Clinical study of transcutaneous vaccination using a hydrogel patch for tetanus and diphtheria

Long-Term Vaccine Delivery and Immunological Responses Using Biodegradable Polymer-Based Carriers

Biodegradable polymers are largely employed in the biomedical field, ranging from tissue regeneration to drug/vaccine delivery. The biodegradable polymers are highly biocompatible and possess negligible toxicity. In addition, biomaterial-based vaccines possess adjuvant properties, thereby enhancing immune responses. This Review introduces the use of different biodegradable polymers and their degradation mechanism. Different kinds of vaccines, as well as the interaction between the carriers with the immune system, then are highlighted. Natural and synthetic biodegradable micro-/nanoplatforms, hydrogels, and scaffolds for local or targeted and controlled vaccine release are subsequently discussed.

Regenerating dynamic organs using biomimetic patches

The regeneration of dynamic organs remains challenging because they are intrinsically anisotropic and undergo large volumetric deformation during normal or pathological function. This hampers the durability and applicability of regenerative medicine approaches. To address the challenges of organ dynamics, a new class of patches have emerged with anisotropic and auxetic properties that mimic native tissue biomechanics and accommodate volumetric deformation. Here, we outline the critical design, materials, and processing considerations for achieving optimal patch biomechanics according to target pathology and summarize recent advances in biomimetic patches for dynamic organ regeneration. Furthermore, we discuss the challenges and opportunities which, if overcome, would open up new applications in organ regeneration and expedite the clinical translation of patch-based therapeutics.

Recent Advances and Future Perspectives in Polymer-Based Nanovaccines

Vaccination is the most valuable and cost-effective health measure to prevent and control the spread of infectious diseases. A significant number of infectious diseases and chronic disorders are still not preventable by existing vaccination schemes; therefore, new-generation vaccines are needed. Novel technologies such as nanoparticulate systems and adjuvants can enable safe and effective vaccines for difficult target populations such as newborns, elderly, and the immune-compromised. More recently, polymer-based particles have found application as vaccine platforms and vaccine adjuvants due to their ability to prevent antigen degradation and clearance, coupled with enhanced uptake by professional antigen-presenting cells (APCs). Polymeric nanoparticles have been applied in vaccine delivery, showing significant adjuvant effects as they can easily be taken up by APCs. In other words, polymer-based systems offer a lot of advantages, including versatility and flexibility in the design process, the ability to incorporate a range of immunomodulators/antigens, mimicking infection in different ways, and acting as a depot, thereby persisting long enough to generate adaptive immune responses. The aim of this review is to summarize the properties, the characteristics, the added value, and the limitations of the polymer-based nanovaccines, as well as the process of their development by the pharmaceutical industry.

Low Adenovirus Vaccine Doses Administered to Skin Using Microneedle Patches Induce Better Functional Antibody Immunogenicity as Compared to Systemic Injection

Adenovirus-based vaccines are demonstrating promising clinical potential for multiple infectious diseases, including COVID-19. However, the immunogenicity of the vector itself decreases its effectiveness as a boosting vaccine due to the induction of strong anti-vector neutralizing immunity. Here we determined how dissolvable microneedle patches (DMN) for skin immunization can overcome this issue, using a clinically-relevant adenovirus-based Plasmodium falciparum malaria vaccine, AdHu5–PfRH5, in mice. Incorporation of vaccine into patches significantly enhanced its thermostability compared to the liquid form. Conventional high dose repeated immunization by the intramuscular (IM) route induced low antigen-specific IgG titres and high anti-vector immunity. A low priming dose of vaccine, by the IM route, but more so using DMN patches, induced the most efficacious immune responses, assessed by parasite growth inhibitory activity (GIA) assays. Administration of low dose AdHu5–PfRH5 using patches to the skin, boosted by high dose IM, induced the highest antigen-specific serum IgG response after boosting, the greatest skewing of the antibody response towards the antigen and away from the vector, and the highest efficacy. This study therefore demonstrates that repeated use of the same adenovirus vaccine can be highly immunogenic towards the transgene if a low dose is used to prime the response. It also provides a method of stabilizing adenovirus vaccine, in easy-to-administer dissolvable microneedle patches, permitting storage and distribution out of cold chain.

Vaccination into the Dermal Compartment: Techniques, Challenges, and Prospects

In 2019, an 'influenza pandemic' and 'vaccine hesitancy' were listed as two of the top 10 challenges to global health by the WHO. The skin is a unique vaccination site, due to its immune-rich milieu, which is evolutionarily primed to respond to challenge, and its ability to induce both humoral and cellular immunity. Vaccination into this dermal compartment offers a way of addressing both of the challenges presented by the WHO, as well as opening up avenues for novel vaccine formulation and dose-sparing strategies to enter the clinic. This review will provide an overview of the diverse range of vaccination techniques available to target the dermal compartment, as well as their current state, challenges, and prospects, and touch upon the formulations that have been developed to maximally benefit from these new techniques. These include needle and syringe techniques, microneedles, DNA tattooing, jet and ballistic delivery, and skin permeabilization techniques, including thermal ablation, chemical enhancers, ablation, electroporation, iontophoresis, and sonophoresis.

A grading system for local skin reactions developed for clinical trials of an intradermal and transcutaneous ETEC vaccine

BACKGROUND

Trials assessing the safety of novel vaccine candidates are essential in the evaluation and development of candidate vaccines. Immunogenicity and dose-sparing features of vaccination approaches which target skin and associated tissues have garnered increased interest; for enteric vaccines, cutaneous vaccination has been of particular interest. Cutaneous vaccine site reactions are among the most common and visible vaccine related adverse events (AEs) when skin routes are used. Regulatory guidelines governing classification of severity focus on functional impact but are insufficient to characterize a spectrum of skin reaction and allow for comparisons of routes, doses and products with similar local cutaneous AEs.

OBJECTIVES

Our group developed a grading scale to evaluate and compare cutaneous vaccine site reactions ahead of early-phase clinical trials of intradermal (ID) and transcutaneous immunization (TCI) with enterotoxigenic E.coli (ETEC) vaccine candidates (adhesin-based vaccine co-administered with LTR192G). We reviewed existing methods for characterizing the appearance and severity of local vaccine site reactions following TCI and ID vaccination and devised a standardized vaccine site appearance grading scale (VSAGS) for use in the clinical development of novel ETEC vaccine candidates which focused on pathophysiologic manifestation of skin findings.

RESULTS

Available data from published reports revealed erythematous papules and pruritus were the most common local AEs associated with TCI. Frequency of reactions varied notably across studies as did TCI vaccination methodologies and products. ID vaccination commonly results in erythema and induration at the vaccine site as well as pigmentation changes. There was no published methodology to characterize the spectrum of dermatologic findings.

CONCLUSION

ID and TCI vaccination are associated with a largely predictable range of cutaneous AEs. A grading scale focused on the appearance of cutaneous changes was useful in comparing cutaneous AEs. A standardized grading scale will facilitate documentation and comparison of cutaneous AEs.

[Development of an Immune Regulation Technology Targeting the Skin and Promotion of the Practical Applications of Transcutaneous Vaccination/Immunotherapy]

In the premise of vaccination and allergen-specific immunotherapy, transcutaneous formulations have an advantage over conventional subcutaneous injections in terms of convenience, simplicity of delivery, and painless administration into the skin. Additionally, since transcutaneous formulations can be rendered cold-chain free, they do not require expert handling during transportation, storage, and stockpiling, which enables reductions in costs and distribution to distant areas. Furthermore, transcutaneous formulations are effective for improving adherence in children with phobias toward injection needles and may help in persuading them to perform self-vaccination and home immunotherapy against allergies in the future. We have been promoting the development of innovative "patch-type formulations for vaccination and immunotherapy" which regard skin as an immune organ and utilize our original transcutaneous administration devices (hydrophilic gel patch and microneedle patch) for their delivery. We have confirmed the safety and efficacy of transcutaneous formulations not only in demonstration experiments using animals but also in physician-initiated clinical studies. Additionally, in order to elucidate the mechanism for the induction of immune responses by transcutaneous formulations, we analyzed the immunological events occurring in the skin and regional lymph nodes which accompanied the application of transcutaneous administration devices or the delivery of antigens (vaccines and allergens) to the skin surface layer. This review presents our results from basic to clinical research on the development of transcutaneous formulations for vaccines and allergen-specific immunotherapy.

Immunogenicity of Milk Protein-Containing Hydrophilic Gel Patch for Epicutaneous Immunotherapy for Milk Allergy

PURPOSE

Epicutaneous immunotherapy (EPIT) involving the skin's immune system is easy to use, painless and has a low risk of systemic side effects; it can be applied to food allergies that have a high morbidity rate in children. In this study, we evaluated the safety and efficacy of hydrophilic gel patch (HG) for EPIT.

METHODS

Milk protein concentrate (MPC)-containing HG was applied to the skin that maintained a barrier function or formed puncture holes with microneedle, and MPC-specific antibodies were measured. The clinical study was conducted involving patients with severe milk allergy.

RESULTS

No specific immune response was induced when immunizing to intact skin, and antibody production was observed by forming puncture holes. It was suggested that MPC contained in HG has immunogenicity and a very small amount of MPC was delivered to intact skin. In the clinical study, the symptom induction threshold increased in four of eight subjects, allowing them to consume milk and switch to oral immunotherapy. Although local skin reactions and temporary elevation of specific IgE antibodies were observed, no systemic side effects appeared throughout the study.

CONCLUSIONS

EPIT using HG is a safe method to enable oral administration even in patients with severe milk allergies.

An Optimized and Feasible Preparation Technique for the Industrial Production of Hydrogel Patches

For hydrogel patches, the laboratory tests could not fully reveal the existing problems of full scale of industrial production, and there are few studies about the preparation technique for the industrial manufacturing process of hydrogel patches. So, the purpose of this work was to elucidate the effects of mainly technological operation and its parameters on the performance of hydrogel patches at the industrial-scale production. The results revealed the following: (1) the aqueous phase was obtained by polyvinylpyrrolidone (PVP) along with tartaric acid dissolved in purified water, then feeding this into a vacuum mixer as a whole in one batch, thus extended the crosslinking reaction time of hydrogel paste (matrix) and allowed the operation of coating/cutting-off to be carried out easily, and there was no permeation of backing layer; (2) the gel strength of the hydrogel patches increased with the increase of working temperature, however, once the temperature exceeded 35 ± 2 °C, the hydrogel paste would lose water severely and the resultant physical crosslinking structure which has lower gel/cohesive strength would easily bring gelatinization/residues during application; (3) the relative humidity (RH) of the standing-workshop was dynamically controlled (namely at 35 ± 2 °C, keeping the RH at 55 ± 5% for 4 days, then 65 ± 5% for 2 days), which would make patches with satisfactory characteristics such as better flexibility, higher adhesive force, smooth flat matrix surface, and without gelatinization/residues and warped edge during the using process; (4) the aging of the packaged hydrogel patches was very sensitive to storage temperature, higher temperature, higher gel strength and lower adhesiveness. The storage temperature of 10 ± 2 °C could effectively prevent matrix aging and adhesion losing, which would also facilitate the expiration date of patches extended obviously. In conclusion, this work provides an optimized and feasible preparation technique for the industrial production of the hydrogel patches and establishes the hydrogel patches as a novel carrier for transdermal drug delivery.

CCR4 Is Critically Involved in Skin Allergic Inflammation of BALB/c Mice

Atopic dermatitis is a chronic inflammatory skin disease involving T-helper (Th) 2 cells, eosinophils, and mast cells. Although CCR4 is a major chemokine receptor expressed on Th2 cells and regarded as a potential therapeutic target for allergic diseases, its role in atopic dermatitis remains unclear. Here, by using a hydrogel patch as a transcutaneous delivery device for ovalbumin (an antigen) and Staphylococcus aureus δ-toxin (a mast cell activator), we efficiently induced acute atopic dermatitis-like skin lesions in BALB/c mice, a strain prone to Th2 responses, which were characterized by increased numbers of eosinophils, mast cells, and CCR4-expressing Th2 cells in the skin lesions; elevated levels of total and ovalbumin-specific IgE in the sera; and increased expression of IL-4, IL-17A, IL-22, CCL17, CCL22, and CCR4 in the skin lesions. Of note, the same model was less efficient in C57BL/6 mice, a strain prone to Th1 responses. Using this atopic dermatitis model in BALB/c mice, we demonstrated that CCR4-deficiency or a CCR4 antagonist ameliorated the allergic responses. Collectively, these results demonstrate that CCR4 plays a pivotal role in skin allergic inflammation of BALB/c mice by recruiting CCR4-expressing Th2 cells and Th17 cells.

New Horizons in the Development of Novel Needle-Free Immunization Strategies to Increase Vaccination Efficacy

The young twenty-first century has already brought several medical advances, such as a functional artificial human liver created from stem cells, improved antiviral (e.g., against HIV) and cancer (e.g., against breast cancer) therapies, interventions controlling cardiovascular diseases, and development of new and optimized vaccines (e.g., HPV vaccine). However, despite this substantial progress and the achievements of the last century, humans still suffer considerably from diseases, especially from infectious diseases. Thus, almost one-fourth of all deaths worldwide are caused directly or indirectly by infectious agents. Although vaccination has led to the control of many diseases, including smallpox, diphtheria, and tetanus, emerging diseases are still not completely contained. Furthermore, pathogens such as Bordetella pertussis undergo alterations making adaptation of the respective vaccine necessary. Moreover, insufficient implementation of vaccination campaigns leads to re-emergence of diseases which were believed to be already under control (e.g., poliomyelitis). Therefore, novel vaccination strategies need to be developed in order to meet the current challenges including lack of compliance, safety issues, and logistic constraints. In this context, mucosal and transdermal approaches constitute promising noninvasive vaccination strategies able to match these demands.

Skin vaccination via fractional infrared laser ablation - Optimization of laser-parameters and adjuvantation

BACKGROUND

Methods to deliver an antigen into the skin in a painless, defined, and reproducible manner are essential for transcutaneous immunization (TCI). Here, we employed an ablative fractional infrared laser (P.L.E.A.S.E. Professional) to introduce clinically relevant vaccines into the skin. To elicit the highest possible antibody titers with this system, we optimized different laser parameters, such as fluence and pore number per area, and tested various adjuvants.

METHODS

BALB/c mice were immunized with Hepatitis B surface antigen (HBsAg) by laser-microporation. Adjuvants used were alum, CRM₁₉₇, monophosphoryl lipid A, heat-labile enterotoxin subunit B of E. coli (LT-B), and CpG ODN1826. The influence of different fluences (2.1 to 16.8J/cm²) and pore densities (5-15%) was investigated. Furthermore, immunogenicity of HBsAg and the commercially available conjugate vaccines ActHIB® and Menveo® applied via TCI was compared to standard i.m. injection. Antigen-specific antibody titers were assessed by luminometric ELISA.

RESULTS

Antibody titers against HBsAg were dependent on pore depth and peaked at a fluence of 8.4J/cm². Immunogenicity was independent of pore density. Adjuvantation with alum significantly reduced antibody titers after TCI, whereas other adjuvants only induced marginal changes in total IgG titers. LT-B and CpG shifted the polarization of the immune response as indicated by decreased IgG1/IgG2a ratios. HBsAg/LT-B applied via TCI induced similar antibody titers compared to i.m. injection of HBsAg/alum. In contrast to i.m. injection, we observed a dose response from 5 to 20μg after TCI. Both, ActHIB® and Menveo® induced high antibody titers after TCI, which were comparable to i.m. injection.

CONCLUSIONS

Alum, the most commonly used adjuvant, is contraindicated for transcutaneous vaccination via laser-generated micropores. TCI with optimized laser parameters induces high antibody titers, which cannot be significantly increased by the tested adjuvants. Commercially available vaccines formulated without alum have the potential for successful TCI via laser-generated micropores, without the need for reformulation.

Recent insights into cutaneous immunization: How to vaccinate via the skin

Technologies and strategies for cutaneous vaccination have been evolving significantly during the past decades. Today, there is evidence for increased efficacy of cutaneously delivered vaccines allowing for dose reduction and providing a minimally invasive alternative to traditional vaccination. Considerable progress has been made within the field of well-established cutaneous vaccination strategies: Jet and powder injection technologies, microneedles, microporation technologies, electroporation, sonoporation, and also transdermal and transfollicular vaccine delivery. Due to recent advances, the use of cutaneous vaccination can be expanded from prophylactic vaccination for infectious diseases into therapeutic vaccination for both infectious and non-infectious chronic conditions. This review will provide an insight into immunological processes occurring in the skin and introduce the key innovations of cutaneous vaccination technologies.

[From basic principles to clinical applications on transcutaneous vaccine]

The recent vigorous transnational migration of people and materials reflecting the development of transportation facilities, changes in social structure, and war disasters has increased the global spread of emerging and re-emerging infectious diseases. Vaccine, which is the major fundamental prophylaxis against infectious diseases, has greatly contributed to the maintenance and improvement of human health worldwide. However, the disadvantages of conventional injection systems hamper the speedy mass-vaccination and the global distribution of vaccines. Transcutaneous immunization systems, which are easy-to-use and low-invasive methods of vaccination, have the potential to overcome certain issues associated with injectable vaccinations. In this review, we provide an outline of recent trends in the development of techniques for the transcutaneous delivery of vaccine antigens. We also introduce basic and clinical research involving our transcutaneous immunization systems that incorporate self-dissolving microneedle patch.

Transcutaneous antigen delivery system

Transcutaneous immunization refers to the topical application of antigens onto the epidermis. Transcutaneous immunization targeting the Langerhans cells of the skin has received much attention due to its safe, needle-free, and noninvasive antigen delivery. The skin has important immunological functions with unique roles for antigen-presenting cells such as epidermal Langerhans cells and dermal dendritic cells. In recent years, novel vaccine delivery strategies have continually been developed; however, transcutaneous immunization has not yet been fully exploited due to the penetration barrier represented by the stratum corneum, which inhibits the transport of antigens and adjuvants. Herein we review recent achievements in transcutaneous immunization, focusing on the various strategies for the enhancement of antigen delivery and vaccination efficacy. [BMB Reports 2013; 46(1): 17-24]

Frontiers of transcutaneous vaccination systems: novel technologies and devices for vaccine delivery

Transcutaneous immunization (TCI) systems that use the skin's immune function are promising needle-free, easy-to-use, and low-invasive vaccination alternative to conventional, injectable vaccination methods. To develop effective TCI systems, it is essential to establish fundamental techniques and technologies that deliver antigenic proteins to antigen-presenting cells in the epidermis and dermis while overcoming the barrier function of the stratum corneum. In this review, we provide an outline of recent trends in the development of techniques for the delivery of antigenic proteins and of the technologies used to enhance TCI systems. We also introduce basic and clinical research involving our TCI systems that incorporate several original devices.

Transcutaneous vaccines--current and emerging strategies

INTRODUCTION

Vaccination, which is the major fundamental prophylaxis against illness and death from infectious disease, has greatly contributed to the global improvement of human health. However, the disadvantages of conventional injection systems hamper the delivery of vaccination technologies to developing countries. The imminent practice of easy-to-use vaccination methods is expected to overcome certain issues associated with injectable vaccinations. One innovative method is the transcutaneous immunization (TCI) system.

AREAS COVERED

Two major strategies for TCI are discussed in this review. One is to promote antigen permeation of the skin barrier by patch systems or nanoparticles. The other is the delivery of antigens into the skin by electroporation and microneedles in order to physically overcome the skin barrier. Moreover, adjuvant development for TCI is discussed.

EXPERT OPINION

Many different approaches have been developed for TCI, which have the potential to be effective, easy-to-use and painless methods of vaccination. However, in practical terms, the guidelines concerning the manufacturing processes and clinical trial evaluation of the procedures have not kept pace with the development of these novel formulations. The accumulation of information regarding skin characteristics and the properties of TCI devices will help refine TCI system development guidelines and thus lead to the improvement of transcutaneous vaccination.

[Development of transcutaneous vaccination system for infectious disease countermeasure]

The recent vigorous transnational migration of people and materials reflecting the development of transportation facilities, changes in social structure, and war disasters has increased the global spread of emerging and re-emerging infections. Once, as the 2009 pandemic influenza A (H1N1) virus, person-to-person transmission was achieved, the spread of pandemic cannot be contained in reality. Thus enhancement of the crisis-management structure against pandemic is critically important to maintain national function. On the basis of this social background, the development of vaccination, which is the only fundamental prophylaxis, is in attention, and earliest possible establishment of system that supply mass-vaccines in a short time is required. Even if, however, rapid manufacture of vaccine antigen is actualized, there are several problems that vaccine is not easily spread across the developing country and mass vaccination is not performed immediately at the time of the crisis, because conventional vaccination is performed mainly by injection. Our research group developed transcutaneous vaccine devices; a hydrogel patch and a dissolving microneedle array which delivered antigens to antigen-presenting cells in the epidermal layer. Our transcutaneous vaccination system receives a high evaluation as novel, easy-to-use, and less-invasive vaccination method against infections from home and abroad. In this review, we introduce the research progress resulted from our basic, preclinical, and clinical study for practical use.

Kinetic analysis and evaluation of the mechanisms involved in the resolution of experimental nontypeable Haemophilus influenzae-induced otitis media after transcutaneous immunization

Transcutaneous immunization (TCI) is a simple and needle-free method with which to induce protective immune responses. Using a chinchilla model of nontypeable Haemophilus influenzae (NTHI)-induced otitis media (OM), we examined the efficacy afforded by TCI with a novel chimeric immunogen called 'chimV4' which targets two critical adhesins expressed by NTHI, outer membrane protein P5 and the majority subunit of NTHI Type IV pilus, PilA. Experimental OM was first established in cohorts of animals, and then TCI performed via a therapeutic immunization regime by rubbing vaccine formulations on hydrated pinnae. The kinetics of resolution of established experimental disease was evaluated by clinically-relevant assessments of OM, bacterial culture of planktonic and adherent NTHI within the middle ear and gross examination of the relative amount of NTHI mucosal biofilms within the middle ear space. Within seven days after primary TCI, a significant reduction in the signs of OM, significantly fewer NTHI adherent to the middle ear mucosa and significant resolution of mucosal biofilms was detected in animals that received chimV4+ the adjuvant LT(R192G-L211A), compared to animals administered LT(R192G-L211A) alone or saline by TCI (p<0.05) with eradication of NTHI within an additional seven days. The mechanism for rapid disease resolution involved efflux of activated dermal dendritic cells from the pinnae after TCI, secretion of factors chemotactic for CD4(+) T-cells, induction of polyfunctional IFNγ- and IL-17-producing CD4(+) T-cells and secretion of host defense peptide within the middle ear. These data support TCI as a therapeutic intervention against experimental NTHI-induced OM and begin to elucidate the host response to immunization by this noninvasive regimen.