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Safety/Efficacy Study of Serqirus A/H7N9 IIV With or Without MF59(R) Adjuvant to Prevent Avian Influenza

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ClinicalTrials.gov Identifier: NCT03682120
Recruitment Status : Recruiting
First Posted : September 24, 2018
Last Update Posted : October 4, 2019
Sponsor:
Information provided by (Responsible Party):
National Institute of Allergy and Infectious Diseases (NIAID)

Brief Summary:
This is a randomized, double-blinded, Phase II study in healthy males and non-pregnant females, 18-64 years of age. This clinical trial is designed to assess the safety, reactogenicity, and immunogenicity of a pre-pandemic 2017 monovalent inactivated influenza A/H7N9 virus vaccine (2017 H7N9 IIV) manufactured by Seqirus Inc (Seqirus) administered at different dosages (3.75 microgram mcg, 7.5 mcg and 15 mcg of hemagglutinin (HA) per dose) given with MF59(R) adjuvant manufactured by Seqirus Inc., or without adjuvant (15 mcg of HA per dose). Phosphate buffered saline (PBS) diluent manufactured by Patheon Manufacturing Services LLC will be used to achieve certain targeted doses. Approximately 371 subjects who are in good health and meet all eligibility criteria will be randomized into one of 4 study groups. The study will be conducted at up to 7 Vaccine and Treatment Unit (VTEU) sites and will last approximately 17 months, with subject participation duration of approximately 13 months. The Primary Objectives of the study are: 1) To assess the safety and reactogenicity following receipt of two doses of 2017 H7N9 IIV administered intramuscularly (IM) at different dosages approximately 21 days apart given with or without MF59(R) adjuvant; 2) To assess the serum hemagglutinin inhibition (HAI) and neutralizing (Neut) antibody responses approximately 21 days following receipt of two doses of 2017 H7N9 IIV administered IM at different dosages approximately 21 days apart with or without MF59(R) adjuvant.

Condition or disease Intervention/treatment Phase
Avian Influenza Influenza Immunisation Biological: A/H7N9 Drug: MF59 adjuvant Other: Phosphate Buffered Saline (PBS) diluent Phase 2

Detailed Description:

This is a randomized, double-blinded, Phase II study in healthy males and non-pregnant females, 18-64 years of age. This clinical trial is designed to assess the safety, reactogenicity, and immunogenicity of a pre-pandemic 2017 monovalent inactivated influenza A/H7N9 virus vaccine (2017 H7N9 IIV) manufactured by Seqirus Inc (Seqirus) administered at different dosages (3.75 mcg, 7.5 mcg and 15 mcg of hemagglutinin (HA) per dose) given with MF59(R) adjuvant manufactured by Seqirus Inc., or without adjuvant (15 mcg of HA per dose). Phosphate buffered saline (PBS) diluent manufactured by Patheon Manufacturing Services LLC will be used to achieve certain targeted doses. Approximately 371 subjects who are in good health and meet all eligibility criteria will be randomized into one of 4 study groups. The study will be conducted at up to 7 Vaccine and Treatment Unit (VTEU) sites and will last approximately 17 months, with subject participation duration of approximately 13 months. The Primary Objectives of the study are: 1) To assess the safety and reactogenicity following receipt of two doses of 2017 H7N9 IIV administered intramuscularly (IM) at different dosages approximately 21 days apart given with or without MF59(R) adjuvant; 2) To assess the serum hemagglutinin inhibition (HAI) and Neutralizing (Neut) antibody responses approximately 21 days following receipt of two doses of 2017 H7N9 IIV administered IM at different dosages approximately 21 days apart with or without MF59(R) adjuvant.

The secondary Objectives are: 1) To assess all unsolicited non-serious Adverse Events (AEs) following receipt of two doses of a 2017 H7N9 IIV administered IM at different dosages approximately 21 days apart with or without MF59(R) adjuvant; 2) To assess medically-attended adverse events (MAAEs) including new-onset chronic medical conditions (NOCMCs), potentially immune-mediated medical conditions (PIMMCs), and all Serious Adverse Events (SAEs) following receipt of two doses of a 2017 H7N9 IIV administered IM at different dosages approximately 21 days apart with or without MF59(R) adjuvant; 3) To assess the serum HAI and Neut antibody responses approximately 7 and 21 days following receipt of a single dose, and approximately 7 days following receipt of two doses of 2017 H7N9 IIV administered IM at different dosages approximately 21 days apart with or without MF59(R) adjuvant.


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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 371 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary Purpose: Prevention
Official Title: A Phase II Study in Healthy Adults 18-64 Years Old to Assess the Safety, Reactogenicity and Immunogenicity of a Seqirus A/H7N9 Inactivated Influenza Vaccine Administered Intramuscularly With or Without MF59(R) Adjuvant
Actual Study Start Date : November 2, 2018
Estimated Primary Completion Date : November 30, 2019
Estimated Study Completion Date : November 30, 2019

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: Arm 1
3.75 mcg per 0.5 ml dose of 2017 A/H7N9 Inactivated Influenza Virus Vaccine (IIV) + MF59(R) adjuvant administered intramuscularly on Day 1 and Day 22. Phosphate buffered saline (PBS) diluent may be used to achieve targeted dosages. N=106
Biological: A/H7N9
Monovalent inactivated, "subunit" influenza virus vaccine containing the HA and NA from influenza A/Hong Kong/125/2017 (H7N9) and the PB2, PB1, PA, NP, M and NS genes from A/Puerto Rico/8/1934 (H1N1).

Drug: MF59 adjuvant
Microfluoridized adjuvant 59 (MF59) is an oil-in-water emulsion.

Other: Phosphate Buffered Saline (PBS) diluent
Diluent for Influenza Virus Vaccine.

Experimental: Arm 2
7.5 mcg per 0.5 ml dose of 2017 A/H7N9 Inactivated Influenza Virus Vaccine (IIV) + MF59(R) adjuvant administered intramuscularly on Day 1 and Day 22. Phosphate buffered saline (PBS) diluent may be used to achieve targeted dosages. N=106
Biological: A/H7N9
Monovalent inactivated, "subunit" influenza virus vaccine containing the HA and NA from influenza A/Hong Kong/125/2017 (H7N9) and the PB2, PB1, PA, NP, M and NS genes from A/Puerto Rico/8/1934 (H1N1).

Drug: MF59 adjuvant
Microfluoridized adjuvant 59 (MF59) is an oil-in-water emulsion.

Other: Phosphate Buffered Saline (PBS) diluent
Diluent for Influenza Virus Vaccine.

Experimental: Arm 3
15 mcg per 0.5 ml dose of 2017 A/H7N9 Inactivated Influenza Virus Vaccine (IIV) + MF59(R) adjuvant administered intramuscularly on Day 1 and Day 22. Phosphate buffered saline (PBS) diluent may be used to achieve targeted dosages. N=106
Biological: A/H7N9
Monovalent inactivated, "subunit" influenza virus vaccine containing the HA and NA from influenza A/Hong Kong/125/2017 (H7N9) and the PB2, PB1, PA, NP, M and NS genes from A/Puerto Rico/8/1934 (H1N1).

Drug: MF59 adjuvant
Microfluoridized adjuvant 59 (MF59) is an oil-in-water emulsion.

Other: Phosphate Buffered Saline (PBS) diluent
Diluent for Influenza Virus Vaccine.

Experimental: Arm 4
15 mcg per 0.5 ml dose of 2017 A/H7N9 Inactivated Influenza Virus Vaccine (IIV) unadjuvanted administered intramuscularly on Day 1 and Day 22. Phosphate buffered saline (PBS) diluent may be used to achieve targeted dosages. N=53
Biological: A/H7N9
Monovalent inactivated, "subunit" influenza virus vaccine containing the HA and NA from influenza A/Hong Kong/125/2017 (H7N9) and the PB2, PB1, PA, NP, M and NS genes from A/Puerto Rico/8/1934 (H1N1).

Other: Phosphate Buffered Saline (PBS) diluent
Diluent for Influenza Virus Vaccine.




Primary Outcome Measures :
  1. Geometric Mean Titers (GMT) of serum Hemagglutinin Inhibition (HAI) antibodies [ Time Frame: Day 43 ]
  2. Geometric Mean Titers (GMT) of serum Neutralizing (Neut) antibodies [ Time Frame: Day 43 ]
  3. Occurrence of clinical safety laboratory adverse events [ Time Frame: day 1 through Day 8 ]
  4. Occurrence of clinical safety laboratory adverse events [ Time Frame: Day 22 through Day 29` ]
  5. Occurrence of solicited injection site reactogenicity events [ Time Frame: Day 1 through Day 8 ]
  6. Occurrence of solicited injection site reactogenicity events [ Time Frame: Day 22 through Day 29 ]
  7. Occurrence of study vaccine-related Serious Adverse Events (SAE's) [ Time Frame: Day 1 through Day 387 ]
  8. Occurrence of systemic reactogenicity events [ Time Frame: Day 1 through Day 8 ]
  9. Occurrence of systemic reactogenicity events [ Time Frame: Day 22 through Day 29 ]
  10. Percentage of subjects achieving Hemagglutinin inhibition (HAI) antibody titer > / = 40 [ Time Frame: Day 43 ]
  11. Percentage of subjects achieving Neutralizing (Neut) antibody titer > / = 40 [ Time Frame: Day 43 ]
  12. Percentage of subjects achieving seroconversion against study vaccine viruses (HAI pre-vaccination titer < 10 and a post-vaccination titer > / = 40 or a pre-vaccination titer > / = 10 and a minimum four-fold rise in post-vaccination titer) [ Time Frame: Day 43 ]
  13. Percentage of subjects achieving seroconversion against study vaccine viruses (Neut antibody pre-vaccination titer < 10 and a post-vaccination titer > / = 40 or a pre-vaccination titer > / = 10 and a minimum four-fold rise in post-vaccination titer) [ Time Frame: Day 43 ]

Secondary Outcome Measures :
  1. Geometric Mean Titers (GMT) of Serum Hemagglutinin Inhibition (HAI) antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 1 ]
  2. Geometric Mean Titers (GMT) of serum Hemagglutinin Inhibition (HAI) antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 22 ]
  3. Geometric Mean Titers (GMT) of serum Hemagglutinin Inhibition (HAI) antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 29 ]
  4. Geometric Mean Titers (GMT) of serum Hemagglutinin Inhibition (HAI) Antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 8 ]
  5. Geometric Mean Titers (GMT) of serum Neutralizing (Neut) antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 22 ]
  6. Geometric Mean Titers (GMT) of serum Neutralizing (Neut) antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 29 ]
  7. Geometric Mean Titres (GMT) of Serum Neutralizing (Neut) antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 1 ]
  8. Geometric Mean Titres (GMT) of Serum Neutralizing (Neut) antibodies against the influenza 2017 H7N9 vaccine virus [ Time Frame: Day 8 ]
  9. Occurrence of all Serious Adverse Events (SAEs), regardless of the assessment of relatedness [ Time Frame: Day 1 through Day 387 ]
  10. Occurrence of all unsolicited adverse events, regardless of the assessment of seriousness or relatedness [ Time Frame: Day 1 through Day 22 ]
  11. Occurrence of all unsolicited adverse events, regardless of the assessment of seriousness or relatedness [ Time Frame: Day 22 through Day 43 ]
  12. Occurrence of medically-attended adverse events (MAAEs), including new-onset chronic medical conditions (NOCMCs), and potentially immune-mediated medical conditions (PIMMCs) [ Time Frame: Day 1 through Day 387 ]
  13. Occurrence of study vaccine-related unsolicited non-serious Adverse Events (AEs) [ Time Frame: Day 1 thrugh Day 22 ]
  14. Occurrence of study vaccine-related unsolicited non-serious Adverse Events (AEs) [ Time Frame: Day 22 through Day 43 ]
  15. Percentage of subjects achieving Hemagglutinin Inhibition (HAI) Antibodies seroconversion against the influenza 2017 H7N9 vaccine [ Time Frame: Day 22 ]
  16. Percentage of subjects achieving Hemagglutinin inhibition (HAI) antibody titers of 40 or greater against the influenza 2017 H7N9 vaccine strain [ Time Frame: Day 22 ]
  17. Percentage of subjects achieving Hemagglutinin inhibition (HAI) antibody titers of 40 or greater against the influenza 2017 H7N9 vaccine strain [ Time Frame: Day 29 ]
  18. Percentage of subjects achieving Hemagglutinin inhibition (HAI) antibody titers of 40 or greater against the influenza 2017 H7N9 vaccine strain [ Time Frame: Day 8 ]
  19. Percentage of subjects achieving Hemagglutinin Inhibition (HAI) seroconversion against the influenza 2017 H7N9 vaccine [ Time Frame: Day 8 ]
  20. Percentage of subjects achieving Hemagglutinin Inhibition (HAI)seroconversion against the influenza 2017 H7N9 vaccine [ Time Frame: Day 29 ]
  21. Percentage of subjects achieving Neutralizing (Neut) antibody seroconversion against the influenza 2017 H7N9 vaccine [ Time Frame: Day 22 ]
  22. Percentage of subjects achieving Neutralizing (Neut) antibody seroconversion against the influenza 2017 H7N9 vaccine [ Time Frame: Day 29 ]
  23. Percentage of subjects achieving Neutralizing (Neut) antibody seroconversion against the influenza 2017 H7N9 vaccine [ Time Frame: Day 8 ]
  24. Percentage of subjects achieving Neutralizing (Neut) antibody titers of 40 or greater against the influenza 2017 H7N9 vaccine strain [ Time Frame: Day 22 ]
  25. Percentage of subjects achieving Neutralizing (Neut) antibody titers of 40 or greater against the influenza 2017 H7N9 vaccine strain [ Time Frame: Day 29 ]
  26. Percentage of subjects achieving Neutralizing (Neut) antibody titers of 40 or greater against the influenza 2017 H7N9 vaccine strain [ Time Frame: Day 8 ]


Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years to 64 Years   (Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   Yes
Criteria

Inclusion Criteria:

  1. Provide written informed consent prior to initiation of any study procedures.
  2. Are able to understand and comply with planned study procedures and be available for all study visits.
  3. Are males or non-pregnant females, 18-64 years of age, inclusive.
  4. Are in good health*. *As determined by physical examination and medical history to evaluate acute or currently ongoing chronic medical diagnoses or conditions, defined as those that have been present for at least 90 days, which would affect the assessment of the safety of subjects or the immunogenicity of study vaccinations. Chronic medical diagnoses or conditions should be stable for the last 60 days (no hospitalizations, Emergency Room, or urgent care for condition and no adverse symptoms that need medical intervention such as medication change/supplemental oxygen). This includes no change in chronic prescription medication, dose, or frequency as a result of deterioration of the chronic medical diagnosis or condition in the 60 days prior to enrollment. Any prescription change that is due to change of health care provider, insurance company, etc., or that is done for financial reasons, as long as in the same class of medication, will not be considered a deviation of this inclusion criterion. Any change in prescription medication due to improvement of a disease outcome, as determined by the site principal investigator or appropriate sub-investigator, will not be considered a deviation of this inclusion criterion. Subjects may be on chronic or as needed (prn) medications if, in the opinion of the site principal investigator or appropriate sub-investigator, they pose no additional risk to subject safety or assessment of reactogenicity and immunogenicity and do not indicate a worsening of medical diagnosis or condition. Similarly, medication changes subsequent to enrollment and study vaccination are acceptable provided there was no deterioration in the subject's chronic medical condition that necessitated a medication change, and there is no additional risk to the subject or interference with the evaluation of responses to study vaccination. [Topical, nasal, and inhaled medications (with the exception of inhaled corticosteroids), herbals, vitamins, and supplements are permitted].
  5. Oral temperature is less than 100.0 degree Fahrenheit.
  6. Pulse is 47 to 100 beats per minute, inclusive.
  7. Systolic blood pressure is 85 to 150 millimeters of Mercury, inclusive.
  8. Diastolic blood pressure is 55 to 95 millimeters of Mercury, inclusive.
  9. Women of childbearing potential* must agree to practice an acceptable contraception method** from 30 days before first study vaccination until 60 days after last study vaccination.

    *Not sterilized via tubal ligation, bilateral oophorectomy, salpingectomy, hysterectomy, or successful Essure(R) placement (permanent, non-surgical, non-hormonal sterilization) with documented radiological confirmation test at least 90 days after the procedure, and still menstruating or < 1 year of the last menses if menopausal.

    **Includes non-male sexual relationships, abstinence from sexual intercourse with a male partner, monogamous relationship with vasectomized partner who has been vasectomized for 180 days or more prior to the subject receiving the first study vaccination, barrier methods such as male or female condoms with spermicide or with the use of applied spermicide, intrauterine devices, NuvaRing(R), and licensed hormonal methods such as implants, injectables, or oral contraceptives ("the pill").

  10. Women of childbearing potential must have a negative serum or urine pregnancy test within 24 hours prior to study vaccination.

Exclusion Criteria:

  1. Have an acute illness*, as determined by the site Principal Investigatoor or appropriate sub-investigator, within 72 hours prior to study vaccination.

    *An acute illness which is nearly resolved with only minor residual symptoms remaining is allowable if, in the opinion of the site principal investigator or appropriate sub-investigator, the residual symptoms will not interfere with the ability to assess safety parameters as required by the protocol.

  2. Have any medical disease or condition that, in the opinion of the site Principal Investigator or appropriate sub-investigator, is a contraindication to study participation*.

    *Including acute or chronic medical disease or condition, defined as persisting for at least 90 days, that would place the subject at an unacceptable risk of injury, render the subject unable to meet the requirements of the protocol, or may interfere with the evaluation of responses or the subject's successful completion of this trial.

  3. Have immunosuppression as a result of an underlying illness or treatment, a recent history or current use of immunosuppressive or immunomodulating disease therapy.
  4. Use of anticancer chemotherapy or radiation therapy (cytotoxic) within 3 years prior to study vaccination.
  5. Have known active neoplastic disease or a history of any hematologic malignancy. Non-melanoma, treated, skin cancers are permitted.
  6. Have known human immunodeficiency virus (HIV), hepatitis B, or hepatitis C infection.
  7. Have known hypersensitivity or allergy to eggs, egg or chicken protein, neomycin, kanamycin, formaldehyde, polysorbate 80, cetyltrimethylammonium bromide (CTAB), squalene-based adjuvants, or other components of the study vaccine.
  8. Have a history of severe reactions following previous immunization with licensed or unlicensed influenza vaccines.
  9. Have a history of Guillian-Barre Syndrome.
  10. Have a history of convulsions or encephalomyelitis within 90 days prior to study vaccination.
  11. Have a history of Potentially Immune Mediated Medical Conditions (PIMMCs)
  12. Have a history of alcohol or drug abuse within 5 years prior to study vaccination.
  13. Have any diagnosis, current or past, of schizophrenia, bipolar disease, or other psychiatric diagnosis that may interfere with subject compliance or safety evaluations.
  14. Have been hospitalized for psychiatric illness, history of suicide attempt, or confinement for danger to self or others within 10 years prior to study vaccination.
  15. Have taken oral or parenteral (including intra-articular) corticosteroids of any dose within 30 days prior to study vaccination.
  16. Have taken high-dose inhaled corticosteroids* within 30 days prior to each study vaccination.

    *High-dose defined as per age as using inhaled high dose per reference chart https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf.

  17. Received a licensed live vaccine within 30 days prior to the first study vaccination, or plan to receive a licensed live vaccine within 30 days before or after each study vaccination.
  18. Received or plan to receive a licensed, inactivated, vaccine (excluding all flu vaccines) within 14 days before or after each study vaccination.
  19. Received or plan to receive seasonal inactivated influenza virus (IIV) within 21 days before or after each study vaccination.
  20. Received immunoglobulin or other blood products (with exception of Rho D immunoglobulin) within 90 days prior to each study vaccination.
  21. Received an experimental agent* within 30 days prior to the first study vaccination, or expect to receive an experimental agent** during the 13-month trial-reporting period.

    *Including vaccine, drug, biologic, device, blood product, or medication.

    **Other than from participation in this trial.

  22. Are participating or plan to participate in another clinical trial with an interventional agent* that will be received during the 13-month trial-reporting period.

    *Including licensed or unlicensed vaccine, drug, biologic, device, blood product, or medication.

  23. Received or plan to receive an influenza A / H7 vaccine* or have a history of influenza A / H7 subtype infection.

    *And assigned to a group receiving influenza A / H7 vaccine, does not apply to documented placebo recipients.

  24. Have traveled to mainland China and had substantial* direct contact with live or freshly slaughtered poultry or pigeons within the past five years.

    *Substantial contact is defined as visited a poultry farm and/or a live poultry market.

  25. Occupational exposure to or substantial direct physical contact* with birds in the past year and through the 21 days after the second study vaccination.

    *Exposure to free range chickens in the yard is exclusionary. Casual contact with birds at petting zoos or county or state fairs or having pet birds does not exclude subjects from study participation.

  26. Female subjects who are breastfeeding at any given time from the first study vaccination until 30 days after the last study vaccination.
  27. Plan to travel outside the US (continental US, Hawaii, and Alaska) from enrollment through 21 days after the second study vaccination.
  28. Receipt of Multimeric-001 (M-001) vaccine.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03682120


Contacts
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Contact: Sharon Frey 13149779032 sharon.frey@health.slu.edu

Locations
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United States, Alabama
University of Alabama at Birmingham School of Medicine - Alabama Vaccine Research Clinic Recruiting
Birmingham, Alabama, United States, 35294-2050
United States, Missouri
Saint Louis University - Center for Vaccine Development Recruiting
Saint Louis, Missouri, United States, 63104-1015
United States, Ohio
Cincinnati Children's Hospital Medical Center - Infectious Diseases Recruiting
Cincinnati, Ohio, United States, 45229-3039
United States, Tennessee
Vanderbilt University Medical Center - Vanderbilt Institute for Clinical and Translational Research - Clinical Research Center (VICTR-CRC) Recruiting
Nashville, Tennessee, United States, 37232-0011
United States, Texas
The University of Texas Medical Branch - Sealy Center for Vaccine Development (SCVD) Recruiting
Galveston, Texas, United States, 77555-5302
Baylor College of Medicine - Molecular Virology and Microbiology Recruiting
Houston, Texas, United States, 77030-3411
United States, Washington
Kaiser Permanente Washington Health Research Institute - Vaccines and Infectious Diseases Recruiting
Seattle, Washington, United States, 98101-1466
Sponsors and Collaborators
National Institute of Allergy and Infectious Diseases (NIAID)

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Responsible Party: National Institute of Allergy and Infectious Diseases (NIAID)
ClinicalTrials.gov Identifier: NCT03682120     History of Changes
Other Study ID Numbers: 17-0076
First Posted: September 24, 2018    Key Record Dates
Last Update Posted: October 4, 2019
Last Verified: September 13, 2018

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: No
Keywords provided by National Institute of Allergy and Infectious Diseases (NIAID):
A/H7N9
Healthy Adults
Immunogenicity
Influenza vaccine
MF59(R) adjuvant
Reactogenicity
Safety
Additional relevant MeSH terms:
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Influenza, Human
Influenza in Birds
Orthomyxoviridae Infections
RNA Virus Infections
Virus Diseases
Respiratory Tract Infections
Respiratory Tract Diseases
Vaccines
MF59 oil emulsion
Immunologic Factors
Physiological Effects of Drugs
Adjuvants, Immunologic