Protection of inactivated influenza virus vaccine against lethal influenza virus infection in diabetic mice

Respiratory Tract Infections in Diabetes - Lessons From Tuberculosis and Influenza to Guide Understanding of COVID-19 Severity

Patients with type-2 diabetes (T2D) are more likely to develop severe respiratory tract infections. Such susceptibility has gained increasing attention since the global spread of Coronavirus Disease 2019 (COVID-19) in early 2020. The earliest reports marked T2D as an important risk-factor for severe forms of disease and mortality across all adult age groups. Several mechanisms have been proposed for this increased susceptibility, including pre-existing immune dysfunction, a lack of metabolic flexibility due to insulin resistance, inadequate dietary quality or adverse interactions with antidiabetic treatments or common comorbidities. Some mechanisms that predispose patients with T2D to severe COVID-19 may indeed be shared with other previously characterized respiratory tract infections. Accordingly, in this review, we give an overview of response to Influenza A virus and to Mycobacterium tuberculosis (Mtb) infections. Similar risk factors and mechanisms are discussed between the two conditions and in the case of COVID-19. Lastly, we address emerging approaches to address research needs in infection and metabolic disease, and perspectives with regards to deployment or repositioning of metabolically active therapeutics.

Type I Diabetes Mellitus Increases the Cardiovascular Complications of Influenza Virus Infection

People with diabetes mellitus are susceptible to both cardiovascular disease and severe influenza A virus infection. We hypothesized that diabetes also increases risks of influenza-associated cardiac complications. A murine type 1 (streptozotocin-induced) diabetes model was employed to investigate influenza-induced cardiac distress. Lung histopathology and viral titres revealed no difference in respiratory severity between infected control and diabetic mice. However, compared with infected control mice, infected diabetic mice had increased serum cardiac troponin I and creatine-kinase MB, left ventricular structural changes and right ventricular functional alterations, providing the first experimental evidence of type I diabetes increasing risks of influenza-induced cardiovascular complications.

Influenza in High-Risk Hosts-Lessons Learned from Animal Models

Factoring significantly into the global burden of influenza disease are high-risk populations that suffer the bulk of infections. Classically, the very young, very old, and pregnant women have been identified as high-risk populations; however, recent research has uncovered several other conditions that contribute to severe infection. By using varied animal models, researchers have identified molecular mechanisms underpinning the increased likelihood for infection due to obesity and malnourishment, as well as insight into the role sex hormones play in antiviral immunity in males, in females, and across the life span. Additionally, novel comorbidity models have helped elucidate the role of chronic infectious and genetic diseases in influenza virus pathogenesis. Animal models play a vital role in understanding the contribution of host factors to influenza severity and immunity. An in-depth understanding of these host factors represents an important step in reducing the burden of influenza among the growing number of people living with one or more chronic medical conditions.

A review of COVID-19 vaccines and major considerations for diabetic patients

The necessity and impact of SARS-CoV2 on the world's health have led to developing and producing practical and useful vaccines for this deadly respiratory virus. Since April 2020, a vaccine for the virus has been developed. Given that comorbidities such as diabetes, hypertension, and cardiovascular disease are more prone to viruses and the risk of infection, vaccines should be designed to protect against high-risk respiratory illnesses. Including SARS, MERS, influenza, and the SARS-CoV-2 provide a safe immune response. Here, we review the information and studies that have been done to help develop strategies and perspectives for producing a safe and ideal vaccine to prevent COVID-19 in normal people, especially at high-risk groups such as diabetes patients.

Immunization with DNA prime-subunit protein boost strategy based on influenza H9N2 virus conserved matrix protein M1 and its epitope screening

Developing an effective universal influenza vaccine against influenza virus with highly conserved antigenic epitopes could induce a broad-spectrum immune response to prevent infection. The soluble protein M1 that can induce the M1 specific immune response was first confirmed in our previous study. In this study, we characterized the immune response induced by DNA prime-subunit protein boost strategy based on the relatively conserved matrix protein 1 (M1) in the BALB/c mouse model, and evaluated its protection ability against a lethal challenge of homologous H9N2 avian influenza virus (A/Chicken/Jiangsu/11/2002). The results showed that 100 μg DNA prime + 100 μg M1 subunit protein boost-strategy significantly increased antibody levels more than vaccination with M1 DNA or M1 subunit protein alone, and induced a more balanced Th1 / Th2 immune response, which not only can provide protection against the homologous virus but also can provide part of the cross-protection against the heterosubtypic PR8 H1N1 strain. In addition, we used an Elispot assay to preliminary screen the T cell epitope in M1 protein, and identified that p22 (M1_11-25 VLSIIPSGPLKAEIA) epitope was the only immunodominant M1-specific CD4⁺ T cell epitopes, which could be helpful in understanding the function of influenza virus T cell epitopes.

Rapid detection and clinical spectrum of the novel influenza H1N1 strain in a diabetic pediatric population

OBJECTIVES

H1N1 infection in diabetic patients is of special concern and serious interest since the virus can place individuals, especially children, at great possible risk of subsequently developing type 1 diabetes. This work aims to describe the demographic characteristics, clinical features, and severity of illness of children with type 1 diabetes mellitus (DM), compare the incidence of pandemic H1N1 virus in children with that of the general pediatric population with influenza-like symptoms, and identify the complications of H1N1 virus infection associated with glycemic control.

METHODS

The present study included 45 children and adolescents with type 1 diabetes, who were subject to clinical and laboratory investigations. Another 30 healthy adolescents and children with a mean age of 10.43 ± 4.38 years were included as a control group. H1N1 reverse-transcriptase quantitative PCR (RT-Q PCR) was tested for H1N1 virus detection.

RESULTS

Diabetic patients positive for (H1N1) showed significantly higher random blood sugar (RBS) levels than diabetic patients negative for (H1N1). Moreover, the H1N1-positive patients had significantly higher hemoglobin (Hb) g/dL, platelet counts, total leukocyte counts (TLCs), and CRP levels. Newly diagnosed patients who were tested positive for (H1N1) and diabetic ketoacidosis (DKA) had significantly higher RBS levels and TLCs than patients who were presented with hyperglycemia.

CONCLUSION

RT-PCR is a rapid and specific method for influenza A (H1N1) virus diagnosis. In addition, early administration of oseltamivir no later than 48 hours after the infection is highly recommended in either diabetic or DKA patients suspected of having H1N1.

Benefits of flu vaccination for persons with diabetes mellitus: A review

Diabetes mellitus imposes a significant and increasing burden on society, with major consequences for human health, welfare and the economy worldwide. Persons with diabetes mellitus are at increased risk of developing severe complications after influenza virus infection and guidelines advise vaccination. The present evidence for influenza vaccine effectiveness in persons with diabetes mellitus is mainly based on observational studies with clinical endpoints like hospitalization and death, indicating a beneficial reduction of morbidity and mortality. Further supportive evidence comes from serological studies, in which persons with diabetes mellitus usually develop similar antibody levels after vaccination as healthy people. Observational studies may be prone to selection bias, and serological studies may not completely mirror vaccine effectiveness in the field. Although more controlled trials in persons with diabetes mellitus with laboratory-confirmed, influenza-specific outcomes would be desirable to better estimate the effect of vaccination, the currently available data justify routine influenza vaccination in persons with diabetes mellitus. As in this risk group, the use of influenza vaccine is far below target worldwide, efforts should be made to increase vaccination coverage.

Influenza Virus and Glycemic Variability in Diabetes: A Killer Combination?

Following the 2009 H1N1 influenza virus pandemic, numerous studies identified the striking link between diabetes mellitus and influenza disease severity. Typically, influenza virus is a self-limiting infection but in individuals who have a pre-existing chronic illness, such as diabetes mellitus, severe influenza can develop. Here, we discuss the latest clinical and experimental evidence for the role of diabetes in predisposing the host to severe influenza. We explore the possible mechanisms that underlie this synergy and highlight the, as yet, unexplored role that blood glucose oscillations may play in disease development. Diabetes is one of the world’s fastest growing chronic diseases and influenza virus represents a constant and pervasive threat to human health. It is therefore imperative that we understand how diabetes increases influenza severity in order to mitigate the burden of future influenza epidemics and pandemics.

Bias in the measure of the effectiveness of seasonal influenza vaccination among diabetics

BACKGROUND

The influenza virus is an important cause of morbidity and mortality for diabetics. The seasonal influenza vaccine's immunologic effectiveness is proven within the type 1 and type 2 diabetic populations, but the level of evidence is low. This article presents a systematic review for the bias in the measure of the effectiveness of seasonal influenza vaccination among diabetics.

METHODS

Using systematic review methods, we searched three electronic databases for published literature (MEDLINE, EMBASE and the Cochrane Library) and two grey literature (SIGLE and NHS EED) databases, to identify studies published between 1997 and 2013, examining the effect of seasonal influenza vaccination, among diabetics, on any measure for influenza morbidity or mortality.

RESULTS

725 records were identified from the three databases and screening, short-listing was undertaken independently by two reviewers. After de-duplication, all records were screened by title and then abstract, and 34 short-listed records were reviewed in full, with 7 studies included: 4 cohort studies and 3 case-control studies, conducted in 7 countries. The most common outcome of interest in studies (n=4) was all-cause mortality among elderly diabetics (>65 years), with individual studies reporting reductions in risk of between 33% [95%CI: 4%-54%] and 68% [95%CI: 58%-75%]. We found only two studies for working-age adult diabetics: one reporting that vaccination prevented hospitalizations due to pneumonia or influenza (vaccine effectiveness [VE] 43%, [95%CI: 28%-54%]) and all-cause hospitalizations (VE: 28% [95%CI: 24%-32%]); and, another reporting no significant decrease in all-cause mortality for working-age adult diabetics. We have identified three major biases: the use of indirect health outcomes, a risk of selection bias (health-seeking bias), and no adjustment for participant pneumococcal vaccination status. The most recent included article finds that morbimortality is still lower during off-season influenza in both vaccinated and non-vaccinated diabetics, indicating important residual confounding.

CONCLUSION

To date, the strength of evidence supporting the routine use of seasonal influenza vaccination is low for diabetics older than 65, and very low for working-age diabetics.

Intranasal Administration of Chitosan Against Influenza A (H7N9) Virus Infection in a Mouse Model

Influenza virus evolves constantly in an unpredictable fashion, making it necessary to vaccinate people annually for effective prevention and control of influenza. In general, however, during the first wave of an influenza outbreak caused by a newly emerging virus strain, influenza morbidity and mortality have been observed to rise sharply due to the lack of a matching vaccine. This necessitates the exploration of novel intervention approaches, particularly those prophylactic or therapeutic agents that have a broad range of antiviral activities and are also proven to be non-toxic. Here, we reported that stimulation of the innate immune system by intranasal administration of chitosan as a single agent was sufficient to completely protect BALB/c mice from lethal infection by H7N9 virus, a newly emerged viral strain that is highly pathogenic to humans. Remarkably, animals could still be protected against lethal challenge by H7N9 (10×LD₅₀), even ten days after the intranasal chitosan administration. The significantly enhanced infiltration of leukocytes in the bronchoalveolar lavage and elevated levels of proinflammatory cytokines in the bronchia/lung tissues revealed the potent activation of mucosal immune responses by intranasally delivered chitosan. We also observed that chitosan can protect mice from three other virus strains. The marked breadth and magnitude of protection against diverse viral strains makes chitosan an attractive candidate as a universal anti-influenza agent.

Cross-protection against influenza virus infection by intranasal administration of nucleoprotein-based vaccine with compound 48/80 adjuvant

The nucleoprotein (NP) of influenza viruses is highly conserved and therefore has become one of the major targets of current universal influenza vaccine (UIV) studies. In this study, the recombinant nucleoprotein (NP) of the A/PR/8/34 (H1N1) influenza virus strain was expressed using an Escherichia coli (E. coli) expression system and then purified as a candidate UIV. The NP protein was administered intranasally or intraperitoneally twice at 3-week intervals to female BALB/c mice in combination with C48/80 adjuvant. Then, the mice were challenged with homologous or heterologous influenza viruses at a lethal dose 3 weeks after the last immunization. The results showed that the serum IgG titers of all of the mice immunized with NP reached a higher level and the protection provided by NP vaccine against the homologous virus depended on the administered dosage and adjuvant. In addition, immunization with 100 μg NP in combination with C48/80 adjuvant could provide good cross-protection against heterologous H9N2 avian influenza viruses. This study indicated that NP as a candidate antigen of UIV immunized intranasally could effectively induce mucosal and cell-mediated immunity, with the potential to control epidemics caused by the appearance of new emerging influenza viruses.

Long-term immunogenicity of an inactivated split-virion 2009 pandemic influenza A H1N1 virus vaccine with or without aluminum adjuvant in mice

In 2009, a global epidemic of influenza A(H1N1) virus caused the death of tens of thousands of people. Vaccination is the most effective means of controlling an epidemic of influenza and reducing the mortality rate. In this study, the long-term immunogenicity of influenza A/California/7/2009 (H1N1) split vaccine was observed as long as 15 months (450 days) after immunization in a mouse model. Female BALB/c mice were immunized intraperitoneally with different doses of aluminum-adjuvanted vaccine. The mice were challenged with a lethal dose (10× 50% lethal dose [LD(50)]) of homologous virus 450 days after immunization. The results showed that the supplemented aluminum adjuvant not only effectively enhanced the protective effect of the vaccine but also reduced the immunizing dose of the vaccine. In addition, the aluminum adjuvant enhanced the IgG antibody level of mice immunized with the H1N1 split vaccine. The IgG level was correlated to the survival rate of the mice. Aluminum-adjuvanted inactivated split-virion 2009 pandemic influenza A H1N1 vaccine has good immunogenicity and provided long-term protection against lethal influenza virus challenge in mice.

The humoral immune response to the inactivated influenza A (H1N1) 2009 monovalent vaccine in patients with Type 2 diabetes mellitus in Korea

AIMS

We evaluated the antibody response to a single-dose adjuvanted, inactivated, pandemic H1N1 influenza vaccination in patients with diabetes and assessed factors associated with the failure to induce antibody responses.

METHODS

Eighty-two patients with Type 2 diabetes were vaccinated and antibody responses were determined with haemagglutination inhibition assay and anti-haemagglutinin antibody ELISA.

RESULTS

Among 70 antibody-negative patients at baseline, 34 (48.6%) achieved seroconversion; 28 (60.9%) in the young adults group and six (25%) in the elderly group acquired H1N1-specific antibodies. Patients in the older age range or with longer duration of diabetes had a lower seroconversion rate.

CONCLUSIONS

Our data show low cross-reactive antibody carrying rate and low seroconversion rate in patients with diabetes. Until larger-scale, case-controlled trials become available, older patients and patients with a longer duration of diabetes should be considered for the two-dose vaccination or have antibody titres measured after the first vaccination.

Comparison of adjuvant efficacy of chitosan and aluminum hydroxide for intraperitoneally administered inactivated influenza H5N1 vaccine

A safe and effective adjuvant is important to develop vaccines against highly pathogenic avian influenza virus. Chitosan, a derivative from the natural amino polysaccharide chitin, has been proved to be an effective adjuvant for inactivated influenza virus vaccine. In this study, protective immunity in mice provided by chitosan-adjuvanted inactivated H5N1 vaccine was compared with that from an aluminum hydroxide-adjuvanted one. Mice were injected intraperitoneally once or twice with various dosages of inactivated vaccine alone or in combination with an adjuvant (chitosan or aluminum hydroxide). To test the immunization effect, mice were challenged with a lethal dose of H5N1 virus. The results showed that the adjuvanted vaccines were more effective than adjuvant-free ones in inducing humoral immune responses and protecting mice against lethal challenge. Chitosan was comparable to the alum adjuvant in efficacy. These findings indicated that chitosan might be a candidate adjuvant for parenteral administration of inactivated influenza vaccines.

Protection against multiple influenza A virus subtypes by intranasal administration of recombinant nucleoprotein

Vaccination is a cost-effective way to control the influenza epidemic. Vaccines based on highly conserved antigens can provide protection against different influenza A strains and subtypes. In this study, the recombinant nucleoprotein (rNP) of the A/PR/8/34 (H1N1) influenza virus strain was effectively expressed using a prokaryotic expression system and then purified with a nickel-charged Sepharose affinity column as a candidate component for an influenza vaccine. The rNP was administered intranasally three times at 3-week intervals to female BALB/c mice in combination with an adjuvant (cholera toxin B subunit containing 0.2% of the whole toxin). Twenty-one days after the last immunization, the mice were challenged with homologous or heterologous influenza viruses at a lethal dose. The results showed that intranasal immunization of 10 μg rNP with adjuvant completely protected the immunized mice against the homologous influenza virus, and immunization with 100 μg rNP in combination with adjuvant provided good cross-protection against heterologous H5N1 and H9N2 avian influenza viruses. The results indicate that such a vaccine administered intranasally can induce mucosal and cell-mediated immunity, thus having the potential to control epidemics caused by new emerging influenza viruses.

A DNA vaccine-encoded nucleoprotein of influenza virus fails to induce cellular immune responses in a diabetic mouse model

Influenza virus infections cause yearly epidemics and are a major cause of lower respiratory tract illnesses in humans worldwide. Influenza virus has long been recognized to be associated with higher morbidity and mortality in diabetic patients. Vaccination is an effective tool to prevent influenza virus infection in this group of patients. Vaccines employing recombinant-DNA technologies are an alternative to inactivated virus and live attenuated virus vaccines. Internal highly conserved viral nucleoprotein (NP) can be delivered as a DNA vaccine to provide heterosubtypic immunity, offering resistance against various influenza virus strains. In this study, we investigated the efficacy of an NP DNA vaccine for induction of cell-mediated immune responses and protection against influenza virus infection in a mouse model of diabetes. Healthy and diabetic BALB/c mice were immunized on days 0, 14, and 28 by injection of NP DNA vaccine. Two weeks after the last immunization, the cellular immune response was evaluated by gamma interferon (IFN-gamma), lymphocyte proliferation, and cytotoxicity assays. The mice were challenged with influenza virus, and the viral titers in the lungs were measured on day 4. Diabetic mice showed significantly smaller amounts of IFN-gamma production, lymphocyte proliferation, and cytotoxicity responses than nondiabetic mice. Furthermore, higher titers of the influenza virus were detected after challenge in the lungs of the diabetic mice. The present data suggest that the NP DNA vaccine with the protocol of immunization described here is not able to induce efficient cellular immune responses against influenza virus infection in diabetic mice.

Efficacy of inactivated vaccine against H5N1 influenza virus infection in mice with type 1 diabetes

We sought to determine susceptibility to highly pathogenic avian influenza (HPAI) H5N1 virus and to explore immune protection of inactivated H5N1 vaccine in streptozotocin-induced type 1 diabetic mice. Susceptibility of diabetic mice to an H5N1 virus was evaluated by comparing the median lethal dose (LD(50)) and the lung virus titers with those of the healthy after the viral infection. To evaluate the influence of diabetes on vaccination, diabetic and healthy mice were immunized once with an inactivated H5N1 vaccine and then challenged with a lethal dose of H5N1 virus. The antibody responses, survival rates, lung virus titers and body weight changes were tested. Mice with type 1 diabetes had higher lung virus titers and lower survival rates than healthy mice after H5N1 virus infection. Inactivated H5N1 vaccine induced protective antibody in diabetic mice, but the antibody responses were postponed and weakened. In spite of this, diabetic mice could be protected against the lethal virus challenge by a single dose of immunization when the amount of the antigen increased. These results indicated that type 1 diabetic mice were more susceptible to H5N1 influenza virus infection than healthy mice, and can be effectively protected by inactivated H5N1 vaccine with increased antigen.

Protection against avian influenza H9N2 virus challenge by immunization with hemagglutinin- or neuraminidase-expressing DNA in BALB/c mice

Avian influenza viruses of H9N2 subtype are widely spread in avian species. The viruses have recently been transmitted to mammalian species, including humans, accelerating the efforts to devise protective strategies against them. In this study, an avian influenza H9N2 virus strain (A/Chicken/Jiangsu/7/2002), isolated in Jiangsu Province, China, was used to infect BALB/c mice for adaptation. After five lung-to-lung passages, the virus was stably proliferated in a large quantity in the murine lung and caused the deaths of mice. In addition, we explored the protection induced by H9N2 virus hemagglutinin (HA)- and neuraminidase (NA)-expressing DNAs in BALB/c mice. Female BALB/c mice aged 6-8 weeks were immunized once or twice at a 3-week interval with HA-DNA and NA-DNA by electroporation, respectively, each at a dose of 3, 10 or 30microg. The mice were challenged with a lethal dose (40x LD(50)) of influenza H9N2 virus four weeks after immunization once or one week after immunization twice. The protections of DNA vaccines were evaluated by the serum antibody titers, residual lung virus titers, and survival rates of the mice. The result showed that immunization once with not less than 10microg or twice with 3microg HA-DNA or NA-DNA provided effective protection against homologous avian influenza H9N2 virus.

Maternal immunization with both hemagglutinin- and neuraminidase-expressing DNAs provides an enhanced protection against a lethal influenza virus challenge in infant and adult mice

Maternal immunization is the major form of protection against many infectious diseases in early life. In this report, transmission of vaccine-specific maternal antibodies and protection of offspring against a lethal influenza virus challenge were studied. Adult female BALB/c mice were immunized intramuscularly with plasmid DNAs encoding influenza virus hemagglutinin (HA), neuraminidase (NA), or mixture of the two plasmids. The levels of specific antibodies in sera of offspring at different ages and the survival rates following the lethal viral challenge were valued. The results showed effective transmission of maternal antibodies and long-lasting protection in offspring. Along with the growth of offspring, the antibody titers in vivo decreased and the ability against virus infection decreased accordingly. The HA-specific maternal antibodies protected the offspring from a lethal influenza infection up to 2 weeks old, and the NA-specific maternal antibodies protected offspring up to 4 weeks old. Furthermore, antibodies transferred by the mother immunized with the mixture of HA and NA DNAs protected the offspring up to 6 weeks old. This suggests that maternal immunization with a mixture of HA and NA DNAs provide the most effective protection against the virus challenge for the offspring of mice.