The Food and Drug Administration’s Committee of Independent Expert Advisors on Thursday voted largely in favor of the agency’s approval of Pfizer’s vaccine to protect babies against the common respiratory virus RSV, a respiratory syncytial (sin-SISH-uhl) virus that can be fatal. for babes
The vaccine, tentatively called Abrysvo, is given to pregnant women between 24 and 36 weeks of gestation, allowing protective antibodies to be produced and then cross the placenta to protect the fetus.
In a phase III trial involving nearly 7,400 pregnant women in 18 countries, the vaccine was nearly 82 percent effective in preventing severe RSV in the first 90 days of a child’s life. After 180 days, the effectiveness was 69 percent. In terms of protection against mild respiratory illness caused by RSV, the trial results did not meet the statistical criteria for efficacy at 90 days, but data at 180 days suggests an efficacy of about 51 percent.
In the first of two votes at today’s one-day meeting, FDA advisers voted unanimously 14 to 0 that the efficacy data looked good and suggested the vaccine would protect babies from RSV.
But the security data that was the focus of the second vote got some members thinking. Although the vaccine appeared to be largely safe in pregnant women and infants compared with placebo, data from the phase II and phase III trials contained a weak signal suggesting that vaccination may increase the risk of preterm birth. In the phase III study, there were 201 preterm infants (before 37 weeks) in the vaccination group, while only 169 preterm infants were in the placebo group. Among these early births, 21 in the vaccination group were early preterm births (before 34 weeks), while there were only 12 early preterm births in the placebo group.
Overall, the differences were not statistically significant, and rates of prematurity were lower than those typically seen in the general population. But, as several FDA consultants noted, the phase III trial did not address this signal, even though it had been observed in the earlier phase II trial. There was also an imbalance in where the signal was visible; Pfizer representatives stressed that there was no difference in preterm birth rates among trial participants in high-income countries, including the US.
Anxiety, but mostly excitement
This burst of data alone may not have been enough to raise concerns. But it worried some consultants, who noted that GSK, another pharmaceutical giant, had developed its own RSV vaccine and was facing the same signal. GSK had a vaccine with a similar design and dose that was similarly administered to pregnant women at the same interval of 24 to 36 weeks of gestation. During the Phase III study, GSK found a statistically significant increase in preterm births. and company refused to judge because of this.
When a pharmaceutical company refuses to test, it’s a big deal, Dr. White. Paul Offit, professor of pediatrics at the Children’s Hospital of Philadelphia, noted in the discussion section of the meeting. “These decisions are never taken lightly,” Offit said.
When the vote came over whether the vaccine safety data were adequate, the results came in 10 to 4, with Ofit among the four who voted no. After the vote, he reiterated that the data provided by Pfizer did not reflect his concerns about GSK’s findings. “If you are in any sense risking preterm birth with this vaccine, I think you will have to pay a heavy price,” he warned.
But most of the panel were less concerned about the uncertainty of the preterm signal, and some expected it to be a statistical anomaly that would disappear as the vaccine was given to more babies. Some members also noted that test data on birth weight and similar rates of developmental delay are reassuring that the vaccine is safe. Pfizer has introduced a post-registration surveillance system to try to track such results.
Overall, many consultants were enthusiastic about the potential of the vaccine. The effectiveness is “very exciting,” said Amanda Cohn, director of the Division of Birth Defects and Childhood Disorders at the Centers for Disease Control and Prevention, voting “yes” on both effectiveness and safety issues. It is “a really important tool for prevention, [I’m] very excited.”
In the US, RSV is one of the leading causes of hospitalization for children under 5 years of age. The CDC estimates that during a typical RSV season, the virus sends 58,000 to 80,000 children under the age of 5 to the hospital, and 100 to 300 die from the infection.
The FDA will now decide whether to approve the vaccine. If it does, the CDC will make recommendations for its use in the US.