A new surface-antigen-adsorbed influenza virus vaccine. II. Studies in a volunteer group

Reactogenicity of two 2010 trivalent inactivated influenza vaccine formulations in adults

OBJECTIVE

To assess the reactogenicity of two 2010 trivalent inactivated influenza vaccine (TIV) formulations among adults, including the formulation associated with febrile convulsions among children in Australia.

DESIGN, SETTING AND PARTICIPANTS

We retrospectively interviewed persons aged ≥18 years who received TIV between 11 March and 24 April 2010 at a large general practice in Perth. All 160 persons who received Influvac® (Solvay) and a random sample of 190 of 451 persons who received Fluvax® (CSL Biotherapies) were included in the assessment; 127 (79%) recipients of Influvac® and 156 (82%) of the Fluvax® recipients completed the interview.

MAIN OUTCOME MEASURES

Patient demographics, the presence of underlying medical conditions, prior influenza vaccination history, self-reported onset of local and/or systemic symptoms within 72 h following receipt of 2010 TIV, and use of anti-fever/pain medication following TIV vaccination were examined.

RESULTS

The mean age of the vaccinees was 54 years for both the Fluvax® and Influvac® brand cohorts and there was no significant difference between the cohorts with regard to gender or the presence of underlying medical conditions. In bivariate analyses, reported swelling (18% vs 7%, p=0.009), muscle pain (12% vs 3%, p=0.014) and use of anti-fever/pain medication after TIV vaccination (12% vs 2%, p=0.008) were each significantly more common for patients who received Fluvax® compared to those who received Influvac®. In multivariate analyses simultaneously controlling for age, gender, receipt of seasonal influenza vaccine prior to 2010 and receipt of 2009 H1N1 pandemic vaccine, vaccination with Fluvax® TIV was a significant independent predictor of muscle pain and/or swelling (OR=3.3, 95% CI 1.5-7.4 p=0.004). No significant differences in the proportion of patients reporting systemic reactions were observed.

CONCLUSIONS

In this setting, 2010 Fluvax® was associated with a greater likelihood of local reactions among adults, compared to 2010 Influvac® TIV.

A multi-valent vaccine approach that elicits broad immunity within an influenza subtype

Vaccines directed toward individual strains of highly variable viruses like influenza lose efficacy when the circulating viruses no longer resemble the vaccine isolate. Historically, inclusion of more than one isolate per subtype of influenza has been limited by the need to include large doses of antigen with typical protein-based vaccine approaches and by concerns that an immunodominant response to one antigen will limit the response to closely related antigens. Here we provide proof of principle demonstrating that a multi-valent vaccine directed against multiple influenza A virus hemagglutinins (HAs) can elicit broad, neutralizing immunity against multiple strains within a single influenza subtype (H3). We employed a DNA vaccine to direct immunity toward the HA component alone, and a live attenuated influenza virus (LAIV) to assess immunity against the whole virus. Delivery of either HA-DNA or LAIV yielded broad protective immunity across multiple antigenic clusters, including heterologous strains, that was similar to the combined immunity of each antigen assessed separately. Priming with HA-DNA followed by an LAIV boost strengthened and broadened the antibody response toward all three H3 HAs. This prime:boost multi-valent approach was thus able to elicit immunity against multiple strains within the H3 subtype without evidence of immune interference between closely related antigens. Although the trivalent vaccine described here is not a universal vaccine, since protection was limited to circulating viruses from about a two-decade period, these data suggest that full protection within a subtype is possible using this approach with multiple antigens from current and predicted future influenza strains.

Live, attenuated influenza virus (LAIV) vehicles are strong inducers of immunity toward influenza B virus

Historically, vaccines developed toward influenza viruses of the B type using methodologies developed for influenza A viruses as a blueprint have not been equally efficacious or effective. Because most influenza research and public attention concerns influenza A viruses, these shortcomings have not been adequately addressed. In this manuscript, we utilized different influenza vaccine vehicles to compare immunogenicity and protection in mice and ferrets after vaccination against an influenza B virus. We report that plasmid DNA vaccines demonstrate low immunogenicity profiles and poor protection compared to either whole, inactivated influenza virus (IIV) or, live, attenuated influenza virus (LAIV) vaccines. When mixed prime:boost regimens using LAIV and IIV were studied, we observed a boosting effect in mice after priming with LAIV that was not seen when IIV was used as the prime. In ferrets LAIV induced high antibody titers after a single dose and provided a boost in IIV-primed animals. Regimens including LAIV as a prime demonstrated enhanced protection, and adjuvantation was required for efficacy using the IIV preparation. Our results differ from generally accepted influenza A virus vaccine models, and argue that strategies for control of influenza B virus should be considered separately from those for influenza A virus.

Influenza: the virus and prophylaxis with inactivated influenza vaccine in "at risk" groups, including COPD patients

Influenza is a major respiratory pathogen, which exerts a huge human and economic toll on society. Influenza is a vaccine preventable disease, however, the vaccine strains must be annually updated due to the continuous antigenic changes in the virus. Inactivated influenza vaccines have been used for over 50 years and have an excellent safety record. Annual vaccination is therefore recommended for all individuals with serious medical conditions, like COPD, and protects the vaccinee against influenza illness and also against hospitalization and death. In COPD patients, influenza infection can lead to exacerbations resulting in reduced quality of life, hospitalization and death in the most severe cases. Although there is only limited literature on the use of influenza vaccination solely in COPD patients, there is clearly enough evidence to recommend annual vaccination in this group. This review will focus on influenza virus and prophylaxis with inactivated influenza vaccines in COPD patients and other "at risk" groups to reduce morbidity, save lives, and reduce health care costs.

Intranasal immunization with inactivated influenza vaccine

The development of improved vaccines against epidemic and pandemic influenza virus infection remains a priority in vaccine research. Killed vaccines given by injection are both cost-effective and induce immunity; however, their limitations are well known. Live vaccines have been in development for many years, but difficulties and safety concerns have prohibited their licensing in Western countries. However, the newer technologies of vaccine development, including DNA vaccines and attenuated virus vaccines produced by reverse genetics, remain a hope for the future. With these problems in mind, emphasis has been given to the development of inactivated vaccines that are administered intranasally, either as repeated doses of saline vaccine or in conjunction with suitable carriers or adjuvants. This review describes these latter developments and concludes that this approach offers advantages and should be vigorously researched.

Immune response and protection against influenza A infection in mice immunised with subunit influenza A vaccine in combination with whole cell or acellular DTP vaccine

Following the demonstration of the strong adjuvant effect of whole-cell DTP vaccine (wDTP) on the immune responses to influenza subunit vaccine, studies were undertaken to identify the component of wDTP responsible for the adjuvant effect, and to determine if acellular DTP (aDTP) vaccine was as effective since it is less reactogenic and likely to replace wDTP for primary or secondary immunisation. In addition, wDTP and aDTP were directly compared in a dose-response study. Experiments in mice indicated that the adjuvant effect of wDTP resided in the LPS component of B. pertussis, since purified LPS enhanced the IgG antibody response, the IgG subclass response and protection to the same level as wDTP. An adjuvant effect was detected using aDTP, but was statistically less pronounced than wDTP by a factor of some 100-fold. These results suggest that immunisation against influenza in infants and young children can be achieved combining small amounts of influenza antigen with wDTP or LPS, and to a lesser extent by combining vaccine with aDTP. However, these results were obtained in mice and should be confirmed in man since species vary considerably in response to adjuvant.

The subclass IgG responses of mice to influenza surface proteins formulated into liposomes

Unprimed mice and mice primed by prior infection with an H1N1 subtype of influenza virus were used to assess the total and subclass IgG serum antibody responses to influenza virus A/Sichuan/2/87 (H3N2) surface haemagglutinin and neuraminidase proteins incorporated into four different formulations of liposomes. Only one of these liposome preparations, DSPC(B), induced greater total IgG, and subclass IgG1 and IgG2a antibody levels, in sera from both primed and unprimed mice than the aqueous A/Sichuan surface preparations alone administered at equivalent levels of haemagglutinin protein. The same DSPC(B) liposome formulation of A/Sichuan antigens was also the only preparation found to elicit levels of IgG2b and IgG3 subclass antibodies above baseline values in these animals.

Production of passive immunity in neonatal ferrets following maternal vaccination with killed influenza A virus vaccines

Neonatal ferrets may be passively immunized following maternal vaccination with formalin-inactivated influenza A virus vaccine, but the level of protection from partial to complete depends upon the number of doses used to vaccinate the mother, the presence or absence of aluminum hydroxide adjuvant, whether or not the mothers were 'primed' by prior infection with a serologically heterologous type A virus, and the age of the neonate at challenge. Neonates were completely protected up to 2 weeks of age, but susceptibility returned to nasal epithelium at 5 weeks and to lung at 7 weeks. Mothers immunized up to 9 months previously also partially or completely protected their offspring, this correlating with the maternal serum haemagglutination-inhibition (HI) antibody titre at the time of neonatal challenge, not the duration of immunity.

Transmissibility of influenza viruses in hamsters

The growth characteristics of a series of influenza A viruses in the turbinates and lungs of hamsters was measured: in addition, the susceptibility of hamsters to infection by these viruses was also determined. These two criteria were used to give estimates of the growth potential of influenza viruses in hamsters, and the results were related to the incidence of transmission of virus from inoculated hamsters to cage-contacts. The results showed that strains of influenza virus reported as virulent for man tended to grow to higher titres in hamster nasal washings and lungs; were more infective for hamsters when inoculated by the intranasal route; and showed a high incidence of spread to cage-contacts. The methods could provide valuable measurements of virus attenuation and transmissibility for man, and the further exploitation of these techniques could facilitate the production and licensing of live, attenuated influenza virus vaccines.

Immunity to influenza in ferrets. XIV: Comparative immunity following infection or immunization with live or inactivated vaccine

Immunization by live influenza virus induced a greater protective effect against subsequent challenge by the homologous virus than by the corresponding killed virus vaccine. Furthermore, tracheas excised from 11-day and 28-day influenza-virus-infected ferrets were more resistant to reinfection than tracheas excised from ferrets immunized by killed influenza vaccine, despite equivalent serum antibody titres at these times. Histological examination of trachea sections taken from vaccinated and virus-infected animals showed an increased cellular inflammatory infiltrate in the latter at Days 11 and 28 after immunization. The amount of IgG detected in these sections, measured by a fluorescent antibody technique, correlated with the extent of cellular infiltration, the fluorescence being both intra- and extracellular for sections from virus-infected animals, but only extracellular in sections from Day-28 vaccinated animals. In contrast there was little or no cellular infiltration into lung tissues, the levels of IgG detected being comparable to those in sections taken from control animals. These results provide further evidence that live influenza vaccines induce local antibody in the upper respiratory tract of ferrets, in contrast to killed influenza vaccines, and that this local induction may play a significant role in the greater protective efficacy of live influenza vaccines.

Responses of volunteers to inactivated influenza virus vaccines

Three different types of bivalent influenza virus vaccine, a whole virus, an aqueous-surface-antigen vaccine and an adsorbed-surface-antigen vaccine were tested at three dosage levels in volunteers primed with respect to only one of the haemagglutinin antigens present in the vaccines. The local and systemic reactions to all three vaccine types were mild in nature and, following first immunization, the aqueous-surface-antigen vaccine was the least reactogenic. The serum haemagglutination-inhibiting antibody response to the A/Victoria/75 component of the vaccines to which the volunteer population was primed, was greatest following immunization with the aqueous-surface-antigen vaccine; the greatest antibody response to the A/New Jersey/76 component of the vaccines was observed following immunization with whole virus vaccine.

Reactogenicity and immunogenicity of a surface-antigen-adsorbed influenza virus vaccine in children

An influenza virus vaccine containing the purified surface haemagglutinin and neuraminidase antigens of A/Victoria/75 and B/Hong Kong/73 viruses adsorbed to an aluminium hydroxide gel was assessed for reactogenicity and immunogenicity in children aged 4 to 11 years, since there is no influenza virus vaccine available for this age group. Significant serum haemagglutination-inhibiting antibody responses to the A/Victoria/75 and B/Hong Kong/73 haemagglutinin antigens present in the vaccine were observed in 47% and 35%, respectively, of the children vaccinated, with a single dose. The vaccine induced no significant local or systemic reactions.

A contribution of cellular immunity to protection against influenza in man

The degree of lymphocyte transformations and leukocyte migration inhibition (LMI) in the presence of inactivated A/Scotland/74 (H3N2) influenza virus vaccine was measured in blood samples collected from 56 medical student volunteers. At the same time the volunteers were skin tested, using the same vaccine. Using the antigenically similar WRL 105 (H3N2), recombinant influenza virus, the level of haemagglutination-inhibiting (HI) antibodies in serum, and neutralizing antibodies in nasal washings collected from the volunteers, were also determined. Each volunteer was then inoculated with live, attenuated WRL 105 influenza virus vaccine and infections demonstrated by virus isolations and serology. Correlations between the ability to infect the volunteers and the various parameters of humoral and cellular immunity were then determined. The results showed a good correlation between the level of serum HI antibody and infection. Thus 16 of 20 volunteers with serum HI antibody titres of 1:10, but only 6 of 20 volunteers with antibody levels of 1:30, showed evidence of infection. No direct correlation was observed between any of the other parameters measured and infection by WRL 105 virus. However, when the LMI and serum HI antibody levels were considered together, a contribution of cellular immunity, as measured by the LMI test, could be found. Of 19 volunteers with low serum HI antibody and low LMI levels, 16 were infected, whereas of 13 volunteers with low HI antibody, but with high LMI levels, only 6 showed evidence of infection with WRL 105 influenza virus.

[Vaccination of infants and schoolchildren with an influenza subunit vaccine (author's transl)]

A new influenza subunit vaccine which contains only hemagglutinin and neuraminidase antigens was investigated for reactogenicity and immunogenicity in children aged between three and 15 years. Children under six years of age received either 500 IU or 1000 IU of the commercial vaccine, those aged from six to 15 years either 1000 IU or 2000 IU. The vaccines contained the virus strains recommended by the World Health Organisation for the vaccination season 1976/77. In a double blind study the vaccinees were allocated at random to the different dosage groups. The children were examined for reactions by the vaccinating physician 24 hours after vaccination. Serum hemagglutination inhibiting antibody titers were determined before vaccination and four weeks after vaccination. In the younger age-group additional antibody determination was made two weeks after a booster injection. A very low rate of side-reactions was observed in all dosage groups. The increase of the antigen content was not associated with a higher rate of side reactions. After the first vaccination a significant rise of antibody titers could be observed in all children. After the booster injection a further increase of these antibody titers was observed. The response of the younger age group to the dosages 500 and 100 IU did not different significantly. In contrast, in the older age group the increase of the dosage from 1000 to 2000 IU was connected with a better immune response. This was especially marked in the antibody titers against the influenza B-strain virus.

Immunity to attenuated influenza virus WRL 105 infection induced by heterologous, inactivated influenza A virus vaccines

Groups of student volunteers were immunized with one of five different inactivated influenza virus vaccines. The concentration of virus in the various vaccines differed by both the international unitage test and by the concentration of haemagglutinin, as measured by the single radial diffusion test; the results of the two methods of standardization showed no correlation. The serum HI response to immunization was variable; volunteers given A/England/72 showed a 16.6-fold increase in homologous serum antibody titre whilst volunteers given A/Hong Kong/68 vaccine showed a 4.2-fold increase. The variable response of volunteers to immunization could not be explained by the varied concentration of virus in the vaccines, as measured by either test, the titres of serum HI antibody present before immunization, or a combination of these two factors.The ability to infect volunteers with WRL 105 virus 4 weeks after immunization with heterologous, inactivated virus vaccine was directly related to the degree of cross-reactivity between the haemagglutinins of this vaccine virus and WRL 105 virus. Thus, the greatest number of infections by the challenge virus were seen in volunteers given A/Hong Kong/68 vaccine, less were observed in volunteers given A/England/72 vaccine, and least were found in groups given A/Port Chalmers/73 or A/Scotland/74 vaccine. However, compared with the incidence of infection in volunteers given B/Hong Kong/73 vaccine, all the heterologous influenza A vaccine gave some immunity to challenge infection.

The response to inactivated influenza A (H3N2) vaccines: the development and effect of antibodies to the surface antigens

A controlled trial of influenza vaccines in a boys' public school from November 1970 to October 1975 provided an opportunity to study the response to vaccine and the effect on subsequent natural challenge in boys with differing natural experience of influenza A strains. The response to influenza A (H3N2) vaccines was assessed by estimating homotypic and heterotypic antibodies to the surface antigens. Previous natural experience of influenza A was found to influence vaccine response and the effect of natural challenge. The antibody response to revaccination with the same strain showed a progressively poorer response to second and third doses. The protectitive effect of naturally acquired and vaccine-induced antibodies was assessed during two outbreaks of influenza A which occurred in the trial period.

A surface antigen influenza vaccine. 2. Pyrogenicity and antigenicity

Conventional influenza vaccine containing whole virus particles purified on a zonal centrifuge is pyrogenic and can cause systemic and local adverse side effects. An improved vaccine was therefore prepared which contained only the surface antigens of the virus adsorbed to aluminium hydroxide. The antigenicity of this vaccine was compared with conventional vaccine in chickens. Both vaccines induced similar titres of serum haemagglutination-inhibition and neuraminidase inhibition antibody. The dose response curves, however, were different. The surface antigens at vaccine strength without aluminium hydroxide were of negligible pyrogenicity in rabbits.

[A new influenza subunit vaccine: reactogenicity and antigenicity in comparison to split and whole virus vaccines (author's transl)]

The reactogenicity and immunogenicity of a new influenza subunit vaccine essentially containing only haemagglutinin and neuraminidase was studied in man. The vaccine was compared to commercially available vaccines, an adjuvant containing tween-ether split vaccine (800 IU per dose), and a fluid whole-virus vaccine (2100 IU per dose). Two dosages (700 and 2100 IU) of the fluid subunit vaccine were compared. All vaccines contained the virus strains recommended by the WHO for the 1975/76 season. In a double-blind study 399 volunteers were randomly selected to receive one of the four vaccines. The volunteers were examined for side-effects 24 and 48 hr after vaccination. Antibodies inhibiting haemagglutination were determined prior to and four weeks after vaccination. The sudunit vaccine at 700 IU per dose caused significantly fewer local side effects than the comparable split vaccine, and resulted in significantly higher antibody titers against both influenza A strains. A comparison of the subunit and whole virus vaccines containing high dosages (2100 IU) showed striking differences in reactogenicity. Subunit vaccine was very well tolerated. whereas whole virus vaccine caused systemic reactions, including fever and headache, in 15% of the volunteers. No significant reactogenicity was seen with a high dosage of subunit vaccine (2100 IU) although this is a three-fold increase on the currently used European dosage. Antibody titers were significantly enhanced however.