Immunization of 2-month-old infants with protein-coupled oligosaccharides derived from the capsule of Haemophilus influenzae type b

MA, Tovar-Rosero YY, Oñate AA, O'Ryan M. Two centuries of vaccination: historical and conceptual approach and future perspectives

Over the past two centuries, vaccines have been critical for the prevention of infectious diseases and are considered milestones in the medical and public health history. The World Health Organization estimates that vaccination currently prevents approximately 3.5-5 million deaths annually, attributed to diseases such as diphtheria, tetanus, pertussis, influenza, and measles. Vaccination has been instrumental in eradicating important pathogens, including the smallpox virus and wild poliovirus types 2 and 3. This narrative review offers a detailed journey through the history and advancements in vaccinology, tailored for healthcare workers. It traces pivotal milestones, beginning with the variolation practices in the early 17th century, the development of the first smallpox vaccine, and the continuous evolution and innovation in vaccine development up to the present day. We also briefly review immunological principles underlying vaccination, as well as the main vaccine types, with a special mention of the recently introduced mRNA vaccine technology. Additionally, we discuss the broad benefits of vaccines, including their role in reducing morbidity and mortality, and in fostering socioeconomic development in communities. Finally, we address the issue of vaccine hesitancy and discuss effective strategies to promote vaccine acceptance. Research, collaboration, and the widespread acceptance and use of vaccines are imperative for the continued success of vaccination programs in controlling and ultimately eradicating infectious diseases.

A Review of Protein- and Peptide-Based Chemical Conjugates: Past, Present, and Future

Over the past few decades, the complexity of molecular entities being advanced for therapeutic purposes has continued to evolve. A main propellent fueling innovation is the perpetual mandate within the pharmaceutical industry to meet the needs of novel disease areas and/or delivery challenges. As new mechanisms of action are uncovered, and as our understanding of existing mechanisms grows, the properties that are required and/or leveraged to enable therapeutic development continue to expand. One rapidly evolving area of interest is that of chemically enhanced peptide and protein therapeutics. While a variety of conjugate molecules such as antibody-drug conjugates, peptide/protein-PEG conjugates, and protein conjugate vaccines are already well established, others, such as antibody-oligonucleotide conjugates and peptide/protein conjugates using non-PEG polymers, are newer to clinical development. This review will evaluate the current development landscape of protein-based chemical conjugates with special attention to considerations such as modulation of pharmacokinetics, safety/tolerability, and entry into difficult to access targets, as well as bioavailability. Furthermore, for the purpose of this review, the types of molecules discussed are divided into two categories: (1) therapeutics that are enhanced by protein or peptide bioconjugation, and (2) protein and peptide therapeutics that require chemical modifications. Overall, the breadth of novel peptide- or protein-based therapeutics moving through the pipeline each year supports a path forward for the pursuit of even more complex therapeutic strategies.

High performance anion exchange chromatographic and colorimetric methods for quality assessment of total and free polysaccharide content in Haemophilus influenzae type b conjugate vaccine containing lactose

The presence of lactose as a stabilizer in Haemophilus influenzae type b (Hib) conjugate vaccine is a challenge for chromatographic resolution of its total and free poly ribosyl ribitol phosphate (PRP) content. Sample pretreatment using ultrafiltration was performed and had removed ≥95% of lactose in shorter time compared to the conventional dialysis process. Separation of free unconjugated PRP was performed using solid-phase extraction C₄ cartridges. Hib conjugate vaccine was then analyzed for determination of total and free PRP, using two validated techniques: high performance anion exchange chromatography with pulsed amperometry (HPAEC-PAD) for ribitol determination and a colorimetric assay for phosphorus determination. Lactose removal had enabled a rapid chromatographic assay via fast depolymerization of PRP using high temperature treatment. Modifying the burning process in the colorimetric assay reduced the analysis time significantly compared to the pharmacopoeial method. Linearity was obtained over the range of 0.10-10.0 μg mL^-1 for the HPAEC method and in the range of 1.0-8.0 μg mL^-1 for the colorimetric one. Stability of Hib conjugate vaccine was investigated. The HPAEC results revealed about a 35% increase in free PRP content after storage under stressed conditions (moisture and temperature). The proposed methods offered a reliable and economic platform for assessing the immunogenicity, efficacy and stability of Hib conjugate vaccine containing lactose for the biopharmaceutical industry.

Molecular size distribution assessment of Haemophilus influenzae vaccine containing lactose by HPAEC-PAD and colorimetric assays

Molecular size distribution of Haemophilus influenzae type b (Hib) conjugate vaccine is an important indicator for its immunogenicity and stability. Molecular size distribution was evaluated by High-Performance Protein Chromatography on Sepharose CL-4B column, and fractions were pooled. The use of high flow rate, incorporation of a calibration standard with the injected buffer and pooling method yielded a superior assay compared to conventional pharmacopeial method. The pools were analyzed for determination of distribution coefficient (K_D) of 0.2 and 0.5 using two validated techniques: High Performance Anion Exchange Chromatography with pulsed amperometric detection (HPAEC-PAD) for ribitol determination and an optimized colorimetric assay for phosphorus determination. Linearity was achieved over range of 0.10-10.0 μg/mL and 1.0-8.0 μg/mL with LOD of 0.03 and 0.28 μg/mL for HPAEC and colorimetric assays, respectively. The developed assays were successfully applied in quality control monitoring of Hib conjugate vaccine. The optimized colorimetric method had shortened the analysis time to 25 min compared to 3.5 h for the European pharmacopeial assay by modifying the burning process. HPAEC stability results revealed 40% decrease in MSD after stressed storage conditions. The proposed assays offer a reliable and economic platform for monitoring the quality attributes of Hib for biopharma industry.

Invasive Haemophilus influenzae Infections after 3 Decades of Hib Protein Conjugate Vaccine Use

Haemophilus influenzae serotype b (Hib) was previously the most common cause of bacterial meningitis and an important etiologic agent of pneumonia in children aged <5 years. Its major virulence factor is the polyribosyl ribitol phosphate (PRP) polysaccharide capsule. In the 1980s, PRP-protein conjugate Hib vaccines were developed and are now included in almost all national immunization programs, achieving a sustained decline in invasive Hib infections. However, invasive Hib disease has not yet been eliminated in countries with low vaccine coverage, and sporadic outbreaks of Hib infection still occur occasionally in countries with high vaccine coverage. Over the past 2 decades, other capsulated serotypes have been recognized increasingly as causing invasive infections. H. influenzae serotype a (Hia) is now a major cause of invasive infection in Indigenous communities of North America, prompting a possible requirement for an Hia conjugate vaccine. H. influenzae serotypes e and f are now more common than serotype b in Europe. Significant year-to-year increases in nontypeable H. influenzae invasive infections have occurred in many regions of the world. Invasive H. influenzae infections are now seen predominantly in patients at the extremes of life and those with underlying comorbidities. This review provides a comprehensive and critical overview of the current global epidemiology of invasive H. influenzae infections in different geographic regions of the world. It discusses those now at risk of invasive Hib disease, describes the emergence of other severe invasive H. influenzae infections, and emphasizes the importance of long-term, comprehensive, clinical and microbiologic surveillance to monitor a vaccine's impact.

Long Term Impact of Conjugate Vaccines on Haemophilus influenzae Meningitis: Narrative Review

H. influenzae serotype b (Hib) used to be the commonest cause of bacterial meningitis in young children. The widespread use of Hib conjugate vaccine has profoundly altered the epidemiology of H. influenzae meningitis. This short review reports on the spectrum of H. influenzae meningitis thirty years after Hib conjugate vaccine was first introduced into a National Immunization Program (NIP). Hib meningitis is now uncommon, but meningitis caused by other capsulated serotypes of H. influenzae and non-typeable strains (NTHi) should be considered. H. influenzae serotype a (Hia) has emerged as a significant cause of meningitis in Indigenous children in North America, which may necessitate a Hia conjugate vaccine. Cases of Hie, Hif, and NTHi meningitis are predominantly seen in young children and less common in older age groups. This short review reports on the spectrum of H. influenzae meningitis thirty years after Hib conjugate vaccine was first introduced into a NIP.

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.

Control of vaccine preventable diseases in Australian infants: reviewing a decade of experience with DTPa-HBV-IPV/Hib vaccine

The combined vaccine against diphtheria, tetanus, pertussis, hepatitis B, poliomyelitis, and Haemophilus influenzae b (DTPa-HBV-IPV/Hib, Infanrix Hexa, GSK) has been used for childhood immunization in Australia according to a two-, four-, six-month schedule since 2009. We reviewed data available in the Australian National Notifiable Diseases Surveillance System, annual vaccination coverage reports, the Database of Adverse Event Notifications, and peer-reviewed literature to assess vaccine coverage rates, incidence of all six vaccine preventable diseases, and the safety profile of DTPa-HBV-IPV/Hib vaccine in Australian infants over a period of ten years of exclusive use. Between 2009 and 2018 vaccine coverage for infants aged 12 months increased from 91.7% to 94.0% and from 84.9% to 92.6% for all and for Indigenous infants, respectively. Over the same time period, there were no reports of poliomyelitis, diphtheria or tetanus in infants <12 months of age. The incidence of hepatitis B among Australian infants <12 months of age remains 10 to 20-fold lower than the national average. Control of Haemophilus influenzae b (Hib) and pertussis disease has continued to be challenging. Timely administration of the primary series, as well as increasing coverage rates, particularly among Indigenous children, has contributed to improvements in Hib and pertussis disease control. The incorporation of additional strategies such as adjustment of the first vaccination encounter to six weeks of age, parental cocooning, and most recently maternal vaccination has further reduced the burden of pertussis, particularly during the first six months of life. The frequency of the ten most common adverse events related to the DTPa-HBV-IPV/Hib vaccine demonstrates an acceptable safety profile. Data collected over ten years of consistent, exclusive use of the DTPa-HBV-IPV/Hib vaccine in Australia highlights combination vaccination as a cornerstone in maintaining infant health.

Rationale and prospects for novel pneumococcal vaccines

Streptococcus pneumoniae remains one of the most frequent bacterial causes of morbidity and mortality worldwide. National immunization programs implementing pneumococcal polysaccharide conjugate vaccines (PCVs) have successfully reduced rates of vaccine-type invasive disease and colonization both via direct effects in immunized children and, in some settings, indirect effects in unimmunized individuals. Limitations of the current PCV approach include the emergence of non-vaccine serotypes contributing to carriage and invasive disease in high-PCV coverage settings and the high cost of goods of PCVs which limits their accessibility in developing countries where the burden of disease remains highest. Furthermore, the distribution of serotypes causing disease varies geographically and includes more serotypes than are currently covered in a single PCV formulation. Researchers have long been exploring the potential of genetically conserved non-capsular pneumococcal antigens as vaccine candidates that might overcome such limitations. To better evaluate the rationale of such approaches, an understanding of the mechanisms of immunity to the various phases of pneumococcal infection is of paramount importance. Herein we will review the evolving understanding of both vaccine-induced and naturally acquired immunity to pneumococcal colonization and infection and discuss how this informs current approaches using serotype-independent pneumococcal vaccine candidates. We will then review the alternative vaccine candidates that have been or are currently under evaluation in clinical trials.

Protein carriers of conjugate vaccines: characteristics, development, and clinical trials

The immunogenicity of polysaccharides as human vaccines was enhanced by coupling to protein carriers. Conjugation transformed the T cell-independent polysaccharide vaccines of the past to T cell-dependent antigenic vaccines that were much more immunogenic and launched a renaissance in vaccinology. This review discusses the conjugate vaccines for prevention of infections caused by Hemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis. Specifically, the characteristics of the proteins used in the construction of the vaccines including CRM, tetanus toxoid, diphtheria toxoid, Neisseria meningitidis outer membrane complex, and Hemophilus influenzae protein D are discussed. The studies that established differences among and key features of conjugate vaccines including immunologic memory induction, reduction of nasopharyngeal colonization and herd immunity, and antibody avidity and avidity maturation are presented. Studies of dose, schedule, response to boosters, of single protein carriers with single and multiple polysaccharides, of multiple protein carriers with multiple polysaccharides and conjugate vaccines administered concurrently with other vaccines are discussed along with undesirable consequences of conjugate vaccines. The clear benefits of conjugate vaccines in improving the protective responses of the immature immune systems of young infants and the senescent immune systems of the elderly have been made clear and opened the way to development of additional vaccines using this technology for future vaccine products.

The burden of nonencapsulated Haemophilus influenzae in children and potential for prevention

PURPOSE OF REVIEW

In countries with established Haemophilus influenzae serotype b (Hib) immunization programmes, nonencapsulated H. influenzae (ncHi) is responsible for most invasive H. influenzae infections across all age groups and is associated with higher case fatality. A pneumococcal conjugate vaccine has recently been licensed, which may potentially also protect against invasive H. influenzae infections.

RECENT FINDINGS

Invasive ncHi disease is uncommon in childhood but has a much higher incidence in the first month of life. Most neonates with invasive ncHi infections are born prematurely and develop septicaemia in the first 48 h of life which can be fatal. After this period, invasive ncHi incidence falls rapidly and remains low throughout childhood. Most infants and children who develop invasive ncHi disease have significant underlying comorbidities, particularly neurological disease, malignancy and other conditions requiring immunosuppressive therapy. Although characteristically associated with respiratory tract infections, at least a quarter of invasive ncHi infections present with meningitis.

SUMMARY

A vaccine against ncHi could have an important preventive role in children with comorbidities. Future studies should focus on assessing specific risk factors for neonatal and childhood ncHi disease and long-term outcomes of children with invasive ncHi meningitis.

Pneumococcal vaccines for allergic airways diseases

BACKGROUND

Asthma is a common global health problem. Environmental exposures such as bacteria may protect against asthma development.

OBJECTIVE

This review aims to examine the possible protective role of pneumococcal infection and vaccination in asthma.

METHODS

A review of known experimental biology and human epidemiology relating to asthma and pneumococcal infection was performed.

RESULTS

Pneumococcal infection can modulate components of allergic airways disease such as airways hyperresponsiveness and airway eosinophilia. Exposure to killed pneumococcus can reproduce these effects and the mechanism may involve control by T regulatory cells.

CONCLUSIONS

Pneumococcal immunoregulatory therapy is a potentially important approach to asthma management that requires further evaluation in well-designed research studies.

CD4+ T cells mediate antibody-independent acquired immunity to pneumococcal colonization

Acquired immunity to Streptococcus pneumoniae (pneumococcus) has long been assumed to depend on the presence of anticapsular antibodies. We found, however, that colonization with live pneumococci of serotypes 6B, 7F, or 14 protected mice against recolonization by any of the serotypes and that protection from acquisition of a heterologous or homologous strain did not depend on anticapsular antibody. Further, intranasal immunization by live pneumococcal colonization or by a killed, nonencapsulated whole-cell vaccine protected antibody-deficient mice against colonization, suggesting independence of antibodies to any pneumococcal antigens. Protection by intranasal immunization with whole-cell vaccine was completely abrogated in T cell-deficient mice, and in mice that were congenitally deficient in CD4(+) T cells or depleted of these cells at the time of challenge. In contrast, mice congenitally deficient in, or depleted of, CD8(+) T cells were fully protected. Protection in this model was observed beyond 2 months after immunization, arguing against innate or nonspecific immune mechanisms. Thus, we find that immunity to pneumococcal colonization can be induced in the absence of antibody, independent of the capsular type, and this protection requires the presence of CD4(+) T cells at the time of challenge.

Haemophilus influenzae type b conjugate vaccines

Haemophilus influenzae type b (Hib) is one of the leading causes of invasive bacterial infection in young children worldwide. During childhood, acquisition of antibody directed against the polysaccharide capsule of the organism, presumably as a result of asymptomatic carriage, confers protection and disease is much less common after the age of 4 years. Like other polysaccharides, the polyribosyl ribitol phosphate (PRP) of the Hib capsule is a T-independent antigen and not immunogenic when administered as a vaccine in infancy. Because the highest rates of disease occur in the first 2 years of life, efficacious Hib vaccines have been designed by covalently linking the PRP capsule to a carrier protein that recruits T-cell help for the polysaccharide immune response and induces anti-PRP antibody production even in the first 6 months of life. Introduction of Hib protein-polysaccharide conjugate vaccines into many industrialized countries over the past 15 years has resulted in the virtual elimination of invasive Hib disease. However, despite the success of the vaccine programme several factors may interfere with the effectiveness of the vaccine in the routine programme, as observed in the UK recently. Such factors may include interference with other concomitant vaccines, waning immunity in the absence of booster doses of vaccine, and reduced natural boosting as a result of decreased transmission of the organism. However, the burden of disease remains highest in resource-poor countries and urgent efforts are needed to provide the benefits of this vaccine for children living in regions where it cannot be used for economic and logistical reasons.

A high degree of natural immunologic priming to the capsular polysaccharide may not prevent Haemophilus influenzae type b meningitis

BACKGROUND

A current debate is whether the immunologic priming of infants with Haemophilus influenzae type b (Hib) conjugate vaccines would be protective in the absence of circulating antibody to the capsular polysaccharide (PS). Data from the prevaccine era on the PS antibody responses of older children to Hib meningitis may be informative on this issue.

METHODS

PS antibody was assayed by radioantigen binding in sera taken in the first month postadmission in 47 children ages 2 to 136 months with culture-proved Hib meningitis.

RESULTS

Sera obtained on admission had very low antibody concentrations, and the subsequent response during convalescence was age-dependent. The major finding is that some patients, including 10 of 11 children older than 2 years, had substantial antibody elevations within a few days of admission, increases resembling the response to PS vaccine in infants primed with PS-protein conjugate vaccines.

CONCLUSIONS

In this group of patients with Hib meningitis, natural priming did not prevent infection. Hib may have the ability to invade despite the capacity for a vigorous antibody response.

Quantitation of low level unconjugated polysaccharide in tetanus toxoid-conjugate vaccine by HPAEC/PAD following rapid separation by deoxycholate/HCl

A simple and rapid acid precipitation method has been applied successfully for separating free capsular polysaccharide of Haemophilus influenzae type b (polyribosyl ribitol phosphate, PRP) from PRP tetanus toxoid conjugate (PRP-T) in a final dosage amount of low-level materials. The unconjugated PRP was found to stay in the supernatant without precipitation, while conjugated PRP-T was fully precipitated. High performance anion exchange chromatography with pulsed amperometric detection (HPAEC-PAD) has been applied for analysis of the PRP content in the supernatant after the separation. This method requires minimum sample handling and is specific, sensitive and reproducible making it suitable for release and stability testing of PRP-T in final containers.

The First Dose of a Haemophilus influenzae Type b Conjugate Vaccine Reactivates Memory B Cells: Evidence for Extensive Clonal Selection, Intraclonal Affinity Maturation, and Multiple Isotype Switches to IgA2

The Ab response of a healthy adult to the first dose of a Haemophilus influenzae type b capsular polysaccharide (HibCP) conjugate vaccine was studied at the level of Ig gene usage by circulating Ab-secreting cells. Forty-one IgA and 17 IgG mRNA sequences were obtained. The major part of the response was confined to IgA Ab-secreting cells, and 72% of the IgA sequences were derived from the progeny of a single rearranged B cell. These sequences could be arranged in a genealogical tree showing multiple somatic mutations and at least two intraclonal isotype switches to IgA2. Fourteen somatic mutations were shared by this clonal progeny, indicating that extreme clonal selection had occurred early in the clonal development. Taking into account the frequency of somatic mutations and the clone size, it was evident that the responding cell population must have originated from a mutated, highly selected, and expanded population of cells existing before vaccination, i.e., memory B cells. The dominating heavy and light chains of the response were combined in a Fab that bound HibCP. It was shown that the shared heavy and light chain mutations increased the affinity for HibCP considerably, indicating that the clonal selection had been driven by affinity. Pre-existing memory cells in unvaccinated adults may explain several features of Ab responses to polysaccharide vaccines and may play a role in acquiring the ability to respond to pure polysaccharides during infancy.

Antibody response to unconjugated Haemophilus influenzae b and pneumococcal polysaccharide vaccines in children with recurrent infections

BACKGROUND

Increasingly, antibody testing is being used to evaluate the status of humoral immunity in patients with recurrent infection and suspected immunodeficiency. In the past, we had been impressed that immunization with unconjugated Haemophilus influenzae b (uHib) vaccine provided useful information about the ability to produce antibody to polysaccharides and that the use of pneumococcal polysaccharide (PPS) vaccine frequently produced results that were difficult to interpret.

OBJECTIVE

The study was carried out to compare antibody responsiveness to vaccination with uHib with the response seen after PPS vaccination.

METHODS

Twenty children (ages, 2 to 13 years; 11 male) who were referred to our immunology clinic because of recurrent infections were immunized with both uHib vaccine and PPS vaccine. Nine children had previously received conjugated Hib vaccine.

RESULTS

All 20 children either responded with a twofold or greater increase in antibody titer after uHib vaccine or had preimmunization antibody concentrations of greater than 400 nanograms antibody nitrogen per milliliter (ng Ab N/ml). All of the children responded to PPS-3 with postimmunization antibody concentrations greater than 400 ng Ab N/ml. Three children had an increase in titer to PPS-7 of less than twofold, seven did not have a twofold increase in titer to PPS-9, and 15 had an increase in titer to PPS-14 of less than twofold.

CONCLUSION

Unconjugated Hib vaccine is a potent immunogen in children over 2 years of age. Prior immunization with the conjugate vaccine did not prevent a response to unconjugated vaccine. Unconjugated Hib vaccine appears to be at least as immunogenic as PPS-3 when used as an assessment vaccine for evaluating antibody responsiveness.

Immune responses of young mice to pneumococcal type 9V polysaccharide-tetanus toxoid conjugate

Pneumococcal type 9V polysaccharide (PS), contained in the current pneumococcal vaccine, induces only a weak antibody response in young children and therefore is not an effective vaccine for young children. To increase its immunogenicity, a conjugate of PS to a protein carrier, tetanus toxoid (TT), was prepared. To quantify the immune response, mouse anti-9V PS immunoglobulin G (IgG) and IgM reference standards were established. Young mice immunized at 2 weeks of age produced IgM antibody in response to 9V PS alone or 9V PS conjugated to TT. However, only the 9V PS-TT conjugate induced an IgG antibody response and an anamnestic effect. Thus, a covalent linkage between TT and 9V PS was required for isotype switching from IgM to IgG. 9V PS-TT adsorbed with aluminum hydroxide adjuvant resulted in a fivefold or greater increase in the IgG antibody level. We also studied the effect of maternal immunization on the immune response of young mice to 9V PS-TT. Maternal immunization before mating or before mating and during gestation primed 2-week-old progeny given two injections of 9V PS-TT to produce more IgM antibody than progeny from unimmunized mothers. The IgG antibody level of neonates at birth was similar to that observed in the mothers and was probably passive antibody. These results indicate that maternal immunization with an optimum dose of a PS-protein conjugate before and/or during pregnancy, followed by immunization of the offspring with the conjugate, could provide young children with an enhanced IgM antibody response to pneumococcal PSs.

Quantification of polysaccharide in Haemophilus influenzae type b conjugate and polysaccharide vaccines by high-performance anion-exchange chromatography with pulsed amperometric detection

A sensitive method for the quantification of polysaccharide (PS) in Haemophilus influenzae type b (Hib) conjugate and PS vaccines has been developed. It is based on measurement of the Hib PS subunit after depolymerization of the PS in sodium hydroxide to produce the subunit, which is characterized by chemical composition and 31P n.m.r. analyses as ribitol-ribose-phosphate. The Hib vaccines were first treated with 0.1 M sodium hydroxide. The Hib PS subunit in the treated vaccines was then analysed directly by high-performance anion-exchange chromatography using a CarboPak PA-1 column, and quantified by pulsed amperometric detection. The PS contents of three conjugate vaccines and three PS vaccines from different manufacturers were determined. Their values were in the expected ranges. This method is particularly useful for vaccines with a sugar stabilizer such as lactose which would interfere with the colorimetric orcinol assay currently used for determination of the PS. The method can measure 0.1 microgram of PS and its sensitivity is at least 30-fold higher than that of the orcinol assay. It may be used for stability studies of conjugate vaccines since a breakdown as low as 5% of the PS from the PS-protein conjugates would be detected.

Characterization of the serum antibody response induced by Haemophilus influenzae type b tetanus protein-conjugate vaccine in infants receiving a DTP-combined vaccine from 2 months of age

The serum antibody response induced by Haemophilus influenzae type b capsular polysaccharide (CPS)-tetanus protein conjugate vaccine combined to DTP vaccine was characterized in infants receiving three injections from 2 months of age. Sixty-five per cent and 94% of infants had anti-CPS antibody levels > or = 1 micrograms ml-1 after the second and third dose, respectively. The antibody response was mostly made up of IgG with a marked IgG1 predominance. Significant rises in bactericidal and in complement-mediated opsonic activities were observed after immunization. These data clearly show that this vaccine can be successfully administered in one syringe together with DTP vaccine during the regular infant immunization programme.

Prevention of Haemophilus influenzae type b disease

Haemophilus influenzae type b (Hib) is the leading cause of meningitis in children < 5 years of age. The majority of cases of Hib occur in infants < 2 years of age. Until recently the only vaccine available against this disease contained the pure polysaccharide (PRP) of Hib (Hib-PRP vaccine). The Hib-PRP vaccine was demonstrated to be efficacious in infants > 18 months of age but not below that age. This product was licensed for routine use in the USA for children aged 24 months or more. Recently a hyperimmune globulin termed bacterial polysaccharide immune globulin (BPIg) was prepared by immunizing adult donors with Hib-PRP, meningococcal and pneumococcal vaccines. BPIg has been demonstrated to prevent Hib infections when it is administered to infants at 4-month intervals. However, BPIg has not been licensed for routine use in the USA. A number of new Hib conjugate vaccines have also been developed in the last few years by convalently linking the Hib-PRP to different carrier proteins. Four different Hib conjugate vaccines have undergone clinical trials in the USA. Two of these vaccines, HbOC (Hib capsular oligosaccharide linked to CRM197) and Hib-OMPC (Hib capsular polysaccharide linked to Neisseria meningitidis outer membrane protein complex) have been demonstrated to protect infants aged 2 months or more from Hib disease. Both HbOC and Hib-OMPC are currently licensed for routine use in the USA. The widespread use of these vaccines should have a substantial impact in reducing morbidity and mortality from Hib disease.

Splenic autotransplantation and the immune system. Adequate testing required for evaluation of effect

The risk of severe infections after splenectomy, even after many years, is now well established. In attempts to prevent these infections, spleen-saving techniques, including autotransplantation of spleen fragments, have been performed, when possible in combination with vaccination. The problem in autotransplantation is the evaluation of functional activity. The results of the tests used until now often do not seem to correlate very well with the risk of developing an overwhelming postsplenectomy infection (OPSI). This may be related to the fact that the tests used evaluate general functions, and not specific spleen-related functions, such as the capacity to mount a primary response to certain polysaccharide antigens present in the capsule of bacteria known to cause OPSI. In this review, the significance of the spleen in the human immune system is discussed and the effects of splenectomy are described, including the precautions that can be taken to diminish the risk of postsplenectomy infections and sepsis. It appears that postsplenectomy vaccination is more successful when recently developed protein-conjugated polysaccharide vaccines are used. Because the present testing of the function of spleen autotransplants is not adequate, we suggest that new tests should be developed, employing appropriate polysaccharide antigens.

Molecular conservation of the P6 outer membrane protein among strains of Haemophilus influenzae: analysis of antigenic determinants, gene sequences, and restriction fragment length polymorphisms

Infections caused by Haemophilus influenzae are a major worldwide health problem. In particular, nontypeable strains of H. influenzae are a common cause of otitis media in infants and children. A vaccine to prevent these infections would result in the prevention of substantial morbidity and cost savings. A problem in identifying an appropriate vaccine antigen has been the enormous antigenic heterogeneity among nontypeable strains of H. influenzae. The present study was undertaken to characterize the conservation of the P6 outer membrane protein (approximately 16,000 daltons) among strains of H. influenzae. A total of 20 type b strains and 20 nontypeable strains of diverse geographic and clinical origins was studied. Three approaches were taken. (i) Antigenic determinants recognized by monoclonal and polyclonal antibodies were present on P6 in all 40 strains tested. The molecular weight of P6 was identical in all strains. (ii) Comparison of the DNA sequences of the P6 genes from three epidemiologically and serologically unrelated strains demonstrated 100% homology at the amino acid level and 97 to 99% homology at the nucleotide level. (iii) Restriction fragment length polymorphism analysis demonstrated that the P6 gene and flanking sequences were highly conserved among all strains. These three independent series of experiments indicated that the P6 protein is highly conserved among strains of H. influenzae. P6 should receive serious consideration for inclusion in a vaccine to prevent infections caused by nontypeable H. influenzae.

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

To assess vaccines, multiple laboratory investigations and immunogenicity studies are conducted but the ultimate tests of the effectiveness of a vaccine are field trials that evaluate disease prevention. Immunogenicity studies are often used as a surrogate for protection, but it is often difficult to determine precisely the level of antibody needed for protection and it is not always clear what immunologic factors most determine protection. However, efficacy trials are difficult to conduct well and there are only a limited number of ways to perform such studies. Nonetheless, the results of efficacy studies are essential for the appropriate selection of the best Hib vaccines and to establish recommendations for optimal use. The first Hib vaccine, the PRP (polyribosylribitol phosphate) polysaccharide vaccine, was shown by several efficacy studies to have no protective efficacy in young infants, and to have only limited, if any, efficacy in older children. The first Hib polysaccharide conjugate vaccine, PRP-D, is more immunogenic and provides better protection than PRP in older children (greater than 18 months of age), but it has limitations in both immunogenicity and protective efficacy when given to children younger than 6 months of age. Newer, more promising, Hib conjugate vaccines are now available, and include HbOC, PRP-OMP, and PRP-T vaccines. Each is currently being evaluated in field trials to evaluate protective efficacy and the methods and results of these trials will be reviewed. The control of invasive Hib disease worldwide will depend upon the appropriate application of knowledge derived from these field trials.

Immunogenicity of four Haemophilus influenzae type b conjugate vaccines in 17- to 19-month-old children

OBJECTIVE

To compare the immunogenicity of four Haemophilus influenzae type b (Hib) conjugate vaccines in different populations of 17- to 19-month-old children in the United States.

DESIGN

Four immunogenicity trials with sera were assayed in one laboratory. Trials 1 and 2 each compared one vaccine in two regions, and trials 3 and 4 were randomized comparisons of multiple vaccines within a region.

SUBJECTS

A convenience sample of 313 healthy children recruited from pediatric practices in Minneapolis, Minn., Dallas and Houston, Tex., and Sellersville, Pa.

MEASUREMENTS AND RESULTS

Children with prevaccination antibody greater than 0.15 microgram/ml showed higher antibody responses to vaccination than children with less than or equal to 0.15 microgram/ml (p less than 0.001). Among the former, there were no significant differences in antibody response to vaccination with the different conjugates within any of the trials. Among children with less than or equal to 0.15 microgram/ml of antibody before vaccination, there were no significant differences in the geometric mean antibody responses of children in trial 1 vaccinated with polyribosylribitol phosphate-diphtheria toxoid (PRP-D) in Dallas or in Minneapolis, or of children in trial 3 in Dallas randomly assigned to receive Hib oligosaccharide-CRM197 (HbOC) or PRP-D. In contrast, in trial 2, children given PRP-tetanus toxoid (PRP-T) in Pennsylvania had a significantly higher geometric mean antibody response than children given PRP-T in Houston (13.5 vs 3.0 micrograms/ml; p = 0.005). In trial 4 in Minneapolis, the geometric mean antibody response was highest in children randomly assigned to receive PRP-outer membrane protein (OMP) (9.3 micrograms/ml), followed by PRP-D (5.0 micrograms/ml) and HbOC (2.3 micrograms/ml) (PRP-OMP vs HbOC; p = 0.005). In all four trials, IgG1 responses predominated compared with IgG2 responses.

CONCLUSIONS

All four conjugate vaccines are immunogenic in children 17 to 19 months of age. However, the magnitude of the anticapsular antibody response varied by vaccine type, the level of antibody in prevaccination sera, and geographic location.

Contribution of a 28-kilodalton membrane protein to the virulence of Haemophilus influenzae

A Haemophilus influenzae b (Hib) membrane protein with a molecular mass of 28 kDa bound polyclonal antisera raised against a highly purified Hib fimbrial subunit. We cloned the gene encoding this protein and found that the gene was expressed in Escherichia coli. DNA sequence analysis identified an 843-bp open reading frame which predicted a 26.78-kDa protein with an amino-terminal signal sequence and a mature protein with 70% similarity to the 28-kDa lipoprotein of E. coli (F. Yu, S. Inouye, and M. Inouye, J. Biol. Chem. 261:2284, 1986). Colony blot hybridization analysis with an intergenic probe of the cloned gene demonstrated that 29 of 32 H. influenzae strains hybridize with this gene. Insertion of a chloramphenicol acetyltransferase gene into the open reading frame inactivated expression of the 28-kDa protein in E. coli. Isogenic Hib strains were derived by marker exchange mutagenesis to generate mutants which no longer expressed the 28-kDa protein as recognized with Western immunoblot analysis. There was no difference in the rate of nasopharyngeal colonization of infant rats or monkeys by the isogenic mutants which lacked the 28-kDa protein compared with colonization by the wild-type strain. In contrast, the frequency of invasion and density of bacteremia in infant rats caused by the isogenic mutants were reduced relative to those caused by the wild-type Hib strain. We conclude that this 28-kDa outer membrane protein aids transepithelial invasion of type b strains but is not essential.

New vaccines against Haemophilus influenzae type b

Recently, great progress has been made in the development of vaccines against Hib. Four polysaccharide-protein conjugate vaccines are actively being tested. Three of these (PRP-D, HbOC, and PRP-OMP) are currently licensed for use in children at 15-18 months of age. Clinical trials of these vaccines in infants are currently being conducted in the United States. If these show the vaccines to be efficacious, licensure for infants will follow. Although much work remains to be done, it seems likely that the effective prevention of serious Hib infections in infants, as well as in older children, is a goal that may be within our reach in the next several years.

Response to a Haemophilus influenzae type b diphtheria CRM197 conjugate vaccine in children with a defect of antibody production to Haemophilus influenzae type b polysaccharide

A defect in antibody response to immunization with Haemophilus influenzae type b (Hib) capsular polysaccharide vaccine has been reported in children with recurrent infections and normal immunoglobin levels. We identified 15 children, aged 2 to 6 years, with this defect, and we evaluated their response to immunization with an Hib capsular oligosaccharide diphtheria CRM197 protein-conjugate vaccine (HbOC). The children received a series of three vaccines: HbOC at 0 and 8 weeks, and the Hib polysaccharide vaccine at 16 weeks. Levels of antibody to the Hib capsular polysaccharide (polyribosyl ribitol phosphate, PRP) and to diphtheria toxoid were obtained before and 4 weeks after each vaccination. The geometric mean serum anti-PRP concentration was 0.17 microgram/ml before immunization and 29.3 micrograms/ml after the second HbOC immunization (week 12). All 15 children had postvaccination anti-PRP antibody levels greater than 1.0 microgram/ml after receiving the second HbOC (week 12). In addition, booster responses were observed after the second Hib conjugate in 13 of the patients and after the Hib polysaccharide in four of the patients. All patients with low preimmunization diphtheria titers had a response to the diphtheria toxoid. These results suggest that conjugation of Hib polysaccharide with diphtheria CRM197 overcomes the defective antibody response to Hib oligosaccharide in children who are initially observed with recurrent infections and inability to respond to the Hib polysaccharide vaccine.

Antibody response of 18 month old children 1 month and 18 months following Haemophilus influenzae type b vaccine administered singly or with DTP vaccine

Seventy-six children (aged 17-19 months) received 10 micrograms of Haemophilus influenzae type b polyribosyl-ribitol phosphate (PRP) vaccine, diluted with either phosphate-buffered saline (PBS) or diphtheria-tetanus-pertussis (DTP) vaccine, in a single-blind randomized trial. There were few side effects when PRP was administered alone. Before vaccination 37 of 76 children (49%) had non-protective antibody levels (less than 0.15 micrograms/mL); 26 of these 37 (70%) achieved antibody levels of greater than 0.15 micrograms/mL 1 month after vaccination. Before vaccination 16 of 76 (21%) had antibody levels of greater than 1.0 micrograms/mL; 1 month after vaccination 39 of 76 children (51%) achieved levels of greater than 1.0 micrograms/mL. Of 12 infants who had antibody levels less than 0.15 micrograms/mL 1 month after immunization, 10 had protective levels 18 months later. Administration of PRP mixed with DTP did not affect antibody response to PRP. The potential use and limitations of PRP vaccine are discussed.

Selective antibody deficiency to Haemophilus influenzae type B capsular polysaccharide vaccination in children with recurrent respiratory tract infection

Fifty-one children between 22 and 158 months of age referred to an immunology clinic with a history of recurrent respiratory tract infections were prospectively evaluated for immunologic abnormalities. Ten of the subjects had a poor response to the Haemophilus influenzae type b (Hib) capsular polysaccharide vaccine (failure to mount a twofold increase in titer or achieve a postimmunization titer greater than 0.2 micrograms ab/ml). There were no differences in mean serum concentrations of IgG, IgM, IgA, isohemagglutinins, or anti-tetanus toxoid between the responders and the nonresponders. None of the 10 nonresponders were deficient in IgG2. Eight of the vaccine failures were immunized with an Hib conjugate vaccine (HbOC) consisting of Hib capsular oligosaccharides coupled to diphtheria toxin. All responded with at least a fivefold increase in antibody after primary immunization with HbOC. Seven of the eight had a postHbOC primary immunization titer greater than 1.0 microgram/ml. This study demonstrates that some children with recurrent infections and with normal IgG subclasses are unable to respond to Hib capsular polysaccharide. This defect, which can be circumvented by presenting the polysaccharide antigen in an alternative form, may be contributing to the symptomatology experienced by these patients.

Haemophilus influenzae type b conjugate vaccine trial in Oxford: implications for the United Kingdom

The safety and immunogenicity of a Haemophilus influenzae type b conjugate vaccine was investigated in 103 infants immunised at 3, 5, and 9 months of age; the infants also received diphtheria, pertussis, and tetanus and polio vaccines. Side effects were compared with 99 matched infants receiving diphtheria, pertussis, and tetanus and polio vaccines only. No serious side effects were observed and the incidence of minor side effects was no greater in the recipients of H influenzae type b conjugate vaccine. Two doses of the vaccine (standard and low) were compared: geometric mean titres of serum anticapsular antibody rose from 0.11 microgram/ml before immunisation to 26.4 micrograms/ml after three immunisations with the standard dose and 14.6 micrograms/ml with the low dose. The geometric mean titre among 21 unimmunized infants at this age was 0.06 micrograms/ml. Both doses therefore generated antibody concentrations likely to be protective after three immunisations. There were no non-responders. Incorporation of an H influenzae type b conjugate vaccine into the primary immunisation schedule has the potential for preventing over 1000 cases of systemic H influenzae type b disease and 50 deaths each year in the United Kingdom.

Development of serum antibodies of the immunoglobulin G class and subclasses against the capsular polysaccharide of Haemophilus influenzae type b in children and adults with invasive infections

The development of total immunoglobulin G (IgG) antibodies and antibodies of the four IgG subclasses in serum against Haemophilus influenzae type b capsular polysaccharide (CPS) was studied in 24 children and 11 adults with invasive Haemophilus influenzae type b infections, by using an enzyme-linked immunosorbent assay. None of the 8 children aged 10 months or younger had increases in the IgG class or in any of the IgG subclasses. In contrast, 14 of 16 children between 10 months and 6 years of age and 10 of 11 adults had significant increases in total IgG, IgG1, or IgG2 antibodies in various combinations, but none of them had increases in IgG3 or IgG4 antibodies. The increases in IgG1 and IgG2 antibodies in the children were of similar magnitudes. Of 11 adult patients, 9 had significant increases in IgG2 antibodies, while only 4 had increases in IgG1 antibodies. In conclusion, this study shows that children younger than approximately 1 year have no IgG response to H. influenzae type b CPS, while individuals above this age have a mixed IgG1 and IgG2 response.

Comparison between radioimmunoassay and direct and indirect enzyme-linked immunosorbent assays for determination of antibodies against Haemophilus influenzae type b capsular polysaccharide

Levels of antibodies against Haemophilus influenzae type b capsular polysaccharide were determined in acute-phase and convalescent-phase serum samples obtained from 21 children with invasive H. influenzae type b infections and from 44 children vaccinated with two H. influenzae type b vaccines. Amounts of immunoglobulin G (IgG), IgM, and IgA antibodies were measured by direct and indirect enzyme-linked immunosorbent assay (ELISA), and the total amount of antibodies was measured by radioimmunoassay (RIA). Results obtained by ELISA were calculated by multiple-point parallel-line comparison and by endpoint analysis. A very good correlation was obtained between direct and indirect ELISA values. In the lower range of antibody concentrations, the correlation between ELISA values obtained by endpoint analysis and those obtained by multiple-point parallel-line comparison was poor, since the latter method of calculation yielded values of up to 1 microgram/ml in sera that were negative according to endpoint analysis. These sera with negative endpoint titers also had undetectable or very low antibody concentrations as measured by RIA. Consistent with this finding, in acute-phase and prevaccination sera with undetectable or low antibody concentrations as measured by RIA, ELISA values calculated by multiple-point parallel-line comparison were much higher. In sera with higher antibody concentrations, however, parallel-line comparisons showed good correlation between RIA and ELISA values. Although no reference method for measuring true antibody concentrations is available, ELISA values as calculated by multiple-point parallel-line comparison appear to overestimate antibody concentrations in sera containing low antibody concentrations, whereas ELISA values obtained by endpoint analysis are less well correlated with RIA values at higher concentrations.

Human antibody responses to two conjugate vaccines of Haemophilus influenzae type B saccharides and diphtheria toxin

Antigenicity of two Haemophilus influenzae type b (Hib) conjugate vaccines was studied by immunizing adults and 2-year-old children. Both vaccines induced strong anti-Hib responses and strong antibody responses to diphtheria toxin (DT), the protein part of the conjugate. The adults' responses were stronger than the children's. A conjugate of Hib oligosaccharide and mutant diphtheria toxin (HbOC) emerged as slightly superior to a conjugate of Hib polysaccharide and diphtheria toxoid (PRP-D). HbOC induced somewhat higher total anti-Hib responses and significantly higher IgG1 anti-Hib responses than PRP-D. IgG1 and IgG2 were the main IgG subclasses of the anti-Hib antibodies, whereas IgG1 and IgG4 were the main subclasses of the anti-DT antibodies. Within this main rule, the ratio IgG1/IgG2 of anti-Hib antibodies varied between individuals. The average ratio was higher than five in children but approximately one in adults. It was lower in adult recipients of the polysaccharide conjugate (0.69) than in adult recipients of the oligosaccharide conjugate (1.55). A large interindividual variation was observed in concentrations of IgG2 of Hib specificity, perhaps reflecting a small number of IgG2-committed B-cell clones participating in the response.

Immunogenicity of the Haemophilus influenzae type b capsular polysaccharide conjugate vaccine in children after systemic Haemophilus influenzae type b infections

We immunized 24 patients (mean age 15.2 +/- 9.3 months) with polyribosylribitol phosphate-diphtheria toxoid conjugate vaccine (PRP-D) 2 months after a systemic Haemophilus influenzae type b infection. Children less than 24 months of age were immunized twice. Serum was obtained for antibody to PRP before and 1 or 2 months after immunization. Three of five children greater than 24 months of age and three of six children 18 to 24 months of age developed greater than 1 microgram/ml of antibody after immunization, and geometric mean postimmunization levels were significantly greater than preimmunization levels for both groups. However, two children who failed to respond to conventional PRP vaccine did not respond as expected to one dose of PRP-D. For children 7 to 17 months of age, the geometric mean PRP antibody levels increased as follows: preimmunization, 0.05 micrograms/ml; after the first dose, 0.28 micrograms/ml (p = 0.003); and after the second dose, 3.39 micrograms/ml (p = 0.001). Of 13 children, 10 developed antibody values greater than 1.0 micrograms/ml. PRP conjugate vaccines are immunogenic in young children who have not developed protective PRP antibody levels after a systemic H. Influenzae type b infection.

Clinical and immunologic responses to the capsular polysaccharide of Haemophilus influenzae type b alone or conjugated to tetanus toxoid in 18- to 23-month-old children

The safety and immunogenicity of Haemophilus influenzae type b (Hib) capsular polysaccharide (CPS) alone, or covalently bound to tetanus toxoid in saline solution (Hib-TT) or adsorbed onto AI(OH)3 (Hib-TT ads), were evaluated after one injection into 18- to 23-month-old healthy children in Sweden. No side reactions were elicited by Hib CPS; side reactions elicited by the two conjugates were similar and comparable to those reported for diphtheria and tetanus toxoids adsorbed. Hib-TT was the most immunogenic of the three vaccines, eliciting about 10-fold higher antibody levels than Hib CPS; of 28 vaccinees, all had greater than 1.0 microgram Ab/mL serum after immunization with Hib-TT. Increases of Hib CPS antibodies within immunoglobulin classes induced by the three vaccines were, in decreasing order, IgG greater than IgM greater than IgA. Within IgG subclasses, rises in IgG1 Hib CPS antibodies were the most frequent, followed by IgG2; some vaccinees with high postimmunization levels also had rises in IgG3 and one in IgG4. Immunization-induced Hib CPS antibodies were bactericidal. Hib-TT also elicited higher levels of tetanus toxoid antibodies than Hib-TT ads; these tetanus toxoid antibodies neutralized tetanus toxin in vivo.