A double-blind trial of a new inactivated, trivalent, intra-nasal anti-influenza vaccine in general practice: relationship between immunogenicity and respiratory morbidity over the winter of 1997-98

BACKGROUND

Influenza is responsible for considerable morbidity not only among older people but in younger age groups as well. However, most large-scale anti-influenza vaccination campaigns are still aimed principally at the elderly using injectable vaccines. Until now there has been much less emphasis on targeting younger populations or using intra-nasal vaccines in mass anti-influenza immunisation programmes.

OBJECTIVES

To assess the immunogenicity of a new inactivated intra-nasal anti-influenza vaccine and to measure its effect on respiratory morbidity in a volunteer general practice population.

STUDY DESIGN

A prospective, double-blind, placebo-controlled trial using the new vaccine was carried out over the winter of 1997-98 on 274 healthy patients aged 12-60 from three Israeli general practices, 182 in the vaccine group and 92 in the placebo group. Following vaccination the changes in the antigen levels and episodes of respiratory illness in the vaccine and placebo groups were measured.

RESULTS

Protective antibody levels occurred after a single dose of vaccine [influenza H1N1, 41% immune pre-vaccination to 73% post-vaccination; influenza H3N2, 35-66%; influenza B, 27-64%]. Between January and March 1998, when influenza activity was at a peak in Israel, the average number of respiratory illness events in the vaccine group [14 events/100 subjects per month] was significantly less than in the placebo group [22 events/100 subjects per month]; similarly, the average number of respiratory illness days in the vaccine group over the same period [69 days/100 subjects per month] was significantly less than in the placebo group [117 days/100 subjects per month].

CONCLUSIONS

The new vaccine possessed significant immunogenicity and was associated with a significant reduction in respiratory morbidity among a group of healthy older children and adults. Since intra-nasal vaccines are simpler to administer and more acceptable to the public than injections the vaccine's potential for use in routine anti-influenza vaccination campaigns seems promising, especially if its beneficial effects are also reproducible in more medically vulnerable populations.

Novel approach for specific detection of herpes simplex virus type 1 and 2 antibodies and immunoglobulin G and M antibodies

Recently a few new herpes simplex virus (HSV) type-specific serological diagnostic tests have been introduced to the commercial market, but these tests have some limitations. Moreover, it is not yet clear which commercial test can be regarded as a "gold standard" for the serodiagnosis of HSV infections. In order to improve the clinical diagnostic value of serological tests for the detection of HSV infections, we developed novel, competition-based enzyme-linked immunosorbent assays for the specific determination of HSV type 2 antibodies (SeroHSV2) and HSV type 1 antibodies (SeroHSV1) and two complementary tests for the detection of HSV immunoglobulin M (IgM) and IgG antibodies (SeroHSV IgM and SeroHSV IgG). These four new kits were evaluated in comparison with some commercial kits for the detection of HSV antibodies that are commonly used at present in Israeli clinical laboratories. The results indicate that SeroHSV2 is highly sensitive (>92%) and highly specific (>94%). SeroHSV2 does not cross-react with other alphaherpesvirus antibodies. SeroHSV1 is highly sensitive (>94%) and specific (>91%) compared to four commercial available kits. SeroHSV IgM is highly specific (>92%) in comparison with other commercial HSV IgM tests. The sensitivity of SeroHSV IgM ranges between 50 and 70% compared to these tests. Further investigation of the discrepant results obtained by using in-house competition tests indicated that SeroHSV IgM is more sensitive. SeroHSV IgG was also found to be highly sensitive (>94%) and highly specific (>92%) compared to the other commercial HSV IgG tests.

Psychological variables as predictors of rubella antibody titers and fatigue--a prospective, double blind study

When exposed to infectious pathogens, human beings manifest variability in the incidence and severity of infection. This variability may partly depend on psychological variables, which have long been thought to contribute to the predisposition, onset, and course of various physical illnesses, including infectious diseases. The objective of the study was to investigate the predictive value of several personality and other psychological variables on antibody titers and fatigue following a specific viral infection. Subjects were divided into a seronegative group (not immune prior to vaccination) (N = 60) and a seropositive group (immune prior to vaccination) (N = 180), based on antibody titers to rubella before and 10.5 weeks after vaccination with live-attenuated rubella virus. Questionnaires assessing externalizing, internalizing, self-esteem, neuroticism, and fatigue-related symptoms were administered to the subjects before vaccination. Fatigue-related symptoms were re-evaluated 10 weeks post vaccination. In the seronegative group, low titers of rubella antibodies, 10.5 post-vaccination, were predicted by high internalizing or neuroticism scores, and by low self-esteem, measured at baseline. Higher externalizing scores indirectly predicted lower titers of antibodies, via fatigue-related symptoms, measured 10 weeks post vaccination. In contrast, in the seropositive group no association was found between any of the psychological variables and antibody titers. Personality and other psychological variables can predict antibody titers to rubella vaccination, in infected individuals. The associations between the psychological variables and antibody titers are complex, and involve both direct and indirect associations. Specific psychological variables can also be used to predict levels of post-vaccination fatigue.

Influence of socioeconomic status on behavioral, emotional and cognitive effects of rubella vaccination: a prospective, double blind study

A double-blind prospective design was used to investigate the immediate and prolonged psychological effects of a specific viral infection, and the role of immune activation in mediating these effects. Subjects were 240 female teenager girls who were vaccinated with rubella vaccine. Based on analysis of levels of antibodies to rubella, subjects were divided into two groups. An experimental group (n = 60), which included subjects who were initially seronegative and were infected following vaccination, and a control group (n = 180), which included subjects who were already immune to rubella before vaccination. Compared with the control group and to their own baseline, low socioeconomic status (SES) subjects within the experimental group showed a significant increase in the severity of depressed mood, social and attention problems, and delinquent behavior. Ten weeks post-vaccination there were no differences between the experimental and control groups in serum levels of interleukin-1 beta, interferon-gamma, soluble interleukin-2 receptors (sIL-2r), and cortisol. However, a significant negative correlation was found between fatigue-related symptoms and sIL-2r levels in the experimental (r = -0.325), but not the control group (r = -0.046). These findings suggest that viral infection can produce prolonged behavioral, emotional and cognitive problems mainly in subjects belonging to the low SES.

Isolation of influenza C virus during an outbreak of influenza A and B viruses

During the winter of 1996 to 1997 two cases of influenza C were confirmed, one by isolation and the second by serology (fourfold increase in hemagglutination inhibition antibodies). The cases of influenza C occurred during an outbreak of influenza A (H3N2) and B viruses. The positive isolation was from one of three throat washings sent to the laboratory, and the other case was from a group of 51 students participating in a study of influenza virus vaccination. It seems, therefore, that influenza C virus should also be considered when examining patients with respiratory infections during the influenza season.

Antibodies to cytomegalo and Epstein-Barr viruses in human saliva and gingival fluid

The prevalence of antibodies to EBV and CMV was studied in 34 samples of whole saliva and gingival crevicular fluids (GCF) obtained from clinically healthy volunteers and compared to the corresponding antibodies present in the serum of each individual. Higher prevalence of serum antibodies was found to EBV (85.2%) than to CMV (64.7%) (P < 0.04). The percentage of saliva samples containing IgG and/or IgA antibodies was not significantly different for the two viruses (79.4% for EBV and 58.8% for CMV). However, in the GCF the percentage to EBV was lower-32.3% as compared to 70.5% for CMV (P < 0.002). The prevalence of CMV in serum saliva and GCF was similar. However, while in the saliva similar levels of IgG and IgA were found, in the GCF IgA prevails. The picture for EBV is different: a similar percentage of antibodies was noticed in serum and saliva, but it was significantly lower in the GCF. However, antibodies to EBV were mostly IgA both in the saliva and the GCF. Although a similar number of samples were positive to both viruses in the saliva, the IgA response to EBV was higher than to CMV (P < 0.05), while in GCF IgA response was higher to CMV (P < 0.05). Passive transudation rather than active transport of plasma-derived Ig is probably responsible for the presence of IgG, while the IgA found in saliva and GCF is derived from local synthesis by plasma cells rather than from selective transport from blood.

Herpes simplex virus-1 and varicella virus infections in familial dysautonomia patients

Familial dystautonomia (FD) patients are deficient in type C fibers, suggesting that there may be a different pattern of infection and clinical presentation when infected by Herpes simplex virus type 1 (HSV-1) or Varicella-Zoster virus (VZV). These viruses infect and are reactivated in the periphery of the body through type C sensory nerve fibers. HSV-1 infects epithelial cells, penetrates into type C fibers, and migrates to the ganglia to generate latent infection. In reactivation, the viral DNA migrates through type C fibers, infecting the epidermis at the entry site. VZV infects through the respiratory tract, causing systemic viral infection and latency in the ganglia, from which it is reactivated and reaches the skin. The study was carried by clinical questionnaire and by HSV and VZV IgG antibodies on fifty-one FD patients and eighty matched controls. The questionnaire revealed that no FD patient had a history of clinical HSV-1 infection, compared to 15% in the control group (P < 0.05), while 50% FD patients had been infected by varicella, compared to 66% in the VZV control group. However in FD, VZV clinical manifestations were mild in comparison to controls. There was no difference in infection rates for some other viral diseases. HSV-1 antibodies were detected in 24% of the FD patients, compared to 38% in the control group (P < 0.1). VZV antibodies were similar in FD and controls (66%, 63%). We concluded that the rate of HSV infection in FD is low and clinical reactivation is rare. The rate of varicella infection appears to be the same for patients and controls, but in FD the clinical presentation is mild. We suggest that these differences are due to the lack of type C fibers in FD patients.

HIV infection and AIDS in Jerusalem: a microcosm of illness in Israel

During the decade 1985-94, 158 individuals (124 males, 34 females) with HIV/AIDS were seen at the AIDS clinic of Hadassah University Hospital. They comprised 10% of the total reported number of HIV-infected Israelis and included 6% of all reported HIV-infected Ethiopians and all HIV-infected West Bank Palestinians. Most individuals (82%) were self-referred; 12% were detected through the local HIV screening clinic. Risk groups for AIDS were homo/bisexuality (39%), heterosexual relations (30%), intravenous drug abuse (15%), contaminated blood transfusions (9%), born to HIV+ mothers (1%), and hemophilia (< 1%). In 5% (all males) no risk factor was given. Of the 158 individuals 29 were Ethiopian immigrants, 25 West Bank Palestinians, and the rest were local Israelis and tourists. Of the 34 females seen, 21 acquired HIV heterosexually, 6 were intravenous drug abusers, 5 were recipients of contaminated transfusions, and 2 were infants. An initial clinical presentation with full-blown AIDS was observed in 30% of the individuals. The range of clinical presentations was similar to that seen in western countries, with Pneumocystis carinii pneumonia, cytomegalovirus retinitis, mycobacterial infections and Kaposi's sarcoma seen most frequently. One case of disseminated cutaneous leishmaniasis was observed. The mortality rate during the follow-up was 55%. In 35% of individuals the immediate cause of death was severe bacterial infections. The Palestinian subpopulation presented at an advanced stage of the disease with a high incidence of transfusion recipients, while most HIV-infected Ethiopians presented with asymptomatic disease transmitted heterosexually. HIV/AIDS as seen at Hadassah University Hospital during 1985-94 exhibited the mixed form of Euro-American AIDS with additional facets of recently introduced African infection.

Enteric viral infections in Gaza children--incidence and associated factors and phenomena

Regular administration of live attenuated polio vaccine (TOPV) to babies in Gaza failed to give adequate protection against infection and disease with wild polio viruses. The possible interference of the "take" of the vaccine was investigated by obtaining demographic, socioeconomic and virological data. More than 100 babies during their first year of life, and their families, were followed. Enteroviruses were isolated in 25.3% and 7.9% of stool samples obtained from healthy babies and babies with diarrhea, respectively. In the same cases, rotaviruses were detected in only 1.9% and 1.4% respectively. It appears that the most common candidates for viral interference in this population are enteroviruses and not rotaviruses, either in healthy babies or in babies suffering from diarrhea.

Prevalence of viral antibodies in gingival crevicular fluid

The prevalence of antibodies to CMV, Mumps and Coxsackie virus strains 1, 3 and 4 was studied in 39 samples of gingival crevicular fluids (GCF) obtained from clinical healthy patients and compared to the corresponding antibodies present in the serum of each individual. In spite of the high prevalence of humoral antibodies to CMV (75%), only 24% of the gingival crevicular fluid samples exhibited IgG or IgA antibodies to this virus. The differences in the prevalence of antibodies against Mumps virus in the sera and GCF were even greater: whereas 87% of the patients exhibited serum antibodies, not even a single gingival fluid sample was found to be positive. Antibodies to Coxsackie B strains 1, 3 and 4 were found in 72%, 63% and 52% of the sera and in 25%, 19% and 33% of the gingival fluid samples (IgG only). The presence of the antibodies and their profile in GCF and serum is different. The mechanism of possible permeation is not clear but it seems that viral antibodies in this milieu are not derived from the serum solely by passive transudation, and that the antibodies are produced locally at least in some of the GCF specimens.

Antibody response to a two-dose regimen of influenza vaccine in allogeneic T cell-depleted and autologous BMT recipients

Induction of protective hemagglutination-inhibition (HI) antibodies in response to influenza virus vaccine and the effectiveness of two doses versus a single dose of vaccine were studied in 48 BMT recipients. The patients were 1-50 years old (median 21 years), 33 with malignant and 15 with non-malignant disease. Thirty-five of the patients underwent allogeneic, T lymphocyte-depleted, BMT and 13, autologous BMT. Nine patients had GVHD at initial immunization. The time interval from BMT to influenza vaccination ranged from 2 to 82 months (median 14.5 months). Two doses of vaccine, administered 1 month apart, consisted of trivalent influenza subunit inactivated vaccine with the following strains: A/Singapore/6/86 (H1N1), A/Sichuan/2/87 (H3N2), and B/Beijing/1/87. There was a statistically significant association between development of protective antibody level (> or = 1:40) and the time interval between BMT and initial vaccination (p < or = 0.001). Regression analysis revealed that longer time interval between the BMT and immunization was positively correlated with seroconversion (a fourfold or greater rise in titers). In the presence of GVHD, there was reduced seroconversion to H1N1, but not to H3N2 or B strains. Influenza vaccination within the first 6 months following BMT was totally ineffective. The efficacy of the vaccine was similar to that described in non-immunocompromised hosts initiated 2 years following BMT. As, overall, specific response was only marginally enhanced by the second dose of vaccine, its indication is questionable.

Detection of herpes simplex virus in gingival tissue

The presence of herpes simplex virus (HSV) antigens was shown by immunofluorescence staining in 26 of 66 (39.3%) specimens of clinically healthy gingiva, but only one sample contained infectious virus. HSV DNA sequences were clearly identified in intact gingival cells by dot blot hybridization in one specimen, and a weak pattern in a second one. Both specimens harbored viral antigens. These findings of viral genome and protein expression suggest that the virus is present in the latent form in the gingiva.

Safety and immunogenicity of Haemophilus type b-tetanus protein conjugate vaccine, mixed in the same syringe with diphtheria-tetanus-pertussis vaccine in young infants

As new vaccines are developed there is increasing interest in reducing the number of injections given to children by combining vaccines in one syringe. We studied the safety and immunogenicity of Haemophilus influenzae type b-tetanus protein conjugate vaccine (PRP-T) administered at ages 2, 4 and 6 months mixed in the same syringe with DTP vaccine and its effects on the seroresponse to DTP vaccine. A group of 112 healthy 2-month-old infants received DTP-PRP-T or DTP-placebo mixed immediately before immunization in the same syringe. The addition of PRP-T to DTP did not increase the rate of local or systemic reactions. After the first, second and third dose, the PRP-T recipients showed a geometric anti-PRP antibody mean of 0.13, 2.31 and 6.40 micrograms/ml vs. 0.07, 0.05 and 0.05 micrograms/ml among the DTP-placebo recipients, respectively. Of the PRP-T recipients, 94 and 98% attained antibody concentration of greater than or equal to 0.15 micrograms/ml protein after the second and third dose, respectively, and 65 and 94% attained a concentration of greater than or equal to 1.0 micrograms/ml after the second and third dose, respectively. At the age of 1 year 94 and 52% of the DTP-PRP-T recipients vs. 12% and 0% of the placebo recipients still maintained titers of greater than or equal to 0.15 and greater than or equal to 1.0 micrograms/ml, respectively. The administration of DTP in the same syringe with PRP-T did not affect significantly the antibody response to diphtheria and tetanus toxoid and to pertussis agglutinins. It is concluded that PRP-T vaccine could be administered in the same syringe as DTP.

Pattern of drug abuse and prevalence of antibodies to human immunodeficiency virus in heroin addicts in Jerusalem, 1989

Intravenous drug abuse is a principal factor in the spread of AIDS. In contrast to many countries in the Western world, most of the heroin addicts in Israel do not inject. This study attempts to clarify the link between the pattern of drug abuse and seroprevalence for human immunodeficiency virus (HIV) among volunteers attending a detoxification clinic in Jerusalem. Three hundred heroin abusers were interviewed about their drug habits and sexual preference. In addition, all participants underwent HIV serological testing. The majority of them took heroin by smoking, with only 19% injecting the drug. None of the participants in the study were HIV seropositive. An association is seen between the pattern of illicit drug use in Israel and the low incidence of AIDS in this country.

Poliomyelitis outbreak in Israel in 1988: a report with two commentaries

An outbreak of 15 cases of paralytic poliomyelitis caused by type 1 poliovirus between July and October, 1988, prompted mass vaccination of the whole Israeli population under the age of 40 years. The focus of the outbreak (12 cases) was the Hadera subdistrict, one of two subdistricts where enhanced inactivated poliovaccine (eIPV) had been the only poliovaccine used for infants since 1982. 9 of the 15 victims were 15 years or older, and 9 had previously been immunised with at least three doses of oral poliovaccine (OPV). The authors are divided in their interpretation of the findings. One group considered that the likely causative factors were the greater susceptibility of young adults previously vaccinated with OPV as well as transmission of wild poliovirus to susceptible people by children with low gut immunity against poliovirus after vaccination with eIPV; they concluded that a vaccination programme combining eIPV with OPV is the best option for Israel in future. The other group believed the causative factors were exposure to contaminated sewage or close social contact within the epidemic foci, the presence of an epidemic strain differing from the wild Mahoney and Sabin type 1 vaccine strains, and the lower seropositivity rates and geometric mean titres of neutralising antibodies to the epidemic than to vaccine strains; they believe that eIPV is the means to achieve effective control of poliomyelitis in Israel.

Rotavirus infection and rotavirus serum antibody in a cohort of children from Gaza observed from birth to the age of one year

Rotaviruses were studied in a cohort of children from Gaza, during their first year of life. Surveillance was effected through visits to the local health clinic by parents and infants, and to a lesser extent, field workers' home visits. The observed rate of diarrhoea (all causes), and of rotavirus-associated diarrhoea was 1.25 and 0.1 episode per child-year, respectively. Of the 130 diarrhoea episodes in the cohort, only 6.9% were rotavirus-associated. Only nine (37.5%) of 24 children in whom rotavirus antigen was detected experienced a bout of diarrhoeal illness. However, 59.2% of cohort children had rotavirus serum antibodies by one year of age. The data indicate that rotavirus excretion in Gazan children tends to be asymptomatic during the first year of life.

How to predict the immune status of poliovirus vaccinees? A comparison of virus neutralization at a very low serum dilution versus ELISA in a cohort of infants

A cohort of children from Gaza was observed from birth to the age of one year. Blood specimens were collected at birth, before and after poliovirus vaccination and at one year of age. Poliovirus immunity before and after vaccination was assessed by ELISA and virus neutralization (NT). Positive predictive values for ELISA were between 81.5% and 90.8%. However, ELISA revealed a high frequency of false negatives, and unacceptably low negative predictive values between 28.6% and 55.4%. The history of poliovirus immunity in the cohort was further investigated by NT. A high level of seropositivity to poliovirus type 1 (PV-1) was found. In cord blood, 83.3% had a NT titre greater than or equal to 4 and 99.0% had a titre greater than or equal to 2. Similarly, by one year of age, 85.7% had a titre greater than or equal to 4 and 90.5% had a titre greater than or equal to 2. Seropositivity to PV-2 and PV-3 were slightly lower, ie 80.8% of children had a PV-2 titre greater than or equal to 4 and 75.4% had a PV-3 titre greater than or equal to 4. As for other developing areas, poliomyelitis eradication in Gaza will come about when universal vaccination fills all 'immunity gaps' and improved sanitation and housing reduces the endemicity of wild polioviruses.

Antibodies to polioviruses in an Israeli population and overseas volunteers

A seroepidemiological survey of prevalence of antibodies to poliovirus types 1-3 was carried out in 1,800 residents of 30 agricultural settlements (kibbutzim) in Israel during 1980 and 1981. The survey showed that in 1980 84%, 90%, and 79% of the kibbutz residents exhibited antibodies to poliovirus types 1-3, respectively. In 1981 the figures were 81%, 91%, and 73%. Significantly lower levels of antibodies for poliovirus type 3 in 1980/1981, and for poliovirus type 1 in 1981, were noticed in the age group 6-17 years compared with the age group of greater than 18 years. Infants and young children of the kibbutzim received the Salk polio vaccine during 1957-1961 and the Sabin oral polio vaccine since 1961. Among overseas volunteers from Western countries who came during 1980 and 1981 to work in the kibbutzim for a limited period of time, 88% exhibited antibodies to poliovirus type 1, 94% to poliovirus type 2, and 75% to poliovirus type 3. No significant differences in the level of antibodies were detected between males and females or between residents in those kibbutzim using or not using wastewater for irrigation.

Prevalence of antibody to current influenza virus strains in adolescents

During the Spring of 1986, 118 pupils aged 15-18 years were surveyed for the presence of humoral antibodies to five influenza strains. Prevalence of humoral immunity (HI) antibodies and immunity was found to be related to the year of the strain's emergence and to length of circulation time in the community. A high percentage of the adolescents were not immune to one or more of the tested strains. More than 40% of the studied group were not immune to the old A strains A/Philipines 2/82 (H3N2) and A/Chile 1/83 (H1N1), nearly 70% were not immune to the two B strains (B/USSR 100/83 and B/Ann Arbor 1/86), and almost the entire group (96%) was unprotected against the recent strain A/Singapore 6/86. Only one pupil was immune to all five strains; 35.6%, 22.2%, 17.8%, and 9.2% were immune to one, two, three, or four of the strains, respectively; and 14.4% were not immune to even one strain.