Studies with a cold-recombinant A/Victoria/3/75 (H3N2) virus. II. Evaluation in adult volunteers

Duration of Virus Shedding After Trivalent Intranasal Live Attenuated Influenza Vaccination in Adults

Objective:

To characterize the probability and duration of viral shedding among adults given trivalent live attenuated influenza vaccine (LATV).

Design:

Prospective surveillance study.

Methods:

Nasal wash samples were collected from adult volunteers at baseline and on days 3, 7, and 10 and between days 17 and 21 following intranasal LAIV vaccination. The presence, titer, and identification of each specific strain of influenza virus shed were determined by standard methodology.

Results:

Twenty subjects received LATV. No samples were positive for influenza virus at baseline. After LAIV vaccination, influenza virus was recovered from 10 of 20 vaccinees on day 3, from 1 of 18 vaccinees on day 7, and from none of the samples on days 10 or 17 through 21. Vaccinees who shed vaccine virus were significantly younger than those who did not (mean age, 26.4 vs 38.6 years;P< .01). Although the presence of specific mucosal immunoglobulin A to influenza B was associated with significantly less shedding of influenza B after vaccination (P= .02), associations of shedding with other measures of immunity were not detected.

Conclusion:

The duration of shedding of vaccine virus after LAIV in adults is limited and may be associated with an individual's prior influenza vaccination history.

A randomized, double-blind study of the safety, transmissibility and phenotypic and genotypic stability of cold-adapted influenza virus vaccine

BACKGROUND

Live attenuated influenza vaccine (LAIV; FluMist) is a trivalent vaccine containing cold-adapted influenza vaccine viruses that infect and replicate in cells lining the nasopharynx to induce immunity. Recovery of viruses (shedding) is measured by culture of nasal specimens. Shedding of vaccine viruses is not equated with transmission because transmission requires more virus than is detected in many nasal swabs. Previous studies with LAIV did not detect transmission to close contacts. The primary objective of this study was to estimate the probability of transmission to placebo contacts in a day care setting.

METHODS

One hundred ninety-seven healthy children aged 9 to 36 months attending day care were randomized to receive vaccine or placebo. Postvaccination viral shedding, safety, genotype and phenotype of shed viruses and probability of transmission were assessed.

RESULTS

Eighty percent of 98 vaccine recipients shed at least one vaccine strain. No clinically significant differences in solicited adverse events attributable to vaccine occurred; safety profiles were similar in both groups. Vaccine virus isolates retained their phenotypic characteristics (cold adaptation and temperature sensitivity) and did not revert at nucleotides known to confer an attenuating phenotype. There was one confirmed transmission of a vaccine strain to a single placebo recipient. According to the Reed-Frost model, the calculated probability of transmission to a child after contact with a single vaccinated child was 0.58% (95% confidence interval, 0-1.7%). There was no increased reactogenicity or other safety concerns in the recipient child.

CONCLUSIONS

Young children in a day care setting had a high rate of shedding and a low rate of transmission. No clinically significant illness occurred among children who received vaccine or placebo or in the child to whom the vaccine virus was transmitted.

Transmission dynamics of the great influenza pandemic of 1918 in Geneva, Switzerland: Assessing the effects of hypothetical interventions

Recurrent outbreaks of the avian H5N1 influenza virus in Asia represent a constant global pandemic threat. We characterize and evaluate hypothetical public health measures during the 1918 influenza pandemic in the Canton of Geneva, Switzerland. The transmission rate, the recovery rate, the diagnostic rate, the relative infectiousness of asymptomatic cases, and the proportion of clinical cases are estimated through least-squares fitting of the model to epidemic curve data of the cumulative number of hospital notifications. The latent period and the case fatality proportion are taken from published literature. We determine the variance and identifiability of model parameters via a simulation study. Our epidemic model agrees well with the observed epidemic data. We estimate the basic reproductive number for the spring wave R1;=1.49 (95% CI: 1.45-1.53) and the reproductive number for the fall wave R2;=3.75 (95% CI: 3.57-3.93). In addition, we estimate the clinical reporting for these two waves to be 59.7% (95% CI: 55.7-63.7) and 83% (95% CI: 79-87). We surmise that the lower reporting in the first wave can be explained by a lack of initial awareness of the epidemic and the relative higher severity of the symptoms experienced during the fall wave. We found that effective isolation measures in hospital clinics at best would only ensure control with probability 0.87 while reducing the transmission rate by >76.5% guarantees stopping an epidemic.

Current status of live attenuated influenza virus vaccine in the US

The efficacy and effectiveness of cold adapted live attenuated (CAIV-T, FluMist intranasal influenza vaccine is reviewed. CAIV-T consists of approximately 10(7) TCID50 per dose of each influenza A/H1N1, influenza A/H3N2, and influenza B vaccine strain. The exact strains are updated each year to antigenically match the antigens recommended by national health authorities for inclusion in the vaccine. In one year in which the vaccine strain did not well match the epidemic strain, the live attenuated vaccine induced a broad immune response that cross-reacted significantly with the drifted strain. The efficacy of CAIV-T in adults was demonstrated with challenge studies and the effectiveness of the vaccine for reducing febrile upper respiratory illness, days of missed work, and days of antibiotic use was demonstrated in a large field trial. In young children, protective efficacy against culture confirmed influenza was demonstrated in a field trial with overall protective efficacy of 92% during a two year study. Vaccine was also highly protective against a strain not contained in the vaccine, with 86% protective efficacy demonstrated against this significantly drifted virus. Effectiveness measures, including protection against febrile otitis media and visits to the doctor were demonstrated. Live attenuated vaccine provides a significant new tool to help prevent influenza.

Safety and efficacy of live attenuated, cold-adapted, influenza vaccine-trivalent

This article describes the efficacy, immunogenicity, and safety of CAIV-T. This vaccine has the potential to significantly contribute to the control of influenza infection and influenza-associated illnesses, including febrile otitis media and lower respiratory disease. When compared with inactivated vaccine, CAIV-T has significant advantages in convenience of administration. The high efficacy of CAIV-T and its efficacy in children against a significantly drifted strain of H3N2 (A/Sydney), a strain not contained in the vaccine, are compelling observations for use of the vaccine in children. Effectiveness in adults was demonstrated using the same vaccine strain against the drifted H3N2 strain. The proposed vaccine administration schedule for healthy individuals aged 9 to 49 years is a single dose administered annually before the winter. For children aged 5 to 8 years, two doses are recommended the first year they are immunized with CAIV-T to ensure protection against all strains contained in the vaccine. Thereafter, a single annual revaccination is sufficient.

The attenuation phenotype conferred by the M gene of the influenza A/Ann Arbor/6/60 cold-adapted virus (H2N2) on the A/Korea/82 (H3N2) reassortant virus results from a gene constellation effect

A single gene reassortant (SGR) virus that derived its M gene from the attenuated influenza A/Ann Arbor/6/60 cold-adapted (CA) donor virus and the remaining genes from the A/Korea/82 (H3N2) wild type (WT) virus (designated A/Korea/82 CA M-SGR) was previously shown to be attenuated in mice, hamsters, ferrets, and humans. The attenuation (ATT) phenotype of this SGR virus could result directly from an altered function of the mutant M gene product of the A/Ann Arbor/6/60 CA virus, which differs from the M gene of the A/Ann Arbor/6/60 WT virus at only one amino acid or, indirectly from a gene constellation effect in which ATT results from an inefficient interaction between the products of the M gene of the A/Ann Arbor/6/60 virus and other genes of the A/Korea/82 virus. Several lines of evidence from the present study are consistent with our interpretation that the ATT phenotype of the A/Korea/82 CA M-SGR results from a gene constellation effect. First, the A/Korea/82 CA M-SGR and an A/Korea/82 SGR containing the A/Ann Arbor/6/60 WT M gene were each restricted in replication in the upper and lower respiratory tract of mice compared with the A/Korea/82 WT virus. Second, an A/Udorn/72 CA M-SGR containing the M gene from the A/Ann Arbor/6/60 CA donor virus in a background of other genes derived from the A/Udorn/72 (H3N2) WT virus was not attenuated in the respiratory tract of mice. These data suggest that the change in the amino acid sequence of the M gene product from the A/Ann Arbor/6/60 WT to CA virus is not responsible for the ATT phenotype of the A/Korea/82 CA M-SGR. In addition, evidence of the genetic instability of the A/Korea/82 CA M-SGR is presented, specifically, an extragenic mutation that results in loss of the ATT phenotype. The implications of these findings for the ATT phenotype of the live attenuated reassortant viruses derived from the A/Ann Arbor/6/60 CA donor virus are discussed.

Modelling the 1985 influenza epidemic in France

The Rvachev-Baroyan-Longini model is a space-time predictive model of the spread of influenza epidemics. It has been applied to 128 cities of the USSR, and more recently, to forecasting the spread of the pandemic of 1968-1969 throughout 52 large cities. It is a deterministic, mass-action, space and time continuous model. The model has been applied to the simulation of the influenza epidemic of 1984-1985 in the 22 French Metropolitan districts and results are presented. Estimates of the parameters of the model were made using the French Communicable Diseases Network data. These parameters are the contact rate, a, (estimate = 0.55) which is the number of people with whom an infectious individual will make contact daily sufficient to pass infection and the infectious period, 1/b, estimated as 2.49 days. The mean annual railroad passenger traffic from district i to district j varies from 0 to 1,991,000 persons depending on the districts. The computer spread of the epidemic is presented on weekly maps. Results are also presented on district charts, giving the size of district epidemics and the time of peak of the epidemic. The precision of the computer fittings was judged satisfactory by the calculated size of peak differing from the real one by less than 100 per cent, in 17 out of 18 districts, and by the calculated time of peak differing from the observed by less than two weeks in 14 out of 18 districts. Although precision could be improved with more detailed information about passenger traffic, the French use of the model has been satisfactory.

A placebo-controlled dose response study of the reactogenicity and immunogenicity of a live cold-recombinant influenza B virus vaccine in healthy volunteers

A live cold-recombinant influenza B virus vaccine (RB77) was given intranasally in a placebo-controlled, double blind study to volunteers in dosages of 10(7.9) EID50/ml, 10(7.25) EID50/ml, 10(5.7) EID50/ml. The tolerability, safety, and immunogenicity of the vaccine were investigated. No revertant virus was found in nasal swabs taken after immunisation. Local reactions were mild and showed a significant increase over the placebo only in the highest dose group. Systemic reactions were not different from the placebo. A significant increase in haemagglutinin inhibition titre was found in the highest dose group against the immunising strain (RB77) and the two wild strains B/TEC and B/Sing.

Biological characteristics of a cold-adapted influenza A virus mutation residing on a polymerase gene

The biological function of a cold-adapted (ca) mutation residing on the PB2 gene of an influenza A/Ann Arbor/6/60 (A/AA/6/60) ca variant virus in the viral replication cycle at 25 degrees C was studied. The viral polypeptide synthesis of A/AA/6/60 ca variant at 25 degrees C was evident approximately 6 hours earlier than the wild type (wt) virus and yielded twice as many products. The quantitative analysis of viral complementary RNA (cRNA), synthesized in the presence of cycloheximide, revealed that A/AA/6/60 ca variant and a single gene reassortant that contains only the PB2 gene of the ca variant with remaining genes of the wt virus produced equal amount of cRNA at 25 degrees and 33 degrees C, which was an amount approximately four fold greater than the wt virus' cRNA synthesized at 25 degrees C. These results strongly suggest that the ca mutation residing on the PB2 gene of A/AA/6/60 ca variant affects the messenger RNA synthesis at 25 degrees C in the primary transcription.

Development and characterization of cold-adapted viruses for use as live virus vaccines

Representative viruses from twelve RNA and two DNA virus genera have been successfully adapted to growth at sub-optimal temperature (cold-adapted). In almost every case, there was a correlation between acquisition of the cold-adaptation phenotype and loss of virulence in the normal host whether animal or man. Overall, the best method of cold adaptation to develop a live virus vaccine line appeared to be a stepwise lowering of the growth temperature allowing time for multiple lesions to occur and/or be selected. In addition, the starting virus should be a recent isolate not as yet adapted to a tissue culture host and the cold-adaptation process should then occur in a host heterologous to the virus' normal host. These viruses have been reviewed in the light of their cold-adaptation method and successful production of an attenuated line as virus vaccine candidate. Finally, detailed information is presented for the cold-adaptation process in influenza virus.

Epidemic influenza in Greater London

The Kermack & McKendrick theory of epidemics has been applied to data on deaths from influenza and influenzal pneumonia in Greater London in the years 1950-78. As a whole the theory gives a good description of the data, and the estimated values of the parameters can be plausibly related to the natural history of the disease. However, the possibility exists that the agreement is merely empirical, and field studies would be required to confirm its validity.

Recombinant cold-adapted attenuated influenza A vaccines for use in children: reactogenicity and antigenic activity of cold-adapted recombinants and analysis of isolates from the vaccinees

Reactogenicity and antigenic activity of recombinants obtained by crossing cold-adapted donor of attenuation A/Leningrad/134/47/57 with wild-type influenza virus strains A/Leningrad/322/79(H1N1) and A/Bangkok/1/79(H3N2) were studied. The recombinants were areactogenic when administered as an intranasal spray to children aged 3 to 15, including those who lacked or had only low titers of pre-existing anti-hemagglutinin and anti-neuraminidase antibody in their blood. After two administrations of vaccines at a 3-week interval, both strains induced antibody in 75 to 95% of the children. On coinfection of chicken embryos with both recombinants, only weak interference was observed. Administration to children of the bivalent vaccine containing H1N1 and H3N2 recombinants induced efficient production of antibody to H1 and H3 hemagglutinins and N1 and N2 neuraminidases without adverse reactions. The recombinants studied were genetically stable as judged by retention of the temperature-sensitive phenotypes and a lack of reversion of the genes carrying temperature-sensitive mutations in all of the reisolates from vaccinated children.

Serological evaluation of an influenza A virus cold-adapted reassortant live vaccine, CR-37 (H1N1), in Japanese adult volunteers

A cold-adapted influenza A virus, CR-37 (H1N1), derived from genetic reassortment between A/Ann Arbor/6/60 (H2N2) cold-adapted variant virus and A/California/10/78 (H1N1) wild-type virus, was tested in Japanese adult volunteer. The CR-37 live virus preparation induced only low-grade clinical reactions in volunteers for the first 3-4 days after inoculation. Two vaccinees who did not show any antibody changes became febrile (over 38.0 degrees C). Skin tests using the vaccine preparation and uninfected allantoic fluid were performed, and indicated that one of these two vaccines was positive for the CR-37 vaccine preparation. A high proportion of the vaccinees whose sera had a haemagglutination-inhibition (HI) antibody titre against the vaccine strain of less than or equal to 64 before inoculation, seroconverted in both HI and neuraminidase-inhibition (NAI) antibody titrations, and only a few seroconverted in the titration of antibody against type-specific internal antigens. The serological examinations against heterotypic H1N1 variants indicated that the cold-adapted live influenza virus vaccine could induce a broad spectrum of HI antibody reactivity and immunity of long duration.

In vivo and in vitro hamster models in the assessment of virulence of recombinant influenza viruses

The virulence of five wild-type influenza A viruses and 14 recombinant viruses, prepared from the cold adapted A/Ann Arbor/6/60 virus and various wild-type viruses, was studied by two methods. Firstly, the viruses were inoculated into hamsters, and the titres present in the lungs and turbinates at 1, 3 and 4 days post-infection were measured. Secondly, the effect of five wild-type and ten recombinant viruses on the ciliated epithelium of in vitro hamster tracheal organ cultures was examined. The results obtained were assessed with reference to the known virulence of the viruses for human volunteers. The results showed that virus strains virulent for man grew to higher titres in hamster lungs and turbinates than attenuated strains; and that virulent strains destroyed the ciliary activity of hamster tracheal organ cultures more quickly and to a greater extent than attenuated strains. Comparison of the results with the known virulence of viruses tested for man suggests that the reduced ability of virus to grow in hamster lung tissue and the relatively little effect on ciliary activity may be used as markers of virus attenuation; however, the growth of virus in hamster turbinates overlaps for virulent and attenuated strains and therefore was not considered a useful marker of virulence.

Dose response of A/Alaska/6/77 (H3N2) cold-adapted reassortant vaccine virus in adult volunteers: role of local antibody in resistance to infection with vaccine virus

An attenuated influenza A candidate vaccine virus, derived from the A/Ann Arbor/6/60 (H2N2) cold-adapted (ca) donor virus and the A/Alaska/6/77 (H3N2) wild-type virus, was evaluated in adult seronegative volunteers (serum hemagglutination-inhibiting antibody titer, less than or equal to 1:8) for level of attenuation, infectivity, antigenicity, and genetic stability. Four groups with similar preinoculation mean titers of serum and nasal wash antibodies were inoculated intranasally with 10(4.5), 10(5.5), 10(6.5), or 10(7.5) 50% tissue culture infectious doses (TCID50) of the ca reassortant virus, and eight other seronegative adult volunteers received the wild-type virus. Only 2 of 66 vaccinees developed fever or mild and brief systemic or upper respiratory tract illness or both. Both volunteers with vaccine-related reactions received the highest dose (10(7.5) TCID50) of ca virus, which indicates that the vaccine retains some mild reactogenicity at a high dosage. In contrast, four of eight volunteers infected with the wild-type virus became ill. Each of the 54 isolates tested retained the temperature-sensitive phenotype of the vaccine virus. Thus, the ca reassortant was genetically stable and attenuated at 10(4.5) to 10(7.5) TCID50 for seronegative adults. The 50% human infective dose of ca virus was approximately 10(5.3) TCID50. Ten and one hundred 50% human infectious doses infected 73 and 83% of vaccinees, respectively, and approximately 75% developed an immunological response at these doses. The failure of the vaccine virus to infect some volunteers was correlated with the presence of pre-inoculation nasal wash immunoglobulin A hemagglutinin antibody.

Immune responses in serum and respiratory secretions following vaccination with a live cold-recombinant (CR35) and inactivated A/USSR/77 (H1N1) influenza virus vaccine

One hundred adult volunteers were administered inactivated vaccine (20 micrograms/0.5 cc) intramuscularly (IM) or intranasally (IN), or 10(4.7) TCID50 of a live cold-adapted vaccine (CR35) IN. Microneutralization (Nt) and radioimmunoprecipitation methods were employed to measure hemagglutinin antibody responses in sera, nasal washes, and in bronchopulmonary lavage fluids. In unprimed recipients, the relative frequency of serum antibody response and magnitude of rise was highest following the IM-inactivated vaccine (100%) and lowest after IN-live vaccine (29%). However, in individuals with pre-existing antibody, the three vaccines given were comparably immunogenic. Occurrences of secretory IgA hemagglutinin antibody in nasal washings were more frequently associated with topical administration of live or inactivated vaccine, whereas, IgG hemagglutinin antibody responses occurred with equal frequency in nasal washings in all three vaccine groups. Analysis of the hemagglutinin antibody responses in the lower respiratory tract showed that the IN-live vaccine favored the induction of secretory IgA hemagglutinin antibody and the IM-inactivated vaccine stimulated a more frequent IgG hemagglutinin antibody response.

Interference following dual inoculation with influenza A (H3N2) and (H1N1) viruses in ferrets and volunteers

The effects of simultaneous inoculation with two attenuated influenza A viruses was studied in ferrets and volunteers. Groups of ferrets were inoculated with an influenza A (H3N2) or (H1N1), virus or a combination of both viruses: the temperature response, serum and local antibody response, and the change in nasal wash protein concentration was determined. The results showed that both viruses were attenuated for ferrets, and that inoculation with both viruses together did not cause clinical reactions. Serological studies on paired serum samples obtained from ferrets showed that both viruses when given separately infected all the inoculated animals; however, dual infection resulted in all ferrets being infected with the influenza A (H3N2) virus strain, but this infection interfered with infection by the influenza A (H1N1) strain. Similar investigations were carried out in volunteers. Again, the clinical reactions and temperature response of volunteers to infection by one or other of the viruses showed both strains to be attenuated for man even when given together. In addition, no adverse clinical reactions were seen in volunteers inoculated with both viruses simultaneously. Serum antibody studies showed that infection by influenza A (H1N1) virus interfered with infection by the influenza A (H2N2) virus strain. These results show evidence of interference by influenza A viruses; however, the direction of interference was one-way, and differed for ferrets and for volunteers.

Infant rat model of attenuation for recombinant influenza viruses prepared from cold-adapted attenuated A/Ann Arbor/6/60

The pathogenicity of 6 wild-type influenza A viruses and 21 recombinant strains prepared from wild-type viruses and cold-adapted A/Ann Arbor/6/60 virus for infant rats was determined. Thus, the titers of virus present in the turbinates and lungs of virus-infected animals was measured serially for 5 days after intranasal infection, and the ability of virus strains to promote subsequent systemic bacterial infection by Haemophilus influenzae was measured at 48 h after virus infection. The results obtained were assessed with reference to the genetic constitution of the virus strains and to virus virulence for volunteers. The results showed that virulent viruses grew to relatively high titers in rat turbinates and significantly promoted systemic infection by H. influenzae. In contrast, attenuated strains grew to lower titers and failed to promote systemic H. influenzae infection. For the strains tested, the results showed clear differences for attenuated and virulent strains, and the model was a reliable indication of virulence for humans. Although the virulent strains tended to grow to higher titers in rat lungs than did attenuated strains, exceptions were found, and this measurement could not reliably discriminate virulent and attenuated virus strains. The results suggest that infant rats can be used to assess the virulence of cold-adapted recombinant influenza virus strains, and thus, they can facilitate the development of such strains for vaccine production.

Live influenza A/Victoria/75 (H3N2) virus vaccines: reactogenicity, immunogenicity, and protection against wild-type virus challenge

Four live influenza A/Victoria/75 (H3N2) recombinant virus vaccines were administered intranasally to a total of 50 volunteers who had little or no detectable serum neutralizing antibody. A recombinant with ts-1[E] having a 38 degrees C shut-off temperature caused febrile reactions or systemic reactions or both in 21% of the volunteers, but one with ts-1A2 having a 37 degrees C shut-off temperature caused no illness. Two recombinants prepared with cold-adapted A/Ann Arbor/6/60 caused 9% febrile reactions or systemic reactions or both. Virus shedding occurred in a minority of the 50 volunteers, but 90% developed a serum neutralizing antibody response. Wild-type A/Victoria/75 virus challenge of 34 of the vaccinated volunteers and 12 others who had had prior natural A/Victoria/75 virus infection revealed similar and significant protection when compared with the 96% infection and 68% febrile illness or systemic illness or both observed in 25 unvaccinated volunteers with little or no serum antibody. These results encourage continued efforts toward development of live influenza virus vaccines.

Studies in man with a cold-recombinant live influenza B virus vaccine

A cold recombinant live influenza B virus vaccine was tested in man. In comparison to a placebo, reactogenicity attributable to virus infection was slight or moderate. No revertant viruses were shed, and there was no evidence of transmission to the placebo group who were housed in close contact with the vaccinees. Serological responses to initial inoculation were moderate; 60% of vaccinees showing twofold increases in serum hemagglutination inhibition (HAI) titers gave a geometric mean titer (GMT) of 1:13. Three weeks after the first vaccination, both the vaccine and the placebo group were revaccinated with homologous live virus vaccine. The group previously given vaccine was resistant to reinfection as judged from clinical reactions and virus shedding and the GMT increased only slightly to 1:16.3. In contrast, the former placebo group responded; mild symptoms were seen, the majority shed viruses and 50% showed twofold increases in serum HAI titers to a geometric mean titer of 1:17.4.