Immunogenicity and reactogenicity of a highly purified vaccine against tick-borne encephalitis

Development of a highly purified tick-borne encephalitis vaccine : A personal historical account

Before the advent of a vaccine, infections with tick-borne encephalitis (TBE) virus in Austria led to the hospitalization of several hundred and, due to underreporting, possibly more than thousand patients with severe neurological disease every year. In the late 1960s and early 1970s, this country had the highest recorded morbidity of TBE in Europe, but similar endemic risk areas exist in many other European countries as well as Central and Eastern Asia. In this article, I describe my personal recollections of the development of a highly purified TBE vaccine in the late 1970s, to which I contributed as a young post-doctoral scientist mentored by Christian Kunz (then director of the Institute of Virology at the Medical Faculty, University of Vienna) in a collaboration with the Austrian biopharmaceutical company Immuno. Low reactogenicity of the newly developed vaccine was a prerequisite for mass vaccination campaigns in Austria that started in the early 1980s. Because of its excellent immunogenicity, broad application of the highly purified vaccine paved the way for a dramatic reduction of the incidence of TBE in Austria, which is outstanding in Europe and referred to as an Austrian success story of immunoprophylaxis.

Comprehensive assessment of specific antibodies on infectious activity of tick-borne encephalitis virus

Vaccines for prophylactic immunization provide the most reliable and effective protection against the vast majority of infectious diseases. Tick-borne encephalitis (TBE) represents a high-priority medical issue at the territory of the Eurasian continent. Of great importance is assessing a role of distinct antibody titers especially low titers, observed quite often in vaccinated individuals, sometimes posing obstacles in determining a threshold of seropositivity as well as the level of specific protection against TBE virus. We aimed at obtaining data to assess antiviral activity of virus-specific antibodies with distinct titer levels based on the in vitro, ex vivo and in vivo experimental studies with a highly virulent Far-Eastern strain of tick-borne encephalitis virus. The in vitro, ex vivo and in vivo comprehensive experimental studies with a highly virulent Far-Eastern strain of tick-borne encephalitis virus (TBEV) were conducted and the dynamics of antiviral activity of virus-specific antibodies at variable titers (1:100–1:3200) was measured (timeframe ranged within 1–96 hours p.i.) to provide a rationale for evaluating the antiviral immune response. It was found that the in vitro experiments demonstrated that the IgG at 1:100 titer exerted a weak anti-TBEV neutralizing effect at all time-points examined. The IgG 1:400 titer caused a 2 log PFU/mL decline in TBEV Dal strain yield at 72 h post-infection, whereas at 1:3200 titer it completely suppressed TBEV replication throughout the observation period. The ex vivo experiments with blood serum obtained from vaccinated subjects demonstrating a range of TBEV antibody titers (sera from vaccinated individuals with varying anti-TBEV antibody titers) and in vivo (outinbred white mice) experiments revealed a delayed virus elimination for antibody titers at 1:100 and 1:200 as well as rapid virus elimination (1–2 days p.i.) for antibody titers greater than 1:400. Thus, antibody titer at 1:400 may be considered as the universal anti-TBEV protection threshold. In order to properly conclude regarding the revaccination schedule it is advised to start with testing blood serum for durability of anti-TBEV immune response. Subjects with TBEV antibody titers at 1:100 and 1:200 should be strongly recommended to undergo a mandatory revaccination. Such an approach is believed to be the most effective way toward enhancing efficacy of vaccine-mediated protection against TBE.

Tick-borne Encephalitis Vaccines

Tick-borne encephalitis (TBE) is a disease that is found from western Europe across Asia and into Japan. In recent years the incidence rate has been increasing as has the endemic range of the virus. Tick-borne encephalitis is caused by three genetically distinct sutypes of viruses within a single TBE virus (TBEV) serocomplex. These three subtypes consist of Far-eastern subtype TBEV (TBEV-FE), Siberian subtype (TBEV-Sib) and European subtype (TBEV-Eu). Each of these subtypes cause clinically distinct diseases with varying degrees of severity. Development of the first vaccines for TBEV began in the late 1930s shortly after the first isolation of TBEV-FE in Russia. In the 1970s Austria began large scale vaccine production and a nationalized vaccine campaign that significantly reduced the incidence rate of TBE. Currently there are four licensed TBE vaccines, two in Europe and two in Russia. These vaccines are all quite similar formalin-inactivated virus vaccines but the each use a different virus strain for production. Published studies have shown that European vaccines are cross-protective in rodent studies and elicit cross-reactive neutralizing antibody responses in human vaccines. European vaccines have been licensed for a rapid vaccine schedule that could be used in response to a significant outbreak and reasonable neutralizing antibody titers can be achieved after a single dose although a second dose provides nearly complete and long-lasting protection. This review focuses on the current status of licensed TBE vaccines and provides a brief summary of technology currently being developed for new vaccines.

Tick-borne encephalitis

We review the epidemiological and clinical characteristics of tick-borne encephalitis, and summarise biological and virological aspects that are important for understanding the life-cycle and transmission of the virus. Tick-borne encephalitis virus is a flavivirus that is transmitted by Ixodes spp ticks in a vast area from western Europe to the eastern coast of Japan. Tick-borne encephalitis causes acute meningoencephalitis with or without myelitis. Morbidity is age dependent, and is highest in adults of whom half develop encephalitis. A third of patients have longlasting sequelae, frequently with cognitive dysfunction and substantial impairment in quality of life. The disease arises in patchy endemic foci in Europe, with climatic and ecological conditions suitable for circulation of the virus. Climate change and leisure habits expose more people to tick-bites and have contributed to the increase in number of cases despite availability of effective vaccines. The serological diagnosis is usually straightforward. No specific treatment for the disease exists, and immunisation is the main preventive measure.

Field effectiveness of vaccination against tick-borne encephalitis

Tick-borne encephalitis (TBE) is a vaccine-preventable disease caused by a flavivirus (TBE virus) that is endemic in many European countries and large parts of Central and Eastern Asia. In Europe, highly purified formalin-inactivated whole virus vaccines are in widespread use, but the vaccination coverage differs significantly between countries with TBE endemicity. Austria presents an exceptional situation because 88% of the total population have a history of TBE vaccination, with 58% being regularly vaccinated within the recommended schedule. In this study, we investigated the field effectiveness of TBE vaccination in Austria for the years 2000-2006 in different age groups on the basis of the documented numbers of hospitalized cases in unvaccinated and vaccinated people and the sizes of these population groups as revealed by representative inquiries. We show that the overall effectiveness in regularly vaccinated persons is about 99% with no statistically significant difference between age groups. It is at least as high after the first two vaccinations, i.e. before the completion of the basic vaccination scheme by a third vaccination, but is significantly lower (about 95%) in those with a record of irregular vaccination. Our data confirm the excellent performance of TBE vaccine under field conditions and provide evidence that, in Austria, about 2800 cases were prevented by vaccination in the years 2000-2006.

The preclinical testing of a formaldehyde inactivated Ross River virus vaccine designed for use in humans

Ross River virus was grown in industrial facilities in vaccine-certified Vero cells in the absence of serum, inactivated using standard formalin-inactivation protocols, treated with Benzonase to digest host cell DNA and purified on a sucrose gradient. Mice given two subcutaneous injections of 0.625 microg of this vaccine or two doses of 0.156 microg vaccine with aluminium hydroxide adjuvant failed to develop a detectable viraemia after intravenous challenge with 10(6)TCID50 of the prototype strain of Ross River virus (T48). Guinea pigs immunised with one or two10 microg doses of vaccine with adjuvant also failed to develop a detectable viraemia following a similar challenge. The levels of neutralising antibody (neutralisation index 1.9-3.1) in the mice protected against challenge with 10(6)TCID50 Ross River virus were similar to those in 16 former epidemic polyarthritis patients (1.1-3.5) who had not experienced a second clinical infection with Ross River virus in the 20 years following their initial infection.

Study of the serological response after vaccination against tick-borne encephalitis in Sweden

The antibody response to vaccination against tick-borne encephalitis (TBE) with FSME-Immun Inject (Immuno AG/Baxter) was studied in 535 persons, mainly adults, attending a vaccination centre in Stockholm, Sweden. Emphasis was laid on long-term follow-up. Antibody activity was measured by three different serological test systems: a commercial ELISA kit, a hemagglutination inhibition (HI) test and a neutralization test (RFFIT). The neutralization test proved to be the most sensitive assay for the detection of the vaccine response, which was demonstrable in the majority of vaccinees (>90% after three and >98% after four and five vaccinations, respectively). ELISA and HI were less sensitive for antibody measurement during primary immunization. Neutralizing antibody activity persisted prior to the third dose in 77% of the vaccinees and prior to the fourth to sixth doses in 89-95% of the vaccinees. ELISA activity, but no neutralizing activity, was found in some individuals. Based on our data and previous experience of vaccine failures after two doses, a more condensed three-dose vaccination schedule may be advantageous and ought to be tested. The persistence of neutralizing antibodies justifies further studies of the antibody responses after the fourth dose for periods beyond the recommended 3-year booster intervals.

Tick-borne encephalopathies : epidemiology, diagnosis, treatment and prevention

Tick-borne encephalopathies constitute a broad range of infectious diseases affecting the brain and other parts of the CNS. The causative agents are both viral and bacterial. This review focuses on the current most important tick-borne human diseases: tick-borne encephalitis (TBE; including Powassan encephalitis) and Lyme borreliosis. Rocky Mountain spotted fever (RMSF) and Colorado tick fever (CTF), less common tick-borne diseases associated with encephalopathy, are also discussed. TBE is the most important flaviviral infection of the CNS in Europe and Russia, with 10 000-12 000 people diagnosed annually. The lethality of TBE in Europe is 0.5% and a post-encephalitic syndrome is seen in over 40% of affected patients, often producing a pronounced impairment in quality of life. There is no specific treatment for TBE. Two vaccines are available to prevent infection. Although these have a good protection rate and good efficacy, there are few data on long-term immunity. Lyme borreliosis is the most prevalent tick-borne disease in Europe and North America, with >50 000 cases annually. Localised early disease can be treated with oral phenoxymethylpenicillin (penicillin V), doxycycline or amoxicillin. The later manifestations of meningitis, arthritis or acrodermatitis can be treated with oral doxycycline, oral amoxicillin or intravenous ceftriaxone; intravenous benzylpenicillin (penicillin G) or cefotaxime can be used as alternatives. The current use of vaccines against Lyme borreliosis in North America is under discussion, as the LYMErix vaccine has been withdrawn from the market because of possible adverse effects, for example, arthritis. RMSF and CTF appear only in North America. RMSF is an important rickettsial disease and is effectively treated with doxycycline. There is no treatment or preventative measure available for CTF.

Immunogenicity of combination DNA vaccines for Rift Valley fever virus, tick-borne encephalitis virus, Hantaan virus, and Crimean Congo hemorrhagic fever virus

DNA vaccines for Rift Valley fever virus (RVFV), Crimean Congo hemorrhagic fever virus (CCHFV), tick-borne encephalitis virus (TBEV), and Hantaan virus (HTNV), were tested in mice alone or in various combinations. The bunyavirus vaccines (RVFV, CCHFV, and HTNV) expressed Gn and Gc genes, and the flavivirus vaccine (TBEV) expressed the preM and E genes. All vaccines were delivered by gene gun. The TBEV DNA vaccine and the RVFV DNA vaccine elicited similar levels of antibodies and protected mice from challenge when delivered alone or in combination with other DNAs. Although in general, the HTNV and CCHFV DNA vaccines were not very immunogenic in mice, there were no major differences in performance when given alone or in combination with the other vaccines.

Identification and characterization of nonsubstrate based inhibitors of the essential dengue and West Nile virus proteases

The 72 known members of the flavivirus genus include lethal human pathogens such as Yellow Fever, West Nile, and Dengue viruses. There is at present no known chemotherapy for any flavivirus and no effective vaccines for most. A common genomic organization and molecular mechanisms of replication in hosts are shared by flaviviruses with a viral serine protease playing a pivotal role in processing the viral polyprotein into component polypeptides, an obligatory step in viral replication. Using the structure of the dengue serine protease complexed with a protein inhibitor as a template, we have identified five compounds, which inhibit the enzyme. We also describe parallel inhibitory activity of these compounds against the West Nile virus Protease. A few of the compounds appear to provide a template for design of more potent and specific inhibitors of the dengue and West Nile virus proteases. Sequence similarities among flaviviral proteases suggests that such compounds might also possibly inhibit other flaviviral proteases.

Experience in the medical management of potential laboratory exposures to agents of bioterrorism on the basis of risk assessment at the United States Army Medical Research Institute of Infectious Diseases (USAMRIID)

Experience in managing laboratory exposures to potential agents of bioterrorism is limited. The United States Army Medical Research Institute of Infectious Diseases reviewed laboratory exposures involving these agents (1989 to 2002) to assess the effectiveness of medical management. The evaluation of 234 persons (78% vaccinated) for exposure to 289 infectious agents revealed 5 confirmed infections (glanders, Q fever, vaccinia, chikungunya, and Venezuelan equine encephalitis). Postexposure antibiotic prophylaxis was given for most moderate- or high-risk bacterial exposures (41/46; 89%); most unvaccinated minimal-risk (7/10; 70%), and subsets of vaccinated minimal-risk exposures (18/53; 34%) but generally not negligible-risk exposures (6/38; 16%). Vaccine "breakthroughs" were not unexpected (enzootic Venezuelan equine encephalitis, localized vaccinia) or presented with mild symptoms (Q fever). A multifaceted policy of personal protective measures, vaccination, early assessment, and postexposure antibiotic prophylaxis was effective in minimizing morbidity and mortality in at-risk laboratory workers.

Flavivirus Immunization with Capsid-Deletion Mutants: Basics, Benefits, and Barriers

The flaviviruses comprise a number of arthropod-transmitted human disease agents that cause significant and increasing health threats in major parts of the world. The development of new vaccines is of vital importance, but the stringent need for safety, efficacy and cost-effectiveness together with the problems associated with the specific immune pathogenesis of some flavivirus infections impose significant challenges to innovative vaccine research. Using tick-borne encephalitis virus (TBEV) as a model, the viral capsid protein gene was recently identified as a novel target for generating flavivirus vaccines. This approach can be applied to produce either attenuated strains that can serve as live vaccines or to make a new type of a genetic vaccine consisting of non-infectious RNA replicons from which subviral particles are synthesized in vivo. Flaviviruses are small, enveloped viruses with an unsegmented positive-stranded RNA genome encoding a single polyprotein that is cleaved into the individual viral proteins. The specific introduction of various deletions and other mutations into the genomic segment coding for the capsid protein C and the biochemical and immunological characterization of the resulting mutants in cell culture and an animal model have revealed remarkable properties of this building block of the nucleocapsid and yielded information that opened the way for new vaccine approaches. In this review the in vitro and in vivo findings with various capsid deletion mutants of TBEV are summarized and discussed in the context of recent structural and biochemical data obtained for protein C of various flaviviruses. Potential benefits of this new strategy for generating flavivirus vaccines as well as hurdles that still have to be overcome are discussed in comparison to conventional or other experimental approaches. Capsid-deletion mutants can be used to rationally design safe and effective vaccine strains or to create new vaccines that combine advantages of genetic vaccination, conventional inactivated, and live vaccines.

Stimulation of the immune system by different TBE-virus vaccines

Tick-borne encephalitis (TBE) is one of the most frequent arthropod-transmitted viral diseases in Europe. Different vaccines against TBE-virus have been developed; a thimerosal-free and also albumin-free vaccine [Ticovac (Baxter Hyland Immuno, Vienna)] was approved in 2000. Contrary to previous experience, 779 cases of fever occurred following the first vaccination of children under 15 years of age and in 62 children febrile convulsions were even observed. Consequently, the composition of the vaccine was changed and albumin was again added [FSME-Immun (Baxter Vaccines, Vienna)] in 2001. The new Encepur Kinder (Chiron-Behring, Marburg) from 2002 is a TBE-vaccine for children without any protein as stabilizer but with a relatively high concentration of sucrose, while the former vaccine Encepur K from 1991 contained polygeline as the stabilizer. The induction of the immune system by the different TBE virus vaccines was compared in an in vitro test in order to find an explanation for the unexpected fever attacks. Whole blood was stimulated with complete vaccine suspension, and TNF-alpha, IL-1beta, IL-6, and IL-8 were determined from heparin/EDTA-plasma and culture supernatants. It was shown that Ticovac and the new Encepur Kinder can induce relatively high amounts of TNF-alpha and lower amounts of IL-1beta. An increase of both cytokines was first observed following an incubation of 4 hours, with a maximum after 15 hours. Concentrations returned to base-line values within 26 hours. The behaviour of both cytokines correlates with the febrile phases in children up to two years old. Albumin or other proteins like polygeline and also immunoglobulins prevented a rise of cytokines.

Formalin-inactivated whole virus and recombinant subunit flavivirus vaccines

The Flaviviridae is a family of arthropod-borne, enveloped, RNA viruses that contain important human pathogens such as yellow fever (YF), Japanese encephalitis (JE), tick-borne encephalitis (TBE), West Nile (WN), and the dengue (DEN) viruses. Vaccination is the most effective means of disease prevention for these viral infections. A live-attenuated vaccine for YF, and inactivated vaccines for JE and TBE have significantly reduced the incidence of disease for these viruses, while licensed vaccines for DEN and WN are still lacking despite a significant disease burden associated with these infections. This review focuses on inactivated and recombinant subunit vaccines (non-replicating protein vaccines) in various stages of laboratory development and human testing. A purified, inactivated vaccine (PIV) candidate for DEN will soon be evaluated in a phase 1 clinical trial, and a second-generation JE PIV produced using similar technology has advanced to phase 2/3 trials. The inactivated TBE vaccine used successfully in Europe for almost 30 years continues to be improved by additional purification, new stabilizers, an adjuvant, and better immunization schedules. The recent development of an inactivated WN vaccine for domestic animals demonstrates the possibility of producing a similar vaccine for human use. Advances in flavivirus gene expression technology have led to the production of several recombinant subunit antigen vaccine candidates in a variety of expression systems. Some of these vaccines have shown sufficient promise in animal models to be considered as candidates for evaluation in clinical trials. Feasibility of non-replicating flavivirus vaccines has been clearly demonstrated and further development is now warranted.

Antigen dependent adverse reactions and seroconversion of a tick-borne encephalitis vaccine in children

Two randomized, double blind dose comparison studies were conducted in 595 children in Austria and Germany with an albumin-free and thiomersal-free tick-borne encephalitis (TBE) vaccine. Vaccinated subjects of an age between 6 months and 12 years randomly assigned received either the full adult dose or half the adult dose. Results from vaccinated children under 1 year of age at the time of the first vaccination (159 subjects) showed an age dependent immune response. There were significantly fewer adverse systemic events (e.g. fever reactions). In children who received only half the adult dose, while seroconversion was not significantly different (93% versus 98%) after the second vaccination, and 100% for both groups after the third vaccination. Based on these results, it is recommended to vaccinate children between the ages of 1 and 12 years with half the adult dose.

TBE vaccination and the Austrian experience

In the pre-vaccination era, Austria had the highest recorded morbidity of tick-borne encephalitis (TBE) in Europe. The disease accounted for more than 50% of all viral meningoencephalitides in the eastern and southern parts of the country. This prompted us to start a cooperative vaccine development project in 1971 with J. Keppie from the Microbiological Research Establishment, Porton Down, England. After very satisfactory results of field studies, conducted in individuals for whom TBE was classified as occupational disease (forest workers, farmers, etc.), the killed virus vaccine (see chapter by N. Barrett in this issue), was made commercially available by Immuno AG Vienna (now Baxter Health-Care). The vaccine proved to be highly immunogenic and very well tolerated in both adults and children. After completing the series of three vaccinations seroconversion rates of >99% were recorded. In Austria, as in other European countries, TBE is now acquired for the most part during leisure activities. In view of this fact a mass vaccination campaign was initiated in 1981. Subsequently, the vaccination coverage of the Austrian population increased from 6% in 1980 to 86% in 2001, exceeding 90% in some of the high-risk areas. Data annually collected by our surveillance system show that the clinical effectiveness of the vaccine is excellent. Based on the assumption that the whole Austrian population is at risk of infection the calculated rate of protection after three doses of the vaccine is 96-98.7%. Breakthrough disease is rare and affects mainly higher age groups. Since the advent of TBE vaccination only one single case has been observed in the age group up to 20. The increasing vaccination coverage led to a more or less steady decline of TBE, drastically reducing the public health problem that the disease poses in Austria, especially in the provinces, where formerly the highest morbidity rates were observed. For example, in Carinthia, in the years 1973-1982 an average annual incidence of 155 was recorded, compared with only four annual cases in the last 4 years. The Austrian experience shows that containment of a tick-borne viral disease is feasible, provided a well-tolerated and effective vaccine is available that is widely accepted by the general population.

Antibody prophylaxis and therapy for flavivirus encephalitis infections

The outbreak of West Nile (WN) encephalitis in the United States has rekindled interest in developing direct methods for prevention and control of human flaviviral infections. Although equine WN vaccines are currently being developed, a WN vaccine for humans is years away. There is also no specific therapeutic agent for flaviviral infections. The incidence of human WN virus infection is very low, which makes it difficult to target the human populations in need of vaccination and to assess the vaccine's economic feasibility. It has been shown, however, that prophylactic application of antiflaviviral antibody can protect mice from subsequent virus challenge. This model of antibody prophylaxis using murine monoclonal antibodies (MAbs) has been used to determine the timing of antibody application and specificity of applied antibody necessary for successful prophylaxis. The major flaviviral antigen is the envelope (E) glycoprotein that binds cellular receptors, mediates cell membrane fusion, and contains an array of epitopes that elicit virus-neutralizing and nonneutralizing antibodies. The protective efficacy of an E-glycoprotein-specific MAb is directly related to its ability to neutralize virus infectivity. The window for successful application of prophylactic antibody to prevent flaviviral encephalitis closes at about 4 to 6 days postinfection concomitant with viral invasion of the brain. Using murine MAbs to modify human disease results in a human antimouse antibody (HAMA) response that eventually limits the effectiveness of subsequent murine antibody applications. To reduce the HAMA response and make these MAbs more generally useful for humans, murine MAbs can be "humanized" or human MAbs with analogous reactivities can be developed. Antiflaviviral human or humanized MAbs might be practical and cost-effective reagents for preventing or modifying flaviviral diseases.

Albumin is a necessary stabilizer of TBE-vaccine to avoid fever in children after vaccination

A thiomersal-free and also an albumin-free tick-borne encephalitis-vaccine (TBE-vaccine) was developed. This vaccine was approved by the Austrian health authorities in the year 2000. Contrary to previous experience, 779 cases of fever attacks occurred following the first vaccination of children under 15 years of age. The induction of the immune system by different TBE virus (TBEV) vaccines (FSME-Immun [1999], Ticovac [2000] and FSME-Immun [2001] all from Baxter Hyland Immuno, Vienna) was compared in an in vitro immune stimulation test in order to find an explanation for the unexpected fever attacks. It was shown that only Ticovac, which contains no albumin as a stabilizer, can induce relative high amounts of TNF-alpha (P < or = 0.0001) and lower amounts of IL-1 beta (P < or = 0.05). Increase of both cytokines is first observed following an incubation of 4 h. The maximum is reached after 15 h. After 26 h, it has reverted to the original value. The course of concentration of both cytokines corresponds to the time of observed febrile phases. Albumin or immunoglobulin prevents a rise of cytokines so that it is recommended to add the albumin again to the vaccine.

Evaluation of European tick-borne encephalitis virus vaccine against recent Siberian and far-eastern subtype strains

To evaluate the efficacy of the European TBE vaccine in east-Siberian and far-eastern regions of Russia, we examined the immune responses of the vaccine against recent TBE virus Siberian (Irkutsk) and far-eastern (Khabarovsk and Vladivostok) isolates. The sera of vaccinated humans showed efficient neutralizing antibody titers (> or =20) against Siberian and far-eastern strains. To evaluate the efficacy of the vaccine in vivo, mice were vaccinated and challenged with lethal doses of the viruses. All vaccinated mice survived each virus challenge. These results suggest that the European vaccine can prevent the TBE virus infection in east-Siberian and far-eastern regions of Russia.

[Tick-born encephalitis]

INTRODUCTION

Tick-borne encephalitis (TBE), a disease contracted through tick bites, is caused by a Flavivirus. Its geographical distribution comes from the geographical distribution of the reservoir of infection--i.e., mainly the tiny mammals living in the forests and bushes. The endemic area spreads from the Rhine to the Urals, from Scandinavia to Italy and Greece.

CURRENT KNOWLEDGE AND KEY POINTS

Symptoms usually evolve in three phases: at first a nonspecific phase with fever and myalgia, then an afebrile phase, and finally a phase with neurological manifestations, such as meningitis, meningoencephalitis and/or myelitis, and fever. Motor neurological sequelae are possible. The cases occurring in the East are characterized by their greater severity compared to those occurring in the West. The diagnosis, easily established given a history of a tick bite in an endemic area, is confirmed by the presence of specific IgM in the blood and/or cerebral spinal fluid.

FUTURE PROSPECT AND PROJECTS

There is no specific treatment. Prevention consists of individual prophylactic measures (self-examination and systematic extraction of ticks after exposure, use of repellents), and in immunization. The vaccine, prepared from inactivated viruses, should be used for target populations, that is, for people exposed to tick bites during their professional or leisure outdoor activities.

Evaluation of tick-borne encephalitis DNA vaccines in monkeys

Tick-borne encephalitis is usually caused by infection with one of two flaviviruses: Russian spring summer encephalitis virus (RSSEV) or Central European encephalitis virus (CEEV). We previously demonstrated that gene gun inoculation of mice with naked DNA vaccines expressing the prM and E genes of these viruses resulted in long-lived homologous and heterologous protective immunity (Schmaljohn et al., 1997). To further evaluate these vaccines, we inoculated rhesus macaques by gene gun with the RSSEV or CEEV vaccines or with both DNA vaccines and compared resulting antibody titers with those obtained by vaccination with a commercial, formalin-inactivated vaccine administered at the human dose. Vaccinations were given at days 0, 30, and 70. All of the vaccines elicited antibodies detected by ELISA and by plaque-reduction neutralization tests. The neutralizing antibody responses persisted for at least 15 weeks after the final vaccination. Because monkeys are not uniformly susceptible to tick-borne encephalitis, the protective properties of the vaccines were assessed by passive transfer of monkey sera to mice and subsequent challenge of the mice with RSSEV or CEEV. One hour after transfer, mice that received 50 microl of sera from monkeys vaccinated with both DNA vaccines had circulating neutralizing antibody levels <20-80. All of these mice were protected from challenge with RSSEV or CEEV. Mice that received 10 microl of sera from monkeys vaccinated with the individual DNA vaccines, both DNA vaccines, or a commercial vaccine were partially to completely protected from RSSEV or CEEV challenge. These data suggest that DNA vaccines may offer protective immunity to primates similar to that obtained with a commercial inactivated-virus vaccine.

Protection against tick-borne encephalitis virus isolated in Japan by active and passive immunization

In order to establish a firm preventive measure for tick-borne encephalitis (TBE) in Japan, we evaluated the immune response of European vaccine against Japanese TBE virus strain (Oshima 5-10) for man and mouse. Furthermore, the efficacy of pre- and post-exposure protection by a polyclonal rabbit anti-TBE virus serum was examined in the mouse model. 80% of vaccinees seroconverted against Oshima 5-10 strain after the 2nd immunization of vaccine and the remaining 20% seroconverted after the 3rd immunization. Two persons with pre-existing anti-Japanese encephalitis virus (JEV) antibodies showed low immune responses against TBE virus. In mouse vaccination and challenge tests, efficient protection was observed in mice challenged with lethal doses of Oshima 5-10 strain as well as those observed in mice with the Western subtype and the Far Eastern subtype of TBE strains. Pre-exposure treatment with rabbit anti-TBE virus serum provided complete protection against lethal challenge with Oshima 5-10 strain. For post-exposure treatment with the antibody, significant protection was observed when mice were treated 24 h after virus challenge, whereas it was not observed 48 h after virus challenge. reserved.

Humoral and cellular immunity induced by antigens adjuvanted with colloidal iron hydroxide

The immunopotentiating activities of colloidal iron hydroxide, a novel, experimental mineral adjuvant, and of aluminium hydroxide. the licensed adjuvant for human vaccines, were compared. Our studies revealed that colloidal iron hydroxide and aluminium hydroxide behaved comparably with respect to supporting induction of an antibody response to tetanus toxoid. Furthermore, mice immunized with both, the experimental vaccine (tick-borne encephalitis virus (TBEV) antigen adsorbed to colloidal iron hydroxide) or with a commercially available TBEV vaccine (adjuvanted with aluminium hydroxide), developed long-lasting antibody responses which protected the animals from TBEV infection even one year after vaccination. The use of colloidal iron hydroxide as adjuvant had the additional advantage to reproducibly support induction of HIV-1 envelope-specific cytotoxic T lymphocytes (CTL), when used as adjuvant for a HIV-1 env-carrying recombinant fowlpox virus and being applied via the subcutaneous route. Aluminium hydroxide was much less active in this respect. Non-adjuvanted recombinant fowlpox elicited CTLs only when given intravenously or intraperitoneally, vaccination routes considered not to be suitable for routine use in humans. Further studies to evaluate the use of colloidal iron as possible alternative and/or supplement for routinely used mineral adjuvants may therefore be warranted.

Vaccination against tick-borne encephalitis under therapeutic immunosuppression. Reduced efficacy in heart transplant recipients

Patients after organ transplantation are at an increased risk of microbial infections and might benefit from active vaccination. Due to therapeutic immunosuppression the efficacy of immunizations is, however, reduced and difficult to predict. Efficacy of vaccination against tick-borne encephalitis (TBE) using an abbreviated immunization schedule was compared in 31 heart transplant recipients (age: 54.5 +/- 11.5 years, mean time after transplantation: 53.5 +/- 23.7 months) under cyclosporine-based immunosuppression and 29 controls. TBE vaccination was well tolerated by the transplant recipients; spectrum and frequency of adverse events were similar to controls. In the transplant patients, seroconversion rate (35% versus 100%; p < 0.001) and the geometric mean of post-vaccinal antibody titres (0.98 (SF: 2.3) U/ml versus 5.46 (2.2) U/ml; p < 0.001) were markedly reduced in comparison to the control group. No clinical or demographic predictors of vaccination success could be established in the transplant patients. Due to the limited efficacy, TBE vaccination cannot be recommended as a routine procedure in heart transplant recipients at risk of TBE virus infection. TBE vaccination may be performed safely in selected cases, but repeated titre controls to confirm vaccination success would be required.

Adverse reactions to tick-borne encephalitis vaccine: FSME-Immun

Vaccination against tick-borne encephalitis with FSME-Immun vaccine was started in the Department of Infectious Diseases, University Medical School of Białystok, Poland, in 1992. No serious adverse reactions after vaccine administration were observed. Post-vaccine side effects were reported in 242 (11.3%) persons after the first dose (n = 2,135) and only in 14 patients (1.2%) after the second one (n = 1,183). These effects were mild and transitory. No relationship was observed between the frequency of adverse reactions, general or local, and the initial anti-TBE virus antibody titres or the age of the immunized individuals. Post-vaccine side effects were reported significantly more frequently among people not bitten by ticks.

Vaccination against tick-borne encephalitis virus, a flavivirus, prevents disease but not infection, although viremia is undetectable

By adoptive transfer of sera or immunoglobulin preparations, vaccine-induced protection against TBEV has been demonstrated to be mediated by antibodies to the surface protein of TBEV, glycoprotein E. Nevertheless, the mechanism of vaccine-induced protection against TBEV remains unclear. Protection by E antibodies without in vitro neutralization was shown by one group, whereas others found a correlation between protection in vivo and neutralization in vitro. Here, the authors confirm in a mouse model of tick-borne encephalitis (TBE) that immunization with the whole-killed virus vaccine protects mice against a subsequent challenge with a highly lethal dose of virus, i.e. 250 LD50 doses. Vaccine-induced immunity, however, is not completely neutralizing as demonstrated by the development of immune responses to a non-structural virus protein absent from the vaccine, yet expressed in the course of virus replication. Antibodies specific for the non-structural protein 1 (NS1) and cytotoxic T-cells could be detected after, but not prior to, virus challenge of vaccinated animals, establishing that protection by this highly effective vaccine is not equivalent with complete neutralization of the challenge virus.

Concomitant infection with tick-borne encephalitis virus and Borrelia burgdorferi sensu lato in patients with acute meningitis or meningoencephalitis

From September 1992 to August 1993, 338 patients over the age of 15 years presented to the Department of Infectious Diseases, University Medical Centre Ljubljana, with acute lymphocytic meningitis. In 89 of these patients (26.3%) serum IgM and IgG antibodies against tick-borne encephalitis (TBE) virus were detected, and in 59 patients (17.5%) a borrelial etiology of disease was demonstrated by one or more of the following presence of intrathecal antibody production, seroconversion to borrelial antigens, presence of erythema migrans, and/or isolation of Borrelia burgdorferi sensu lato from skin or cerebrospinal fluid. Of the 148 patients who fulfilled criteria for TBE or borrelial infection, concomitant infection with TBE virus and B. burgdorferi sensu lato was demonstrated in 12 patients (3.6% of all patients presenting with acute lymphocytic meningitis). In the majority of patients with concomitant infection the clinical features at presentation were characteristic of, or consistent with, TBE. In addition, during follow-up studies, eight of the 12 patients subsequently developed signs and symptoms compatible with minor and/or major manifestations of Lyme borreliosis. Six patients were diagnoses with neuroborreliosis based on signs or symptoms and/or laboratory tests. These findings show that in patients with acute lymphocytic meningitis or meningoencephalitis, originating in TBE and Lyme borreliosis endemic regions, the possibility of concomitant infection should be considered.

Naked DNA vaccines expressing the prM and E genes of Russian spring summer encephalitis virus and Central European encephalitis virus protect mice from homologous and heterologous challenge

Naked DNA vaccines expressing the prM and E genes of two tick-borne flaviviruses, Russian spring summer encephalitis (RSSE) virus and Central European encephalitis (CEE) virus were evaluated in mice. The vaccines were administered by particle bombardment of DNA-coated gold beads by Accell gene gun inoculation. Two immunizations of 0.5 to 1 microg of RSSE or CEE constructs/dose, delivered at 4-week intervals, elicited cross-reactive antibodies detectable by enzyme-linked immunosorbent assay and high-titer neutralizing antibodies to CEE virus. Cross-challenge experiments demonstrated that either vaccine induced protective immunity to homologous or heterologous RSSE or CEE virus challenge. The absence of antibody titer increases after challenge and the presence of antibodies to E and prM, but not NS1, both before and after challenge suggest that the vaccines prevented productive replication of the challenge virus. One vaccination with 0.5 microg of CEE virus DNA provided protective immunity for at least 2 months, and two vaccinations protected mice from challenge with CEE virus for at least 6 months.

Detection of tick-borne encephalitis virus by sample transfer, plaque assay and strand-specific reverse transcriptase polymerase chain reaction: what do we detect?

Experimental inoculation of mice provides a well characterized model for studying infection with tick-borne encephalitis virus (TBEV), a flavivirus pathogenic for humans. Conflicting data on the kinetics of viremia and the development of virus titers in the brain, however, were only recently shown to have resulted from the use of assay systems with different levels of sensitivity in the titration of TBEV, i.e. plaque assay or sample transfer into naive recipient mice. Theoretically, RT-PCR could extend further the detectability to antibody-neutralized virus and when undertaken strand-specifically discriminate active replication from the mere presence of TBEV. We have compared the conventional methods for detection of TBEV with a newly devised RT-PCR method. As expected, RT-PCR, in contrast to the infectivity assays, detected antibody-neutralized virus. Furthermore, the mere presence or active replication of the virus could be differentiated by strand-specific RT-PCR. Plaque assay and sample transfer, in contrast, both detected only infectious virus. However, whereas sample transfer provides higher sensitivity for detection of TBEV from solid organs, the plaque assay is less costly and considering animals welfare more convenient. Thus, the newly devised method may allow the resolution of unanswered questions, while both the traditional infectivity assays retain their benefits in certain situations.

Intrathecal IgM, IgA and IgG antibody response in tick-borne encephalitis. Long-term follow-up related to clinical course and outcome

BACKGROUND

Tick-borne encephalitis (TBE) of western subtype causes long-term morbidity and is considered a health problem in Scandinavia, eastern and central parts of Europe and Russia. The pathophysiology is not fully elucidated. As TBE RNA is rarely demonstrable in cerebrospinal fluid (CSF) the kinetics of the CSF antibody response to the disease has attracted attention.

OBJECTIVES

To investigate the intrathecal TBE-specific antibody response and to correlate its intensity and persistence to the clinical course. To compare indirect, commercially-based ELISA methods indexed against albumin ratio or IgG ratio with the capture ELISA method for the establishment of CSF response.

STUDY DESIGN

The specific IgM, IgG and IgA antibody responses in serum and CSF were analysed in 69 Swedish patients included in a prospective study of TBE from the acute phase up to 11-13 months after onset.

RESULTS

Antibody response by all three classes was demonstrable in serum and CSF. All methods were useful, but capture technique was the most sensitive and results were easiest to interpret. Peak IgM activity was seen early during the disease and persisted after 6 weeks. Maximum IgG levels were encountered in late convalescent samples (median 6 weeks). Intrathecal antibody production was demonstrable in nearly all patients: in 41% days 0-6, in 97% days 7-19, in 98% days 21-61 and-at lower levels-in 84% of the patients after 1 year (50/52 of CSF-serum sampled in the interval 11-61 days). Day 9 after onset, patients with dominating encephalitic symptoms showed significantly lower intrathecal IgM activity. The persistence of serum and CSF antibodies did not correlate to severity of disease.

CONCLUSIONS

Capture IgM and IgG assays were superior to indirect ELISA. Low early CSF IgM response correlated to encephalitic symptoms, otherwise the intensity and duration of intrathecal antibody response were of limited value for the prediction of clinical course and long-term outcome.

Pre- and postexposure protection by passive immunoglobulin but no enhancement of infection with a flavivirus in a mouse model

Antibody-dependent enhancement of flavivirus infection, which except for dengue virus is without clear proof in vivo, is still under debate. Recently, postexposure immunoglobulin prophylaxis against tick-borne encephalitis virus, a flavivirus, was claimed to possibly have worsened the outcome of infection due to antibody-dependent enhancement. In the present study, antibody-dependent enhancement and pre- or postexposure protection by passive administration of tick-borne encephalitis virus immunoglobulin were evaluated in a mouse model. Preexposure treatment with homologous murine or heterologous human immunoglobulin provided complete protection against lethal challenge with tick-borne encephalitis virus. For postexposure treatment with antibody, the degree of protection correlated with the amount of immunoglobulin administered and was inversely related to the time interval between infection and treatment. Indications of enhancement of infection would have been increased lethality or reduced mean survival time, but neither was observed under the conditions used in our experiments despite the broad range of immunoglobulin and virus challenge doses applied. In contrast to these in vivo results, antibody-dependent enhancement of tick-borne encephalitis virus infection of murine peritoneal macrophages was readily demonstrable in vitro. Thus, antibody-dependent enhancement of viral infection in vitro does not necessarily predict enhancement in vivo.

Recombinant and virion-derived soluble and particulate immunogens for vaccination against tick-borne encephalitis

Using different forms of the envelope glycoprotein E from tick-borne encephalitis virus we investigated the influence of physical and antigenic structure on the efficacy of vaccination. Different protein E-containing preparations were either derived from purified virions or were produced as recombinant proteins in COS cells. These included soluble dimeric forms (virion-derived protein E dimers with and without membrane anchor; recombinant protein E dimers without membrane anchor), micellar aggregates of protein E (rosettes), and recombinant subviral particles (RSPs). The structural differences between these immunogens were verified by sedimentation analysis, immunoblotting and epitope mapping with a panel of monoclonal antibodies. Specific immunogenicities were determined in mice in comparison to formalin-inactivated whole virus. Rosettes and RSPs were excellent immunogens and exhibited similar efficacies as inactivated virus in terms of antibody induction and protection against challenge, whereas all of the soluble forms were much less immunogenic. These data emphasize the importance of the immunogen's antigenic and physical structure for an effective stimulation of the immune system and indicate that RSPs represent an excellent candidate for a recombinant vaccine against tick-borne encephalitis.

The molecular biology of tick-borne encephalitis virus. Review article

Tick-borne encephalitis (TBE) virus is a member of the flavivirus genus and the family Flaviviridae. Like other flaviviruses such as yellow fever, Japanese encephalitis or the dengue viruses, it is an important human pathogen, endemic in many European countries, Russia and China. The disease can be effectively prevented by vaccination with a formalin-inactivated whole virus vaccine. In recent years major advances have been made in the understanding of the molecular biology of TBE virus, including the complete sequence analysis of the genomic RNA of the European and Far Eastern strains. As shown in these studies, the virion RNA contains a single long open reading frame that codes for the structural proteins at the 5' end and the nonstructural proteins at the 3' end. Co- and posttranslational cleavages by a viral and cellular proteases lead to the formation of individual viral proteins. The mature virion is composed of an isometric capsid surrounded by a lipid envelope with two membrane-associated proteins. One of these, protein E, is of paramount importance for several important viral functions, especially during the entry phase of the viral life cycle. Protein E is also responsible for the induction of a protective immune response. A detailed map of antigenic sites has been established and the structure of an anchor-free form of E is currently being investigated by X-ray diffraction analysis. Understanding the molecular basis of the functions of this protein together with the knowledge of its three-dimensional structure may provide clues for developing specific antiviral agents. Protein E has also been shown to be an important determinant of virulence, with single amino acid substitutions at selected sites leading to attenuation. Engineering of such mutations into cDNA clones to produce new recombinant viruses may open up new avenues for the development of live vaccines.

Clinical manifestations and antibody prevalence of Lyme borreliosis and tick-borne encephalitis in Sweden: a study in five endemic areas close to Stockholm

Five populations, including 903 individuals living in 5 different areas close to Stockholm, were studied with regard to clinical manifestations and antibody prevalence of Lyme borreliosis (LB) and tick-borne encephalitis (TBE). The study areas involved 4 groups of islands in the Baltic Sea and 1 island in Lake Mälaren. Serum samples from each individual were tested for antibody activity to Borrelia burgdorferi using a sonicated whole spirochete antigen in an ELISA, and to TBE-virus (TBEV) by ELISA and haemagglutination inhibition. A history of LB was reported by 1-21% and antibodies to Borrelia burgdorferi were found in 7-29% of the participants from the various areas. An increasing seroprevalence with age was seen. In sera from 3 different control groups, including 502 individuals living in non-endemic areas, antibodies to Borrelia burgdorferi were detected in 1-2% and from 1 control group including 150 individuals living in the city of Stockholm, in 9%. A history of TBE was reported by 0-6% of the individuals and in non-immunized individuals seropositivity was seen in 4-22%, depending on the area investigated. No antibody activity to TBEV could be detected in sera from persons in the 3 control groups living in non-endemic areas, whereas 5% of the controls from Stockholm were found to be positive. The prevalence rates of antibodies to TBEV in persons vaccinated against TBE were 40%, 53% and 79% after 1, 2 and 3 injections, respectively.

Cellular and humoral immune responses in haemophiliacs after vaccination against tick-borne encephalitis

The primary immune response to a viral antigen (tick-borne encephalitis, TBE) has been determined in haemophiliacs. Twelve HIV-negative and four clinically asymptomatic, HIV-positive haemophiliacs as well as 16 age-matched healthy controls were included in the study. Antibody responses after TBE vaccination were comparable in HIV-negative haemophiliacs and controls; however, antibody titres in HIV-infected haemophiliacs were significantly lower after completion of the three-dose vaccination schedule (geometric mean reciprocal antibody titres (SEM): controls, 193 (1.37), HIV-positive haemophiliacs, 13 (2.18), P < 0.005). TBE vaccination failed to induce a T cell proliferative response in the HIV-positive haemophiliacs. While in HIV-negative patients the antigen-specific lymphoproliferative responses after primary and one booster vaccination were comparable to those of the controls, cellular responses were decreased in HIV-negative haemophiliacs following a second booster immunization 19 months after primary immunization (3H-thymidine incorporation, delta dpm, mean +/- SEM: controls, 34662 +/- 7129, HIV-negative haemophiliacs, 14339 +/- 7420, P < 0.005). As the protective mechanisms for TBE infection are not yet completely understood, further work will be necessary to determine whether the decreased capacity to mount a sufficient long-term cellular memory response in HIV-negative haemophiliacs might be important for the protective effect of TBE vaccination in this population.

Two-year survey of the incidence of Lyme borreliosis and tick-borne encephalitis in a high-risk population in Sweden

A survey was made over a two-year period (September 1987 to August 1989) of a population living in an area endemic for Lyme borreliosis and tick-borne encephalitis in Sweden. For each patient a blood sample was collected and a questionnaire completed annually. All sera were tested for an antibody response to Borrelia burgdorferi in an EIA using sonicated antigen and for an antibody response to the tick-borne encephalitis virus using an EIA and a haemagglutination inhibition test. Antibodies to Borrelia burgdorferi and tick-borne encephalitis virus were detected in 89 (25.7%) and 40 (11.6%) respectively of 346 samples collected in August 1987. In the first year of the study 14 of 303 subjects (4.6%) developed Lyme borreliosis and in the second year 9 of 277 subjects (3.2%). A significant increase in the antibody titre for Borrelia burgdorferi was seen in 14 of 303 (4.6%) subjects in the first year and 8 of 277 (2.9%) subjects in the second year. An earlier episode of Lyme borreliosis or an elevated antibody titre did not seem to protect against reinfection. One case of tick-borne encephalitis was seen each year. Seroconversion for tick-borne encephalitis virus was found in 3 of 258 (1.2%) subjects in the first year and 5 of 211 (2.4%) in the second year, excluding subjects who had undergone successful immunisation or had earlier been hospitalised for tick-borne encephalitis. The study thus demonstrated a high yearly incidence of tick-borne infections in a population at risk.

Characterization of the hepatitis C virus E2/NS1 gene product expressed in mammalian cells

Truncated and full-length versions of the hepatitis C virus protein domain encoding a presumptive envelope glycoprotein designated E2/NS1 were stably expressed in CHO cell lines. Characterization of the processing events involved in the maturation of E2/NS1 revealed that a high-mannose form resident in the endoplasmic reticulum was the most abundant form detected intracellularly. The ionophore carboxyl cyanide m-chlorophenyl-hydrazone was used to show that the E2/NS1 glycoprotein resided in the endoplasmic reticulum. The full-length form of E2/NS1 appeared to be cell-associated and could not be detected as a secreted product. C-terminal truncated molecules could be detected in the extracellular media as fully processed glycoproteins containing terminal sialic acid additions. These truncated glycoproteins are predicted to be biologically relevant targets of the host immune response and are therefore potential subunit vaccine candidates.

Molecular epidemiology of tick-borne encephalitis virus: cross-protection between European and Far Eastern subtypes

Tick-borne encephalitis virus isolates from widely separated geographic regions of the USSR, six isolates from Hungary and one from France were compared with the European and Far Eastern prototype viruses. Peptide mapping by limited proteolysis yielded similar patterns for five selected isolates from the USSR. All isolates from Hungary and France exhibited the same reactivity pattern with a panel of 16 protein E-specific monoclonal antibodies, whereas 10 out of 12 isolates from the Soviet Union showed minor differences at certain epitopes. However, no correlation between geographic origin of the isolates and their antigenic structure was observed. No statistically significant difference in the degree of protection was detected when mice were immunized with the European prototype vaccine and challenged with three selected Asian isolates and one from the European part of the USSR.

A randomized phase II study of a new tick-borne encephalitis vaccine using three different doses and two immunization regimens

A new, highly purified inactivated tick-borne encephalitis (TBE) vaccine (FSME-Vaccine Behring, BI 71.061) was recently registered in Germany. A multinational phase II study was performed in seven centres located in areas endemic for TBE. A total of 379 healthy adults were randomly allocated into three dosage groups (1.0, 1.5 and 2.0 micrograms antigen per dose, respectively) and into two immunization schedules [vaccination with one dose of 0.5 ml intramuscularly on days 0, 7 and 21 (abbreviated schedule), or on days 0, 28 and 300 (conventional schedule)]. Antibody response to vaccination was assayed by enzyme-linked immunosorbent assay (ELISA), haemagglutination inhibition test (HIT) and neutralization test (NT). Seroconversion rates in the different groups 28 days after one single dose were 75.3-83.5% in ELISA, 35.8-50.6% in HIT, and 100% in NT. All vaccinees showed seroconversion in all tests on day 42 in the conventional schedule and on day 35 in the abbreviated schedule, with the exception of one subject, who remained seronegative in HIT only. Geometric mean titres (GMT) of about 3000 in ELISA were achieved by two vaccinations in the conventional schedule and showed a booster increase to 5500-8000 GMT after revaccination on day 300. Overall frequency of adverse events (related and unrelated) was 37% (conventional schedule) and 46% (abbreviated schedule) after the first, 9% and 21% after the second, and 5% and 15% after the third vaccination, respectively. Generally, side effects were mild and transient, including mainly headache, fever, malaise and local irritation. Serious, vaccine-related side effects did not occur.(ABSTRACT TRUNCATED AT 250 WORDS)

Vaccines for foreign travel

Exotic infections are a significant threat to the child traveling to or going to live in the developing world. Vaccines are available that can prevent some of these infections. It is essential that basic routine childhood vaccination be up to date and that necessary modifications be made from the usual schedule in the United States. The current requirements and local disease conditions (both endemic and epidemic) for each country to be visited must be known so that appropriate vaccines are received. Resources for this information are listed. Details for each vaccine are given, including indications, dose, booster, side effects, contraindications, and other specific information.

Antibody response to gp E of tick-borne encephalitis virus: comparison between natural infection and vaccination breakdown

Human sera obtained after tick-borne encephalitis (TBE) without prior vaccination were compared with sera from patients after a vaccination breakdown. Most sera previously shown to have high titers of IgG and IgM against TBE virus as detected in the ELISA and hemagglutination inhibition (HI) tests also reacted in Western blot with TBE virus E protein which is involved in virus neutralization. The serum of a patient with a vaccination breakdown, however, reacted only very weakly with the E protein in the Western blot in spite of a high amount of antibodies detectable in ELISA. Using SDS-denaturated virus as an antigen in ELISA (imitating the blotting condition), this serum revealed a significant reduction in its reactivity with denatured virus compared to the control sera. This indicates that the patient had an insufficient immune response against certain denaturation resistant epitopes which might contribute to development of disease despite vaccination. The analysis of the immune response of human sera at the epitope level revealed a characteristic "fingerprint" for each serum reflecting the genetic control of the production of antibody populations against different antigenic determinants.

A new vaccine against tick-borne encephalitis: initial trial in man including a dose-response study

A new vaccine against tick-borne encephalitis was investigated in 56 healthy volunteers randomized for five different doses of antigen in a comparative group trial. Good tolerability and high immunogenicity were found using three different antibody test systems. The dose response study revealed that there was a strong relationship between the amount of antigen administered and the antibody response over the range of 0.03-3.0 micrograms antigen per dose.

Prevalence of tick-borne encephalitis and Lyme borreliosis in a defined Swedish population

Sera from 346 individuals living on Lisö, an area south of Stockholm, endemic for tick-borne encephalitis (TBE) and Lyme borreliosis, were tested for antibody activity to TBE-virus (TBEV) and Borrelia burgdorferi, using a sonicate antigen, by haemagglutination-inhibition and ELISA, respectively. 10/346 (3%) individuals had a history of previous serologically confirmed TBE with encephalitic symptoms, and 33/346 (10%) had a history of previous erythema chronicum migrans (ECM). Four individuals (1%) had been treated for neuroborreliosis and another 4 (1%) for acrodermatitis chronica atrophicans (ACA). Antibodies to TBEV and B. burgdorferi were detected in 40/346 (12%) and 89/346 (26%) individuals, respectively. The seroprevalence of Lyme borreliosis increased with age, time spent on Lisö, and number of reported tick-bites. For TBE there was a correlation between seropositivity and time spent on Lisö only. In sera from 50 healthy blood-donors, living in a non-endemic area, no antibody activity to TBEV could be detected and only 1/50 (2%) had antibodies to borrelia. In sera from 150 age and sex matched control individuals, living in the city of Stockholm, antibody activity to TBEV and borrelia was found in 8/150 (5%) and 13/150 (9%), respectively.