unknown cause occurred
in Wuhan, China. By January 2020, a novel coronavirus was identified as
the etiologic agent. Within a month the genetic sequence of the virus
became available (MN908947.3). Severe ac te respiratory syndrome
coronavirus 2 (SARS-CoV-2) infec ions and the resulting disease, coro-
navirus disease 2019 (COVID-19), have spread globally. On 11 March
2020, the World Health Organization (WHO) declared the COVID-19
outbreak a pandemi1. To date, the United States has reported the
most cases globally3. No vaccines are currently available to prevent
SARS-CoV-2 infe tion or COVID-19.
The RNA vaccine platform has enabled rapid vaccine development
in response to this pandemic. RNA vaccines provide flexibility in the
design and expression of vaccine antigens that can mimic antigen
structure and expression during natural infection. RNA is required
for protein s nthesis, does not integrate into the genome, is transiently
expressed, and is metabolized and eliminated by the body’s natural
mechanisms and, therefore, is considered safe4–7. RNA-based prophylac -
tic infectious disease vaccines and RNA therapeutics have been shown
o be safe and well-tolerated in clinical trials. In general, vaccination with RNA elicits a robust innate immune response. RNA directs expression of the vaccine antigen in host cells and has intrinsic adjuvant effects
8.
A strength of the RNA vaccine manufacturing platform, irrespective of
the encoded pathogen antigen, is the ability to rapidly produce large quantities of vaccine doses against a new pathogen
9,10.
Vaccine RNA can be modified by incorporating 1-methyl-pseudouridine
which dampens innate immune sensing and increases mRNA translation
in vivo11. The BNT162b1 vaccine candidate now being studied clinically
incorporates such nucleoside-modified messenger RNA (modRNA)
and encodes the receptor-binding domain (RBD) of the SARS-CoV-2
spike protein, a key target of virus-neutralizing antibodies12–14. The
RBD antigen expressed by BNT162b1 is modified by the addition of a
T4 fibritin-derived foldon trimerization domain to increase its immu -
nogenicity15 by multivalent display16. The proper folding of the RBDs in
the resulting protein construct has been confirmed by high resolution
structural analysis (U.S., manuscript in preparation)17. The vaccine RNA
is formulated in lipid nanoparticles (LNPs) for more efficient delivery
into cells after intramuscular injection18. BNT162b1 is one of several
RNA-based SARS-CoV-2 vaccine candidates being studied in parallel https://doi.org/10.1038/s41586-020-2639-4
Received: 29 June 2020Accepted: 4 August 2020Published online: 12 August 2020
1New York University Langone Vaccine Center, New York, NY, USA. 2New York University Grossman School of Medicine, New York, NY, USA. 3University of Maryland School of Medicine, Center
for Vaccine Development and Global Health, Baltimore, MD, USA. 4Vaccine Research and Development, Pfizer Inc, Hurley, UK. 5Vaccine Research and Development, Pfizer Inc, Pearl River, NY,
USA. 6Vaccine Research and Development, Pfizer Inc, Collegeville, PA, USA. 7University of Texas Medical Branch, Galveston, TX, USA. 8BioNTech, Mainz, Germany. 9University of Rochester,
Rochester, NY, USA. 10Rochester General Hospital, Rochester, NY, USA. 11Cincinnati Children’s Hospital, Cincinnati, OH, USA. 12These authors contributed equally: Mark J. Mulligan, Kirsten E.
Lyke, Nicholas Kitchin. ✉e-mail: [email protected] ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 3
FDA-CBER-2022-5812-0231602
2 | Nature | www.nature.com
Articlefor selection to advance to a safety and efficacy trial. Here, we present
available data, through 14 days after a second dose in adults 18 to 55
years of age, from an ongoing Phase 1/2 vaccine study with BNT162b1,
which is also enrolling adults 65 to 85 years of age (ClinicalTrials.gov
identifier: NCT04368728).
Study Design and Demographics
Between 04 May 2020 and 19 June 2020, 76 participants were screened,
and 45 participants were randomized and vaccinated. Twelve partici-
pants per dose level (10 µg and 30 µg) were vaccinated with BNT162b1
on Days 1 and 21, and 12 participants received a 100- µg dose on Day 1.
Nine participants received placebo (Figure 1 ). The study population
consisted of healthy male and nonpregnant female participants with a
mean age of 35.4 years (range: 19 to 54 years); 51.1% were male and 48.9%
were female. Most participants were white (82.2%) and non-Hispanic/
non-Latinx (93.3%) (Extended Data Table 1).
Safety and T olerability
In the 7 days following either Dose 1 or 2, pain at the injection site was
the most frequent solicited local reaction, reported after Dose 1 by
58.3% (7/12) in the 10-µg, 100.0% (12/12 each) in the 30- µg and 100-µg
BNT162b1 groups, and 22.2% (2/9) in the placebo group. After Dose 2,
pain was reported by 83.3% (10/12) and 100.0% of BNT162b1 recipients
at the 10- µg and 30- µg dose levels, respectively, and by 16.7% of pla -
cebo recipients. All local reactions were mild or moderate in severity
except for one report of severe pain following Dose 1 of 100 µg BNT162b1
(Figure 2; Extended Data Table 2).
The most common systemic events reported in the 7 days after each
vaccination in both BNT162b1 and placebo recipients were mild to
moderate fatigue and headache. Reports of fatigue and headache were
more common in the BNT162b1 groups compared to the placebo group.
Additionally, chills, muscle pain, and joint pain were reported among
BNT162b1 recipients and not in placebo recipients. Systemic eve ts
increased with dose level and were reported in a greater number of
participants after the second dose (10-µg and 30-µg groups). Follow -
ing Dose 1, fever (defined as ≥38.0 °C) was reported by 8.3% (1/12) of
participants in both the 10-µg and 30-µg groups and by 50.0% (6/12) of
BNT162b1 recipients in the 100-µg group. Following Dose 2 8.3% (1/12)
of participants in the 10-µg group and 75.0% (9/12) of participants in
the 30-µg group reported fever ≥38.0 °C Based on the reactogenicity
reported after the first dose of 100 µg and the second dose of 30 µg,
participants who received an initial 100- µg dose did not receive a sec-
ond 100- µg dose. Fevers generally resolved within 1 day of onset. No
Grade 4 systemic events or fever were r ported. (Figure 3a, b , Extended
Data Table 3). Most local reactions and systemic events peaked by Day
2 after vaccination and resolved by Day 7.
Adverse events (AEs (Extended Data Table 4) were reported by 50.0%
(6/12) of participants who received either 10 µg or 30 µg of BNT162b1, 58.3% (7/12) of those who received 100 µg of BNT162b1, and 11.1% (1/9) of placebo recipients. Two participants reported a severe AE: Grade 3
fever 2 day after vaccination in the 30-µg group, and sleep disturbance
1 day after vaccination in the 100-µg group. Related AEs were reported
by 2 % (3/12 n the 10-µg groups) to 50% (6/12 each in 30-µg and 100-µg
groups) of BNT162b1 recipients and by 11.1% (1/9) of placebo recipients.
No serious adverse events (SAEs) were reported.
No Grade 1 or greater change in routine clinical laboratory values or
laboratory abnormalities were observed for most participants after
either of the BNT162b1 vaccinations. Of those with laboratory changes,
the largest changes were decreases in lymphocyte count after Dose 1
in 8.3% (1/12), 45.5% (5/11), and 50.0% (6/12) of 10 µg, 30 µg, and 100 µg
BNT162b1 recipients, respectively. One participant each in the 10-µg
group (8.3% [1/12]) and 30-µg group (9.1% [1/11]) dose levels and 4 par-
ticipants in the 100-µg group (33.3% [4/12]) had Grade 3 decreases in lymphocytes. These post-Dose 1 decreases in lymphocyte count,
were transient and returned to normal 6 to 8 days after vaccination
(Extended Data Figure 1). In addition, Grade 2 neutropenia was noted 6 to 8 days after the second dose in 1 participant each in the 10-µg and
30-µg BNT162b1 groups. These two participants continue to be followed
in the study and no AEs or clinical manifestations of neutropenia have
been reported to date. None of the postvaccination abnormalities
observed were associated with clinical findings.
Immunogenicity
RBD-binding IgG concentrations and SARS-CoV-2 neutralizing titers
were assessed at baseline, and at 7 and 21 days after the first dose and
at 7 (Day 28) and 14 days (Day 35) after the second dose of BNT162b1. By
21 days after the first dose (for all three dose levels) geometric mean concentrations (GMCs) of RBD-binding IgG ranged from 534 to 1,778 U/mL (Figure 4a). In comparison, a panel of 38 SARS-CoV-2 infection/
COVID-19 convalescent sera drawn at least 14 days after a polymer -
ase chain reaction (PCR)-confirmed diagnosis from patients 18 to 83
years of age had an RBD-binding IgG GMC of 602 U/mL. (Additional
information on the convalescent serum panel is presented in Meth -
ods.) By 7 days after the second dose (for the 10 µg and 30 µg dose
levels) RBD-binding IgG GMCs had increased to 4,813 to 27,872 U/mL.
RBD-binding antibody concentrations among participants who
received one dose of 100 µg BNT162b1 did not increase beyond 21 days
after the first vaccination. In the participants who received the 10 µg
and 30 µg doses of BNT162b1, highly elevated RBD-binding antibody
concentrat ons persisted to the last time point evaluated (Day 35, 14
days af er the second dose). These RBD-binding antibody concentra-tions were 5,880 to 16,166 U/mL compared to 602 U/mL in the human conv lescent serum panel.
For al doses, small increases in SARS-CoV-2 neutralizing geometric
mean titers (GMTs) were observed 21 days after Dose 1 (Figure 4b ).
Substantially greater serum neutralizing GMTs were achieved 7 days
fter the second 10 µg and 30 µg dose, reaching 168 to 267. Neutralizing
GMTs further increased by 14 days after the second dose to 180 at the
10 µg dose level and 437 at the 30 µg dose level, compared to 94 for the
convalescent serum panel. The kinetics and durability of neutralizing titers are being monitored.
Discussion
The RNA-based SARS-CoV-2 vaccine candidate BNT162b1 administered
at 10 µg, 30 µg, and 100 µg to healthy adults 18 to 55 years of age exhib -
ited a tolerability and safety profile consistent with those previously
observed for mRNA-based vaccines5. A clear dose-level response in
elicited neutralizing titers was observed after Doses 1 and 2 in adults
18 to 55 years of age with a particularly steep dose response between
the 10 µg and 30 µg dose levels.
Based on the tolerability profile of the first dose at 100 µg and the
second dose at 30 µg, participants randomized to the 100-µg group
did not receive a second vaccination. Reactogenicity was generally
greater after the second dose in the other two dosing levels; however,
symptoms were transient and resolved within a few days. Transient
decreases in lymphocytes (Grades 1-3) were observed within a few
days after vaccination, with lymphocyte counts returning to baseline
within 6 to 8 days in all participants. These laboratory abnormalities
were not associated with clinical findings. RNA vaccines are known
to induce type I interferon, which has been associated with transient
migration of lymphocytes into tissues19–22.
Robust immunogenicity was observed after vaccination with
BNT162b1. RBD-binding IgG concentrations were detected at 21 days
after the first dose and substantially increased 7 days after the second
dose given at Day 21. After the first dose, the RBD-binding IgG GMCs
(10 µg dose recipients) were similar to those observed in a panel of ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 4
FDA-CBER-2022-5812-0231603
Nature | www.nature.com | 338 convalescent human serum samples, obtained at least 14 days after a
PCR-confirmed diagnosis of SARS-CoV-2 infection/COVID-19. Post-Dose
1 GMCs were similar in the 30 µg and 100 µg groups and higher than
those in the convalescent serum panel. After Dose 2 with 10 µg or
30 µg BNT162b1, the RBD-binding IgG GMCs were ~8.0-fold to ~50-fold
that of the convalescent serum panel GMC.
The higher RBD-binding IgG GMC elicited by the vaccine relative
to the GMC of the human convalescent serum panel may be attrib -
uted, in part, to antibodies that bind epitopes that are exposed on the
RNA-expressed RBD immunogen and the recombinant RBD target
antigen of the binding assay but are buried and inaccessible to antibody
on the RBDs that are incorporated into the spikes of SARS-CoV-2 viri-
ons. Therefore, neutralization provides a measure of vaccine-elicited antibody response that is more relevant to potential protection. Neu-
tralization titers were measurable after a single vaccination at Day 21 for
all dose levels. At Day 28 (7 days after Dose 2), substantial SARS-CoV-2
neutralization titers were observed. The virus-neutralizing GMTs after
the 10 µg and 30 µg Dose 2 were, respectively, 1.8-fold and 2.8-fold the
GMT of the convalescent serum panel. By Day 35 (14 days after Dose
2), despite the decrease in RBD-binding IgG titers since Day 28, neu -
tralizing GMTs continued to rise, to 1.9-fold and 4.6-fold the GMT of
the convalescent panel for the 10 µg and 30 µg doses, respectively,
consistent with affinity maturation.
Assuming that neutralization titers induced by natural infection
provide protection from COVID-19 disease, comparing vaccine-induced
SARS-CoV-2 neutralization titers to those from sera of convalescent
humans provides a benchmark for the magnitude of the vaccine-elicited
response and the vaccine’s potential to provide protection. Because
a protective human neutralizing titer is unknown, these findings are
not proof of vaccine efficacy. Efficacy will be determined in a pivotal
Phase 3 trial. Because the 100 µg dose level cohort was not boosted,
no data for immunogenicity after a second vaccination at this dose
level are available; however, there were no substantial differences in
immunogenicity between the 30 µg and 100 µg dose levels after Dose
1. This observation suggests that a well-tolerated and immunoge ic
dose level may be between 10 µg and 30 µg for this vaccine candidate.
Our study had several limitations. While we used convalescent sera
as a comparator, the kind of immunity (T cells versu B cells or both)
and level of immunity needed to protect from COVID-19 are unknown.
Further, this analysis of available data did not assess immune responses
or safety beyond 2 weeks after the second dose of vaccine. Both are
important to inform the public health use of this vaccine. Follow-up
will continue for all participants and will include collection of SAEs for
6 months and COVID-19 infection and multiple additional immuno -
genicity measurements through up to two years. While our population
of healthy adults 55 years of age and younger is appropriate for a Phase
1/2 study, it does not accurat ly re lect the population at highest risk for
COVID-19. Adults 65 years of ag and over have already been enrolled in
this study and results will be reported as they become available. Later
phases of this study will prioritize enrollment of more diverse popula -
tions, including hose with chronic underlying health conditions and from racial/ethnic groups adversely affected by COVID-19
23.
The clin cal testing of BNT162b1 described here has taken place in the
context of a b oader, ongoing COVID-19 vaccine development program.
That program includes the clinical testing of three additional vaccine
cand dates ncluding candidates encoding the full-length spike, and a
parallel trial in Germany, in which additional immune responses, includ -
ing neutralizing responses against variant strains and cell-mediated
responses, are being assessed (U.S. manuscript in preparation)24. The
resulting comparative data will allow us to address whether a full-length
spike immunogen, which presents additional epitopes, is better able
than the relatively small RBD immunogen encoded by BNT162b1 to
elicit high virus neutralizing titers that are robust to potential antigenic drift of SARS-CoV-2. The clinical findings for the BNT162b1 RNA-based
vaccine candidate are encouraging and strongly support accelerated
clinical development, including efficacy testing, and at-risk manu -
facturing to maximize the opportunity for the rapid production of a
SARS-CoV-2 vaccine to prevent COVID-19.
Online content
Any methods, additional references, Nature Research reporting sum-
maries, source data, extended data, supplementary information,
acknowledgements, peer review information; details of author con -
tributions and competing interests; and statements of data and code
availability are available at https://doi.org/10.1038/s41586 020 2639-4 .
1. World Health Organization. WHO Director-General’s opening rema ks at he media
briefing on COVID-19. Available from: https://www.who i t/dg/
speeches/detail/who-
director-general-s opening-remarks-at-the-media bri ing o covid-19–11-march-2020 .
Published: 11 Mar 2020. Accessed: 01 Apr 2020
2. Johns Hopkins University Coronavirus Resource Cent r. COVID 19 dashboard by the Center for Systems Science and Engineering
CSSE) at Johns Hopkins University (JHU).
https://coronavirus.jhu.edu/map.html (2020).
3. World Health Organization. Coronavirus dise se 2 19 (COVID-19) situation report - 154. https:/
/www.who.int/docs/default-source/c ronaviruse/
situation-reports/20200622-covid-19-si p-154.pdf?sfvrsn=d0249d8d_2 (2020).
4. Alberer, M. et al. Safety and immunogenici y of a mRNA rabies vaccine in healthy adults: an open-label, non-randomised, prospective, first-in-human phase 1 clinical trial.
Lancet
390, 1511-1520 (2017).
5. Feldman, R.A. et al. mRNA v ccines gainst H10N8 and H7N9 influenza viruses of pandemic potential are immunog nic and well tolerated in healthy adults in phase 1
randomized clinica trials. Vaccine 37, 3326-3334 (2019).
6. Kranz, L.M t al. Syste ic RNA delivery to dendritic cells exploits antiviral defence for
cancer immunotherapy. Na
ture 534, 396-401 (2016).
7. Sahin, U. e al. Personalized RNA mutanome vaccines mobilize poly-specific therapeutic immunity ag inst cancer. Natur
e 547, 222-226 (2017).
8. etsch, M et al. Protective efficacy of in vitro synthesized, specific mRNA vaccines
against influ nza A virus infection.
Nat. Biotechnol. 30, 1210-1216 (2012).
9. Rau S., Jasny, E., Schmidt, K.E., & Petsch, B. New vaccine technologies to combat outbreak situations. Front. Immunol. 9, 1
963 (2018).
10 Sahin, U., Karikó, K., & Türeci, Ö. mRNA-based therapeutics—developing a new class of drugs. Nat. Rev. Drug. Discov
. 13, 759-780 (2014).
11. Kariko, K. et al. Incorporation of pseudouridine into mRNA yields superior nonimmunogenic vector with increased translational capacity and biological stability. Mol. Ther. 16, 183
3-1840 (2008).
12. He, Y. et al. Receptor-binding domain of SARS-CoV spike protein induces highly potent neutralizing antibodies: implication for dev
eloping subunit vaccine. Biochem. Biophys.
Res. Commun. 324, 773-781 (2004).
13. Zost, S.J., Gilchuk, P., Chen, R.E. et al. Rapid isolation and profiling of a diverse panel of human monoclonal antibodies targeting the SAR
S-CoV-2 spike protein. bioRxiv. https://
doi.org/10.1101/2020.05.12.091462 (2020).
14. Brouwer, P.J.M., Caniels, T.G., van der Straten, K. et al. Potent neutralizing antibodie
s from
COVID-19 patients define multiple targets of vulnerability. Science. https://doi.org/
10.1126/science.abc5902 (2020)
15. Guthe, S. et al. Very fast folding and association of a trimerization domain from bacteriophage T4 fibritin. J. Mol. Biol. 337, 905-
915 (2004).
16. Bachmann, M.F. & Zinkernagel, R.M. Neutralizing antiviral B cell responses. Annu. Rev. Immunol. 15, 235-
70 (1997).
17. Sahin, U. et al. A trimeric SARS-CoV-2 receptor-binding domain RNA vaccine is highly immunogenic and protective in non-human primates. Manuscrip
t in
preparation
18. Pardi, N. et al. Expression kinetics of nucleoside-modified mRNA delivered in lipid nanoparticles to mice by various routes.
J. Controlled Release 217, 345-351 (2015).
19. Foster, G.R. et al. IFN-alpha subtypes differentially affect human T cell motility. J. Immunol. 1
73, 1663-1670 (2004).
20. Hopkins, R.J. et al. Randomized, double-blind, placebo controlled, safety and immunogenicity study of 4 formulations of anthrax vaccine adsorbed plus CPG 7909 (AV790
9) in healthy adult volunteers. Vaccine 31, 3051-3058 (2013).
21. Regules, J.A. et al. A recombinant vesicular stomatitis virus ebola vaccine. N. Engl. J. Med. 3
76, 330-334 (2017).
22. Lai, L. et al. Emergency postexposure vaccination with vesicular stomatitis virus-vectored Ebola vaccine after needle
stick. JAMA. 313, 1249-1255 (2015).
23. Stokes, E.K. et al. Coronavirus disease 2019 case surveillance — United States, January
22–May 30, 2020. MMWR Morb. Mortal. Wkly. Rep. 69, 759-765 (2020).
24. Sahin et al. 2020, Concurrent antibody and T cell responses in a COVID-19 vaccine, manuscript in preparation.
Publisher
’s note Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
© The Author(s), under exclusive licence to Springer Nature Limited 2020
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 5
FDA-CBER-2022-5812-0231604
Figure 1 | Disposition of participants. Participants not assigned (n=20) were screened but not randomized because enrollmen had closed.
4 | Nature | www .nature.com
ArticleACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 6
FDA-CBER-2022-5812-0231605
Figure 2 | Local reactions reported within 7 days of vaccination for all dose
levels. Solicited injection-site (local) reactions were: pain at injection site
(mild: does not interfere with activity; moderate: interferes with activity; severe: prevents daily activity; Grade 4: emergency room visit or hospitalization) and redness and swelling (mild: 2.0 to 5.0 cm in diameter; moderate: >5.0 to 10.0 cm in diameter; severe: >10.0 cm in diameter; Grade 4: necrosis or exfoliative de mat tis for redness, and necrosis for swelling). Data were collected with the use of electronic diaries for 7 days after each vaccination.
Nature | www.nature.com | 5
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 7
FDA-CBER-2022-5812-0231606
Figure 3 | a. Systemic even s and medication use reported within 7 days
after Vaccination 1 for all dos levels and b. After Vaccination 2 for the 10-µg and 30-µg dos level . Solicited systemic events were: fatigue, headache, chills, new or orsened muscle pain, new or worsened joint pain (mild: does not nterfe e with activity; moderate: some interference with activ y; severe: pr vents daily activity), vomiting (mild: 1 to 2 times in 24 hours; mod rate: >2 t mes in 24 hours; severe: requires intravenous hydration), diarrhea (mild: 2 to 3 loose stools in 24 hours; moderate: 4 to 5 loose stools in 24 hours; severe: 6 or more loose stools in 24 hours); Grade 4 for all events: emergency room visit or hospitalization; and fever (mild: 38.0 °C to 38.4 °C; moderate: 38.5 °C to 38.9 °C; severe: 39.0 °C to 40.0 °C; Grade 4: >40.0 °C). Medication: proportion of participants reporting use of antipyretic or pain medication. Data were collected with the use of electronic diaries for 7 days after each vaccination.
6 | Nature | www .nature.com
ArticleACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 8
FDA-CBER-2022-5812-0231607
Figure 4 | Immunogenicity of BNT162b1. Participants in groups of 15 were
vaccinated with the indicated dose levels of BNT162b1 (n=12) or with placebo (n=3) on Days 1 (all dose levels and placebo) and 21 (10 µg and 30 µg dose levels and placebo). Reponses in placebo recipients for each of the osing groups are combined. The 28-day bleed is 7 days after the second vaccin tion. Se a were obtained before vaccination (Day 1) and 7, 21, and 28 days after the fi st vaccination. Human COVID-19 convalescent sera (HCS, n=38) were obtained at least 14 days after PCR-confirmed diagnosis and t a tim when the donors were asymptomatic. a. GMCs of recombinant RBD-binding IgG. Because Luminex
assay measured antibody concentrations are in arbitrary units, they cannot be directly translated into concentrations on a molar or mass basis. Lower limit of quantitation is 1.15. b . 50% SARS-CoV-2 neutralizing GMTs. Each data point
represents a serum sample, and each vertical bar represents a geometric mean with 95% CI. The number above the bars are either the GMC or GMT for the group. Arrows indicate timing of vaccination (blood draws were conducted prior to vaccination on vaccination days).
Nature | www.nature.com | 7
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 9
FDA-CBER-2022-5812-0231608
Methods
Study design
This study was conducted in healthy men and nonpregnant women
18 to 55 years of age to assess the safety, tolerability, and immuno -
genicity of ascending dose levels of various BNT162 mRNA vaccine
candidates. In the part of the study reported here, assessment of three
dose levels (10- µg, 30- µg, or 100- µg) of the BNT162b1 candidate was
conducted at two sites in the United States. This study utilized a sentinel
cohort design with progression and dose escalation taking place after
review of data from the sentinel cohort at each dose level.
Eligibility
Key exclusion criteria included individuals with known infection with
human immunodeficiency virus, hepatitis C virus, or hepatitis B virus;
immunocompromised individuals and those with a history of auto -
immune disease; and those with increased risk for severe COVID-19,
previous clinical or microbiological diagnosis of COVID-19, receipt of
medications intended to prevent COVID-19, previous vaccination with
any coronavirus vaccine, a positive serological test for SARS-CoV-2
IgM and/or IgG at the screening visit, and a SARS-CoV-2 nucleic acid
amplification test (NAAT)-positive nasal swab within 24 hours before
study vaccination.
The final protocol and informed consent document were approved
by institutional review boards for each of the participating investiga-tional centers. This study was conducted in compliance with all Inter-
national Council for Harmonisation (ICH) Good Clinical Practice (GCP)
guidelines and the ethical principles of the Declaration of Helsinki.
A signed and dated informed consent form was required before any
study-specific activity was performed.
Endpoints
In this report, results from the following study primary endpoints are
presented: the proportion of participants reporting solicited local reac -
tions, systemic events, and use of antipyretic and/or pain medi ation
within 7 days after vaccination, AEs and SAEs (available through up to ~45 days after Dose 1), and the proportion of participants with clin cal
laboratory abnormalities 1 and 7 days after vaccinat on and grading
shifts in laboratory assessments between baseline and 1 and 7 days after
Dose 1 and between Dose 2 and 7 days after Dose 2 Secondary endpoints
included: SARS-CoV-2 neutralizing GMTs and SARS CoV-2 RBD-binding
IgG GMCs 7 and 21 days after Dose 1 and 7 and 14 days after Dose 2.
Procedures
Study participants were randomly assigned to a vaccine group using
an interactive web-based response technology system with each group
comprising 15 participants (12 ac ve vaccine recipients and 3 placebo
recipients). Participants were to receive two 0.5-mL doses of either
BNT162b1 or placebo administered by intramuscular injection into
the deltoid muscle.
BNT162b1 incorporates a Good Manufacturing Practice (GMP)-grade
mRNA drug ubsta ce that encodes the trimerized SARS-CoV-2 spike
glycoprotein RBD antigen. The coding sequence for the antigen has
been deposited with GenBank, accession code MN908947.3. The mRNA
is fo mulated with lipids as the mRNA-LNP drug product. The vaccine
was supplied as a buffered-liquid solution for intramuscular injection
and was stored at -80 °C. The placebo was a sterile saline solution for inject on (0.9% sodium chloride injection, in a 0.5-mL dose).
Safety assessments
Safety assessments included a 4-hour observation after vaccination
(for the first 5 participants vaccinated in each group), or a 30-minute
observation (for the remainder of participants) for immediate AEs.
The safety assessments also included self-reporting of solicited local
reactions (redness, swelling, and pain at the injection site), systemic events (fever, fatigue, headache, chills, vomiting, diarrhea, muscle
pain, and joint pain), the use of antipyretic and/or pain medication in
an electronic diary for 7 days after vaccination, and the reporting of
unsolicited AEs and SAEs after vaccination. Hematology and chemistry
assessments were conducted at screening, 1 and 7 days after Dose 1,
and 7 days after Dose 2.
There were protocol-specified safety stopping rules for all sentinel
cohort participants. Both an internal review committee and an external
data monitoring committee reviewed all safety data. No stopping rules
were met prior to the publication of this report.
Human convalescent serum panel
The 38 human SARS-CoV-2 infection/COVID-19 convalescent sera were
drawn from participants 18 to 83 years of age, at least 14 days after
PCR-confirmed diagnosis, and at a time when participants were asymp -
tomatic. The mean age of the donors was 45 years of age. Neutralizing
GMTs in subgroups of the donors were as follows: ≤ 55 years of age
- 82 (n=29); > 55 years of age – 142 (n=9); symptomatic infections – 90
(n=35); asymptomatic infections – 156 (n=3) The antibody titer for
the one hospitalized individual was 618 The sera were obtained from
Sanguine Biosciences (Sherman Oaks, CA), the MT Group (Van Nuys,
CA), and Pfizer Occupational Health and Wellness (Pearl River, NY).
Immunogenicity assessments
50 mL of blood was colle ted for immunogenicity assessments before
each study vaccination, at 7 and 21 days after Dose 1, and at 7 and 14 days
after Dose 2 In the RBD-binding IgG assay, a recombinant SARS-CoV-2
RBD contai ing a C terminal Avitag™ (Acro Biosystems Cat# SPD-C82E9)
and no foldon domain was bound to streptavidin-coated Luminex®
mic ospheres. Briefly, 1.25 × 107 microspheres/mL were coated with
streptavidin by 1-ethyl-3-[3-dimethylaminopropyl] carbodiimide
hydrochloride (EDC) reaction. Recombinant RBD Avitag was coupled to
s reptavidin beads by incubating for 90 minutes at room temperature
with shaking (35 RPM). Beads were blocked in 1% BSA buffer for 30 min -
utes at room temperature. Heat-inactivated subject serum was diluted
1:500, 1:5000, and 1:50000 in assay buffer (PBS with 0.5% BSA, 0.05%
Tween, and 0.02% sodium azide). Following a 16- to 20-hour incubation
at 2-8 °C with shaking (300 RPM), plates were washed three times in a
solution containing 0.05% Tween-20. An R-Phycoerythrin-conjugated
goat anti-human polyclonal antibody ( Jackson Labs) was then added
to plates for 90 minutes at room temperature with shaking (300 RPM).
Plates were then washed a final time in a solution containing 0.05%
Tween-20. Data were captured as median fluorescent intensities using a
Luminex reader and converted to U/mL antibody concentrations using
a reference standard curve with arbitrary assigned concentrations
of 100 U/mL and accounting for the serum dilution factor. The refer-
ence standard was composed of a pool of five COVID-19 convalescent
serum samples (>14 days post PCR diagnosis). Three dilutions are used
to increase the likelihood that at least one result for any sample will
fall within the usable range of the standard curve. Assay results were
reported in U/mL of IgG. The final assay results are expressed as the
GMC of all sample dilutions that produced a valid assay result within
the assay range.
The SARS-CoV-2 neutralization assay used a previously described
strain of SARS-CoV-2 (USA_WA1/2020) that had been rescued by reverse
genetics and engineered by the insertion of an mNeonGreen gene into
open reading frame 7 of the viral genome25. This reporter virus gener-
ates similar plaque morphologies and indistinguishable growth curves
from the wild-type virus. Viral master stocks (2 × 107 PFU/mL) used
for the neutralization assay were grown in Vero E6 cells as previously
described25. When testing patient convalescent serum specimens, the
fluorescent neutralization assay produced comparable results as the
conventional plaque reduction neutralization assay26. Briefly, serial
dilutions of heat inactivated sera were incubated with the reporter
virus to yield approximately a 10% to 30% infection rate of the Vero
ArticleACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 10
FDA-CBER-2022-5812-0231609
monolayer) for 1 hour at 37 °C before inoculating Vero CCL81 cell mon -
olayers (targeted to have 8,000 to 15,000 cells per well) in 96 well plates
to allow accurate quantification of infected cells. Total cell counts per
well were enumerated by nuclear stain (Hoechst 33342) and fluorescent
virally infected foci were detected 16 to 24 hours after inoculation with
a Cytation™ 7 Cell Imaging Multi-Mode Reader (BioTek) with Gen5 Image
Prime version 3.09. Titers were calculated in GraphPad Prism version
8.4.2 by generating a 4-parameter (4PL) logistical fit of the percent
neutralization at each serial serum dilution. The 50% neutralization
titer (VNT50) was reported as the interpolated reciprocal of the dilution
yielding a 50% reduction in fluorescent viral foci.
Statistical analysis
The sample size for the reported part of the study was not based on sta -
tistical hypothesis testing. The primary safety objective was evaluated
by descriptive summary statistics for local reactions, systemic events,
abnormal hematology and chemistry laboratory parameters, AEs, and
SAEs after each vaccine dose for each vaccine group. The secondary
immunogenicity objectives were descriptively summarized at the vari -
ous time points. All participants with data available were included in
the safety and immunogenicity analyses.
Reporting summary
Further information on research design is available in the Nature
Research Reporting Summary linked to this paper.
Data availability
Upon request, and subject to review, Pfizer will provide the data that
support the findings of this study. Subject to certain criteria, condi -
tions, and exceptions, Pfizer may also provide access to the related
individual anonymized participant data. See https://www.pfizer.com/
science/clinical-trials/trial-data-and-results for more information.
These data are interim data from an ongoing study, with the database
not locked. Data have not yet been source verified or subjected to sta d -
ard quality check procedures that would occur at the time of database
lock and may therefore be subject to change.
25. Xie X. et al. An infectious cDNA clone of SARS CoV-2. Cell Host Microbe. 27, 841-848
(2020).
26. Muruato, A.E., Fontes Garfias, C.R., Ren, P.
et al. A high throughput neutra izing antibody
assay for COVID-19 diagnosis and vaccine evaluation. bioRxiv https://doi.org/10.1101/
2020.05.21.109546 (2020).Acknowledgements The authors would like to thank Carol Monahan and Deb Gantt (Pfizer
Inc) for writing and editorial support and Hua Ma, James Trammel, and Kiran Challagali
(Pfizer Inc) for statistical analysis support in the generation of this manuscript. We would like to thank all the participants who volunteered for this study. We also acknowledge the following individuals for their contributions to this work: NYU Langone Vaccine Center: Angelica Kottkamp, MD, Ramin Herati, MD, Rebecca Pellet Madan, MD, Mary Olson, DNP, ANP-BC, Marie Samanovic-Golden, PhD, Elisabeth Cohen, MD, Amber Cornelius, MS, Laura Frye, MPH, Heekoung Youn, RN, CCRC, MA, Baby Jane Fran, RN, Kanika Ballani, PharmD, MBA, Natalie Veling, RN, Juanita Erb, RN, BSN, MPA, Mahnoor Ali, BA, Lisa Zhao, BA, Stephanie Rettig, MPH, Hibah Khan, MPA, Harry Lambert, BA, Kelly Hu, BA, and Jonathan Hyde, BS. Staffing services were supported in part by an NYU CTSA grant (UL1 TR001445) from the National Center for Advancing Translational Sciences, National Institutes of Health. Center for Vaccine Development and Global Health, University of Maryland Sc ool of Medicine: Monica McArthur, MD, PhD, Justin Ortiz, MD, MS, FACP, FCCP, Rekha Rapaka, MD, Linda Wadsworth, RN, Ginny Cummings, RN, Toni Robinson, RN, Nancy G eenberg, RN, Lisa Chrisley, RN, Wanda Somrajit, RN, Jennifer Marron, RN, BSN, MS, Constanc Thomas, RN, Kelly Brooks, RN, Lisa Turek, RN, Patricia Farley, RN, Staci Eddington Pa agiot Komninou, Mardi Reymann, Kathy Strauss, Biraj Shrestha, Sudhaunshu J shi, Robin Barnes, RN, Roohali Sukhavasi, Myounghee Lee, PharmD, Alyson Kwon, and Terry Sharp. University of Rochester and Rochester General Hospital: Emily Pierce, RN and Mary Criddle, RN. Cincinnati Children’s Hospital: Amy Cline, RN, Susan Parker RN, Michelle Di key, APRN, Kristen Buschle, APRN. Pfizer Inc: Andrea Cawein, John L erez MD, MSc, Harpreet Seehra, Dina Tresnan, DVM, PhD, Robert Maroko, MD, Helen Smith, Sarah Tweedy, Amy Jones, Greg Adams, Rabia Malick, Emily Worobetz, Erica Weaver Lipi g Zhang armel Devlin, Donna Boyce, Elisa Harkins Tull, Mark Boaz, Michael Cru , Vaccines Clinical Assay Team and Vaccines Assay Development Team. BioNTech: Corinna Rosenbaum, Christian Miculka, Andreas Kuhn, Ferdia Bates, Paul Strecker nd A exandra Kemmer-Brück. BioNTech is the sponsor of the study. Pfizer was respons ble for he design, data collection, data analysis, data interpretation, and writing of the repo t he corresponding authors had full access to all the data in the study and had final responsibility for the decision to submit the data for publication. All study data were available to all authors.
Author contributions KUJ, PRD, CG, NK SL, AG, RB, and US were involved in the design of
the overall study and strategy. KN, MJM, EEW, RF, and ARF provided feedback on the study design. WK, DC, KAS, KRT CFG and PYS performed the immunological analyses. MJM, KN, EEW, RF, ARF, KEL, and VR olle ted data as study investigators. PL and KK developed the statistical desi n and oversaw the data analysis. JA, KUJ, PRD, and WCG drafted the initial version of the manuscript All authors reviewed and edited the manuscript and approved the final version.
Compe ing interests NK, JA, AG, SL, RB, KAS, PL, KK, WK, DC, KRT, PRD, WCG, and KUJ are
mployee of Pfizer and may hold stock options. US and ÖT are stock owners,
management board members, and employees at BioNTech SE (Mainz, Germany) and are
nv tors on patents and patent applications related to RNA technology. MJM, KEL, KN,
EEW, ARF, RF, and VR received compensation from Pfizer for their role as study
nvestigators. CFG and PYS received compensation from Pfizer to perform the
neutralization assay.
Additional information
Supplementary information is available for this paper at https://doi.org/10.1038/s41586-020-2639-4 .
Correspondence and requests for materials should be addressed to J.A.Peer review information Nature thanks Barbra Richardson and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.Reprints and permissions information is available at http://www.nature.com/reprints.
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 11
FDA-CBER-2022-5812-0231610
Extended Data Figure 1 | Post Vaccination Changes in Lymphocyte Coun
Over Time. Figure represents box-and-whisker plots for obs rved values at the
following timepoints: Dose 1/Day 1-3: ~1 day after Dose 1; Dose 2/Day 6 8: ~7 days after Dose 1; Pre-Dose 2: before Dose 2; Dose 2/Day 6-8: 7 days after Dose 2. Symbols denote group means – O: placebo; +: 10 µg; X: 30 µg; Δ: 100 µg. Center
line of box denotes median; lower and upper edges denote first and third quartiles; lower and upper whiskers denote minimum and maximum.
Article
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 12
FDA-CBER-2022-5812-0231611
Extended Data Table 1 | Demographic Characteristics.
N = number of subjects in the specified group, or the total sample. This value is the denominator for e percen age calculations. n = Number of subjects with the specified characteristic.
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 13
FDA-CBER-2022-5812-0231612
Extended Data Table 2 | Adverse Events.
N: number of subjects in the specified group or the total sample. This value is the denominator for the percentage calculations. n: number of subjects reporting at least 1 occurrence of the
specified adverse event category. For "any event", n: the number of subjects reporting at least 1 occurr nce of any adverse event; Related: Assessed by the investigator as related to investiga-tional product.
Article
ACCELERATED ARTICLE PREVIEW
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 14
FDA-CBER-2022-5812-0231613
1 nature research | reporting summary April 2020
Corresponding author(s): Judith Absalon
Last updated by author(s): Jul 27, 2020
Reporting Summary
Nature Research wishes to improve the reproducibility of the work that we publish. This form provides structure for consistency and transparency
in reporting. For further information on Nature Research policies, see our Editorial Policies and the Editorial Policy Checklist .
Statistics
For all statistical analyses, confirm that the following items are present in the figure legend, table legend, main text, or Methods section.
n/a Confirmed
The exact sample size ( n) for each experimental group/condition, given as a discrete number and unit of measurement
A statement on whether measurements were taken from distinct samples or whether the same sample was measured repeatedly
The statistical test(s) used AND whether they are one or two sided
Only common tests should be described solely by name; describe more complex techniques in the Methods section.
A description of all covariates tested
A description of any assumptions or corrections, such as tests of normality and adjustment for multiple comparisons
A full description of the statistical parameters including central tendency (e.g. means) or other basic estimates (e.g. regression coefficient) AND variation (e.g. standard deviation) or associated estimates of uncertainty (e.g. confidence intervals)
For null hypothesis testing, the test statistic (e.g. F, t, r) with confidence intervals, effect sizes, degrees of freedom and P value noted
Give P values as exact values whenever suitable.
For Bayesian analysis, information on the choice of priors and Markov chain Monte Carlo settings
For hierarchical and complex designs, identification of the appropriate level for tests and full reporting of outcomes
Estimates of effect sizes (e.g. Cohen's d, Pearson's r), indicating how they were calculated
Our web collection on statistics for biologists contains articles on many of the points above.
Software and code
Policy information about availability of computer code
Data collection Inform (for data collected in the case report form) and electronic diary (Signant Health platform) for participant self reported reactogenicity
Data analysis SAS 9.4
For manuscripts utilizing custom algorithms or software that are central to the research but not yet described in published literature, software must be made available to editors and reviewers. We strongly encourage code deposition in a community repository (e.g. GitHub). See the Nature Research guidelines for submitting code & software for further information.
Data
Policy information about availability of data
All manuscripts must include a data availability statement . This statement should provide the following information, where applicable:
Accession codes, unique identifiers, or web links for publicly available datasets A list of figures that have associated raw data A description of any restrictions on data availability
Upon request, and subject to review, Pfizer will provide the data that support the findings of this study. Subject to certain criteria, conditions and exceptions, Pfizer may also provide access to the related individual anonymized participant data. See https://www.pfizer.com/science/clinical trials/trial data and results for more information
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 15
FDA-CBER-2022-5812-0231614
2 nature research | reporting summary April 2020Field-specific reporting
Please select the one below that is the best fit for your research. If you are not sure, read the appropriate sections before making your selection.
Life sciences Behavioural & social sciences Ecological, evolutionary & environmental sciences
For a reference copy of the document with all sections, see nature.com/documents/nr-reporting-summary-flat.pdf
Life sciences study design
All studies must disclose on these points even when the disclosure is negative.
Sample size The sample size for this interim report was not based on statistical hypothesis testing. A total of 45 participants were enrolled in this part of
the study. For the purposes of tolerability and dose escalation study a total of 15 participants (12 receiving vaccine and 3 receiving placebo) was deemed sufficient for a dosing finding phase study.
Data exclusions All safety and immunogenicity data that were available at the time of the data snapshot were included in the interim report. No data were excluded from the analyses.
Replication This is an interim report of an ongoing human clinical trial. There was no attempt at replication of study findings
Randomization This is an randomized controlled trial. Study participants were randomly assigned to a vaccine group using an interactive web based response technology system with each group comprising 15 participants (12 active vaccine recipients and 3 placebo recipients).
Blinding This is an observer blinded study which is investigator blinded but Sponsor unblinded during Stage 1 (the stage from which data in the manuscript are presented). Investigators were unblinded to group level data but not subject level data for the purposes of interpretation and summary of the results included in this interim report.
Reporting for specific materials, systems and methods
We require information from authors about some types of materials, experimental systems and methods used in many studies. Here, indicate whether each material, system or method listed is relevant to your study. If you are not sure if a list item applies to your research, read the appropriate section before selecting a response.
Materials & experimental systems
n/a Involved in the study
Antibodies
Eukaryotic cell lines
Palaeontology and archaeology
Animals and other organisms
Human research participants
Clinical data
Dual use research of concernMethods
n/a Involved in the study
ChIP seq
Flow cytometry
MRI based neuroimaging
Human research participants
Policy information about studies involving human research participants
Population characteristics Study participants were healthy men or women 18 55 years of age. Key exclusion criteria included individuals with known infection with human immunodeficiency virus, hepatitis C virus, or hepatitis B virus; immunocompromised individuals and those with a history of autoimmune disease; those with increased risk for severe COVID 19; previous clinical or microbiological diagnosis of COVID 19; receipt of medications intended to prevent COVID 19; previous vaccination with any coronavirus vaccine; a positive serological test for SARS CoV 2 IgM and/or IgG at the screening visit; and a SARS CoV 2 NAATpositive nasal swab within 24 hours before study vaccination.
Recruitment Study participants were recruited at the two individual sites and recruitment strategies were at the discretion of individual sites and could include identification of interested individuals from the sites local database or through advertising in the local community. Once recruited participants were screened for eligibility based on pre specified protocol criteria. Eligible participants were then randomized to vaccine or placebo in a blinded manner. These processes therefore did not led themselves to enrollment biases however participants who did not know about the study may have had less of an opportunity to participate.
Ethics oversight The study protocol was approved by the western institutional review board for one site and by the Langone Health New York University Institutional IRB prior to enrollment of any participants
Note that full information on the approval of the study protocol must also be provided in the manuscript.
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 16
FDA-CBER-2022-5812-0231615
3 nature research | reporting summary April 2020Clinical data
Policy information about clinical studies
All manuscripts should comply with the ICMJE guidelines for publication of clinical research and a completed CONSORT checklist must be included with all submissions.
Clinical trial registration ClinicalTrials.gov identifier: NCT04368728
Study protocol Details of protocol elements can be accessed from clinicaltrials.gov
Data collection Data were collected at screening (up to 14 days before vaccination) and for randomized participants at the investigative site at
baseline, 1 day, 7 days and 21 days, after Dose 1, 7 days after dose 2 and up to 14 days after dose 2. Both safety and/or serum collection for immunogenicity assessments were collected for all stated time points. In addition, reactogenicity data were assessed through participant self reports via an electronic diary for 7 days after dose 1.
Outcomes In this interim report, the following study primary endpoints are presented: the proportion of participants reporting prompted local reactions, systemic events, and use of antipyretic and/or pain medication within 7 days after vaccination, AEs and serious adverse events (SAEs) (available through up to ~45 days after Dose 1), and the proportion of participants with clinical laboratory abnormalities 1 and 7 days after vaccination and grading shifts in laboratory assessments between baseline and 1 and 7 days after Dose 1 and between Dose 2 and 7 days after Dose 2. Secondary endpoints included: SARS CoV 2 neutralizing geometric mean titers (GMTs); SARS CoV 2 RBD binding IgG geometric mean concentrations (GMCs) 7 and 21 days after Dose 1 and 7 and 14 days after Dose 2
090177e194f9acfd\Final\Final On: 21-Sep-2020 21:22 (GMT)
Page 17
FDA-CBER-2022-5812-0231616
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 18
FDA-CBER-2022-5812-0231617
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 19
FDA-CBER-2022-5812-0231618
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 20
FDA-CBER-2022-5812-0231619
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 21
FDA-CBER-2022-5812-0231620
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 22
FDA-CBER-2022-5812-0231621
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 23
FDA-CBER-2022-5812-0231622
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 24
FDA-CBER-2022-5812-0231623
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 25
FDA-CBER-2022-5812-0231624
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 26
FDA-CBER-2022-5812-0231625
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 27
FDA-CBER-2022-5812-0231626
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 28
FDA-CBER-2022-5812-0231627
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 29
FDA-CBER-2022-5812-0231628
090177e1954406cc\Final\Final On: 15-Oct-2020 19:54 (GMT)
Page 30
FDA-CBER-2022-5812-0231629
The new england journal of medicine
n engl j med nejm.org 1The authors' affiliations are listed in the
Appendix. Address reprint requests to Dr. Absalon at Pfizer, 401 N. Middletown Rd., Pearl River, NY 10965, or at judith . absalon@ pfizer . com.
*A complete list of investigators in the
C4591001 Clinical Trial Group is pro-
vided in the Supplementary Appendix ,
available at NEJM.org.
Drs. Polack and Thomas contributed equally to this article.
This article was published on December
10, 2020, at NEJM.org.
DOI: 10.1056/NEJMoa2034577
Copyright © 2020 Massachusetts Medical Society.BACKGROUND
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (Covid-19) have afflicted tens of millions of people in a worldwide pandemic. Safe and effective vaccines are needed urgently.
METHODS
In an ongoing multinational, placebo-controlled, observer-blinded, pivotal efficacy trial, we randomly assigned persons 16 years of age or older in a 1:1 ratio to receive two doses, 21 days apart, of either placebo or the BNT162b2 vaccine candidate (30 μg per dose). BNT162b2 is a lipid nanoparticle–formulated, nucleoside-modified RNA vaccine that encodes a prefusion stabilized, membrane-anchored SARS-CoV-2 full-length spike protein. The primary end points were efficacy of the vaccine against laboratory-confirmed Covid-19 and safety.
RESULTS
A total of 43,548 participants underwent randomization, of whom 43,448 received injections: 21,720 with BNT162b2 and 21,728 with placebo. There were 8 cases of Covid-19 with onset at least 7 days after the second dose among participants as-signed to receive BNT162b2 and 162 cases among those assigned to placebo; BNT162b2 was 95% effective in preventing Covid-19 (95% credible interval, 90.3 to 97.6). Similar vaccine efficacy (generally 90 to 100%) was observed across subgroups defined by age, sex, race, ethnicity, baseline body-mass index, and the presence of coexisting conditions. Among 10 cases of severe Covid-19 with onset after the first dose, 9 occurred in placebo recipients and 1 in a BNT162b2 recipient. The safety profile of BNT162b2 was characterized by short-term, mild-to-moderate pain at the injection site, fatigue, and headache. The incidence of serious adverse events was low and was similar in the vaccine and placebo groups.
CONCLUSIONS
A two-dose regimen of BNT162b2 conferred 95% protection against Covid-19 in persons 16 years of age or older. Safety over a median of 2 months was similar to that of other viral vaccines. (Funded by BioNTech and Pfizer; ClinicalTrials.gov number, NCT04368728.)ABSTRACTSafety and Efficacy of the BNT162b2 mRNA
Covid-19 Vaccine
Fernando P. Polack, M.D., Stephen J. Thomas, M.D., Nicholas Kitchin, M.D.,
Judith Absalon, M.D., Alejandra Gurtman, M.D., Stephen Lockhart, D.M.,
John L. Perez, M.D., Gonzalo Pérez Marc, M.D., Edson D. Moreira, M.D.,
Cristiano Zerbini, M.D., Ruth Bailey, B.Sc., Kena A. Swanson, Ph.D.,
Satrajit Roychoudhury, Ph.D., Kenneth Koury, Ph.D., Ping Li, Ph.D.,
Warren V. Kalina, Ph.D., David Cooper, Ph.D., Robert W. Frenck, Jr., M.D.,
Laura L. Hammitt, M.D., Özlem Türeci, M.D., Haylene Nell, M.D., Axel Schaefer, M.D.,
Serhat Ünal, M.D., Dina B. Tresnan, D.V.M., Ph.D., Susan Mather, M.D.,
Philip R. Dormitzer, M.D., Ph.D., Uğur Şahin, M.D., Kathrin U. Jansen, Ph.D.,
and William C. Gruber, M.D., for the C4591001 Clinical Trial Group* Original Article
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 31
FDA-CBER-2022-5812-0231630
n engl j med nejm.org 2The new england journal of medicine
Coronavirus disease 2019 (Covid-19)
has affected tens of millions of people globally
1 since it was declared a pandemic
by the World Health Organization on March 11, 2020.
2 Older adults, persons with certain coex-
isting conditions, and front-line workers are at highest risk for Covid-19 and its complications. Recent data show increasing rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and Covid-19 in other populations, in-cluding younger adults.
3 Safe and effective pro-
phylactic vaccines are urgently needed to contain the pandemic, which has had devastating medi-cal, economic, and social consequences.
We previously reported phase 1 safety and im-
munogenicity results from clinical trials of the vaccine candidate BNT162b2,
4 a lipid nanoparticle–
formulated,5 nucleoside-modified RNA (modRNA)6
encoding the SARS-CoV-2 full-length spike, modi-fied by two proline mutations to lock it in the prefusion conformation.
7 Findings from studies
conducted in the United States and Germany among healthy men and women showed that two 30-μg doses of BNT162b2 elicited high SARS-CoV-2 neutralizing antibody titers and robust antigen-specific CD8+ and Th1-type CD4+ T-cell respons-es.
8 The 50% neutralizing geometric mean titers
elicited by 30 μg of BNT162b2 in older and young-er adults exceeded the geometric mean titer mea-sured in a human convalescent serum panel, de-spite a lower neutralizing response in older adults than in younger adults. In addition, the reactoge-nicity profile of BNT162b2 represented mainly short-term local (i.e., injection site) and systemic responses. These findings supported progression of the BNT162b2 vaccine candidate into phase 3.
Here, we report safety and efficacy findings
from the phase 2/3 part of a global phase 1/2/3 trial evaluating the safety, immunogenicity, and efficacy of 30 μg of BNT162b2 in preventing Covid-19 in persons 16 years of age or older. This data set and these trial results are the basis for an application for emergency use authorization.
9 Col-
lection of phase 2/3 data on vaccine immunoge-nicity and the durability of the immune response to immunization is ongoing, and those data are not reported here.
Methods
Trial Objectives, Participants and Oversight
We assessed the safety and efficacy of two 30-μg doses of BNT162b2, administered intramuscu-larly 21 days apart, as compared with placebo. Adults 16 years of age or older who were healthy or had stable chronic medical conditions, includ-ing but not limited to human immunodeficiency virus (HIV), hepatitis B virus, or hepatitis C vi-rus infection, were eligible for participation in the trial. Key exclusion criteria included a medi-cal history of Covid-19, treatment with immuno-suppressive therapy, or diagnosis with an im-munocompromising condition.
Pfizer was responsible for the design and
conduct of the trial, data collection, data analysis, data interpretation, and the writing of the manuscript. BioNTech was the sponsor of the trial, manufactured the BNT162b2 clinical trial material, and contributed to the interpretation of the data and the writing of the manuscript. All the trial data were available to all the authors, who vouch for its accuracy and completeness and for adherence of the trial to the protocol, which is available with the full text of this article at NEJM.org. An independent data and safety mon-itoring board reviewed efficacy and unblinded safety data.
Trial Procedures
With the use of an interactive Web-based sys-tem, participants in the trial were randomly as-signed in a 1:1 ratio to receive 30 μg of BNT162b2 (0.3 ml volume per dose) or saline placebo. Participants received two injections, 21 days apart, of either BNT162b2 or placebo, deliv-ered in the deltoid muscle. Site staff who were responsible for safety evaluation and were un-aware of group assignments observed partici-pants for 30 minutes after vaccination for any acute reactions.
Safety
The primary end points of this trial were solic-ited, specific local or systemic adverse events and use of antipyretic or pain medication within 7 days after the receipt of each dose of vaccine or placebo, as prompted by and recorded in an electronic diary in a subset of participants (the reactogenicity subset), and unsolicited adverse events (those reported by the participants with-out prompts from the electronic diary) through 1 month after the second dose and unsolicited serious adverse events through 6 months after the second dose. Adverse event data through ap-proximately 14 weeks after the second dose are included in this report. In this report, safety A Quick Take
is available at
NEJM.org
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 32
FDA-CBER-2022-5812-0231631
n engl j med nejm.org 3Safety and Efficacy of the BNT162b2 Vaccine
data are reported for all participants who pro-
vided informed consent and received at least one dose of vaccine or placebo. Per protocol, safety re-sults for participants infected with HIV (196 pa-tients) will be analyzed separately and are not included here.
During the phase 2/3 portion of the study, a
stopping rule for the theoretical concern of vac-cine-enhanced disease was to be triggered if the one-sided probability of observing the same or a more unfavorable adverse severe case split (a split with a greater proportion of severe cases in vac-cine recipients) was 5% or less, given the same true incidence for vaccine and placebo recipients. Alert criteria were to be triggered if this probabil-ity was less than 11%.
Efficacy
The first primary end point was the efficacy of BNT162b2 against confirmed Covid-19 with onset at least 7 days after the second dose in participants who had been without serologic or virologic evi-dence of SARS-CoV-2 infection up to 7 days after the second dose; the second primary end point was efficacy in participants with and partici-pants without evidence of prior infection. Con-firmed Covid-19 was defined according to the Food and Drug Administration (FDA) criteria as the presence of at least one of the following symptoms: fever, new or increased cough, new or increased shortness of breath, chills, new or in-creased muscle pain, new loss of taste or smell, sore throat, diarrhea, or vomiting, combined with a respiratory specimen obtained during the symp-tomatic period or within 4 days before or after it that was positive for SARS-COV-2 by nucleic acid amplification–based testing, either at the central laboratory or at a local testing facility (using a protocol-defined acceptable test).
Major secondary end points included the ef-
ficacy of BNT162b2 against severe Covid-19. Se-vere Covid-19 is defined by the FDA as confirmed Covid-19 with one of the following additional features: clinical signs at rest that are indicative of severe systemic illness; respiratory failure; evi-dence of shock; significant acute renal, hepatic, or neurologic dysfunction; admission to an in-tensive care unit; or death. Details are provided in the protocol.
An explanation of the various denominator
values for use in assessing the results of the trial is provided in Table S1 in the Supplemen-tary Appendix, available at NEJM.org. In brief, the safety population includes persons 16 years of age or older; a total of 43,448 participants constituted the population of enrolled persons injected with the vaccine or placebo. The main safety subset as defined by the FDA, with a me-dian of 2 months of follow-up as of October 9, 2020, consisted of 37,706 persons, and the reac-togenicity subset consisted of 8183 persons. The modified intention-to-treat (mITT) efficacy pop-ulation includes all age groups 12 years of age or older (43,355 persons; 100 participants who were 12 to 15 years of age contributed to person-time years but included no cases). The number of persons who could be evaluated for efficacy 7 days after the second dose and who had no evi-dence of prior infection was 36,523, and the number of persons who could be evaluated 7 days after the second dose with or without evi-dence of prior infection was 40,137.
Statistical Analysis
The safety analyses included all participants who received at least one dose of BNT162b2 or placebo. The findings are descriptive in nature and not based on formal statistical hypothesis testing. Safety analyses are presented as counts, percentages, and associated Clopper–Pearson 95% confidence intervals for local reactions, systemic events, and any adverse events after vaccination, according to terms in the Medical
Dictionary for Regulatory Activities (MedDRA), ver-
sion 23.1, for each vaccine group.
Analysis of the first primary efficacy end
point included participants who received the vac-cine or placebo as randomly assigned, had no evidence of infection within 7 days after the second dose, and had no major protocol devia-tions (the population that could be evaluated). Vaccine efficacy was estimated by 100 × (1 − IRR), where IRR is the calculated ratio of confirmed cases of Covid-19 illness per 1000 person-years of follow-up in the active vaccine group to the corresponding illness rate in the placebo group. The 95.0% credible interval for vaccine efficacy and the probability of vaccine efficacy greater than 30% were calculated with the use of a Bayesian beta-binomial model. The final analy-sis uses a success boundary of 98.6% for prob-ability of vaccine efficacy greater than 30% to compensate for the interim analysis and to control the overall type 1 error rate at 2.5%.
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 33
FDA-CBER-2022-5812-0231632
n engl j med nejm.org 4The new england journal of medicine
1272 Did not undergo randomization
1152 Did not meet eligibility criteria
64 Had other reason
33 Withdrew13 Underwent randomization
after cutoff
5 Had unspecified reason4 Were withdrawn by physician1 Was lost to follow-up
99 Were not vaccinated
1 Did not sign the informed consent document
316 Did not receive dose 2
96 Withdrew86 Were no longer eligible61 Were lost to follow-up46 Had ongoing or pending
status
18 Had adverse event
5 Were pregnant2 Were withdrawn by
physician
1 Died1 Had medication error
(no adverse event)304 Did not receive dose 2
100 Withdrew
62 Were lost to follow-up56 Had ongoing or pending
status
51 Were no longer eligible28 Had adverse event
4 Were pregnant2 Were withdrawn by
physician
1 Died
18,556 Received dose 2 of BNT162b2 18,530 Received dose 2 of placebo43,448 Were injected with vaccine or placebo
21,720 Were assigned to receive BNT162b221,728 Were assigned to receive placebo
37,706 Received vaccine or placebo
and had median follow-up of 2 mo43,548 Underwent randomization44,820 Participants were screened
18,860 Received dose 1 of BNT162b2 18,846 Received dose 1 of placebo
48 Discontinued trial after dose 2
27 Withdrew18 Were lost to follow-up
1 Died1 Was withdrawn by physician1 Had medication error
(no adverse event)95 Discontinued trial after dose 2
66 Withdrew25 Were lost to follow-up
2 Died1 Had other reason1 Declined further procedures
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 34
FDA-CBER-2022-5812-0231633
n engl j med nejm.org 5Safety and Efficacy of the BNT162b2 Vaccine
Moreover, primary and secondary efficacy end
points are evaluated sequentially to control the familywise type 1 error rate at 2.5%. Descriptive analyses (estimates of vaccine efficacy and 95% confidence intervals) are provided for key sub-groups.
Results
Participants
Between July 27, 2020, and November 14, 2020, a total of 44,820 persons were screened, and 43,548 persons 16 years of age or older under-went randomization at 152 sites worldwide (United States, 130 sites; Argentina, 1; Brazil, 2; South Africa, 4; Germany, 6; and Turkey, 9) in the phase 2/3 portion of the trial. A total of Figure 1 (facing page). Enrollment and Randomization.
The diagram represents all enrolled participants
through November 14, 2020. The safety subset (those
with a median of 2 months of follow-up, in accordance with application requirements for Emergency Use Au-thorization) is based on an October 9, 2020, data cut-off date. The further procedures that one participant in the placebo group declined after dose 2 (lower right corner of the diagram) were those involving collection of blood and nasal swab samples.
Table 1. Demographic Characteristics of the Participants in the Main Safety Population.*
CharacteristicBNT162b2
(N=18,860)Placebo
(N=18,846)Total
(N=37,706)
Sex — no. (%)
Male 9,639 (51.1) 9,436 (50.1) 19,075 (50.6)
Female 9,221 (48.9) 9,410 (49.9) 18,631 (49.4)
Race or ethnic group — no. (%)†White 15,636 (82.9) 15,630 (82.9) 31,266 (82.9)
Black or African American 1,729 (9.2) 1,763 (9.4) 3,492 (9.3)
Asian 801 (4.2) 807 (4.3) 1,608 (4.3)
Native American or Alaska Native 102 (0.5) 99 (0.5) 201 (0.5)
Native Hawaiian or other Pacific Islander 50 (0.3) 26 (0.1) 76 (0.2)
Multiracial 449 (2.4) 406 (2.2) 855 (2.3)
Not reported 93 (0.5) 115 (0.6) 208 (0.6)
Hispanic or Latinx 5,266 (27.9) 5,277 (28.0) 10,543 (28.0)
Country — no. (%)Argentina 2,883 (15.3) 2,881 (15.3) 5,764 (15.3)
Brazil 1,145 (6.1) 1,139 (6.0) 2,284 (6.1)
South Africa 372 (2.0) 372 (2.0) 744 (2.0)
United States 14,460 (76.7) 14,454 (76.7) 28,914 (76.7)
Age group — no. (%)16–55 yr 10,889 (57.7) 10,896 (57.8) 21,785 (57.8)
>55 yr 7,971 (42.3) 7,950 (42.2) 15,921 (42.2)
Age at vaccination — yrMedian 52.0 52.0 52.0
Range 16–89 16–91 16–91
Body-mass index‡≥30.0: obese 6,556 (34.8) 6,662 (35.3) 13,218 (35.1)
* Percentages may not total 100 because of rounding.
† Race or ethnic group was reported by the participants.‡ The body-mass index is the weight in kilograms divided by the square of the height in meters.
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 35
FDA-CBER-2022-5812-0231634
n engl j med nejm.org 6The new england journal of medicine
43,448 participants received injections: 21,720
received BNT162b2 and 21,728 received placebo (Fig. 1). At the data cut-off date of October 9, a total of 37,706 participants had a median of at least 2 months of safety data available after the second dose and contributed to the main safety data set. Among these 37,706 participants, 49% were female, 83% were White, 9% were Black or African American, 28% were Hispanic or Latinx, 35% were obese (body mass index [the weight in kilograms divided by the square of the height in meters] of at least 30.0), and 21% had at least one coexisting condition. The median age was 52 years, and 42% of participants were older than 55 years of age (Table 1 and Table S2).
Safety
Local Reactogenicity
The reactogenicity subset included 8183 partici-pants. Overall, BNT162b2 recipients reported more local reactions than placebo recipients. Among BNT162b2 recipients, mild-to-moderate pain at 83
14
6051
78
12
6
061
71
97
151
66
8 7
17
1
Redness Swelling>55 Yr of Age, Dose 2>55 Yr of Age, Dose 116–55 Yr of Age, Dose 216–55 Yr of Age, Dose 1100
8090
70
60
40
30
1050
20
0ALocal EventsMild Moderate Severe Grade 4Percentage of Participants100
8090
70
60
40
30
1050
20
0
100
8090
70
60
40
30
1050
20
0
Pain at Injection
SiteBNT162b2Placebo
BNT162b2Placebo
BNT162b2PlaceboBNT162b2Placebo
BNT162b2Placebo
BNT162b2PlaceboBNT162b2Placebo
BNT162b2Placebo
BNT162b2PlaceboBNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
100
8090
70
60
40
30
1050
20
0Figure 2. Local and Systemic Reactions Reported
within 7 Days after Injection of BNT162b2 or Placebo,
According to Age Group.
Data on local and systemic reactions and use of medi-
cation were collected with electronic diaries from par-ticipants in the reactogenicity subset (8,183 partici-pants) for 7 days after each vaccination. Solicited injection-site (local) reactions are shown in Panel A. Pain at the injection site was assessed according to the following scale: mild, does not interfere with activ-ity; moderate, interferes with activity; severe, prevents daily activity; and grade 4, emergency department visit or hospitalization. Redness and swelling were mea-sured according to the following scale: mild, 2.0 to 5.0 cm in diameter; moderate, >5.0 to 10.0 cm in di-ameter; severe, >10.0 cm in diameter; and grade 4, necrosis or exfoliative dermatitis (for redness) and ne-crosis (for swelling). Systemic events and medication use are shown in Panel B. Fever categories are desig-nated in the key; medication use was not graded. Ad-ditional scales were as follows: fatigue, headache, chills, new or worsened muscle pain, new or worsened joint pain (mild: does not interfere with activity; mod-erate: some interference with activity; or severe: pre-vents daily activity), vomiting (mild: 1 to 2 times in 24 hours; moderate: >2 times in 24 hours; or severe: requires intravenous hydration), and diarrhea (mild: 2 to 3 loose stools in 24 hours; moderate: 4 to 5 loose stools in 24 hours; or severe: 6 or more loose stools in 24 hours); grade 4 for all events indicated an emer-gency department visit or hospitalization. I bars repre-
sent 95% confidence intervals, and numbers above the I bars are the percentage of participants who re-
ported the specified reaction.
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 36
FDA-CBER-2022-5812-0231635
n engl j med nejm.org 7Safety and Efficacy of the BNT162b2 Vaccine
4142
34
1411 122128
1411 116 61147
33
16
052
2435
1083745
13822
5 4 2 159
23
0 125
18
6 8 71420
128 9630134
23
11
039
1423
862938
10519
4 31 051
17100
8090
70
60
40
30
1050
20
0
BNT162b2Placebo
FeverBNT162b2Placebo
FatigueBNT162b2Placebo
HeadacheBNT162b2Placebo
ChillsBNT162b2Placebo
Vomiting>55 Yr of Age, Dose 2>55 Yr of Age, Dose 116–55 Yr of Age, Dose 216–55 Yr of Age, Dose 1
BNT162b2Placebo
DiarrheaBNT162b2Placebo
Muscle PainBNT162b2Placebo
Joint PainBNT162b2Placebo
Use of antipyretic
medicationBSystemic Events and Use of MedicationMild; temperature 38.0 to 38.4°C Moderate; temperature >38.4 to 38.9°C Severe; temperature >38.9 to 40.0°C Grade 4Percentage of Participants100
8090
70
60
40
30
1050
20
0
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
100
8090
70
60
40
30
1050
20
0
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
100
8090
70
60
40
30
1050
20
0
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
BNT162b2Placebo
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 37
FDA-CBER-2022-5812-0231636
n engl j med nejm.org 8The new england journal of medicine
the injection site within 7 days after an injection
was the most commonly reported local reaction, with less than 1% of participants across all age groups reporting severe pain (Fig. 2). Pain was reported less frequently among participants old-er than 55 years of age (71% reported pain after the first dose; 66% after the second dose) than among younger participants (83% after the first dose; 78% after the second dose). A noticeably lower percentage of participants reported injec-tion-site redness or swelling. The proportion of participants reporting local reactions did not increase after the second dose (Fig. 2A), and no participant reported a grade 4 local reaction. In general, local reactions were mostly mild-to-mod-erate in severity and resolved within 1 to 2 days.
Systemic Reactogenicity
Systemic events were reported more often by younger vaccine recipients (16 to 55 years of age) than by older vaccine recipients (more than 55 years of age) in the reactogenicity subset and more often after dose 2 than dose 1 (Fig. 2B). The most commonly reported systemic events were fatigue and headache (59% and 52%, re-spectively, after the second dose, among younger vaccine recipients; 51% and 39% among older recipients), although fatigue and headache were also reported by many placebo recipients (23% and 24%, respectively, after the second dose, among younger vaccine recipients; 17% and 14% among older recipients). The frequency of any severe systemic event after the first dose was 0.9% or less. Severe systemic events were reported in less than 2% of vaccine recipients after either dose, except for fatigue (in 3.8%) and headache (in 2.0%) after the second dose.
Fever (temperature, ≥38°C) was reported after
the second dose by 16% of younger vaccine re-cipients and by 11% of older recipients. Only 0.2% of vaccine recipients and 0.1% of placebo recipi-ents reported fever (temperature, 38.9 to 40°C) af-ter the first dose, as compared with 0.8% and 0.1%, respectively, after the second dose. Two participants each in the vaccine and placebo groups reported temperatures above 40.0°C. Younger vaccine recipients were more likely to use antipyretic or pain medication (28% after dose 1; 45% after dose 2) than older vaccine re-cipients (20% after dose 1; 38% after dose 2), and placebo recipients were less likely (10 to 14%) than vaccine recipients to use the medications, regardless of age or dose. Systemic events in-cluding fever and chills were observed with the first 1 to 2 days after vaccination and resolved shortly thereafter.
Daily use of the electronic diary ranged from
90 to 93% for each day after the first dose and from 75 to 83% for each day after the second dose. No difference was noted between the BNT162b2 group and the placebo group.
Adverse Events
Adverse event analyses are provided for all en-rolled 43,252 participants, with variable follow-up time after dose 1 (Table S3). More BNT162b2 recipients than placebo recipients reported any adverse event (27% and 12%, respectively) or a related adverse event (21% and 5%). This distri-bution largely reflects the inclusion of transient reactogenicity events, which were reported as adverse events more commonly by vaccine recipi-ents than by placebo recipients. Sixty-four vac-cine recipients (0.3%) and 6 placebo recipients (<0.1%) reported lymphadenopathy. Few partici-pants in either group had severe adverse events, serious adverse events, or adverse events leading to withdrawal from the trial. Four related serious adverse events were reported among BNT162b2 recipients (shoulder injury related to vaccine ad-ministration, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia). Two BNT162b2 recipients died (one from arteriosclerosis, one from cardiac arrest), as did four placebo recipients (two from unknown causes, one from hemorrhagic stroke, and one from myocardial infarction). No deaths were con-sidered by the investigators to be related to the vaccine or placebo. No Covid-19–associated deaths were observed. No stopping rules were met dur-ing the reporting period. Safety monitoring will continue for 2 years after administration of the second dose of vaccine.
Efficacy
Among 36,523 participants who had no evidence of existing or prior SARS-CoV-2 infection, 8 cases of Covid-19 with onset at least 7 days after the second dose were observed among vaccine re-cipients and 162 among placebo recipients. This case split corresponds to 95.0% vaccine efficacy (95% confidence interval [CI], 90.3 to 97.6; Ta-
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 38
FDA-CBER-2022-5812-0231637
n engl j med nejm.org 9Safety and Efficacy of the BNT162b2 Vaccine
ble 2). Among participants with and those with-
out evidence of prior SARS CoV-2 infection, 9 cases of Covid-19 at least 7 days after the second dose were observed among vaccine recipients and 169 among placebo recipients, corresponding to 94.6% vaccine efficacy (95% CI, 89.9 to 97.3). Supple-mental analyses indicated that vaccine efficacy among subgroups defined by age, sex, race, eth-nicity, obesity, and presence of a coexisting condi-tion was generally consistent with that observed in the overall population (Table 3 and Table S4). Vaccine efficacy among participants with hyper-tension was analyzed separately but was consis-tent with the other subgroup analyses (vaccine efficacy, 94.6%; 95% CI, 68.7 to 99.9; case split: BNT162b2, 2 cases; placebo, 44 cases). Figure 3 shows cases of Covid-19 or severe Covid-19 with onset at any time after the first dose (mITT popu-lation) (additional data on severe Covid-19 are available in Table S5). Between the first dose and the second dose, 39 cases in the BNT162b2 group and 82 cases in the placebo group were observed, resulting in a vaccine efficacy of 52% (95% CI, 29.5 to 68.4) during this interval and indicating early protection by the vaccine, starting as soon as 12 days after the first dose.Discussion
A two-dose regimen of BNT162b2 (30 μg per dose, given 21 days apart) was found to be safe and 95% effective against Covid-19. The vaccine met both primary efficacy end points, with more than a 99.99% probability of a true vaccine ef-ficacy greater than 30%. These results met our prespecified success criteria, which were to es-tablish a probability above 98.6% of true vaccine efficacy being greater than 30%, and greatly exceeded the minimum FDA criteria for authori-zation.
9 Although the study was not powered to
definitively assess efficacy by subgroup, the point estimates of efficacy for subgroups based on age, sex, race, ethnicity, body-mass index, or the presence of an underlying condition associ-ated with a high risk of Covid-19 complications are also high. For all analyzed subgroups in which more than 10 cases of Covid-19 occurred, the lower limit of the 95% confidence interval for efficacy was more than 30%.
The cumulative incidence of Covid-19 cases
over time among placebo and vaccine recipients begins to diverge by 12 days after the first dose, 7 days after the estimated median viral incuba-Table 2. Vaccine Efficacy against Covid-19 at Least 7 days after the Second Dose.*
Efficacy End Point BNT162b2 PlaceboVaccine Efficacy, %
(95% Credible
Interval)‡Posterior
Probability
(Vaccine Efficacy
>30%)§
No. of
CasesSurveillance
Time (n)†No. of
CasesSurveillance
Time (n)†
(N=18,198) (N=18,325)
Covid-19 occurrence at least
7 days after the second
dose in participants with-out evidence of infection8 2.214 (1,7411) 162 2.222 (17,511) 95.0 (90.3–97.6) >0.9999
(N=19,965) (N=20,172)
Covid-19 occurrence at least
7 days after the second dose in participants with and those without evidence of infection9 2.332 (18,559) 169 2.345 (18,708) 94.6 (89.9–97.3) >0.9999
* The total population without baseline infection was 36,523; total population including those with and those without prior evidence of infec-
tion was 40,137.
† The surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the
end point. The time period for Covid-19 case accrual is from 7 days after the second dose to the end of the surveillance period.
‡ The credible interval for vaccine efficacy was calculated with the use of a beta-binomial model with prior beta (0.700102, 1) adjusted for the
surveillance time.
§ Posterior probability was calculated with the use of a beta-binomial model with prior beta (0.700102, 1) adjusted for the surveillance time.
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 39
FDA-CBER-2022-5812-0231638
n engl j med nejm.org 10The new england journal of medicine
tion period of 5 days,10 indicating the early onset
of a partially protective effect of immunization.
The study was not designed to assess the efficacy of a single-dose regimen. Nevertheless, in the interval between the first and second doses, the observed vaccine efficacy against Covid-19 was 52%, and in the first 7 days after dose 2, it was 91%, reaching full efficacy against disease with onset at least 7 days after dose 2. Of the 10 cases of severe Covid-19 that were observed after the first dose, only 1 occurred in the vaccine group. This finding is consistent with overall high ef-ficacy against all Covid-19 cases. The severe case split provides preliminary evidence of vaccine-mediated protection against severe disease, al-leviating many of the theoretical concerns over vaccine-mediated disease enhancement.
11The favorable safety profile observed during
phase 1 testing of BNT162b24,8 was confirmed in
the phase 2/3 portion of the trial. As in phase 1, reactogenicity was generally mild or moderate, and reactions were less common and milder in older adults than in younger adults. Systemic reactogenicity was more common and severe after the second dose than after the first dose, although local reactogenicity was similar after the two doses. Severe fatigue was observed in approximately 4% of BNT162b2 recipients, which is higher than that observed in recipients of some vaccines recommended for older adults.
12
This rate of severe fatigue is also lower than that observed in recipients of another approved viral vaccine for older adults.
13 Overall, reactogenicity
events were transient and resolved within a couple Table 3. Vaccine Efficacy Overall and by Subgroup in Participants without Evidence of Infection before 7 Days after Dose 2.
Efficacy End-Point
SubgroupBNT162b2
(N=18,198)Placebo
(N=18,325)Vaccine Efficacy, %
(95% CI)†
No. of
CasesSurveillance
Time
(No. at Risk)*No. of
CasesSurveillance
Time
(No. at Risk)*
Overall 8 2.214 (17,411) 162 2.222 (17,511) 95.0 (90.0–97.9)
Age group
16 to 55 yr 5 1.234 (9,897) 114 1.239 (9,955) 95.6 (89.4–98.6)
>55 yr 3 0.980 (7,500) 48 0.983 (7,543) 93.7 (80.6–98.8)
≥65 yr 1 0.508 (3,848) 19 0.511 (3,880) 94.7 (66.7–99.9)
≥75 yr 0 0.102 (774) 5 0.106 (785) 100.0 (−13.1–100.0)
Sex
Male 3 1.124 (8,875) 81 1.108 (8762) 96.4 (88.9–99.3)
Female 5 1.090 (8,536) 81 1.114 (8,749) 93.7 (84.7–98.0)
Race or ethnic group‡
White 7 1.889 (14,504) 146 1.903 (14,670) 95.2 (89.8–98.1)
Black or African American 0 0.165 (1,502) 7 0.164 (1,486) 100.0 (31.2–100.0)
All others 1 0.160 (1,405) 9 0.155 (1,355) 89.3 (22.6–99.8)
Hispanic or Latinx 3 0.605 (4,764) 53 0.600 (4,746) 94.4 (82.7–98.9)
Non-Hispanic, non-Latinx 5 1.596 (12,548) 109 1.608 (12,661) 95.4 (88.9–98.5)
Country
Argentina 1 0.351 (2,545) 35 0.346 (2,521) 97.2 (83.3–99.9)
Brazil 1 0.119 (1,129) 8 0.117 (1,121) 87.7 (8.1–99.7)
United States 6 1.732 (13,359) 119 1.747 (13,506) 94.9 (88.6–98.2)
* Surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the end
point. The time period for Covid-19 case accrual is from 7 days after the second dose to the end of the surveillance period.
† The confidence interval (CI) for vaccine efficacy is derived according to the Clopper–Pearson method, adjusted for surveillance time.
‡ Race or ethnic group was reported by the participants. “All others” included the following categories: American Indian or Alaska Native,
Asian, Native Hawaiian or other Pacific Islander, multiracial, and not reported.
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 40
FDA-CBER-2022-5812-0231639
n engl j med nejm.org 11Safety and Efficacy of the BNT162b2 Vaccine
of days after onset. Lymphadenopathy, which
generally resolved within 10 days, is likely to have resulted from a robust vaccine-elicited im-mune response. The incidence of serious adverse events was similar in the vaccine and placebo groups (0.6% and 0.5%, respectively).
This trial and its preliminary report have
several limitations. With approximately 19,000 participants per group in the subset of partici-pants with a median follow-up time of 2 months after the second dose, the study has more than 83% probability of detecting at least one adverse event, if the true incidence is 0.01%, but it is not large enough to detect less common adverse events reliably. This report includes 2 months of follow-up after the second dose of vaccine for half the trial participants and up to 14 weeks’ maximum follow-up for a smaller subset. Therefore, both Figure 3. Efficacy of BNT162b2 against Covid-19 after the First Dose.
Shown is the cumulative incidence of Covid-19 after the first dose (modified intention-to-treat population). Each
symbol represents Covid-19 cases starting on a given day; filled symbols represent severe Covid-19 cases. Some
symbols represent more than one case, owing to overlapping dates. The inset shows the same data on an enlarged y axis, through 21 days. Surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the end point. The time period for Covid-19 case accrual is from the first dose to the end of the surveillance period. The confidence interval (CI) for vaccine efficacy (VE) is derived accord-ing to the Clopper–Pearson method.
Cumulative Incidence (%)2.4
1.62.0
1.2
0.8
0.4
0.0
0 119 112 105 98 91 84 77 70 63 56 42 28 49 35 21 14 7
Days after Dose 1
BNT162b2, 30 μg (N=21,669) Efficacy End-Point Subgroup Placebo (N=21,686) VE (95% CI)BNT162b2Placebo
percent person-yr (no. at risk)
Covid-19 occurrence
After dose 1
After dose 1 to before dose 2Dose 2 to 7 days after dose 2≥7 Days after dose 25039
29275
82
21
172Surveillance time No. of participants
4.015 (21,314)person-yr (no. at risk)Surveillance time No. of participants
3.982 (21,258) 82.0 (75.6–86.9)
52.4 (29.5–68.4)90.5 (61.0–98.9)94.8 (89.8–97.6)0.5
0.4
0.3
0.2
0.1
0.0
0 18 12 21 15 9 6 3
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 41
FDA-CBER-2022-5812-0231640
n engl j med nejm.org 12The new england journal of medicine
the occurrence of adverse events more than 2 to
3.5 months after the second dose and more comprehensive information on the duration of protection remain to be determined. Although the study was designed to follow participants for safety and efficacy for 2 years after the second dose, given the high vaccine efficacy, ethical and practical barriers prevent following placebo re-cipients for 2 years without offering active im-munization, once the vaccine is approved by regulators and recommended by public health authorities. Assessment of long-term safety and efficacy for this vaccine will occur, but it cannot be in the context of maintaining a placebo group for the planned follow-up period of 2 years after the second dose. These data do not address whether vaccination prevents asymptomatic in-fection; a serologic end point that can detect a history of infection regardless of whether symp-toms were present (SARS-CoV-2 N-binding anti-body) will be reported later. Furthermore, given the high vaccine efficacy and the low number of vaccine breakthrough cases, potential establish-ment of a correlate of protection has not been feasible at the time of this report.
This report does not address the prevention
of Covid-19 in other populations, such as young-er adolescents, children, and pregnant women. Safety and immune response data from this trial after immunization of adolescents 12 to 15 years of age will be reported subsequently, and addi-tional studies are planned to evaluate BNT162b2 in pregnant women, children younger than 12 years, and those in special risk groups, such as immunocompromised persons. Although the vaccine can be stored for up to 5 days at stan-dard refrigerator temperatures once ready for use, very cold temperatures are required for shipping and longer storage. The current cold storage re-quirement may be alleviated by ongoing stability studies and formulation optimization, which may also be described in subsequent reports.
The data presented in this report have sig-
nificance beyond the performance of this vac-cine candidate. The results demonstrate that Covid-19 can be prevented by immunization, provide proof of concept that RNA-based vac-cines are a promising new approach for protect-ing humans against infectious diseases, and demonstrate the speed with which an RNA-based vaccine can be developed with a sufficient investment of resources. The development of BNT162b2 was initiated on January 10, 2020, when the SARS-CoV-2 genetic sequence was re-leased by the Chinese Center for Disease Control and Prevention and disseminated globally by the GISAID (Global Initiative on Sharing All Influ-enza Data) initiative. This rigorous demonstration of safety and efficacy less than 11 months later provides a practical demonstration that RNA-based vaccines, which require only viral genetic sequence information to initiate development, are a major new tool to combat pandemics and other infec-tious disease outbreaks. The continuous phase 1/2/3 trial design may provide a model to reduce the protracted development timelines that have delayed the availability of vaccines against other infectious diseases of medical importance. In the context of the current, still expanding pan-demic, the BNT162b2 vaccine, if approved, can contribute, together with other public health mea-sures, to reducing the devastating loss of health, life, and economic and social well-being that has resulted from the global spread of Covid-19.
Supported by BioNTech and Pfizer.Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
A data sharing statement provided by the authors is available
with the full text of this article at NEJM.org.
We thank all the participants who volunteered for this study;
and the members of the C4591001 data and safety monitoring board for their dedication and their diligent review of the data. We also acknowledge the contributions of the C4591001 Clinical Trial Group (see the Supplementary Appendix); Tricia Newell and Emily Stackpole (ICON, North Wales, PA) for editorial sup-port funded by Pfizer; and the following Pfizer staff: Greg Ad-ams, Negar Aliabadi, Mohanish Anand, Fred Angulo, Ayman Ayoub, Melissa Bishop-Murphy, Mark Boaz, Christopher Bowen, Salim Bouguermouh, Donna Boyce, Sarah Burden, Andrea Ca-wein, Patrick Caubel, Darren Cowen, Kimberly Ann Cristall, Michael Cruz, Daniel Curcio, Gabriela Dávila, Carmel Devlin, Gokhan Duman, Niesha Foster, Maja Gacic, Luis Jodar, Stephen Kay, William Lam, Esther Ladipo, Joaquina Maria Lazaro, Marie-Pierre Hellio Le Graverand-Gastineau, Jacqueline Lowenberg, Rod MacKenzie, Robert Maroko, Jason McKinley, Tracey Melle-lieu, Farheen Muzaffar, Brendan O’Neill, Jason Painter, Eliza-beth Paulukonis, Allison Pfeffer, Katie Puig, Kimberly Rarrick, Balaji Prabu Raja, Christine Rainey, Kellie Lynn Richardson, Elizabeth Rogers, Melinda Rottas, Charulata Sabharwal, Vilas Satishchandran, Harpreet Seehra, Judy Sewards, Helen Smith, David Swerdlow, Elisa Harkins Tull, Sarah Tweedy, Erica Weaver, John Wegner, Jenah West, Christopher Webber, David C. Whrit-enour, Fae Wooding, Emily Worobetz, Xia Xu, Nita Zalavadia, Liping Zhang, the Vaccines Clinical Assay Team, the Vaccines Assay Development Team, and all the Pfizer colleagues not named here who contributed to the success of this trial. We also acknowledge the contributions of the following staff at BioNTech: Corinna Rosenbaum, Christian Miculka, Andreas Kuhn, Ferdia Bates, Paul Strecker, Ruben Rizzi, Martin Bexon, Eleni Lagkadinou, and Alexandra Kemmer-Brück; and the fol-lowing staff at Polymun: Dietmar Katinger and Andreas Wagner.
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 42
FDA-CBER-2022-5812-0231641
n engl j med nejm.org 13Safety and Efficacy of the BNT162b2 Vaccine
Appendix
The authors’ affiliations are as follows: Fundacion INFANT (F.P.P.) and iTrials-Hospital Militar Central (G.P M.), Buenos Aires; State
University of New York, Upstate Medical University, Syracuse (S.J.T.), and Vaccine Research and Development, Pfizer, Pearl River (J.A.,
A.G., K.A.S., K.K., W.V.K., D.C., P.R.D., K.U.J., W.C.G.) — both in New York; Vaccine Research and Development, Pfizer, Hurley,
United Kingdom (N.K., S.L., R.B.); Vaccine Research and Development (J.L.P., P.L.) and Worldwide Safety, Safety Surveillance and Risk Management (S M.), Pfizer, Collegeville, PA; Associação Obras Sociais Irmã Dulce and Oswaldo Cruz Foundation, Bahia (E.D M.), and Centro Paulista de Investigação Clinica, São Paulo (C.Z.) — both in Brazil; Global Product Development, Pfizer, Peapack, NJ (S.R.); Cincinnati Children’s Hospital, Cincinnati (R.W.F.); Johns Hopkins Bloomberg School of Public Health, Baltimore (L.L.H.); BioNTech, Mainz (ÖT., U.Ş.), and Medizentrum Essen Borbeck, Essen (A.S.) — both in Germany; Tiervlei Trial Centre, Karl Bremer Hospital, Cape
Town, South Africa (H.N.); Hacettepe University, Ankara, Turkey (S.Ü.); and Worldwide Safety, Safety Surveillance and Risk Manage-ment, Pfizer, Groton, CT (D.B.T.).
References
1.Johns Hopkins University Coronavi-
rus Resource Center. COVID-19 dash-board by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 2020 (https://coronavirus . jhu
. edu/ map . html).
2.World Health Organization. WHO
Director-General’s opening remarks at
the media briefing on COVID-19 —
11 March 2020 (https://www . who . int/
director - general/ speeches/ detail/ who
- director - general - s - opening - remarks - at
- the - media - briefing - on - covid - 19 - - - 11
- march - 2020).
3.Centers for Disease Control and Pre-
vention. COVID-19 information page
(https://www . cdc . gov/ coronavirus/ 2019
- ncov/ index . html).
4.Walsh EE, Frenck RW Jr, Falsey AR, et
al. Safety and immunogenicity of two RNA-
based Covid-19 vaccine candidates. N Engl J Med. DOI: 10.1056/NEJMoa2027906.5.Pardi N, Tuyishime S, Muramatsu H,
et al. Expression kinetics of nucleoside-modified mRNA delivered in lipid nanopar-ticles to mice by various routes. J Control Release 2015; 217: 345-51.
6.Karikó K, Muramatsu H, Welsh FA, et
al. Incorporation of pseudouridine into mRNA yields superior nonimmunogenic vector with increased translational capaci-ty and biological stability. Mol Ther 2008; 16: 1833-40.
7.Wrapp D, Wang N, Corbett KS, et al.
Cryo-EM structure of the 2019-nCoV spike in the prefusion conformation. Science 2020; 367: 1260-3.
8.Sahin U, Muik A, Derhovanessian E,
et al. BNT162b2 elicits SARS-CoV-2 neu-tralising antibodies and TH1 T cells in humans. preprint.
9. Food and Drug Administration. Guid-
ance for industry: emergency use authori-
zation for vaccines to prevent COVID-19. October 2020 (https://www . fda . gov/ media/
142749/ download).
10. Lauer SA, Grantz KH, Bi Q, et al. The
incubation period of coronavirus disease
2019 (COVID-19) from publicly reported confirmed cases: estimation and appli-cation. Ann Intern Med 2020; 172: 577-82.
11.Haynes BF, Corey L, Fernandes P, et
al. Prospects for a safe COVID-19 vac-cine. Sci Transl Med 2020; 12(568):
eabe0948.
12. Cowling BJ, Perera RAPM, Valkenburg
SA, et al. Comparative immunogenicity of several enhanced influenza vaccine options for older adults: a randomized, controlled trial. Clin Infect Dis 2020; 71: 1704-14.
13. Food and Drug Administration.
Shringrix (zoster vaccine recombinant, adjuvanted) product information. 2019 (https://www . fda . gov/ vaccines - blood
- biologics/ vaccines/ shingrix).
Copyright © 2020 Massachusetts Medical Society.
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
090177e195d05d30\Final\Final On: 16-Dec-2020 20:21 (GMT)
Page 43
FDA-CBER-2022-5812-0231642
090177e1964a7725\Final\Final On: 16-Feb-2021 01:00 (GMT)
Page 44
FDA-CBER-2022-5812-0231643
090177e1964a7725\Final\Final On: 16-Feb-2021 01:00 (GMT)
Page 45
FDA-CBER-2022-5812-0231644
090177e1964a7725\Final\Final On: 16-Feb-2021 01:00 (GMT)
Page 46
FDA-CBER-2022-5812-0231645
090177e1964a7725\Final\Final On: 16-Feb-2021 01:00 (GMT)
Page 47
FDA-CBER-2022-5812-0231646
090177e1964a7725\Final\Final On: 16-Feb-2021 01:00 (GMT)
Page 48
FDA-CBER-2022-5812-0231647
090177e1964a7725\Final\Final On: 16-Feb-2021 01:00 (GMT)
Page 49
FDA-CBER-2022-5812-0231648
CorrespondenceThe new england journal of medicine
n engl j med nejm.org 1Neutralizing Activity of BNT162b2-Elicited Serum
To the Editor: BNT162b2 is a nucleoside-modi-
fied RNA vaccine expressing the full-length pre-fusion spike glycoprotein (S) of severe acute re-spiratory syndrome coronavirus 2 (SARS-CoV-2). In a randomized, placebo-controlled clinical trial involving approximately 44,000 participants, im-munization conferred 95% efficacy against coro-navirus disease 2019 (Covid-19).
1
New, highly transmissible SARS-CoV-2 variants
that were first detected in the United Kingdom (B.1.1.7 lineage), South Africa (B.1.351 lineage), and Brazil (P.1 lineage) with mutations in the S gene
are spreading globally. To analyze effects on neu-tralization elicited by BNT162b2, we engineered S mutations from each of the three new lineages
into USA-WA1/2020, a relatively early isolate of the virus from January 2020 (Fig. S1 in the Sup-plementary Appendix, available with the full text of this letter at NEJM.org). We thereby produced three recombinant viruses representing each of these lineages and two additional ones in which we engineered subsets of mutations of the B.1.351 lineage. Thus, the first recombinant virus had all the mutations found in the S gene in the B.1.1.7
lineage (B.1.1.7-spike), the second had all the mutations found in the S gene in the P.1 lineage
(P.1-spike), the third had all the mutations found in the S gene in the B.1.351 lineage (B.1.351-spike),
the fourth had an N-terminal domain deletion found in the B.1.351 lineage and the globally dominant D614G substitution (B.1.351-Δ242-244+D614G), and the fifth had the three muta-tions from the B.1.351 lineage affecting amino acids in the receptor-binding site (K417N, E484K, and N501Y) and a D614G substitution (B.1.351-RBD+D614G). The mutant amino acid residues in the B.1.351-RBD+D614G recombinant virus are also among those in the P.1 lineage virus, al-though in the P.1 lineage virus, K417 is mutated to threonine rather than asparagine. All the mu-tant viruses yielded infectious viral titers exceed-ing 10
7 plaque-forming units per milliliter. The
B.1.1.7-spike and B.1.351-spike viruses formed plaques that were smaller than those formed by the other viruses (Fig. S2).
We performed 50% plaque reduction neutral-
ization testing (PRNT
50) using 20 serum samples
that had been obtained from 15 participants in the pivotal trial
1,2 2 or 4 weeks after the administra-
tion of the second dose of 30 μg of BNT162b2 (which occurred 3 weeks after the first immuni-zation) (Fig. S3). All the serum samples efficient-ly neutralized USA-WA1/2020 and all the viruses with variant spikes. Almost all of them did so at titers higher than 1:40. Geometric mean neutral-izing titers against USA-WA1/2020, B.1.1.7-spike, P.1-spike, B.1.351-spike, B.1.351-Δ242-244+D614G, and B.1.351-RBD+D614G viruses were 532, 663, 437, 194, 485, and 331, respectively (Fig. 1 and Table S1). Thus, as compared with neutralization of USA-WA1/2020, neutralization of B.1.1.7-spike and P.1-spike viruses was roughly equivalent, and neutralization of B.1.351-spike virus was robust but lower. Our data are also consistent with lower neutralization titers against the virus with the full set of B.1.351-spike mutations than against virus with either subset of mutations. Our findings also suggest that mutations that result in amino acid substitutions K417N, E484K, and N501Y in the receptor-binding site have a greater effect on neutralization than the 242–244 deletion affecting the N-terminal domain of the spike protein.
Limitations of the study include the potential
for mutations to alter neutralization by affecting spike function rather than antigenicity. Therefore, each neutralization assay with a different target virus is unique, and comparisons between neu-tralization titers from different assays should be interpreted with caution. Neutralizing activity against the B.1.351 lineage virus was robust at a geometric mean titer that was much higher than that obtained after one dose of BNT162b2, when strong efficacy was already observed in the C4591001 efficacy trial.
1-3 T-cell immunity may
also be involved in protection,4 and BNT162b2
The New England Journal of Medicine
Copyright © 2021 Massachusetts Medical Society. All rights reserved.
090177e1967884c4\Final\Final On: 09-Mar-2021 16:53 (GMT)
Page 50
FDA-CBER-2022-5812-0231649
The new england journal of medicine
n engl j med nejm.org 2immunization elicits CD8+ T-cell responses that
recognize multiple variants.5 Ultimately, conclu-
sions about vaccine-mediated protection that are extrapolated from neutralization or T-cell data must be validated by real-world evidence collected in regions where the SARS-CoV-2 variants are circulating.
Yang Liu, Ph.D.
Jianying Liu, Ph.D.Hongjie Xia, Ph.D.Xianwen Zhang, B.S.Camila R. Fontes-Garfias, Ph.D.
University of Texas Medical BranchGalveston, TX
Kena A. Swanson, Ph.D.Hui Cai, Ph.D.Ritu Sarkar, M.A.Wei Chen, M.S.Mark Cutler, Ph.D.David Cooper, Ph.D.
Pfizer Vaccine Research and DevelopmentPearl River, NYScott C. Weaver, Ph.D.
University of Texas Medical Branch Galveston, TX
Alexander Muik, Ph.D. Ugur Sahin, M.D.
BioNTech Mainz, Germany
Kathrin U. Jansen, Ph.D.
Pfizer Vaccine Research and Development Pearl River, NY
Xuping Xie, Ph.D.
University of Texas Medical Branch Galveston, TX xuxie@ utmb . edu
Philip R. Dormitzer, M.D., Ph.D.
Pfizer Vaccine Research and Development Pearl River, NY philip . dormitzer@ pfizer . com
Pei-Yong Shi, Ph.D.
University of Texas Medical Branch Galveston, TX peshi@ utmb . edu
Drs. Y. Liu and J. Liu contributed equally to this letter.Figure 1. Serum Neutralization of Variant Strains of SARS-CoV-2 after the Second Dose of BNT162b2 Vaccine.
Shown are the results of 50% plaque reduction neutralization testing (PRNT 50) with the use of 20 samples obtained
from 15 trial participants 2 weeks (circles) or 4 weeks (triangles) after the administration of the second dose of the
BNT162b2 vaccine. The mutant viruses were obtained by engineering the full set of mutations in the B.1.1.7, P.1., or B.1.351 lineage or subsets of the S gene mutations in the B.1.351 lineage (B.1.351-Δ242-244+D614G and B.1.351-
RBD+D614G) into USA-WA1/2020. Each data point represents the geometric mean PRNT
50 obtained with a serum
sample against the indicated virus, including data from repeat experiments, as detailed in Table S1 in the Supple-mentary Appendix. The data for USA-WA1/2020 are from three experiments; for B.1.1.7-spike, B.1.351-Δ242-
244+D614G, and B.1.351-RBD-D614G viruses from one experiment each; and for P.1-spike and B.1.351-spike viruses
from two experiments each. In each experiment, the neutralization titer was determined in duplicate assays, and the geometric mean was taken. The heights of bars and the numbers over the bars indicate geometric mean titers. The I bars indicate 95% confidence intervals. Statistical analysis was performed with the use of the Wilcoxon signed-rank test. The statistical significance of the difference between geometric mean titers in the USA-WA1/2020 neutral-ization assay and in each variant virus neutralization assay with the same serum samples are as follows: P = 0.02 for B.1.1.7-spike; P = 0.06 for P.1-spike; P<0.001 for B.1.351-spike; P = 0.99 for B.1.351-Δ242-244+D614G; and P = 0.005 for
B.1.351-RBD+D614G. LOD denotes limit of detection.PRNT50 (log2)1280
320640
160
80
40
20
USA-WA1/2020 B.1.1.7-Spike P.1-Spike B.1.351-Spike B.1.351-Δ242-244
+D614GB.1.351-RBD
+D614G532 663
437485 331
194
LOD
The New England Journal of Medicine
Copyright © 2021 Massachusetts Medical Society. All rights reserved.
090177e1967884c4\Final\Final On: 09-Mar-2021 16:53 (GMT)
Page 51
FDA-CBER-2022-5812-0231650
Correspondence
n engl j med nejm.org 3Supported by Pfizer and BioNTech.
Disclosure forms provided by the authors are available with
the full text of this letter at NEJM.org.
A preliminary version of this letter was published on February 17,
2021, and was updated on March 8, 2021, at NEJM.org.
1.Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of
the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med 2020;383:2603-15.
2.Walsh EE, Frenck RW Jr, Falsey AR, et al. Safety and immuno-
genicity of two RNA-based Covid-19 vaccine candidates. N Engl J Med 2020;383:2439-50.
3.Sahin U, Muik A, Vogler I, et al. BNT162b2 induces SARS-CoV-2-neutralising antibodies and T cells in humans. December 11, 2020 (https://www . medrxiv . org/ content/ 10 . 1101/ 2020 . 12 . 09
. 20245175v1). preprint.
4.Liao M, Liu Y, Yuan J, et al. Single-cell landscape of bron-
choalveolar immune cells in patients with COVID-19. Nat Med
2020;26:842-4.
5.Skelly DT, Harding AC, Gilbert-Jaramillo J, et al. Vaccine-
induced immunity provides more robust heterotypic immunity than natural infection to emerging SARS-CoV-2 variants of con-cern. February 9, 2021 (https://www.researchsquare.com/article/rs-226857/v1). preprint.
DOI: 10.1056/NEJMc2102017
Correspondence Copyright © 2021 Massachusetts Medical Society.
The New England Journal of Medicine
Copyright © 2021 Massachusetts Medical Society. All rights reserved.
090177e1967884c4\Final\Final On: 09-Mar-2021 16:53 (GMT)
Page 52
FDA-CBER-2022-5812-0231651