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Cargnin Faccin F, Perez DR. Pandemic preparedness through vaccine development for avian influenza viruses. Hum Vaccin Immunother 2024; 20:2347019. [PMID: 38807261 PMCID: PMC11141480 DOI: 10.1080/21645515.2024.2347019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/22/2024] [Indexed: 05/30/2024] Open
Abstract
Influenza A viruses pose a significant threat to global health, impacting both humans and animals. Zoonotic transmission, particularly from swine and avian species, is the primary source of human influenza outbreaks. Notably, avian influenza viruses of the H5N1, H7N9, and H9N2 subtypes are of pandemic concern through their global spread and sporadic human infections. Preventing and controlling these viruses is critical due to their high threat level. Vaccination remains the most effective strategy for influenza prevention and control in humans, despite varying vaccine efficacy across strains. This review focuses specifically on pandemic preparedness for avian influenza viruses. We delve into vaccines tested in animal models and summarize clinical trials conducted on H5N1, H7N9, and H9N2 vaccines in humans.
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Affiliation(s)
- Flavio Cargnin Faccin
- Department of Population Health, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Daniel R. Perez
- Department of Population Health, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
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2
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Bliss CM, Nachbagauer R, Mariottini C, Cuevas F, Feser J, Naficy A, Bernstein DI, Guptill J, Walter EB, Berlanda-Scorza F, Innis BL, García-Sastre A, Palese P, Krammer F, Coughlan L. A chimeric haemagglutinin-based universal influenza virus vaccine boosts human cellular immune responses directed towards the conserved haemagglutinin stalk domain and the viral nucleoprotein. EBioMedicine 2024; 104:105153. [PMID: 38805853 PMCID: PMC11154122 DOI: 10.1016/j.ebiom.2024.105153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 04/19/2024] [Accepted: 04/25/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND The development of a universal influenza virus vaccine, to protect against both seasonal and pandemic influenza A viruses, is a long-standing public health goal. The conserved stalk domain of haemagglutinin (HA) is a promising vaccine target. However, the stalk is immunosubdominant. As such, innovative approaches are required to elicit robust immunity against this domain. In a previously reported observer-blind, randomised placebo-controlled phase I trial (NCT03300050), immunisation regimens using chimeric HA (cHA)-based immunogens formulated as inactivated influenza vaccines (IIV) -/+ AS03 adjuvant, or live attenuated influenza vaccines (LAIV), elicited durable HA stalk-specific antibodies with broad reactivity. In this study, we sought to determine if these vaccines could also boost T cell responses against HA stalk, and nucleoprotein (NP). METHODS We measured interferon-γ (IFN-γ) responses by Enzyme-Linked ImmunoSpot (ELISpot) assay at baseline, seven days post-prime, pre-boost and seven days post-boost following heterologous prime:boost regimens of LAIV and/or adjuvanted/unadjuvanted IIV-cHA vaccines. FINDINGS Our findings demonstrate that immunisation with adjuvanted cHA-based IIVs boost HA stalk-specific and NP-specific T cell responses in humans. To date, it has been unclear if HA stalk-specific T cells can be boosted in humans by HA-stalk focused universal vaccines. Therefore, our study will provide valuable insights for the design of future studies to determine the precise role of HA stalk-specific T cells in broad protection. INTERPRETATION Considering that cHA-based vaccines also elicit stalk-specific antibodies, these data support the further clinical advancement of cHA-based universal influenza vaccine candidates. FUNDING This study was funded in part by the Bill and Melinda Gates Foundation (BMGF).
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Affiliation(s)
- Carly M Bliss
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Division of Cancer & Genetics and Systems Immunity University Research Institute, School of Medicine, Cardiff University, Cardiff, UK
| | - Raffael Nachbagauer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chiara Mariottini
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Frans Cuevas
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jodi Feser
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Abdi Naficy
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - David I Bernstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey Guptill
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA
| | - Emmanuel B Walter
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Bruce L Innis
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Adolfo García-Sastre
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Global Health and Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Icahn Genomics Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Palese
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Vaccine Research and Pandemic Preparedness (C-VaRPP), Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lynda Coughlan
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; University of Maryland School of Medicine, Department of Microbiology and Immunology, Baltimore, MD 21201, USA; University of Maryland School of Medicine, Center for Vaccine Development and Global Health (CVD), Baltimore, MD 21201, USA.
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3
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Jang H, Matsuoka M, Freire M. Oral mucosa immunity: ultimate strategy to stop spreading of pandemic viruses. Front Immunol 2023; 14:1220610. [PMID: 37928529 PMCID: PMC10622784 DOI: 10.3389/fimmu.2023.1220610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/11/2023] [Indexed: 11/07/2023] Open
Abstract
Global pandemics are most likely initiated via zoonotic transmission to humans in which respiratory viruses infect airways with relevance to mucosal systems. Out of the known pandemics, five were initiated by respiratory viruses including current ongoing coronavirus disease 2019 (COVID-19). Striking progress in vaccine development and therapeutics has helped ameliorate the mortality and morbidity by infectious agents. Yet, organism replication and virus spread through mucosal tissues cannot be directly controlled by parenteral vaccines. A novel mitigation strategy is needed to elicit robust mucosal protection and broadly neutralizing activities to hamper virus entry mechanisms and inhibit transmission. This review focuses on the oral mucosa, which is a critical site of viral transmission and promising target to elicit sterile immunity. In addition to reviewing historic pandemics initiated by the zoonotic respiratory RNA viruses and the oral mucosal tissues, we discuss unique features of the oral immune responses. We address barriers and new prospects related to developing novel therapeutics to elicit protective immunity at the mucosal level to ultimately control transmission.
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Affiliation(s)
- Hyesun Jang
- Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA, United States
| | - Michele Matsuoka
- Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA, United States
| | - Marcelo Freire
- Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA, United States
- Division of Infectious Diseases and Global Public Health Department of Medicine, University of California San Diego, La Jolla, CA, United States
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4
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Subburayalu J. Immune surveillance and humoral immune responses in kidney transplantation - A look back at T follicular helper cells. Front Immunol 2023; 14:1114842. [PMID: 37503334 PMCID: PMC10368994 DOI: 10.3389/fimmu.2023.1114842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/22/2023] [Indexed: 07/29/2023] Open
Abstract
T follicular helper cells comprise a specialized, heterogeneous subset of immune-competent T helper cells capable of influencing B cell responses in lymphoid tissues. In physiology, for example in response to microbial challenges or vaccination, this interaction chiefly results in the production of protecting antibodies and humoral memory. In the context of kidney transplantation, however, immune surveillance provided by T follicular helper cells can take a life of its own despite matching of human leukocyte antigens and employing the latest immunosuppressive regiments. This puts kidney transplant recipients at risk of subclinical and clinical rejection episodes with a potential risk for allograft loss. In this review, the current understanding of immune surveillance provided by T follicular helper cells is briefly described in physiological responses to contrast those pathological responses observed after kidney transplantation. Sensitization of T follicular helper cells with the subsequent emergence of detectable donor-specific human leukocyte antigen antibodies, non-human leukocyte antigen antibodies their implication for kidney transplantation and lessons learnt from other transplantation "settings" with special attention to antibody-mediated rejection will be addressed.
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Affiliation(s)
- Julien Subburayalu
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Center for Regenerative Therapies (CRTD), Technische Universität Dresden, Dresden, Germany
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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5
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Safety and Viral Shedding of Live Attenuated Influenza Vaccine (LAIV) in Chinese Healthy Juveniles and Adults: A Phase Ⅰ Randomized, Double-Blind, Placebo-Controlled Study. Vaccines (Basel) 2022; 10:vaccines10111796. [DOI: 10.3390/vaccines10111796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
This study was a randomized, double-blind, placebo-controlled study to evaluate the safety and viral shedding of live attenuated influenza vaccine (LAIV) in Chinese healthy juveniles and adults. A total of 80 Eligible volunteers were divided into two age groups (≥18 and 3–17 years old). Volunteers were randomly and equally assigned to the experimental group and placebo-controlled group by ratio of 3:1 in each age group. Vaccination was carried out in steps. Totally, 34 (56.67%) adverse events and 24 (40.00%) adverse reactions of the LAIV group were reported. Most adverse reactions were grade 1 and grade 2, and the incidence of adverse reactions that grade 3 was 5%. The most common local reaction was runny nose/nasal congestion (n = 4, 6.67%). And the most common general reaction was fever (n = 10, 16.67%). There were no statistically significant differences in the incidence of total adverse reactions, different grades of adverse reactions, and symptoms between the experimental group and placebo-controlled group. No severe adverse events were reported. Three subjects (5.00%) had been detected vaccine strains on the 3rd day after LAIV vaccination; one was type B and the other two were H3N2. Four subjects (6.67%) had been detected with vaccine strains on the 7th day after LAIV vaccination, all were H3N2. There were no subjects detected carrying the influenza virus on the 15th day after vaccination. There were no statistically significant differences in the positive rate of vaccine strains of influenza virus between the experimental group and placebo-controlled group. The vaccine was well tolerated and not associated with increased rates in adverse reactions or the occurrence of severe adverse events. Pathogenicity of shed vaccine virus to surrounding people was not observed. Thus, Phase Ⅱ study can be carried out as scheduled.
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Baek K, Maharjan S, Akauliya M, Thapa B, Kim D, Kim J, Kim M, Kang M, Kim S, Bae JY, Lee KW, Park MS, Lee Y, Kwon HJ. Comparison of vaccination efficacy using live or ultraviolet-inactivated influenza viruses introduced by different routes in a mouse model. PLoS One 2022; 17:e0275722. [PMID: 36215268 PMCID: PMC9550053 DOI: 10.1371/journal.pone.0275722] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
Influenza is a major cause of highly contagious respiratory illness resulting in high mortality and morbidity worldwide. Annual vaccination is an effective way to prevent infection and complication from constantly mutating influenza strains. Vaccination utilizes preemptive inoculation with live virus, live attenuated virus, inactivated virus, or virus segments for optimal immune activation. The route of administration also affects the efficacy of the vaccination. Here, we evaluated the effects of inoculation with ultraviolet (UV)-inactivated or live influenza A virus strains and compared their effectiveness and cross protection when intraperitoneal and intramuscular routes of administration were used in mice. Intramuscular or intraperitoneal inoculation with UV-inactivated Influenza A/WSN/1933 provided some protection against intranasal challenge with a lethal dose of live Influenza A/WSN/1933 but only when a high dose of the virus was used in the inoculation. By contrast, inoculation with a low dose of live virus via either route provided complete protection against the same intranasal challenge. Intraperitoneal inoculation with live or UV-inactivated Influenza A/Philippines/2/1982 and intramuscular inoculation with UV-inactivated Influenza A/Philippines/2/1982 failed to produce cross-reactive antibodies against Influenza A/WSN/1933. Intramuscular inoculation with live Influenza A/Philippines/2/1982 induced small amounts of cross-reactive antibodies but could not suppress the cytokine storm produced upon intranasal challenge with Influenza A/WSN/1993. None of the tested inoculation conditions provided observable cross protection against intranasal challenge with a different influenza strain. Taken together, vaccination efficacy was affected by the state and dose of the vaccine virus and the route of administration. These results provide practical data for the development of effective vaccines against influenza virus.
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Affiliation(s)
- Kyeongbin Baek
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Sony Maharjan
- Institute of Medical Science, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Madhav Akauliya
- Institute of Medical Science, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Bikash Thapa
- Department of Biomedical Science, Hallym University, Chuncheon, Republic of Korea
| | - Dongbum Kim
- Institute of Medical Science, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Jinsoo Kim
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Minyoung Kim
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Mijeong Kang
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Suyeon Kim
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Joon-Yong Bae
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea
| | - Keun-Wook Lee
- Department of Biomedical Science, Hallym University, Chuncheon, Republic of Korea
| | - Man-Seong Park
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea
| | - Younghee Lee
- Department of Biochemistry, College of Natural Sciences, Chungbuk National University, Cheongju, Republic of Korea
| | - Hyung-Joo Kwon
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Republic of Korea
- Institute of Medical Science, College of Medicine, Hallym University, Chuncheon, Republic of Korea
- * E-mail:
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7
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Choy RKM, Bourgeois AL, Ockenhouse CF, Walker RI, Sheets RL, Flores J. Controlled Human Infection Models To Accelerate Vaccine Development. Clin Microbiol Rev 2022; 35:e0000821. [PMID: 35862754 PMCID: PMC9491212 DOI: 10.1128/cmr.00008-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The timelines for developing vaccines against infectious diseases are lengthy, and often vaccines that reach the stage of large phase 3 field trials fail to provide the desired level of protective efficacy. The application of controlled human challenge models of infection and disease at the appropriate stages of development could accelerate development of candidate vaccines and, in fact, has done so successfully in some limited cases. Human challenge models could potentially be used to gather critical information on pathogenesis, inform strain selection for vaccines, explore cross-protective immunity, identify immune correlates of protection and mechanisms of protection induced by infection or evoked by candidate vaccines, guide decisions on appropriate trial endpoints, and evaluate vaccine efficacy. We prepared this report to motivate fellow scientists to exploit the potential capacity of controlled human challenge experiments to advance vaccine development. In this review, we considered available challenge models for 17 infectious diseases in the context of the public health importance of each disease, the diversity and pathogenesis of the causative organisms, the vaccine candidates under development, and each model's capacity to evaluate them and identify correlates of protective immunity. Our broad assessment indicated that human challenge models have not yet reached their full potential to support the development of vaccines against infectious diseases. On the basis of our review, however, we believe that describing an ideal challenge model is possible, as is further developing existing and future challenge models.
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Affiliation(s)
- Robert K. M. Choy
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
| | - A. Louis Bourgeois
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
| | | | - Richard I. Walker
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
| | | | - Jorge Flores
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
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8
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Qiu J, Tian X, Liu Y, Lu T, Wang H, Shi Z, Lu S, Xu D, Qiu T. Univ-flu: A structure-based model of influenza A virus hemagglutinin for universal antigenic prediction. Comput Struct Biotechnol J 2022; 20:4656-4666. [PMID: 36090813 PMCID: PMC9436755 DOI: 10.1016/j.csbj.2022.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
The rapid mutations on hemagglutinin (HA) of influenza A virus (IAV) can lead to significant antigenic variance and consequent immune mismatch of vaccine strains. Thus, rapid antigenicity evaluation is highly desired. The subtype-specific antigenicity models have been widely used for common subtypes such as H1 and H3. However, the continuous emerging of new IAV subtypes requires the construction of universal antigenic prediction model which could be applied on multiple IAV subtypes, including the emerging or re-emerging ones. In this study, we presented Univ-Flu, series structure-based universal models for HA antigenicity prediction. Initially, the universal antigenic regions were derived on multiple subtypes. Then, a radial shell structure combined with amino acid indexes were introduced to generate the new three-dimensional structure based descriptors, which could characterize the comprehensive physical–chemical property changes between two HA variants within or across different subtypes. Further, by combining with Random Forest classifier and different training datasets, Univ-Flu could achieve high prediction performances on intra-subtype (average AUC of 0.939), inter-subtype (average AUC of 0.771), and universal-subtype (AUC of 0.978) prediction, through independent test. Results illustrated that the designed descriptor could provide accurate universal antigenic description. Finally, the application on high-throughput antigenic coverage prediction for circulating strains showed that the Univ-Flu could screen out virus strains with high cross-protective spectrum, which could provide in-silico reference for vaccine recommendation.
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Kok A, Fouchier RAM, Richard M. Cross-Reactivity Conferred by Homologous and Heterologous Prime-Boost A/H5 Influenza Vaccination Strategies in Humans: A Literature Review. Vaccines (Basel) 2021; 9:vaccines9121465. [PMID: 34960210 PMCID: PMC8708856 DOI: 10.3390/vaccines9121465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Avian influenza viruses from the A/H5 A/goose/Guangdong/1/1996 (GsGd) lineage pose a continuing threat to animal and human health. Since their emergence in 1997, these viruses have spread across multiple continents and have become enzootic in poultry. Additionally, over 800 cases of human infection with A/H5 GsGd viruses have been reported to date, which raises concerns about the potential for a new influenza virus pandemic. The continuous circulation of A/H5 GsGd viruses for over 20 years has resulted in the genetic and antigenic diversification of their hemagglutinin (HA) surface glycoprotein, which poses a serious challenge to pandemic preparedness and vaccine design. In the present article, clinical studies on A/H5 influenza vaccination strategies were reviewed to evaluate the breadth of antibody responses induced upon homologous and heterologous prime-boost vaccination strategies. Clinical data on immunological endpoints were extracted from studies and compiled into a dataset, which was used for the visualization and analysis of the height and breadth of humoral immune responses. Several aspects leading to high immunogenicity and/or cross-reactivity were identified, although the analysis was limited by the heterogeneity in study design and vaccine type used in the included studies. Consequently, crucial questions remain to be addressed in future studies on A/H5 GsGd vaccination strategies.
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10
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Safety and Efficacy of Spray Intranasal Live Attenuated Influenza Vaccine: Systematic Review and Meta-Analysis. Vaccines (Basel) 2021; 9:vaccines9090998. [PMID: 34579235 PMCID: PMC8472940 DOI: 10.3390/vaccines9090998] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 01/15/2023] Open
Abstract
Although influenza is a major public health concern, little is known about the use of spray live attenuated influenza vaccine (LAIV) among adults. For this reason, we conducted a systematic review and meta-analysis to investigate the efficacy and safety of LAIV, especially in adults with/without clinical conditions and children <2 years, with the final aim of possibly extending the clinical indications. PubMed/MEDLINE and Scopus were the two databases consulted through February 2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A critical appraisal was conducted. Analyses were performed by using ProMeta3 software. Twenty-two studies were included, showing that LAIV was associated with a higher probability of seroconversion when compared with a placebo and considering the A/H1N1 serotype (pooled OR = 2.26 (95% CI = 1.12–4.54), p-value = 0.022; based on 488 participants, without heterogeneity (I2 = 0.0%)). The meta-analysis also confirmed no significant association with systemic adverse events. Only rhinorrhea, nasal congestion, and sore throat were significantly associated with LAIV compared to the placebo. Despite limited available evidence, LAIV has proved to be a safe and effective flu vaccination, also due to its very low invasiveness, and our review’s results can be considered a starting point for guiding future research and shaping forthcoming vaccination campaigns.
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11
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Abstract
Live attenuated, cold-adapted influenza vaccines exhibit several desirable characteristics, including the induction of systemic, mucosal, and cell-mediated immunity resulting in breadth of protection, ease of administration, and yield. Seasonal live attenuated influenza vaccines (LAIVs) were developed in the United States and Russia and have been used in several countries. In the last decade, following the incorporation of the 2009 pandemic H1N1 strain, the performance of both LAIVs has been variable and the U.S.-backbone LAIV was less effective than the corresponding inactivated influenza vaccines. The cause appears to be reduced replicative fitness of some H1N1pdm09 viruses, indicating a need for careful selection of strains included in multivalent LAIV formulations. Assays are now being implemented to select optimal strains. An improved understanding of the determinants of replicative fitness of vaccine strains and of vaccine effectiveness of LAIVs is needed for public health systems to take full advantage of these valuable vaccines.
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Affiliation(s)
- Kanta Subbarao
- WHO Collaborating Centre for Reference and Research on Influenza and Department of Microbiology and Immunology, University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3000, Australia
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12
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Nachbagauer R, Feser J, Naficy A, Bernstein DI, Guptill J, Walter EB, Berlanda-Scorza F, Stadlbauer D, Wilson PC, Aydillo T, Behzadi MA, Bhavsar D, Bliss C, Capuano C, Carreño JM, Chromikova V, Claeys C, Coughlan L, Freyn AW, Gast C, Javier A, Jiang K, Mariottini C, McMahon M, McNeal M, Solórzano A, Strohmeier S, Sun W, Van der Wielen M, Innis BL, García-Sastre A, Palese P, Krammer F. A chimeric hemagglutinin-based universal influenza virus vaccine approach induces broad and long-lasting immunity in a randomized, placebo-controlled phase I trial. Nat Med 2021; 27:106-114. [PMID: 33288923 DOI: 10.1038/s41591-020-1118-7] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 10/02/2020] [Indexed: 11/09/2022]
Abstract
Seasonal influenza viruses constantly change through antigenic drift and the emergence of pandemic influenza viruses through antigenic shift is unpredictable. Conventional influenza virus vaccines induce strain-specific neutralizing antibodies against the variable immunodominant globular head domain of the viral hemagglutinin protein. This necessitates frequent re-formulation of vaccines and handicaps pandemic preparedness. In this completed, observer-blind, randomized, placebo-controlled phase I trial (NCT03300050), safety and immunogenicity of chimeric hemagglutinin-based vaccines were tested in healthy, 18-39-year-old US adults. The study aimed to test the safety and ability of the vaccines to elicit broadly cross-reactive antibodies against the hemagglutinin stalk domain. Participants were enrolled into five groups to receive vaccinations with live-attenuated followed by AS03-adjuvanted inactivated vaccine (n = 20), live-attenuated followed by inactivated vaccine (n = 15), twice AS03-adjuvanted inactivated vaccine (n = 16) or placebo (n = 5, intranasal followed by intramuscular; n = 10, twice intramuscular) 3 months apart. Vaccination was found to be safe and induced a broad, strong, durable and functional immune response targeting the conserved, immunosubdominant stalk of the hemagglutinin. The results suggest that chimeric hemagglutinins have the potential to be developed as universal vaccines that protect broadly against influenza viruses.
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Affiliation(s)
- Raffael Nachbagauer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Moderna, Cambridge, MA, USA
| | - Jodi Feser
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Abdollah Naficy
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - David I Bernstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey Guptill
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA
| | - Emmanuel B Walter
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Daniel Stadlbauer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick C Wilson
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
- The Committee on Immunology, University of Chicago, Chicago, IL, USA
| | - Teresa Aydillo
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Global Health and Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mohammad Amin Behzadi
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Disha Bhavsar
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carly Bliss
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christina Capuano
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Juan Manuel Carreño
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Veronika Chromikova
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carine Claeys
- GSK, Wavre, Belgium
- Spmt-Arista Asbl, Brussels, Belgium
| | - Lynda Coughlan
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alec W Freyn
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Gast
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Andres Javier
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kaijun Jiang
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chiara Mariottini
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meagan McMahon
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Monica McNeal
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alicia Solórzano
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Pfizer, Pearl River, NY, USA
| | - Shirin Strohmeier
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Biotechnology, University of Natural Resources and Life Sciences, Vienna, Austria
| | - Weina Sun
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Bruce L Innis
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Adolfo García-Sastre
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Global Health and Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The Tisch Cancer Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Palese
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The Tisch Cancer Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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13
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Brickley EB, Wright PF, Khalenkov A, Neuzil KM, Ortiz JR, Rudenko L, Levine MZ, Katz JM, Brooks WA. The Effect of Preexisting Immunity on Virus Detection and Immune Responses in a Phase II, Randomized Trial of a Russian-Backbone, Live, Attenuated Influenza Vaccine in Bangladeshi Children. Clin Infect Dis 2020; 69:786-794. [PMID: 30481269 PMCID: PMC6695513 DOI: 10.1093/cid/ciy1004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 11/25/2018] [Indexed: 02/06/2023] Open
Abstract
Background In a 2012 Phase II clinical trial, 300 Bangladeshi children aged 24 to 59 months with no prior influenza vaccine exposure were randomized to receive a single intranasally-administered dose of either trivalent, Russian-backbone, live, attenuated influenza vaccine (LAIV) or placebo. Protocol-defined analyses, presented in the companion manuscript, demonstrate decreased viral detection and immunogenicity for A/H1N1pdm09, relative to the A/H3N2 and B strains. This post hoc analysis of the trial data aims to investigate the LAIV strain differences by testing the hypothesis that preexisting humoral and mucosal immunity may influence viral recovery and immune responses after LAIV receipt. Methods We used logistic regressions to evaluate the relations between markers of preexisting immunity (ie, hemagglutination inhibition [HAI], microneutralization, and immunoglobulin G and immunoglobulin A (both serum and mucosal antibodies) and LAIV viral recovery in the week post-vaccination. We then tested for potential effect modification by baseline HAI titers (ie, <10 versus ≥10) and week 1 viral recovery on the LAIV-induced serum and mucosal immune responses, measured between days 0 and 21 post-vaccination. Results Higher levels of preexisting immunity to influenza A/H3N2 and B were strongly associated with strain-specific prevention of viral shedding upon LAIV receipt. While evidence of LAIV immunogenicity was observed for all 3 strains, the magnitudes of immune responses were most pronounced in children with no evidence of preexisting HAI and in those with detectable virus. Conclusions The results provide evidence for a bidirectional association between viral replication and immunity, and underscore the importance of accounting for preexisting immunity when evaluating virologic and immunologic responses to LAIVs. Clinical Trials Registration NCT01625689.
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Affiliation(s)
- Elizabeth B Brickley
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom.,Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Hanover
| | - Peter F Wright
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexey Khalenkov
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Kathleen M Neuzil
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore
| | - Justin R Ortiz
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore
| | - Larisa Rudenko
- Department of Virology, Institute of Experimental Medicine, Saint Petersburg, Russia
| | - Min Z Levine
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacqueline M Katz
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - W Abdullah Brooks
- Department of International Health, Johns Hopkins University, Baltimore, Maryland
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14
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Rowley AH, Baker SC, Arrollo D, Gruen LJ, Bodnar T, Innocentini N, Hackbart M, Cruz-Pulido YE, Wylie KM, Kim KYA, Shulman ST. A Protein Epitope Targeted by the Antibody Response to Kawasaki Disease. J Infect Dis 2020; 222:158-168. [PMID: 32052021 PMCID: PMC7296860 DOI: 10.1093/infdis/jiaa066] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/07/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Kawasaki disease (KD) is the leading cause of childhood acquired heart disease in developed nations and can result in coronary artery aneurysms and death. Clinical and epidemiologic features implicate an infectious cause but specific antigenic targets of the disease are unknown. Peripheral blood plasmablasts are normally highly clonally diverse but the antibodies they encode are approximately 70% antigen-specific 1-2 weeks after infection. METHODS We isolated single peripheral blood plasmablasts from children with KD 1-3 weeks after onset and prepared 60 monoclonal antibodies (mAbs). We used the mAbs to identify their target antigens and assessed serologic response among KD patients and controls to specific antigen. RESULTS Thirty-two mAbs from 9 of 11 patients recognize antigen within intracytoplasmic inclusion bodies in ciliated bronchial epithelial cells of fatal cases. Five of these mAbs, from 3 patients with coronary aneurysms, recognize a specific peptide, which blocks binding to inclusion bodies. Sera from 5/8 KD patients day ≥ 8 after illness onset, compared with 0/17 infant controls (P < .01), recognized the KD peptide antigen. CONCLUSIONS These results identify a protein epitope targeted by the antibody response to KD and provide a means to elucidate the pathogenesis of this important worldwide pediatric problem.
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Affiliation(s)
- Anne H Rowley
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Microbiology/Immunology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Susan C Baker
- Department of Microbiology and Immunology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois, USA
| | - David Arrollo
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Leah J Gruen
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Tetyana Bodnar
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nancy Innocentini
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Matthew Hackbart
- Department of Microbiology and Immunology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois, USA
| | - Yazmin E Cruz-Pulido
- Department of Microbiology and Immunology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois, USA
| | - Kristine M Wylie
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
- McDonnell Genome Institute, Washington University School of Medicine, St Louis, Missouri, USA
| | - Kwang-Youn A Kim
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Stanford T Shulman
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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15
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Affiliation(s)
- Kanta Subbarao
- World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia.,Department of Microbiology and Immunology, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
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16
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Kongchanagul A, Samnuan K, Wirachwong P, Surichan S, Puthavathana P, Pitisuttithum P, Boonnak K. A live attenuated H5N2 prime- inactivated H5N1 boost vaccination induces influenza virus hemagglutinin stalk specific antibody responses. Vaccine 2020; 38:852-858. [PMID: 31708176 DOI: 10.1016/j.vaccine.2019.10.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/05/2019] [Accepted: 10/26/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The emergence and spread of highly pathogenic avian influenza (H5N1) viruses have raised global concerns of a possible human pandemic, spurring efforts towards H5N1 influenza vaccine development and improvements in vaccine administration methods. We previously showed that a prime-boost vaccination strategy induces robust and broadly cross-reactive antibody responses against the hemagglutinin globular head domain. Here, we specifically measure antibodies against the conserved hemagglutinin stem region in serum samples obtained from the prior study to determine whether stalk-reactive antibodies can also be induced by the prime-boost regimen. METHOD Serum samples collected from 60 participants before vaccination and on days 7, 28 and 90 following boosting vaccination were used in this study. 40 participants received two doses of live attenuated H5N2 vaccine (LAIV H5N2) followed by one dose of inactivated H5N1 vaccine a year later, while 20 participants received only the inactivated H5N1 vaccine. We tested these serum samples for stalk-reactive antibodies via enzyme-linked immunosorbent (ELISA) and microneutralization assays. RESULTS Stalk-specific antibody levels measured by both assays were found to be significantly higher in primed individuals than the unprimed group. ELISA results showed that 22.5, 70.5 and 57.5% of primed participants had a four-fold or more increase in stalk antibody titers on days 7, 28 and 90 following boosting vaccination, respectively; whereas the unprimed group had no increase. Peak geometric mean titers (GMT) for stalk antibodies in the LAIV H5N2 experienced group (24,675 [95% CI; 19,531-31,174]) were significantly higher than those who received only the inactivated H5N1 vaccine (8877 [7140-11,035]; p < 0·0001). Moreover, stalk antibodies displaying neutralizing activity also increased in primed participants, but not in the unprimed group. CONCLUSION Our finding emphasizes the importance of prime-boost vaccination for effectively inducing stalk antibodies, which is an attractive target for developing vaccines that induce stalk reactive antibodies.
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Affiliation(s)
| | - Karnyart Samnuan
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Thailand
| | | | | | | | - Punnee Pitisuttithum
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Thailand; Vaccine Trial Centre, Faculty of Tropical Medicine, Mahidol University, Thailand
| | - Kobporn Boonnak
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Thailand.
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17
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Bernstein DI, Guptill J, Naficy A, Nachbagauer R, Berlanda-Scorza F, Feser J, Wilson PC, Solórzano A, Van der Wielen M, Walter EB, Albrecht RA, Buschle KN, Chen YQ, Claeys C, Dickey M, Dugan HL, Ermler ME, Freeman D, Gao M, Gast C, Guthmiller JJ, Hai R, Henry C, Lan LYL, McNeal M, Palm AKE, Shaw DG, Stamper CT, Sun W, Sutton V, Tepora ME, Wahid R, Wenzel H, Wohlbold TJ, Innis BL, García-Sastre A, Palese P, Krammer F. Immunogenicity of chimeric haemagglutinin-based, universal influenza virus vaccine candidates: interim results of a randomised, placebo-controlled, phase 1 clinical trial. THE LANCET. INFECTIOUS DISEASES 2020; 20:80-91. [PMID: 31630990 PMCID: PMC6928577 DOI: 10.1016/s1473-3099(19)30393-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/10/2019] [Accepted: 06/20/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Influenza viruses cause substantial annual morbidity and mortality globally. Current vaccines protect against influenza only when well matched to the circulating strains. However, antigenic drift can cause considerable mismatches between vaccine and circulating strains, substantially reducing vaccine effectiveness. Moreover, current seasonal vaccines are ineffective against pandemic influenza, and production of a vaccine matched to a newly emerging virus strain takes months. Therefore, there is an unmet medical need for a broadly protective influenza virus vaccine. We aimed to test the ability of chimeric H1 haemagglutinin-based universal influenza virus vaccine candidates to induce broadly cross-reactive antibodies targeting the stalk domain of group 1 haemagglutinin-expressing influenza viruses. METHODS We did a randomised, observer-blinded, phase 1 study in healthy adults in two centres in the USA. Participants were randomly assigned to one of three prime-boost, chimeric haemagglutinin-based vaccine regimens or one of two placebo groups. The vaccine regimens included a chimeric H8/1, intranasal, live-attenuated vaccine on day 1 followed by a non-adjuvanted, chimeric H5/1, intramuscular, inactivated vaccine on day 85; the same regimen but with the inactivated vaccine being adjuvanted with AS03; and an AS03-adjuvanted, chimeric H8/1, intramuscular, inactivated vaccine followed by an AS03-adjuvanted, chimeric H5/1, intramuscular, inactivated vaccine. In this planned interim analysis, the primary endpoints of reactogenicity and safety were assessed by blinded study group. We also assessed anti-H1 haemagglutinin stalk, anti-H2, anti-H9, and anti-H18 IgG antibody titres and plasmablast and memory B-cell responses in peripheral blood. This trial is registered with ClinicalTrials.gov, number NCT03300050. FINDINGS Between Oct 10, 2017, and Nov 27, 2017, 65 participants were enrolled and randomly assigned. The adjuvanted inactivated vaccine, but not the live-attenuated vaccine, induced a substantial serum IgG antibody response after the prime immunisation, with a seven times increase in anti-H1 stalk antibody titres on day 29. After boost immunisation, all vaccine regimens induced detectable anti-H1 stalk antibody (2·2-5·6 times induction over baseline), cross-reactive serum IgG antibody, and peripheral blood plasmablast responses. An unsolicited adverse event was reported for 29 (48%) of 61 participants. Solicited local adverse events were reported in 12 (48%) of 25 participants following prime vaccination with intramuscular study product or placebo, in 12 (33%) of 36 after prime immunisation with intranasal study product or placebo, and in 18 (32%) of 56 following booster doses of study product or placebo. Solicited systemic adverse events were reported in 14 (56%) of 25 after prime immunisation with intramuscular study product or placebo, in 22 (61%) of 36 after immunisation with intranasal study product or placebo, and in 21 (38%) of 56 after booster doses of study product or placebo. Disaggregated safety data were not available at the time of this interim analysis. INTERPRETATION The tested chimeric haemagglutinin-based, universal influenza virus vaccine regimens elicited cross-reactive serum IgG antibodies that targeted the conserved haemagglutinin stalk domain. This is the first proof-of-principle study to show that high anti-stalk titres can be induced by a rationally designed vaccine in humans and opens up avenues for further development of universal influenza virus vaccines. On the basis of the blinded study group, the vaccine regimens were tolerable and no safety concerns were observed. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- David I Bernstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey Guptill
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA
| | - Abdollah Naficy
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Raffael Nachbagauer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jodi Feser
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Patrick C Wilson
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA; The Committee on Immunology, University of Chicago, Chicago, IL, USA
| | - Alicia Solórzano
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Emmanuel B Walter
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA; Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Randy A Albrecht
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Global Health and Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kristen N Buschle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yao-Qing Chen
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Michelle Dickey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Haley L Dugan
- The Committee on Immunology, University of Chicago, Chicago, IL, USA
| | - Megan E Ermler
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; GlaxoSmithKline, Collegeville, PA, USA
| | - Debra Freeman
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA
| | - Min Gao
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA
| | - Christopher Gast
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Jenna J Guthmiller
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Rong Hai
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Microbiology and Plant Pathology, Institute for Integrative Genome Biology, University of California, Riverside, CA, USA
| | - Carole Henry
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Linda Yu-Ling Lan
- The Committee on Immunology, University of Chicago, Chicago, IL, USA
| | - Monica McNeal
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Anna-Karin E Palm
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Dustin G Shaw
- The Committee on Immunology, University of Chicago, Chicago, IL, USA
| | | | - Weina Sun
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Victoria Sutton
- Duke Early Phase Clinical Research Unit, Duke Clinical Research Institute, Durham, NC, USA
| | - Micah E Tepora
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Rahnuma Wahid
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Heather Wenzel
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Teddy John Wohlbold
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce L Innis
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Adolfo García-Sastre
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Global Health and Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Palese
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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18
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Pitisuttithum P, Wirachwong P. A review of epidemic preparedness for influenza through local vaccine production: national security for Thailand. Hum Vaccin Immunother 2019; 15:2440-2445. [PMID: 31335234 PMCID: PMC6816430 DOI: 10.1080/21645515.2019.1638205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Being vigilant of the potential for an influenza pandemic, the Global Action Plan for Influenza Vaccines (GAP) promoted the establishment and maintenance of local vaccine manufacturing capacity. In accordance with this, the Thai government has developed its national strategic plan for influenza pandemic preparedness including the plan for manufacturing influenza vaccine in Thailand. With the support of WHO, the Thai Government Pharmaceutical Organization (GPO) as the developed local production capacity of influenza vaccines. The H1N1 live attenuated influenza vaccine (LAIV) and H5N2 LAIV produced by GPO have been proven to be safe and immunogenic through clinical trials, followed by Thai FDA licensure for pandemic use. The GPO-produced H5N2 LAIV has been proven to have priming effects on an inactivated subunit H5N1 booster vaccine. This Thai local manufacturer is now expanding its capacity to Inactivated Influenza Vaccine (IIV), aiming for sustainable influenza vaccine production for national coverage.
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Affiliation(s)
- Punnee Pitisuttithum
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University , Bangkok , Thailand
| | - Ponthip Wirachwong
- Research and Development Institute, Government Pharmaceutical Organization , Bangkok , Thailand
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19
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Switzer C, Babiuk L, Loeb M. Determining optimal community protection strategies for the influenza vaccine. Expert Rev Vaccines 2019; 18:755-764. [PMID: 31288585 DOI: 10.1080/14760584.2019.1642110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Seasonal influenza poses a major risk to the health of the population. Optimal strategies for influenza vaccination can help to reduce this risk. Areas covered: Systematic evaluations of the burden of influenza are first reviewed. Key meta-analysis, randomized trials, and observational studies are critically reviewed to provide the best estimates of the efficacy of influenza vaccine. The concept of herd effect is first introduced and this is followed by the rationale and the evidence to support herd effect that can be provided with strategic use of influenza vaccination in populations. Challenges including the effect of repeated influenza vaccination and vaccine hesitancy are reviewed. The citations were selected by the authors based on PubMed searches of the literature. Expert opinion: Efforts to develop new vaccines, including a universal vaccine, offer the best prospects for improved herd effect. Increasing uptake in new populations can increase likelihood of a herd effect.
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Affiliation(s)
- Charlotte Switzer
- a Department of Health Research Evidence, and Impact, McMaster University , Hamilton , Ontario , Canada
| | - Lorne Babiuk
- b Department of Agricultural Life and Environmental Sciences, University of Alberta , Edmonton , Alberta , Canada
| | - Mark Loeb
- a Department of Health Research Evidence, and Impact, McMaster University , Hamilton , Ontario , Canada
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20
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Fox A, Quinn KM, Subbarao K. Extending the Breadth of Influenza Vaccines: Status and Prospects for a Universal Vaccine. Drugs 2019; 78:1297-1308. [PMID: 30088204 DOI: 10.1007/s40265-018-0958-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite the widespread use of seasonal influenza vaccines, there is urgent need for a universal influenza vaccine to provide broad, long-term protection. A number of factors underpin this urgency, including threats posed by zoonotic and pandemic influenza A viruses, suboptimal effectiveness of seasonal influenza vaccines, and concerns surrounding the effects of annual vaccination. In this article, we discuss approaches that are being investigated to increase influenza vaccine breadth, which are near-term, readily achievable approaches to increase the range of strains recognized within a subtype, or longer-term more challenging approaches to produce a truly universal influenza vaccine. Adjuvanted and neuraminidase-optimized vaccines are emerging as the most feasible and promising approaches to extend protection to cover a broader range of strains within a subtype. The goal of developing a universal vaccine has also been advanced with the design of immunogenic influenza HA-stem constructs that induce broadly neutralizing antibodies. However, these constructs are not yet sufficiently immunogenic to induce lasting universal immunity in humans. Advances in understanding how T cells mediate protection, and how viruses are packaged, have facilitated the rationale design and delivery of replication-incompetent virus vaccines that induce broad protection mediated by lung-resident memory T cells. While the lack of clear mechanistic correlates of protection, other than haemagglutination-inhibiting antibodies, remains an impediment to further advancing novel influenza vaccines, the pressing need for such a vaccine is supporting development of highly innovative and effective strategies.
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Affiliation(s)
- Annette Fox
- WHO Collaborating Centre for Reference and Research on Influenza, and the Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, VIC, Australia
| | - Kylie M Quinn
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, VIC, Australia
| | - Kanta Subbarao
- WHO Collaborating Centre for Reference and Research on Influenza, and the Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, VIC, Australia.
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21
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Zhao H, Xu K, Jiang Z, Shao M, Liu S, Li X, Wang J, Li C. A neuraminidase activity-based microneutralization assay for evaluating antibody responses to influenza H5 and H7 vaccines. PLoS One 2018; 13:e0207431. [PMID: 30440054 PMCID: PMC6237356 DOI: 10.1371/journal.pone.0207431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 10/31/2018] [Indexed: 11/20/2022] Open
Abstract
Outbreaks of the highly pathogenic avian influenza H5N1 and H7N9 viruses have spurred an unprecedented research effort to develop antivirals and vaccines against influenza. Standardized methods for vaccine evaluation are critical for facilitating vaccine development. Compared with hemagglutination inhibition assays, mounting evidence suggest that microneutralization tests (MNTs) is a better choice for the evaluation of candidate pandemic influenza vaccines because they measure neutralizing antibody activity in cell cultures and are more sensitive in detecting H5 and H7. Here, we report a MNT measuring neuraminidase activity as the read-out (NA-MNT) for quantitative analysis of neutralizing antibodies against avian influenza viruses. Compared to the conventional microneutralization assay (ELISA-MNT), the NA-MNT is faster with lower intra- and inter-assay variations, while no difference in geometric mean titers was found between these two assays for the evaluation of H5N1 and H7N9 vaccines. These results suggest that NA-MNT is a reliable and high throughput method which could facilitate the development of candidate pandemic influenza vaccine.
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MESH Headings
- Animals
- Antibodies, Neutralizing/genetics
- Antibodies, Neutralizing/immunology
- Antibodies, Viral/immunology
- Antibody Formation/immunology
- Birds/virology
- Hemagglutinin Glycoproteins, Influenza Virus
- Humans
- Influenza A Virus, H5N1 Subtype/immunology
- Influenza A Virus, H5N1 Subtype/pathogenicity
- Influenza A Virus, H7N9 Subtype/immunology
- Influenza A Virus, H7N9 Subtype/pathogenicity
- Influenza Vaccines/immunology
- Influenza in Birds/immunology
- Influenza in Birds/virology
- Influenza, Human/genetics
- Influenza, Human/immunology
- Influenza, Human/virology
- Neuraminidase/genetics
- Neuraminidase/immunology
- Pandemics
- Vaccines, Inactivated/immunology
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Affiliation(s)
- Hui Zhao
- Division of Viral Vaccine III, National Institutes for Food and Drug Control and WHO Collaborating Center for Standardization and Evaluation of Biologicals, Beijing, P.R. China
| | - Kangwei Xu
- Division of Viral Vaccine III, National Institutes for Food and Drug Control and WHO Collaborating Center for Standardization and Evaluation of Biologicals, Beijing, P.R. China
| | - Zheng Jiang
- Division of Viral Vaccine III, National Institutes for Food and Drug Control and WHO Collaborating Center for Standardization and Evaluation of Biologicals, Beijing, P.R. China
| | - Ming Shao
- Division of Viral Vaccine III, National Institutes for Food and Drug Control and WHO Collaborating Center for Standardization and Evaluation of Biologicals, Beijing, P.R. China
| | - Shuzhen Liu
- Division of Viral Vaccine III, National Institutes for Food and Drug Control and WHO Collaborating Center for Standardization and Evaluation of Biologicals, Beijing, P.R. China
| | - Xuguang Li
- Center for Biologics Evaluation, Ottawa, Biologics and Genetic Therapies Directorate, Health Canada and WHO Collaborating Center for Standardization and Evaluation, Ottawa, Canada
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada
| | - Junzhi Wang
- Division of Viral Vaccine III, National Institutes for Food and Drug Control and WHO Collaborating Center for Standardization and Evaluation of Biologicals, Beijing, P.R. China
- * E-mail: (JW); (CL)
| | - Changgui Li
- Division of Viral Vaccine III, National Institutes for Food and Drug Control and WHO Collaborating Center for Standardization and Evaluation of Biologicals, Beijing, P.R. China
- * E-mail: (JW); (CL)
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22
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Avian Influenza A Virus Pandemic Preparedness and Vaccine Development. Vaccines (Basel) 2018; 6:vaccines6030046. [PMID: 30044370 PMCID: PMC6161001 DOI: 10.3390/vaccines6030046] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/17/2018] [Accepted: 07/21/2018] [Indexed: 12/24/2022] Open
Abstract
Influenza A viruses can infect a wide range of hosts, creating opportunities for zoonotic transmission, i.e., transmission from animals to humans, and placing the human population at constant risk of potential pandemics. In the last hundred years, four influenza A virus pandemics have had a devastating effect, especially the 1918 influenza pandemic that took the lives of at least 40 million people. There is a constant risk that currently circulating avian influenza A viruses (e.g., H5N1, H7N9) will cause a new pandemic. Vaccines are the cornerstone in preparing for and combating potential pandemics. Despite exceptional advances in the design and development of (pre-)pandemic vaccines, there are still serious challenges to overcome, mainly caused by intrinsic characteristics of influenza A viruses: Rapid evolution and a broad host range combined with maintenance in animal reservoirs, making it near impossible to predict the nature and source of the next pandemic virus. Here, recent advances in the development of vaccination strategies to prepare against a pandemic virus coming from the avian reservoir will be discussed. Furthermore, remaining challenges will be addressed, setting the agenda for future research in the development of new vaccination strategies against potentially pandemic influenza A viruses.
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23
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Jang H, Elaish M, KC M, Abundo MC, Ghorbani A, Ngunjiri JM, Lee CW. Efficacy and synergy of live-attenuated and inactivated influenza vaccines in young chickens. PLoS One 2018; 13:e0195285. [PMID: 29624615 PMCID: PMC5889186 DOI: 10.1371/journal.pone.0195285] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/19/2018] [Indexed: 01/07/2023] Open
Abstract
Outbreaks of novel highly pathogenic avian influenza viruses have been reported in poultry species in the United States since 2014. These outbreaks have proven the limitations of biosecurity control programs, and new tools are needed to reinforce the current avian influenza control arsenal. Some enzootic countries have implemented inactivated influenza vaccine (IIV) in their control programs, but there are serious concerns that a long-term use of IIV without eradication may result in the selection of novel antigenically divergent strains. A broadly protective vaccine is needed, such as live-attenuated influenza vaccine (LAIV). We showed in our previous studies that pc4-LAIV (a variant that encodes a C-terminally truncated NS1 protein) can provide significant protection against heterologous challenge virus in chickens vaccinated at 2–4 weeks of age through upregulation of innate and adaptive immune responses. The current study was conducted to compare the performances of pc4-LAIV and IIV in young chickens vaccinated at 1 day of age. A single dose of pc4-LAIV was able to induce stronger innate and mucosal IgA responses and protect young immunologically immature chickens better than a single dose of IIV. Most importantly, when 1-day-old chickens were intranasally primed with pc4-LAIV and subcutaneously boosted with IIV three weeks later, they showed a rapid, robust, and highly cross-reactive serum antibody response and a high level of mucosal IgA antibody response. This vaccination regimen warrants further optimization to increase its range of protection.
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MESH Headings
- Animals
- Animals, Newborn
- Antibodies, Viral/biosynthesis
- Antibodies, Viral/blood
- Antibodies, Viral/genetics
- Antigens, Viral/genetics
- Chickens/immunology
- Cross Reactions
- Immunity, Innate/genetics
- Immunity, Mucosal/genetics
- Immunization, Secondary/methods
- Immunization, Secondary/veterinary
- Influenza A virus/genetics
- Influenza A virus/immunology
- Influenza Vaccines/administration & dosage
- Influenza Vaccines/genetics
- Influenza Vaccines/immunology
- Influenza in Birds/immunology
- Influenza in Birds/prevention & control
- Poultry Diseases/immunology
- Poultry Diseases/prevention & control
- Vaccination/methods
- Vaccination/veterinary
- Vaccines, Attenuated/administration & dosage
- Vaccines, Attenuated/genetics
- Vaccines, Attenuated/immunology
- Vaccines, Inactivated/administration & dosage
- Vaccines, Inactivated/genetics
- Vaccines, Inactivated/immunology
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Affiliation(s)
- Hyesun Jang
- Food Animal Health Research Program, Ohio Agricultural Research and Development Center, The Ohio State University, Wooster, Ohio, United States of America
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, United States of America
| | - Mohamed Elaish
- Food Animal Health Research Program, Ohio Agricultural Research and Development Center, The Ohio State University, Wooster, Ohio, United States of America
| | - Mahesh KC
- Food Animal Health Research Program, Ohio Agricultural Research and Development Center, The Ohio State University, Wooster, Ohio, United States of America
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, United States of America
| | - Michael C. Abundo
- Food Animal Health Research Program, Ohio Agricultural Research and Development Center, The Ohio State University, Wooster, Ohio, United States of America
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, United States of America
| | - Amir Ghorbani
- Food Animal Health Research Program, Ohio Agricultural Research and Development Center, The Ohio State University, Wooster, Ohio, United States of America
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, United States of America
| | - John M. Ngunjiri
- Food Animal Health Research Program, Ohio Agricultural Research and Development Center, The Ohio State University, Wooster, Ohio, United States of America
- * E-mail: (JMN); (CWL)
| | - Chang-Won Lee
- Food Animal Health Research Program, Ohio Agricultural Research and Development Center, The Ohio State University, Wooster, Ohio, United States of America
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, United States of America
- * E-mail: (JMN); (CWL)
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24
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Czakó R, Vogel L, Sutton T, Matsuoka Y, Krammer F, Chen Z, Jin H, Subbarao K. H5N2 vaccine viruses on Russian and US live attenuated influenza virus backbones demonstrate similar infectivity, immunogenicity and protection in ferrets. Vaccine 2018; 36:1871-1879. [PMID: 29503113 PMCID: PMC5854182 DOI: 10.1016/j.vaccine.2018.02.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 11/19/2022]
Abstract
The continued detection of zoonotic influenza infections, most notably due to the avian influenza A H5N1 and H7N9 subtypes, underscores the need for pandemic preparedness. Decades of experience with live attenuated influenza vaccines (LAIVs) for the control of seasonal influenza support the safety and effectiveness of this vaccine platform. All LAIV candidates are derived from one of two licensed master donor viruses (MDVs), cold-adapted (ca) A/Ann Arbor/6/60 or ca A/Leningrad/134/17/57. A number of LAIV candidates targeting avian H5 influenza viruses derived with each MDV have been evaluated in humans, but have differed in their infectivity and immunogenicity. To understand these differences, we generated four H5N2 candidate pandemic LAIVs (pLAIVs) derived from either MDV and compared their biological characteristics in vitro and in vivo. We demonstrate that all candidate pLAIVs, regardless of gene constellation and derivation, were comparable with respect to infectivity, immunogenicity, and protection from challenge in the ferret model of influenza. These observations suggest that differences in clinical performance of H5 pLAIVs may be due to factors other than inherent biological properties of the two MDVs.
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Affiliation(s)
- Rita Czakó
- Emerging Respiratory Viruses Section, Laboratory of Infectious Diseases, NIAID, NIH, USA
| | - Leatrice Vogel
- Emerging Respiratory Viruses Section, Laboratory of Infectious Diseases, NIAID, NIH, USA
| | - Troy Sutton
- Emerging Respiratory Viruses Section, Laboratory of Infectious Diseases, NIAID, NIH, USA
| | - Yumiko Matsuoka
- Emerging Respiratory Viruses Section, Laboratory of Infectious Diseases, NIAID, NIH, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Hong Jin
- MedImmune Vaccines, Mountain View, CA, USA
| | - Kanta Subbarao
- Emerging Respiratory Viruses Section, Laboratory of Infectious Diseases, NIAID, NIH, USA.
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25
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Krammer F. Stopping emerging influenza viruses at their origin. THE LANCET INFECTIOUS DISEASES 2017; 17:784-786. [DOI: 10.1016/s1473-3099(17)30297-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 04/18/2017] [Indexed: 01/09/2023]
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