Grading of Recommendations, Assessment, Development, and Evaluation (GRADE): Use of JYNNEOS® (orthopoxvirus) vaccine booster (Policy Questions 3 and 4)

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CDC vaccine recommendations are developed using an explicit evidence-based method based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Table 1.1: Policy Question 3 and PICO

Policy question: Should persons who are at continued risk for occupational exposure to more virulent orthopoxviruses such as variola virus or monkeypox virus receive a booster dose of JYNNEOS® every two years after the primary JYNNEOS® series?
Population Persons who are at risk for occupational exposure to variola virus or monkeypox virus
Intervention Booster with JYNNEOS® 2 years after primary series
Comparison No vaccine booster after JYNNEOS® primary series
Outcomes
  1. Prevention of disease
  2. Severity of disease
  3. Serious adverse events
  4. Myo-/ peri- carditis

Table 1.2: Policy Question 4 and PICO

Policy question: Should persons who are at continued risk for occupational exposure to replication-competent orthopoxviruses like vaccinia virus or cowpox virus receive a booster dose of JYNNEOS® at least every 10 years after the primary JYNNEOS® series?
Population Persons who are at risk for occupational exposure to replication competent orthopoxviruses like vaccinia virus or cowpox virus
Intervention Booster with JYNNEOS® at least every 10 years
Comparison No vaccine booster after JYNNEOS® primary series
Outcomes
  1. Prevention of disease
  2. Severity of disease
  3. Serious adverse events
  4. Myo-/ peri- carditis

Table 2: Outcomes and Rankings

Outcome Importance* Included in evidence profile
Prevention of disease Critical Yes
Severity of disease Critical Yes
Serious adverse events** Critical Yes
Myo-/ peri- carditis Important Yes
Minor adverse events Not important No

*Three options: 1. Critical; 2. Important but not critical; 3. Not important for decision making

**Serious adverse events were defined according to the standard FDA definition. In addition, data was collected about any smallpox vaccine-specific adverse event: postvaccinial encephalitis, eczema vaccinatum, progressive vaccinia, and generalized vaccinia.

Appendix 1: Studies Included in the Review of Evidence

Last name first author, Publication year Study design Country (or more detail, if needed) Age (measure central tendency – mean/SD; median/IQR; range) Total population N Intervention N comparison Outcomes Funding source
RCT data
NCT02038881
Overton3
Overton et al. 2020
Phase II, Randomized, Open-label USA Mean 35
SD 6.7
87 31 27 Safety and immunogenicity in HIV+ patients Bavarian Nordic
Observational data for the intervention
NCT00686582
Von Sonnenburg 3
Phase II, non-randomized, open-label Germany Mean 34.6
SD 10.2
304 92 NA Safety and immunogenicity Bavarian Nordic
Observational data for the comparison
VRC 201
Parrino1
Parrino 2007
Phase I/Ib randomized, placebo controlled, double-blinded trial USA Mean and
SD NR,
adults
77 NA 19 Immunogenicity, safety, Dryvax challenge, cell mediated/humoral immune responses NIAID
NCT00437021
Frey 2
Frey et al. 2013
Troy et al. 2015
Phase II, Double-blind, Randomized, Dose-finding Study USA Mean 24.7
SD 4.2
208 NA 67 Safety and immunogenicity NIAID
NCT01668537
Greenburg4
2014
Phase II, Randomized, Double-blind, Multicenter USA Mean 27.7
SD 6.28
651 NA 327 Safety and immunogenicity Bavarian Nordic
NCT00879762
Frey3
Troy et al. 2015
Frey et al. 2014
Phase II, randomized, double blinded USA Mean 26.5
SD NR
91 NA 45 Safety and immunogenicity NIAID
NCT00316602
Greenburg2
Greenberg 2015
Phase II, non-randomized, open-label USA and Mexico Mean 27.7
SD 6.11
632 NA 632 Safety and immunogenicity in people with atopic dermatitis NIAID and Bavarian Nordic
NCT00914732
Frey4
Troy et al. 2015
Frey et al. 2015
Phase II, randomized, triple blinded USA Mean 27.2
SD 4.6
523 NA 167 Safety and immunogenicity NIAID and Bavarian Nordic
NCT00189904
Greenburg1
Greenberg et al. 2013
Phase I/II, non-randomized, open-label USA Mean 37.9
SD NR
151 NA 60 Safety and immunogenicity in HIV positive patients NIAID
NCT01144637
Overton2
Overton et al. 2018
Randomized, Double-Blind, Placebo-Controlled Phase III Trial USA Mean 27.7
SD 6.3
4005 NA 4005 immunogenicity, safety, and tolerability Bavarian Nordic and BARDA
NCT00189917
von Sonnenburg2
Darsow et al. 2016
Von Sonnenburg et al. 2014
Open-label, Controlled Phase I Pilot Study Germany Mean NR
SD NR
60 NA 60 Safety and immunogenicity NIAID and Bavarian Nordic
NCT00133575
Seaman/Wilck
Seaman et al. 2010
Wilck et al. 2010
Phase I/II, randomized, double blinded, placebo-controlled USA Mean 25.2, SD=3.7 72 NA 10 Safety and immunogenicity and surrogate efficacy (Dryvax challenge) NIAID
NCT01913353
Pittman
Pittman 2019
Phase 3, open-label,
randomized clinical trial
U.S. military, stationed in Korea Mean 23.5
SD 4.67
433 NA 220 Immunogenicity,
Surrogate efficacy (ACAM2000 challenge),
Adverse events
Bavarian Nordic, US Army Medical Research Institute of Infectious Diseases
NCT01827371
Frey5
Anderson et al. 2020
Jackson et al. 2017
Phase II, Randomized, Open-Label USA Mean 27.4
SD 5.3
435 NA 115 Safety and immunogenicity NIAID
NCT00082446
Frey1
Frey 2007
Sano 2009
Phase I, randomized, partially blinded,
placebo controlled clinical trial
USA Mean 24.8
SD 3.8
90 NA 30 Immunogenicity, Cell-mediated immunity, Surrogate efficacy (Dryvax challenge),
Adverse events
NIAID
NCT00316589
Overton1
Overton et al. 2015
Phase II, Multicenter, Open-label, Controlled USA Mean 37.5
SD 8.0
579 NA 439 Safety and immunogenicity HHS and NIAID
NCT00189959
Pokorny
Von Kremplehuber et al. 2010
Phase II, Double-blind, randomized, Dose-finding Study Switzerland Mean 23.3
SD 3.0
165 NA 55 Safety and immunogenicity NIAID and Bavarian Nordic
Vollmar
Vollmar et al. 2005
Phase 1, randomized, double-blinded and open-label Germany Mean 32.8 68 NA 16 Safety and immunogenicity Bavarian Nordic

Table 3a: Summary of Studies Reporting Outcome A – Prevention of Disease

Authors last name, pub year Age or other characteristic of importance N intervention N comparison Comparator vaccine Absolute difference/effect estimate Study limitations (Risk of Bias)
RCT data
NCT00316589
Overton3
Overton et al. 2015
Age: Mean 35
SD 6.7
HIV positive vaccinia naïve adults
31 27 No vaccine booster after MVA-BN primary series Geometric mean titer:
Mean 3.56 titer units more (1.84 more to 6.89 more)
Seroconversion rate: RR = 1.00 (0.94 to 1.06); 0 fewer per 1,000 (from 60 fewer to 60 more)
Serious risk of bias due to high attrition rate in the per protocol population
Observational data for the intervention
NCT00686582
Von Sonnenburg 3
Mean 34.6
SD 10.2
Healthy vaccinia naïve adults
75 NA NA From pooled all observational studies (comparison and intervention):
Among intervention: 74/75 (99%) seroconverted
Among Comparison: 3326/3539 (94%) seroconverted
Seroconversion rate: RR 1.05 (1.02 to 1.08); 47 more per 1,000 (from 19 more to 75 more)
Observational for the comparison
NCT00437021
Frey 2
Frey et al. 2013
Troy et al. 2015
Mean 24.7
SD 4.2
Healthy vaccinia naïve adults
NA 63 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT01668537
Greenburg4
2014
Mean 27.7
SD 6.28
Healthy vaccinia naïve adults
NA 297 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT00316602
Greenburg2
Greenberg 2015
Mean 26.5
SD NR
Healthy vaccinia naïve adults and vaccinia naïve adults with atopic dermatitis
NA 451 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT00914732
Frey4
Troy et al. 2015
Frey et al. 2015
Mean 27.7
SD 6.11
Healthy vaccinia naïve adults
NA 148 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT00189904
Greenburg1
Greenberg et al. 2013
Mean 37.9
SD NR
Healthy vaccinia naïve adults and HIV + vaccinia naïve adults
NA 60 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT01144637
Overton2
Overton et al. 2018
Mean 27.7
SD 6.3
Healthy vaccinia naïve adults
NA 1906 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT00189917
von Sonnenburg2
Darsow et al.  2016
Von Sonnenburg et al. 2014
Mean NR
SD NR
Healthy vaccinia naïve adults and vaccinia naïve adults with a history of atopic dermatitis, active atopic dermatitis or allergic rhinitis
NA 56 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT01913353
Pittman
Pittman 2019
Mean 23.5
SD 4.67
Healthy vaccinia naïve adults
NA 185 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT00082446
Frey1
Frey 2007
Sano 2009
Mean 24.8
SD 3.8
Healthy vaccinia naïve adults
NA 15 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT00316589
Overton1
Overton et al. 2015
Mean 37.5
SD 8.0
Healthy vaccinia naïve adults and HIV + vaccinia naïve adults
NA 298 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
NCT00189959
Pokorny
Von Kremplehuber et al. 2010
Mean 23.3
SD 3.0
Healthy vaccinia naïve adults
NA 52 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Vollmar
Vollmar et al. 2005
Mean 32.8
Healthy vaccinia naïve adult males
NA 16 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.

Table 3b: Summary of Studies Reporting Outcome B – Severity of Disease

Authors last name, pub year Age or other characteristic of importance N intervention N comparison Comparator vaccine Absolute difference/effect estimate Study limitations (Risk of Bias)
No data available for this outcome.

Table 3c: Summary of Studies Reporting Outcome C – Serious Adverse Events (SAE)

Authors last name, pub year Age or other characteristic of importance N intervention N comparison Comparator vaccine Absolute difference/effect estimate Study limitations (Risk of Bias)
RCT
NCT00316589
Overton3
Overton et al. 2015
Age: Mean 35
SD 6.7
HIV positive vaccinia naïve adults
31 27 No vaccine booster after MVA-BN primary series Not estimable
No serious adverse events were recorded among the intervention or comparison groups
Serious risk of bias due to high attrition rate in the per protocol population
Observational intervention
NCT00686582
Von Sonnenburg 3
Mean 34.6
SD 10.2
Healthy vaccinia naïve adults
751 NA NA Not estimable
Among intervention: 0/75 (0%) had vaccine-related SAEs
Among comparison: 3/5265 (0.1%) had vaccine related SAEs
Observational comparison
Parrino 1 Mean and
SD NR
Healthy vaccinia naïve adults
NA 19 No vaccine booster after TBC-MVA primary series Pooled studies. See observational intervention for effect estimate.
Frey 2 Mean 24.7
SD 4.2
Healthy vaccinia naïve adults
NA 67 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Greenburg 4 Mean 27.7
SD 6.28
Healthy vaccinia naïve adults
NA 327 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Frey 3 Mean 26.5
SD NR
Healthy vaccinia naïve adults
NA 45 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Greenburg 2 Mean 26.5
SD NR
Healthy vaccinia naïve adults and vaccinia naïve adults with atopic dermatitis
NA 632 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
1 SAE2 was recorded for a participant, a healthy vaccinia naïve adult, in this comparison group
Frey 4 Mean 27.7
SD 6.11
Healthy vaccinia naïve adults
NA 167 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Greenburg 1 Mean 37.9
SD NR
Healthy vaccinia naïve adults and HIV + vaccinia naïve adults
NA 60 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Overton 2 Mean 27.7
SD 6.3
Healthy vaccinia naïve adults
NA 3003 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Von Sonnenburg 2 Mean NR
SD NR
Healthy vaccinia naïve adults and vaccinia naïve adults with a history of atopic dermatitis, active atopic dermatitis or allergic rhinitis
NA 60 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Seaman/Wilck Mean 25.2, SD=3.7
Healthy vaccinia naïve adults
NA 10 No vaccine booster after Acambis MVA primary series Pooled studies. See observational intervention for effect estimate.
Pittman Mean 23.5
SD 4.67
Healthy vaccinia naïve US military soldiers
NA 220 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Frey 5 Mean 27.4
SD 5.3
Healthy vaccinia naïve adults
NA 1163 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
1 SAE3 was recorded for a participant in this comparison group
Frey 1 Mean 24.8
SD 3.8
Healthy vaccinia naïve adults
NA 30 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Overton 1 Mean 37.5
SD 8.0
Healthy vaccinia naïve adults and HIV + vaccinia naïve adults
NA 439 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
1 SAE4 was recorded for a participant, an HIV positive vaccinia naïve adult, in this comparison group
Pokorny Mean 23.3
SD 3.0
Healthy vaccinia naïve adults
NA 545 No vaccine booster after MVA-BN primary series Pooled studies. See observational intervention for effect estimate.
Vollmar
Vollmar et al. 2005
Mean 32.8
Healthy vaccinia naïve adult males
NA 16 MVA-BN Pooled studies. See observational intervention for effect estimate.

1. N=75 is the reported number at risk for those at risk for serious adverse events. Reasons for attrition not reported

2. Extra ocular muscle paresis event in one person 8 days after second MVA-BN vaccination; deemed probably related by investigators.

3. Acute myocardial infarction event in one person 117 days after the first MVA-BN dose. Deemed related to vaccination because no other reasonable etiology was found. Number at risk is 116 because one subject was initially randomized to study arm C but was vaccinated out of the window and was analyzed in study arm A.

4. Pneumonia and pleurisy event in one person 1 day after second MVA-BN dose. Deemed “possibly but unlikely” to be associated with vaccination.

5. One person missing all symptom data.

Table 3d: Summary of Studies Reporting Outcome D – Myo/pericarditis

Authors last name, pub year Age or other characteristic of importance N intervention N comparison Comparator vaccine Absolute difference/effect estimate Study limitations (Risk of Bias)
RCT
NCT00316589
Overton3
Overton et al. 2015
Age: Mean 35
SD 6.7
HIV positive vaccinia naïve adults
31 27 No vaccine booster after MVA-BN primary series Not estimable
No myopericarditis events were recorded among the intervention or comparison groups
Serious risk of bias due to high attrition rate in the per protocol population

Table 4: GRADE Summary of Findings

Certainty assessment № of patients Effect Certainty Importance
№ of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations JYNNEOS® OPXV vaccine primary series followed by a JYNNEOS® booster every 2 years JYNNEOS® OPXV vaccine primary series Relative
(95% CI)
Absolute
(95% CI)
A. Prevention of disease (assessed with: Geometric mean titer)
11,2 randomized trials seriousa not serious very seriousb,c not seriousd none 26 20 - mean 3.56 titer units more
(1.84 more to 6.89 more)
Level 4
VERY LOW
CRITICAL
A. Prevention of disease (assessed with: seroconversion rate)
11,2 randomized trials seriousa not serious very seriousb,c seriousd,e none 26/26 (100.0%) 20/20 (100.0%) RR 1.00
(0.94 to 1.06)
0 fewer per 1,000
(from 60 fewer to 60 more)
Level 4
VERY LOW
CRITICAL
A. Prevention (assessed with: seroconversion rate)
123,4,5,6,7,8,9,10,11,12,13,14,15,16,
17,18,19,20,21,22,23,24,25,26,27,28,29,30,
31,32,33, 39
observational studies very seriousf seriousg PQ3: serioush
PQ4: very serioush
seriousi none 74/75 (98.7%) 3326/3539 (94.0%) RR 1.05
(1.02 to 1.08)
47 more per 1,000
(from 19 more to 75 more)
Level 4
VERY LOW
CRITICAL
C. Serious adverse events (assessed with: vaccine related SAE rate)
11,2 randomized trials not serious not serious seriousc very seriousj none 0/31 (0.0%) 0/27 (0.0%) not estimable Level 4
VERY LOW
CRITICAL
C. Serious adverse events (assessed with: vaccine related SAE rate)
173,4,5,6,7,8,9,10,11,12,13,14,15,16,
17,18,19,20,21,22,23,24,25,26,27,28,29,30,
31,32,33,34,35,36,37,38,39
observational studies very seriousf seriousg serioush seriousk none 0/75 (0.0%) 3/5265 (0.1%) not estimable Level 4
VERY LOW
CRITICAL
D. Myo-/pericarditis (assessed with: myo-/pericarditis event rate)
11,2 randomized trials seriousl not serious seriousc very seriousj none 0/31 (0.0%) 0/27 (0.0%) not estimable Level 4
VERY LOW
IMPORTANT

References in this table: 123456789101112131415161718192021222324252627282930313233343536373839

Table 5: Summary of Evidence for Outcomes of Interest

Outcome Importance Included in profile Certainty
Prevention of disease Critical Yes Very low
Severity of disease Important Yes NA (No data available)
Serious adverse events Critical Yes Very low
Myo-/pericarditis Critical Yes Very low
Minor adverse events Not important No N/A

Explanations

a. High attrition rate in per protocol population.

b. Immunogenicity as assessed with GMT is an indirect measure of efficacy.

c. Available intervention data gives a booster at day 84. Indirect evidence for 2 year booster.

d. There is one study with a small sample size.

e. 95% CI suggests there may be the potential for benefit or harm.

f. Many studies have serious concerns for risk of bias. Observational data has a higher risk for bias there were some concerns in a few studies for attrition and timing of outcome ascertainment.

g. Only one study contributes data to the intervention. Others contribute data to the comparison. Can’t assess inconsistency for intervention.

h. PQ3: Downgrade for indirectness because the comparisons are between studies. PQ4: h. Downgrade for indirectness because the comparisons are between studies. Further downgrade for indirectness because 2-year booster data is indirect data for 10-year booster data.

i. Though the confidence interval is small, the number of participants in the intervention group is small and therefore may not provide a precise estimate.

j. Study population is very small and would be poor at estimating the rate of rare outcomes.

k. Few people in the intervention group. Wide confidence interval.

l. High attrition rate and unclear information about randomization procedure.

View the complete list of GRADE evidence tables‎

  1. Overton, E. T., Lawrence, S. J., Stapleton, J. T., Weidenthaler, H., Schmidt, D., Koenen, B., Silbernagl, G., Nopora, K., Chaplin, P.. A randomized phase II trial to compare safety and immunogenicity of the MVA-BN smallpox vaccine at various doses in adults with a history of AIDS. Vaccine; Mar 4 2020.
  2. Bavarian Nordic, . Randomized, Open-label Phase II Trial to Assess the Safety and Immunogenicity of MVA-BN Smallpox Vaccine in Immunocompromised Subjects With HIV Infection. 2014.
  3. Bavarian Nordic, , and, National,Institute,of,Allergy, Diseases, Infectious. An Open-Label Phase II Study to Evaluate Immunogenicity and Safety of a Single IMVAMUNE Booster Vaccination Two Years After the Last IMVAMUNE Vaccination in Former POX-MVA-005 Vaccinees. 2008.
  4. Frey, S. E., Winokur, P. L., Salata, R. A., El-Kamary, S. S., Turley, C. B., Walter, E. B.,Jr., Hay, C. M., Newman, F. K., Hill, H. R., Zhang, Y., Chaplin, P., Tary-Lehmann, M., Belshe, R. B.. Safety and immunogenicity of IMVAMUNE R smallpox vaccine using different strategies for a post event scenario. Vaccine; 2013.
  5. Troy, J. D., Hill, H. R., Ewell, M. G., Frey, S. E.. Sex difference in immune response to vaccination: A participant-level meta-analysis of randomized trials of IMVAMUNE smallpox vaccine. Vaccine; 2015.
  6. MVA Post-Event: administration Timing and Boost Study. https://clinicaltrials.gov/show/NCT00437021; 2007.
  7. Bavarian Nordic, . A Phase II Trial to Compare a Liquid-frozen and a Freeze-dried Formulation of IMVAMUNE (MVA-BN®) Smallpox Vaccine in Vaccinia-naïve Healthy Subjects. 2013.
  8. A Phase II Trial to Compare a Liquid-frozen and a Freeze-dried Formulation of IMVAMUNE (MVA-BN®) Smallpox Vaccine in Vaccinia-naïve Healthy Subjects. https://clinicaltrials.gov/show/NCT01668537; 2012.
  9. Bavarian Nordic, , National Institute of Allergy and Infectious Diseases, . A Phase II Study on Immunogenicity and Safety of MVA-BN® (IMVAMUNE™) Smallpox Vaccine in Subjects With Atopic Dermatitis. 2006.
  10. Greenberg, R. N., Hurley, Y., Dinh, D. V., Mraz, S., Vera, J. G., Von Bredow, D., Von Krempelhuber, A., Roesch, S., Virgin, G., Arndtz-Wiedemann, N., Meyer, T. P., Schmidt, D., Nichols, R., Young, P., Chaplin, P.. A multicenter, open-label, controlled phase II study to evaluate safety and immunogenicity of MVA smallpox vaccine (IMVAMUNE) in 18-40 year old subjects with diagnosed atopic dermatitis. PLoS ONE; 2015.
  11. Frey, S. E., Wald, A., Edupuganti, S., Jackson, L. A., Stapleton, J. T., El Sahly, H., El-Kamary, S. S., Edwards, K., Keyserling, H., Winokur, P., Keitel, W., Hill, H., Goll, J. B., Anderson, E. L., Graham, I. L., Johnston, C., Mulligan, M., Rouphael, N., Atmar, R., Patel, S., Chen, W., Kotloff, K., Creech, C. B., Chaplin, P., Belshe, R. B.. Comparison of lyophilized versus liquid modified vaccinia Ankara (MVA) formulations and subcutaneous versus intradermal routes of administration in healthy vaccinia-naive subjects. Vaccine; 2015.
  12. Lyophilized IMVAMUNE® (1×10^8 TCID50) Versus Liquid IMVAMUNE® (1×10^8 TCID50) Administered Subcutaneously and a Lower Dose Liquid IMVAMUNE® (2×10^7 TCID50) Administered Intradermally. https://clinicaltrials.gov/show/NCT00914732; 2009.
  13. National Institute of Allergy and Infectious Diseases, . Lyophilized IMVAMUNE® (1×10^8 TCID50) Versus Liquid IMVAMUNE® (1×10^8 TCID50) Administered Subcutaneously and a Lower Dose Liquid IMVAMUNE® (2×10^7 TCID50) Administered Intradermally. 2010.
  14. Greenberg, R. N., Overton, E. T., Haas, D. W., Frank, I., Goldman, M., von Krempelhuber, A., Virgin, G., Bädeker, N., Vollmar, J., Chaplin, P.. Safety, immunogenicity, and surrogate markers of clinical efficacy for modified vaccinia Ankara as a smallpox vaccine in HIV-infected subjects. J Infect Dis; Mar 1 2013.
  15. Bavarian Nordic, , National Institute of Allergy and Infectious Diseases, . Safety, Tolerability and Immune Response of IMVAMUNE (MVA-BN)Smallpox Vaccine in HIV Infected Patients. 2005.
  16. Overton, E. T., Lawrence, S. J., Wagner, E., Nopora, K., Rosch, S., Young, P., Schmidt, D., Kreusel, C., De Carli, S., Meyer, T. P., Weidenthaler, H., Samy, N., Chaplin, P.. Immunogenicity and safety of three consecutive production lots of the non replicating smallpox vaccine MVA: A randomised, double blind, placebo controlled phase III trial. PLoS ONE [Electronic Resource]; 2018.
  17. Bavarian Nordic, . A Trial to Evaluate Immunogenicity and Safety of Three Consecutive Production Lots of IMVAMUNE® (MVA-BN®) Smallpox Vaccine in Healthy, Vaccinia-naïve Subjects. 2013.
  18. A Trial to Evaluate Immunogenicity and Safety of Three Consecutive Production Lots of IMVAMUNE® (MVA-BN®) Smallpox Vaccine in Healthy, Vaccinia-naïve Subjects. https://clinicaltrials.gov/show/NCT01144637; 2010.
  19. Darsow, U., Sbornik, M., Rombold, S., Katzer, K., von Sonnenburg, F., Behrendt, H., Ring, J.. Long-term safety of replication-defective smallpox vaccine (MVA-BN) in atopic eczema and allergic rhinitis. Journal of the European Academy of Dermatology and Venereology; 2016.
  20. von Sonnenburg, F., Perona, P., Darsow, U., Ring, J., von Krempelhuber, A., Vollmar, J., Roesch, S., Baedeker, N., Kollaritsch, H., Chaplin, P.. Safety and immunogenicity of modified vaccinia Ankara as a smallpox vaccine in people with atopic dermatitis. Vaccine; 2014.
  21. Bavarian Nordic, , United States Army Medical Research Institute of Infectious Diseases, . A Non-inferiority Trial to Compare MVA-BN® Smallpox Vaccine to ACAM2000®. 2015.
  22. Pittman, P. R., Hahn, M., Lee, H. S., Koca, C., Samy, N., Schmidt, D., Hornung, J., Weidenthaler, H., Heery, C. R., Meyer, T. P. H., Silbernagl, G., Maclennan, J., Chaplin, P.. Phase 3 Efficacy Trial of Modified Vaccinia Ankara as a Vaccine against Smallpox. New England Journal of Medicine; 2019.
  23. Sano, J., Chaitman, B. R., Swindle, J., Frey, S. E.. Electrocardiography screening for cardiotoxicity after modified Vaccinia Ankara vaccination. American Journal of Medicine; 2009.
  24. Hughes, C. M., Newman, F. K., Davidson, W. B., Olson, V. A., Smith, S. K., Holman, R. C., Yan, L., Frey, S. E., Belshe, R. B., Karem, K. L., Damon, I. K.. Analysis of variola and vaccinia virus neutralization assays for smallpox vaccines. Clinical & Vaccine Immunology: CVI; 2012.
  25. Frey, S. E., Newman, F. K., Kennedy, J. S., Sobek, V., Ennis, F. A., Hill, H., Yan, L. K., Chaplin, P., Vollmar, J., Chaitman, B. R., Belshe, R. B.. Clinical and immunologic responses to multiple doses of IMVAMUNE (Modified Vaccinia Ankara) followed by Dryvax challenge. Vaccine; 2007.
  26. Elizaga, M. L., Vasan, S., Marovich, M. A., Sato, A. H., Lawrence, D. N., Chaitman, B. R., Frey, S. E., Keefer, M. C.. Prospective Surveillance for Cardiac Adverse Events in Healthy Adults Receiving Modified Vaccinia Ankara Vaccines: A Systematic Review. PLoS ONE; 2013.
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