TIV and High Dose TIV in Subjects With Rheumatoid Arthritis

This is a randomized, double-blinded, Phase II study in adults with Rheumatoid Arthritis
receiving TNF-alpha inhibitor therapy, aged 18 years to 64 years of age. This study is
designed to investigate the immunogenicity, safety, and reactogenicity of two different
doses of inactivated trivalent influenza virus vaccine given at two dose levels (15 mcg and
60 mcg) administered IM in individuals with rheumatoid arthritis receiving anti-TNF-alpha
therapy or age and gender matched control subjects. The study is conducted over two seasons,
2011-2012 and 2012-2013. Subjects enrolling between October 2011 and February 2012 will
receive the 2011-2012 vaccine, while those enrolling after July 2012 will receive the
2012-2013 vaccine. Immunogenicity testing will determine the proportion of subjects in each
group with titer a 4-fold rise in HAI titers (defined as either a pre-vaccination HAI titer
<1:10 and a post-vaccination HAI titer >/=1:40 or a pre-vaccination HAI titer >/=1:10 and a
minimum four-fold rise in post-vaccination HAI titer) against each of the specific influenza
strains included in vaccine the subject received at day 21 following vaccination. The
proportion of subjects in each group achieving a serum HAI titer of >/= 1:40 or a 4-fold
rise in HAI titer or greater in HAI titer against each strain in the vaccine compared to the
controls subjects. Safety testing will assess the occurrence of vaccine-associated Serious
adverse events (SAEs) throughout the course of the study, and the occurrence of solicited
local and systemic adverse events (AEs) within 8 days post vaccination. Solicited AEs
(including rheumatoid arthritis clinical status) will be assessed during the course of the
study. Subjects will have four face to face visits and one telephone contact. Day 0 will
include the consent process, a medical history and physical exam for the RA subjects to
assess the activity of their RA at the time of enrollment, vital signs, phlebotomy for
prevaccine serology. Subjects will be randomized to receive IM seasonal TIV or High-Dose TIV
at this visit and will receive the assigned vaccine. They will be observed for 20 minutes
and will be taught to fill out a 7 day memory aid that will assess daily temperature, local
and systemic reactogenicity. A telephone call will be made to assess reactogenicity and to
review the memory aid on day 3. Subjects will return on day 7 for review of the memory aid,
AEs/SAEs, vital signs and phlebotomy for serology. A physical exam will be performed if
indicated. They will return on day 21 and at 6 months for review of AEs/SAEs, vital signs
and phlebotomy for serology. A physical exam will be performed if indicated.

Inclusion Criteria:

Inclusion Criteria for RA Subjects

- Male or non-pregnant female between the ages of 18 and 64 years, inclusive, who has
stable RA and has received TNFi therapy during the previous 3 months.

- Female subjects: for the 30 days prior to enrollment through 30 days following
receipt of TIV or HTIV vaccine must fulfill one of the following: (i) she is not able
to bear children because she has been surgically sterilized (tubal ligation or
hysterectomy) for at least one year or is at least 1 year post-menopausal or (ii) she
agrees to practice effective methods of contraception including, but not limited to,
abstinence, barrier methods (such as a condom or diaphragm) used with a spermicide,
birth control pills, patches or hormonal shots or hormonal implants, NuvaRing and
IUDs (intrauterine devices). Adherence to contraceptive method will be captured on
the appropriate case report form (CRF).

- In good health, as determined by vital signs (see toxicity table in section 9.2.1.1),
medical history to ensure any existing medical diagnoses or conditions are stable and
not considered clinically significant, and physical examination.

- Intend to be available through 6 months following receipt of vaccine.

- Able to understand and comply with planned study procedures.

- Provide written informed consent prior to initiation of any study procedures.

Inclusion Criteria for Healthy Subjects

- Male or non-pregnant female between the ages of 18 and 64 years, inclusive.

- Female subjects: for the 30 days prior to enrollment through 30 days following
receipt of TIV or HTIV vaccine must fulfill one of the following: (i) she is not able
to bear children because she has been surgically sterilized (tubal ligation or
hysterectomy) for at least one year or is at least 1 year post-menopausal or (ii) she
agrees to practice effective methods of contraception including, but not limited to,
abstinence, barrier methods (such as a condom or diaphragm) used with a spermicide,
birth control pills, patches or hormonal shots or hormonal implants, NuvaRing and
IUDs (intrauterine devices). Adherence to contraceptive method will be captured on
the appropriate case report form (CRF).

- In good health, as determined by vital signs (see toxicity table in section 9.2.1.1),
medical history to ensure any existing medical diagnoses or conditions are stable and
not considered clinically significant, and physical examination.

- Intend to be available through 6 months following receipt of vaccine.

- Able to understand and comply with planned study procedures.

- Provide written informed consent prior to initiation of any study procedures.

Exclusion Criteria:

Exclusion Criteria for all Subjects

- For subjects enrolled after July 2012: Enrolled in this study during the 2011-2012
flu season.

- Has received the seasonal influenza vaccine for the current season. For subjects
enrolling between October 2011 and February 2012, this is the 2011-2012 seasonal
influenza vaccine. For subjects enrolling after July 2012, this is the 2012-2013
seasonal influenza vaccine.

- Has a known allergy to eggs, egg proteins or other components in the vaccines (i.e.
formaldehyde, gelatin sodium phosphate, sodium chloride, octylphenol ethoxylate).

- Has a known or suspected latex allergy or sensitivity.

- Has a positive urine or serum pregnancy test within 24 hours prior to vaccination (if
female of childbearing potential as defined in Inclusion criterion 2), or women who
are breastfeeding.

- Has a history of severe reactions following immunization with contemporary influenza
virus vaccines.

- Has an active neoplastic disease or a history of any hematologic malignancy (cancers
of blood or bone marrow) or current bleeding or blood clotting disorder.

- For "healthy volunteer" (without RA) subjects: Long term (at least 14 days of
prednisone 2 mg/kg or equivalent other glucocorticoid) use of oral, parenteral or
high-dose inhaled steroids (>800 mcg/day of beclomethasone dipropionate or
equivalent) within the preceding 6 months. (Nasal and topical steroids are allowed.)

- Has a diagnosis of a current and uncontrolled major psychiatric disorder.

- Has been hospitalized in the past 10 years for psychiatric illness, suicide attempt,
or confinement for danger to self or others.

- Is receiving listed psychiatric drugs as below*. Subjects who are receiving a single
antidepressant drug and are stable for at least 3 months prior to enrollment, without
decompensating are allowed enrollment into the study.

* aripiprazole, clozapine, ziprasidone, haloperidol, molindone, loxapine,
thioridazine, thiothixene, pimozide, fluphenazine, risperidone, mesoridazine,
quetiapine, trifluoperazine, chlorprothixene, chlorpromazine, perphenazine,
trifluopromazine, olanzapine, carbamazepine, divalproex sodium, lithium carbonate,
lithium citrate, lamotrigine, prochlorperazine, paliperidone or iloperidone.

- Has a history of receiving immunoglobulin or other blood product within the 3 months
prior to vaccination in this study.

- Has received an experimental/investigational agent (vaccine, drug, biologic, device,
blood product, or medication) within 28 days prior to vaccination in this study, or
expects to receive an experimental/investigational agent within the study time period
(180 days after vaccination in this study).

- Is participating or plans to participate in another clinical trial with a licensed
product during the 6-month study period.

- Has received any other licensed vaccines within 14 days (for inactivated vaccines) or
21 days (for live vaccines) prior to vaccination in this study, or expects to receive
a licensed vaccine during the 21 days after vaccination in this study.

- Has received antiviral agent against influenza A and/or B within 48 hours prior to
vaccination in this study. Antiviral agents should not be administered until 2 weeks
after vaccination in this study unless medically necessary.

- Has an acute or chronic medical condition other than RA that, in the opinion of the
investigator, would interfere with the evaluation of responses (this includes, but is
not limited to: known chronic liver, lung or heart disease, chronic anemia, (non-RA
subjects only), metabolic disorders such as diabetes (resolved gestational diabetes
is acceptable), significant renal disease, transplant recipients, system lupus
erythematosus, psoriatic arthritis or gout).

- Has a moderate to severe acute illness and/or an oral temperature greater than or
equal to 100.4 degrees Fahrenheit, within 72 hours prior to vaccination. (This may
result in a temporary delay of vaccination).

- Immunosuppression as a result of an underlying illness or treatment other than RA
therapy, or use of anti-cancer chemotherapy or radiation therapy within the preceding
36 months.

- Known infection with HIV, Hepatitis B or Hepatitis C infection or autoimmune
hepatitis.

- Has a history of alcohol or drug abuse in the last 5 years.

- Has a history of Guillain-Barré Syndrome.

- Has any condition that would, in the opinion of the site investigator, place the
subject at an unacceptable risk or render the subject unable to meet the requirements
of the protocol.