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Ramachandran P, Grose C. Serious neurological adverse events in immunocompetent children and adolescents caused by viral reactivation in the years following varicella vaccination. Rev Med Virol 2024; 34:e2538. [PMID: 38658176 PMCID: PMC11170866 DOI: 10.1002/rmv.2538] [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: 03/12/2024] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
Serious adverse events following vaccination include medical complications that require hospitalisation. The live varicella vaccine that was approved by the Food and Drug Administration in the United States in 1995 has an excellent safety record. Since the vaccine is a live virus, adverse events are more common in immunocompromised children who are vaccinated inadvertently. This review includes only serious adverse events in children considered to be immunocompetent. The serious adverse event called varicella vaccine meningitis was first reported in a hospitalised immunocompetent child in 2008. When we carried out a literature search, we found 15 cases of immunocompetent children and adolescents with varicella vaccine meningitis; the median age was 11 years. Eight of the children had received two varicella vaccinations. Most of the children also had a concomitant herpes zoster rash, although three did not. The children lived in the United States, Greece, Germany, Switzerland, and Japan. During our literature search, we found five additional cases of serious neurological events in immunocompetent children; these included 4 cases of progressive herpes zoster and one case of acute retinitis. Pulses of enteral corticosteroids as well as a lack of herpes simplex virus antibody may be risk factors for reactivation in immunocompetent children. All 20 children with adverse events were treated with acyclovir and recovered; 19 were hospitalised and one child was managed as an outpatient. Even though the number of neurological adverse events remains exceedingly low following varicella vaccination, we recommend documentation of those caused by the vaccine virus.
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Affiliation(s)
- Prashanth Ramachandran
- Peter Doherty Institute for Infection and Immunity, University of Melbourne; Department of Neurology, Royal Melbourne Hospital; and Department of Neurology, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Charles Grose
- Division of Infectious Diseases, Virology Laboratory, Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States
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2
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Levin MJ, Weinberg A. Immune Responses to Varicella-Zoster Virus Vaccines. Curr Top Microbiol Immunol 2022; 438:223-246. [PMID: 35102438 DOI: 10.1007/82_2021_245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The live attenuated varicella vaccine is intended to mimic the tempo and nature of the humoral and cell-mediated immune responses to varicella infection. To date, two doses of varicella vaccine administered in childhood have been very effective in generating varicella-zoster virus (VZV) immune responses that prevent natural infection for at least several decades. After primary infection, the infecting VZV establishes latency in sensory and cranial nerve ganglia with the potential to reactivate and cause herpes zoster. Although, the immune responses developed during varicella are important for preventing herpes zoster they wane with increasing age (immune senescence) or with the advent of immune suppression. Protection can be restored by increasing cell-mediated immune responses with two doses of an adjuvanted recombinant VZV glycoprotein E vaccine that stimulates both VZV-and gE-specific immunity. This vaccine provides ~85-90% protection against herpes zoster for 7-8 years (to date).
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Affiliation(s)
- Myron J Levin
- Departments of Pediatrics and Medicine, University of Colorado Denver School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Adriana Weinberg
- Departments of Pediatrics, Medicine, and Pathology, University of Colorado Denver School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
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3
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Immune Responses to Varicella-Zoster Virus Glycoprotein E Formulated with Poly(Lactic-co-Glycolic Acid) Nanoparticles and Nucleic Acid Adjuvants in Mice. Virol Sin 2020; 36:122-132. [PMID: 32757147 DOI: 10.1007/s12250-020-00261-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/01/2020] [Indexed: 12/15/2022] Open
Abstract
The subunit herpes zoster vaccine Shingrix is superior to attenuated vaccine Zostavax in both safety and efficacy, yet its unlyophilizable liposome delivery system and the limited supply of naturally sourced immunological adjuvant QS-21 still need to be improved. Based on poly(lactic-co-glycolic acid) (PLGA) delivery systems that are stable during the lyophilization and rehydration process and using a double-emulsion (w/o/w) solvent evaporation method, we designed a series of nanoparticles with varicella-zoster virus antigen glycoprotein E (VZV-gE) as an antigen and nucleic acids including polyinosinic-polycytidylic acid (Poly I:C) and phosphodiester CpG oligodeoxynucleotide (CpG ODN), encapsulated as immune stimulators. While cationic lipids (DOTAP) have more potential than neutral lipids (DOPC) for activating gE-specific cell-mediated immunity (CMI) in immunized mice, especially when gE is encapsulated in and presented on the surface of nanoparticles, PLGA particles without lipids have the greatest potential to induce not only the highest gE-specific IgG titers but also the strongest gE-specific CMI responses, including the highest proportions of interferon-γ (IFN-γ)- and interleukin-2 (IL-2)-producing CD4+/CD8+ T cells according to a flow cytometry assay and the greatest numbers of IFN-γ- and IL-2-producing splenocytes according to an enzyme-linked immunospot (ELISPOT) assay. These results showed that immune-stimulating nucleic acids together with the PLGA delivery system showed promise as a safe and economical varicella and zoster vaccine candidate.
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4
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Bobrowski AE, Muller WJ. Varicella infection following vaccination in a pediatric kidney transplant recipient. Pediatr Transplant 2020; 24:e13667. [PMID: 32068320 DOI: 10.1111/petr.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/19/2019] [Accepted: 01/07/2020] [Indexed: 12/22/2022]
Abstract
Live viral vaccines have historically been avoided in children after solid organ transplantation. Multiple reports of safety and immunogenicity, largely in the pediatric liver transplant population, have led to a reconsideration of this recommendation. Here, we report the case of a 4-year-old boy who inadvertently received the live attenuated MMR-varicella vaccine (MMRV) at a routine well-child visit 16 months after receiving a living donor kidney transplant. This was not known until after he was admitted with rash and documented disseminated varicella infection 5 weeks later. He was treated with intravenous acyclovir followed by oral therapy and recovered fully. This case and its discussion illustrate what is still unknown about the risk-to-benefit ratio of live viral vaccination in any individual transplant recipient. Criteria to determine which patients should receive these vaccines should be evaluated before their use after transplant becomes routine, and all recipients and their families should be counseled to have a low threshold to seek medical care for any febrile illness or rash after live viral vaccination.
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Affiliation(s)
- Amy E Bobrowski
- Division of Pediatric Kidney Diseases, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | - William J Muller
- Division of Infectious Diseases, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
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5
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Tovar Salazar A, McKhann A, Chen H, Bosch RJ, Weinberg A. Immune Correlates of Herpes Zoster in People Living with HIV on Effective Antiretroviral Therapy. AIDS Res Hum Retroviruses 2019; 35:890-895. [PMID: 31179712 DOI: 10.1089/aid.2019.0053] [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: 01/06/2023] Open
Abstract
Herpes zoster (HZ) has high morbidity in people living with HIV (PLHIV). We investigated immunological factors that correlated with the development of HZ in PLHIV with controlled HIV replication on antiretroviral therapy (ART). PLHIV who developed HZ on ART (cases), with undetectable plasma HIV RNA, and CD4 counts ≥200 cells/μL were matched 1:1 to controls by CD4 count, age, gender, race, and duration of ART. Varicella-zoster virus (VZV)-specific T cells and circulating regulatory T cells (Treg) were measured by flow cytometry before and after HZ. Differences between cases and controls were assessed by paired t-tests and longitudinal changes by Wilcoxon signed rank test. HZ cases (N = 31) had higher CD4+FOXP3+CD25+% Treg before HZ compared with 31 controls. After VZV ex vivo restimulation, cases had lower T cell responses, including CD8+perforin+% cytotoxic T lymphocytes (CTLs), CD4+IL10+%, and CD4+TGFβ+% compared with controls. Overall, Treg negatively correlated with VZV-specific Th1 responses. Moreover, Treg decreased over time on ART in HZ cases, VZV-CTLs were stable and did not increase even after HZ. Increased circulating Treg and decreased VZV-specific T cell immune responses were associated with the risk of HZ in PLHIV. The kinetics of Treg over time, but not of VZV-CTLs, paralleled the natural history of HZ, whose incidence decreases over time on effective ART.
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Affiliation(s)
- Adriana Tovar Salazar
- Department of Pediatrics, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
| | - Ashley McKhann
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Huichao Chen
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Ronald J. Bosch
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Adriana Weinberg
- Department of Pediatrics, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
- Department of Medicine, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
- Department of Pathology, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
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6
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Sullivan NL, Eberhardt CS, Wieland A, Vora KA, Pulendran B, Ahmed R. Understanding the immunology of the Zostavax shingles vaccine. Curr Opin Immunol 2019; 59:25-30. [PMID: 30970291 DOI: 10.1016/j.coi.2019.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/17/2022]
Abstract
Zostavax is a live-attenuated varicella zoster virus (VZV) vaccine recommended for use in adults >50 years of age to prevent shingles. The main risk factor for the development of shingles is age, which correlates with decreasing cell-mediated immunity. These data suggest a predominant role of T cell immunity in controlling VZV latency. However, other components of the immune system may also contribute. In this review, we will discuss how the immune system responds to Zostavax, focusing on recent studies examining innate immunity, transcriptomics, metabolomics, cellular, and humoral immunity.
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Affiliation(s)
- Nicole L Sullivan
- MRL, Department of Infectious Diseases and Vaccines, Merck & Co., Inc., Kenilworth, New Jersey, USA.
| | - Christiane S Eberhardt
- Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA; Center for Vaccinology and Neonatal Immunology, Department of Pediatrics and Pathology-Immunology, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Switzerland
| | - Andreas Wieland
- Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
| | - Kalpit A Vora
- MRL, Department of Infectious Diseases and Vaccines, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Bali Pulendran
- Institute for Immunity, Transplantation and Infection, Department of Pathology, Department of Microbiology and Immunology, Stanford University, Stanford, CA 94305, USA
| | - Rafi Ahmed
- Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
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Perciani CT, Farah B, Kaul R, Ostrowski MA, Mahmud SM, Anzala O, Jaoko W, MacDonald KS. Live attenuated varicella-zoster virus vaccine does not induce HIV target cell activation. J Clin Invest 2019; 129:875-886. [PMID: 30511963 DOI: 10.1172/jci124473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/27/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Varicella-zoster virus (VZV) is under consideration as a promising recombinant viral vector to deliver foreign antigens including HIV. However, new vectors have come under increased scrutiny, since trials with adenovirus serotype 5-vectored (Ad5-vectored) HIV vaccine demonstrated increased HIV risk in individuals with pre-immunity to the vector that was thought to be associated with mucosal immune activation (IA). Therefore, given the prospect of developing an HIV/VZV chimeric vaccine, it is particularly important to define the impact of VZV vaccination on IA. METHODS Healthy VZV-seropositive Kenyan women (n = 44) were immunized with high-dose live attenuated VZV vaccine, and we assessed the expression on CD4+ T cells isolated from blood, cervix, and rectum of IA markers including CD38 and HLA-DR and of markers of cell migration and tissue retention, as well as the concentration of genital and intestinal cytokines. A delayed-start group (n = 22) was used to control for natural variations in these parameters. RESULTS Although immunogenic, VZV vaccination did not result in significant difference in the frequency of cervical activated (HLA-DR+CD38+) CD4+ T cells (median 1.61%, IQR 0.93%-2.76%) at 12 weeks after vaccination when compared with baseline (median 1.58%, IQR 0.75%-3.04%), the primary outcome for this study. VZV vaccination also had no measurable effect on any of the IA parameters at 4, 8, and 12 weeks after vaccination. CONCLUSION This study provides the first evidence to our knowledge about the effects of VZV vaccination on human mucosal IA status and supports further evaluation of VZV as a potential vector for an HIV vaccine. TRIAL REGISTRATION ClinicalTrials.gov NCT02514018. FUNDING Primary support from the Canadian Institutes for Health Research (CIHR). For other sources, see Acknowledgments.
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Affiliation(s)
- Catia T Perciani
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Bashir Farah
- Kenyan AIDS Vaccine Initiative-Institute of Clinical Research (KAVI-ICR), University of Nairobi, Nairobi, Kenya
| | - Rupert Kaul
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada
| | - Mario A Ostrowski
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Center, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Salaheddin M Mahmud
- Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Omu Anzala
- Kenyan AIDS Vaccine Initiative-Institute of Clinical Research (KAVI-ICR), University of Nairobi, Nairobi, Kenya.,Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Walter Jaoko
- Kenyan AIDS Vaccine Initiative-Institute of Clinical Research (KAVI-ICR), University of Nairobi, Nairobi, Kenya.,Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | | | - Kelly S MacDonald
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada.,Section of Infectious Diseases, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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8
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Papp KA, Haraoui B, Kumar D, Marshall JK, Bissonnette R, Bitton A, Bressler B, Gooderham M, Ho V, Jamal S, Pope JE, Steinhart AH, Vinh DC, Wade J. Vaccination Guidelines for Patients With Immune-Mediated Disorders on Immunosuppressive Therapies. J Cutan Med Surg 2018; 23:50-74. [PMID: 30463418 PMCID: PMC6330697 DOI: 10.1177/1203475418811335] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND: Patients with immune-mediated diseases on immunosuppressive therapies have more infectious episodes than healthy individuals, yet vaccination practices by physicians for this patient population remain suboptimal. OBJECTIVES: To evaluate the safety and efficacy of vaccines in individuals exposed to immunosuppressive therapies and provide evidence-based clinical practice recommendations. METHODS: A literature search for vaccination safety and efficacy in patients on immunosuppressive therapies (2009-2017) was conducted. Results were assessed using the Grading of Recommendation, Assessment, Development, and Evaluation system. RESULTS: Several immunosuppressive therapies attenuate vaccine response. Thus, vaccines should be administered before treatment whenever feasible. Inactivated vaccines can be administered without treatment discontinuation. Similarly, evidence suggests that the live zoster vaccine is safe and effective while on select immunosuppressive therapy, although use of the subunit vaccine is preferred. Caution regarding other live vaccines is warranted. Drug pharmacokinetics, duration of vaccine-induced viremia, and immune response kinetics should be considered to determine appropriate timing of vaccination and treatment (re)initiation. Infants exposed to immunosuppressive therapies through breastmilk can usually be immunized according to local guidelines. Intrauterine exposure to immunosuppressive agents is not a contraindication for inactivated vaccines. Live attenuated vaccines scheduled for infants and children ⩾12 months of age, including measles, mumps, rubella, and varicella, can be safely administered as sufficient time has elapsed for drug clearance. CONCLUSIONS: Immunosuppressive agents may attenuate vaccine responses, but protective benefit is generally maintained. While these recommendations are evidence based, they do not replace clinical judgment, and decisions regarding vaccination must carefully assess the risks, benefits, and circumstances of individual patients.
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Affiliation(s)
- Kim A Papp
- 1 K Papp Clinical Research, Waterloo, ON, Canada.,2 Probity Medical Research, Waterloo, ON, Canada
| | - Boulos Haraoui
- 3 Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Deepali Kumar
- 4 University Health Network, Toronto, ON, Canada.,5 Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John K Marshall
- 6 Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Alain Bitton
- 8 McGill University Health Centre, Montreal, QC, Canada
| | - Brian Bressler
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,10 St Paul's Hospital, Vancouver, BC, Canada
| | - Melinda Gooderham
- 2 Probity Medical Research, Waterloo, ON, Canada.,11 Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Vincent Ho
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shahin Jamal
- 12 Vancouver Coastal Health, Vancouver, BC, Canada
| | - Janet E Pope
- 13 Faculty of Medicine, University of Western Ontario, London, ON, Canada.,14 St Joseph's Health Care, London, ON, Canada
| | - A Hillary Steinhart
- 5 Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,15 Mount Sinai Hospital, Toronto, ON, Canada
| | - Donald C Vinh
- 8 McGill University Health Centre, Montreal, QC, Canada.,16 Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - John Wade
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,17 Vancouver General Hospital, Vancouver, BC, Canada
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Levin MJ, Kroehl ME, Johnson MJ, Hammes A, Reinhold D, Lang N, Weinberg A. Th1 memory differentiates recombinant from live herpes zoster vaccines. J Clin Invest 2018; 128:4429-4440. [PMID: 30024861 DOI: 10.1172/jci121484] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/13/2018] [Indexed: 12/14/2022] Open
Abstract
The adjuvanted varicella-zoster virus (VZV) glycoprotein E (gE) subunit herpes zoster vaccine (HZ/su) confers higher protection against HZ than the live attenuated zoster vaccine (ZV). To understand the immunologic basis for the different efficacies of the vaccines, we compared immune responses to the vaccines in adults 50 to 85 years old. gE-specific T cells were very low/undetectable before vaccination when analyzed by FluoroSpot and flow cytometry. Both ZV and HZ/su increased gE-specific responses, but at peak memory response (PMR) after vaccination (30 days after ZV or after the second dose of HZ/su), gE-specific CD4+ and CD8+ T cell responses were 10-fold or more higher in HZ/su compared with ZV recipients. Comparing the vaccines, T cell memory responses, including gE-IL-2+ and VZV-IL-2+ spot-forming cells (SFCs), were higher in HZ/su recipients and cytotoxic and effector responses were lower. At 1 year after vaccination, all gE-Th1 and VZV-IL-2+ SFCs remained higher in HZ/su compared with ZV recipients. Mediation analyses showed that IL-2+ PMR were necessary for the persistence of Th1 responses to either vaccine and VZV-IL-2+ PMR explained 73% of the total effect of HZ/su on persistence. This emphasizes the biological importance of the memory responses, which were clearly superior in HZ/su compared with ZV participants.
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Affiliation(s)
- Myron J Levin
- Department of Pediatrics, and.,Department of Medicine, University of Colorado School of Medicine
| | - Miranda E Kroehl
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, and
| | | | - Andrew Hammes
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, and
| | - Dominik Reinhold
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, and
| | | | - Adriana Weinberg
- Department of Pediatrics, and.,Department of Medicine, University of Colorado School of Medicine.,Department of Pathology, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado USA
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