Prevention of invasive Haemophilus influenzae type b disease: lessons from vaccine efficacy trials

Glycoconjugate Vaccines for Prevention of Haemophilus influenzae Type b Diseases

This review summarizes the experience in laboratory- and industrial-scale syntheses of glycoconjugate vaccines used for prevention of infectious diseases caused by Haemophilus influenzae type b bacteria based on the linear capsular polysaccharide poly-3-β-D-ribosyl-(1→1)-D-ribitol-5-phosphate (PRP) or related synthetic oligosaccharide ligands. The methods for preparation of related oligosaccharide derivatives and results of the studies evaluating effect of their length on immunogenic properties of the conjugates with protein carriers are overviewed.

Vi capsular polysaccharide: Synthesis, virulence, and application

Vi capsular polysaccharide, a linear homopolymer of α-1,4-linked N-acetylgalactosaminuronate, is characteristically produced by Salmonella enterica serovar Typhi. The Vi capsule covers the surface of the producing bacteria and serves as an virulence factor via inhibition of complement-mediated killing and promoting resistance against phagocytosis. Furthermore, Vi also represents a predominant protective antigen and plays a key role in the development of vaccines against typhoid fever. Herein, we reviewed the latest advances associated with the Vi polysaccharide, from its synthesis and transport within bacterial cells, mechanisms involved in virulence, immunological characteristics, and applications in vaccine, as well as its purification and detection methods.

The impact of routine infant immunization with Haemophilus influenzae type b conjugate vaccine in Malawi, a country with high human immunodeficiency virus prevalence

Malawi has extreme poverty and a high-human immunodeficiency virus (HIV) prevalence. Following Haemophilus influenzae type b (Hib) conjugate vaccine introduction during 2002, we evaluated vaccine impact by reviewing hospital surveillance data for acute bacterial meningitis in Blantyre district among children age 1-59 months admitted during 1997-2005. Documented annual Hib meningitis incidence rates decreased from 20-40/100,000 to near zero among both rural and urban residents despite no change in pneumococcal meningitis incidence rates. Before vaccine introduction, an average of 10 children/year had Hib meningitis and HIV infection compared to 2/year during 2003-2004 and none during 2005. Vaccine effectiveness was high following two or more doses of vaccine. The most urgent future need is for a sustainable routine infant immunization program, including a less expensive vaccine that preferably is delivered in a multivalent form.

Biologic properties and vaccine potential of the staphylococcal poly-N-acetyl glucosamine surface polysaccharide

Staphylococci have become the most common causes of nosocomial bacterial infections, and this fact, along with increasing problems associated with antimicrobial resistance, spurs the need for finding immunotherapeutic alternatives to prevent and possibly treat these infections. Most virulent, clinical isolates of both coagulase-negative staphylococci (CoNS) and Staphylococcus aureus carry the ica locus which encodes proteins that synthesize a polymer of beta-1-6 linked N-acetyl glucosamine residues (PNAG). Animal studies have shown purified PNAG can elicit protective immunity against both CoNS and S. aureus, suggesting its potential as a broadly protective vaccine for many clinically important strains of staphylococci.

Changes in treatment strategies for acute otitis media after full implementation of the pneumococcal seven valent conjugate vaccine

BACKGROUND

Administration of the pneumococcal seven valent conjugate vaccine (PCV-7) results in significant reductions in the incidence of invasive pneumococcal disease and nasopharyngeal colonization rates; however, the reduction in the overall incidence of acute otitis media (AOM) is minimal. Despite an ongoing shortage of PCV-7 in the United States, during which children are receiving fewer doses at longer intervals than the recommended dosing schedule, the incidence of invasive pneumococcal disease in young children has continued to decrease.

PURPOSE

The purpose of this article is to review why the reported effect of PCV-7 on AOM infection rates does not match the reduction in invasive pneumococcal disease or the reduction in nasopharyngeal carriage of Streptococcus pneumoniae.

METHODS

The potential effect of a fully implemented PCV-7 schedule on AOM infections is calculated based on serotype-specific AOM reduction rates observed in clinical studies. Clinical success rates of various antimicrobials used in the treatment of AOM in children fully immunized with PCV-7 also are calculated based on projected PCV-7-induced changes in pathogen profiles and documented antimicrobial resistance rates. Questions regarding potential serotype substitution in children with AOM but not invasive pneumococcal disease, the increased incidence of infection with Haemophilus influenzae in children immunized with PCV-7 and the possibility of herd immunity also will be addressed.

RESULTS

Although the majority of penicillin-nonsusceptible S. pneumoniae are included in PCV-7, AOM caused by these strains will not completely disappear, especially in children 24 months of age and younger.

CONCLUSIONS

Consequently, clinicians must continue to consider penicillin-nonsusceptible pneumococci when prescribing antimicrobials for AOM.

The introduction of routine Haemophilus influenzae type b conjugate vaccine in Chile: a framework for evaluating new vaccines in newly industrializing countries

OBJECTIVE

To determine the burden of Haemophilus influenzae type b (Hib) disease, the safety and immunogenicity of Hib conjugate vaccine, the practicality of combining Hib conjugate and diphtheria-tetanus-pertussis vaccines and the effectiveness of routine vaccination.

STUDY DESIGNS

A series of studies were carried out involving infants and children in Santiago, Chile. The study designs included retrospective surveillance, cost-benefit analysis, randomized placebo-controlled trials of safety and immunogenicity and a Phase IV postlicensure evaluation of vaccine effectiveness.

RESULTS

The studies included in this stepwise process showed that Hib invasive disease was a significant public health problem with a substantial economic burden; that combining Hib conjugate and diphtheria-tetanus-pertussis vaccines was practical, safe and elicited a strong immunologic response; and that the combined formulation afforded a high level of protection against invasive Hib disease (90% effectiveness).

CONCLUSIONS

In July, 1996, Chile became only the third newly industrializing country to introduce routine Hib conjugate vaccination. New vaccines, such as Hib conjugates, will be more expensive than existing ones. The stepwise process used in Chile may serve as an example for the evaluation of new vaccines in nonindustrialized countries.

Large scale, postlicensure, selective vaccination of Chilean infants with PRP-T conjugate vaccine: practicality and effectiveness in preventing invasive Haemophilus influenzae type b infections

BACKGROUND

Haemophilus influenzae type b (Hib) conjugate vaccines have demonstrated an impressive impact in diminishing Hib disease in industrialized countries. However, their high cost prompts nonindustrialized countries to corroborate their effectiveness under local conditions before considering their programmatic implementation. Such a postlicensure evaluation of vaccine effectiveness was undertaken in Chile.

METHODS

After its licensure in Chile polyribosylribitol phosphate-tetanus toxoid protein conjugate vaccine (PRP-T), combined with diphtheria-tetanus-pertussis vaccine, was introduced into the Expanded Program on Immunization schedules in 36 health centers throughout metropolitan Santiago for 12 months, whereas 35 similar health centers administered only diphtheria-tetanus toxoid-pertussis vaccine. Bacteriologic surveillance data for invasive Hib cases collected over the ensuing 30 months were analyzed.

RESULTS

In an intent-to-vaccinate (effectiveness) analysis, PRP-T provided 90.2% protection (95% confidence interval, 74.5 to 100%) against invasive Hib disease (40 vs. 4 cases, P < 0.001). Vaccine effectiveness was 91.3% against meningitis (22 vs. 2 cases) and 80% against pneumonia and empyema (10 vs. 2 cases, P = 0.039). Vaccine efficacy among infants who received all three doses of PRP-T was 91.7% (95% confidence interval, 64.8 to 100%).

CONCLUSIONS

Programmatic use of Hib conjugate vaccine administered in combination with diphtheria-tetanus-pertussis vaccine constitutes a highly effective and practical intervention in Chile, a newly industrializing country.

Beware of surrogate outcome measures

Surrogate outcome measures may speed up clinical research if they can be measured earlier in a study than the primary outcome of interest. We review the justification for their use and conclude that reliance on them may be harmful. Results obtained with surrogates should therefore be regarded as preliminary. Large, definitive trials with clinically relevant outcomes should always be performed before new interventions are accepted.

Specificity of antibodies induced after immunization of mice with the mycobacterial heat shock protein of 65 kD

We have previously shown in mice and monkeys that mycobacterial heat shock proteins (hsp) of 65 and 70 kD exert a strong in vivo helper effect when conjugated to synthetic peptides or bacterial oligosaccharides and given in the absence of any adjuvants. Considering the degree of homology existing in the phylogeny among hsp belonging to the same family, we studied whether antibodies induced in mice with this protocol of immunization with the mycobacterial 65-kD hsp (hsp65) would cross-react, and to what extent, with hsp homologues from other origins, notably with the Escherichia coli GroEL protein and with the human homologue (hsp60). The results obtained show that antibodies to the mycobacterial hsp65 cross-reacted with the E. coli GroEL protein, both in ELISA and Western blot experiments, but not with the human hsp60. In competitive ELISA experiments, the binding of these antibodies to solid-phase hsp65 was very effectively inhibited by low concentrations of the mycobacterial hsp65; however, for human hsp60, 100 times higher concentrations were required in order to obtain similar patterns of inhibition. Finally, murine antibodies to the mycobacterial hsp65 always failed to give positive results in Western blot experiments using extracts of murine cells. Taken together, these data suggest that, after immunization of mice with the mycobacterial hsp65 conjugated to peptides or oligosaccharides in the absence of adjuvants, anti-hsp65 antibodies are induced which cross-react well with hsp homologues from other prokaryotes (e.g. E. coli GroEL), but which weakly bind the human hsp homologue. These results may have implications for the potential use of microbial hsp molecules in the design of conjugated vaccine constructs.

Comparison of naturally acquired and vaccine-induced antibodies to Haemophilus influenzae type b capsular polysaccharide

The objective of this study was to assess qualitative differences in the types of Haemophilus influenzae type B (Hib) capsular polysaccharide (polyribosylribitol phosphate [PRP]) antibodies induced in children 15 to 27 months of age by (i) natural exposure, (ii) PRP vaccine, and by (iii) PRP-diphtheria toxoid conjugate vaccine, (iv) PRP-group B Neisseria meningitidis outer membrane vesicle conjugate vaccine, and (v) Haemophilus type B oligosaccharide conjugate vaccine (HbOC). The highest levels of total Hib-PRP antibody measured by radioimmunoassay and immunoglobulin G (IgG) measured by enzyme-linked immunosorbent assay were seen after HbOC immunization. IgG1 Hib-PRP antibodies predominated in all groups, and there were no differences between the groups in the proportion of IgG and IgA Hib-PRP antibodies. However, the proportions of IgM differed significantly by group. The highest proportions of IgM occurred in naturally acquired antibody and after PRP vaccine, and the lowest proportion occurred after HbOC vaccine. IgG light-chain V kappa type alpha PRP antibody was present in all groups, and the level correlated with the total IgG Hib-PRP antibody level. Therefore, HbOC induced the highest concentrations of V kappa II type alpha PRP antibody, and the naturally acquired antibody group had the lowest levels. IgG light-chain V kappa III antibody levels were also highest in the HbOC group, but there was no correlation between V kappa III antibody levels and total amount of IgG Hib-PRP antibody. These data demonstrate qualitative differences in the antibody repertoires induced by natural exposure, the Hib-PRP vaccine, and each of the different Hib conjugate vaccines. We doubt that there are major differences in the protection afforded by these different antibody repertoires, because these differences do not appear to correlate with differences in protective efficacy in older children.

New carriers and adjuvants in the development of vaccines

Different approaches are being followed to enhance the immunogenicity of established and newly developed vaccines. Some of them foresee the utilization of carrier molecules recognized by the immune systems of a large proportion of the human population. Others are directed mainly towards the development of improved adjuvants and delivery systems.

Mycobacterial heat-shock proteins as carrier molecules. II: The use of the 70-kDa mycobacterial heat-shock protein as carrier for conjugated vaccines can circumvent the need for adjuvants and Bacillus Calmette Guérin priming

In a recent work, we have shown that mycobacterial heat-shock proteins (hsp) of 65-kDa (GroEL-type) and 70-kDa (DnaK-type) acted as carrier molecules in mice, previously primed with Mycobacterium tuberculosis var. bovis (bacillus Calmette-Guérin, BCG), for the induction of high and long-lasting titers of IgG against the repetitive malaria synthetic peptide (NANP)40. Anti-peptide antibodies were induced when the malaria peptide, conjugated to the mycobacterial hsp, was given in the absence of any adjuvants (Lussow et al., Eur. J. Immunol. 1991. 87:2960). In this report, we show that mice immunized with peptides or oligosaccharides conjugated to the 70-kDa hsp produced high titers of IgG antibodies in the absence of any previous priming with BCG. The anti-peptide antibody response persisted for at least 1 year. This adjuvant-free carrier effect of the 70-kDa hsp was T cell dependent, since no anti-peptide nor anti-70-kDa IgG antibodies were induced in athymic nu/nu mice. Previous immunization of mice with the 65-kDa or 70-kDa hsp did not have any negative effect on the induction of anti-peptide IgG antibodies after immunization with hsp-peptide conjugates in the absence of adjuvants. Furthermore, preimmunization with the 65-kDa hsp could substitute for BCG in providing an effective priming for the induction of anti-(NANP) antibodies. Finally, both the 65-kDa and 70-kDa hsp acted as carrier molecules for the induction of IgG antibodies to group C meningococcal oligosaccharides, in the absence of adjuvants. These findings strongly suggest that the use of hsp as carriers in conjugated constructs for the induction of anti-peptide and anti-oligosaccharide antibodies could be of value in the design of new vaccines for eventual use in humans.

Bacterial vaccines: old and new, veterinary and medical

Developments in veterinary and medical bacterial vaccines are outlined. In the former case, economic considerations are paramount, and cruder, less purified products of proven efficacy continue to be employed. For human use, however, safety and absence of side effects are increasingly demanded. Various examples of human and veterinary vaccines are discussed, and interaction between the two fields is illustrated by reference to the pig-bel disease in New Guinea and the possible aetiology of Sudden Infant Death Syndrome.