Developing vaccines against pandemic influenza

Vaccine hesitancy: acceptance of COVID-19 vaccine in Pakistan

Purpose

The delay in acceptance or refusal to get vaccinated despite the availability of services is called vaccine hesitancy. The Global Polio Eradication Initiative in Pakistan faced consistent barriers preventing the eradication of the disease in the country. Similarly with the advent of the coronavirus disease 2019 (COVID-19) pandemic mass vaccination drives were initiated to a vaccine hesitant population. The aim of this study is to explore the prevalence and reasons for COVID-19 vaccine hesitancy in the Pakistani population.

Materials and Methods

Cross-sectional study conducted during July to September 2021 using a snowball sampling technique targeting the adult population of Pakistan. The modified version of the vaccine hesitancy questionnaire related to the Strategic Advisory Group of Experts on Immunization Vaccine Hesitancy matrix was distributed online.

Results

Out of 973 participants, 52.4% were immediately willing to take the vaccine and constituted the acceptance group whereas the remaining 47.6% who were still not sure formed the hesitant group. Support from leaders was found to be statistically significant for the difference between the hesitant and acceptance groups (p-value=0.027). Hesitant people were concerned about the effectiveness of the vaccine (60.9%) and potential side effects (57.9%) as it was not sufficiently tested prior to launch (44.7%). Age and education were significant factors affecting the acceptance of vaccination. The most trusted source of information regarding vaccination was health care workers (43.8%).

Conclusion

A moderately high prevalence of vaccine hesitancy was reported in Pakistan. To overcome it, policymakers need to address the reasons for it. Leaders, celebrities, and healthcare workers can play an instrumental role in dispelling conspiracy theories regarding vaccines and making the vaccination drive a success.

Knowledge, beliefs, attitudes and perceived risk about COVID-19 vaccine and determinants of COVID-19 vaccine acceptance in Bangladesh

Bangladesh govt. launched a nationwide vaccination drive against SARS-CoV-2 infection from early February 2021. The objectives of this study were to evaluate the acceptance of the COVID-19 vaccines and examine the factors associated with the acceptance in Bangladesh. In between January 30 to February 6, 2021, we conducted a web-based anonymous cross-sectional survey among the Bangladeshi general population. At the start of the survey, there was a detailed consent section that explained the study’s intent, the types of questions we would ask, the anonymity of the study, and the study’s voluntary nature. The survey only continued when a respondent consented, and the answers were provided by the respondents themselves. The multivariate logistic regression was used to identify the factors that influence the acceptance of the COVID-19 vaccination. A total of 605 eligible respondents took part in this survey (population size 1630046161 and required sample size 591) with an age range of 18 to 100. A large proportion of the respondents are aged less than 50 (82%) and male (62.15%). The majority of the respondents live in urban areas (60.83%). A total of 61.16% (370/605) of the respondents were willing to accept/take the COVID-19 vaccine. Among the accepted group, only 35.14% showed the willingness to take the COVID-19 vaccine immediately, while 64.86% would delay the vaccination until they are confirmed about the vaccine’s efficacy and safety or COVID-19 becomes deadlier in Bangladesh. The regression results showed age, gender, location (urban/rural), level of education, income, perceived risk of being infected with COVID-19 in the future, perceived severity of infection, having previous vaccination experience after age 18, having higher knowledge about COVID-19 and vaccination were significantly associated with the acceptance of COVID-19 vaccines. The research reported a high prevalence of COVID-19 vaccine refusal and hesitancy in Bangladesh. To diminish the vaccine hesitancy and increase the uptake, the policymakers need to design a well-researched immunization strategy to remove the vaccination barriers. To improve vaccine acceptance among people, false rumors and misconceptions about the COVID-19 vaccines must be dispelled (especially on the internet) and people must be exposed to the actual scientific facts.

While studies on COVID-19 vaccine is ongoing, the public's thoughts and attitudes to the future COVID-19 vaccine

OBJECTIVE

In this study, we aim to investigate the thoughts and attitudes of individuals towards the future COVID-19 vaccine.

METHODS

This descriptive study was carried out on the web between 10/06/2020 and 10/07/2020. The sample constitutes all individuals above 18 years of age using social media and smartphone. The e-survey form was shared by the researchers via the web for a month, and those who completed the survey were included in the study and formed the sample of the research.

RESULTS

Seven-hundred and fifty-nine people participated. 49.7% of the participants stated to be vaccinated; 38.4% of them stated to be vaccinated their children against COVID-19; if the vaccine for COVID-19 is developed. The request for the COVID-19 vaccine had relationship with gender, occupation, health insurance, anxiety level, having children and willing to get vaccinated for their children. "Afraid of the side effects of vaccine", "don't think it can be reliable as it will be a new vaccine" and "COVID-19 infection is a biological weapon and the vaccine will serve those who produce this virus" were the most common reasons for rejection of vaccine.

CONCLUSION

In our study, afraid of the side effects of vaccine and not thinking it can be reliable as it will be a new vaccine are the most reasons of indecision and rejection about COVID 19 vaccine. In order for the future COVID 19 vaccination campaign to not fail, media, politicians and healthcare professionals should closely follow the vaccination development processes, inform the public transparently and consider public's concerns.

CROSS-PROTECTIVE PROPERTIES OF AN INFLUENZA VACCINE BASED ON HBC4M2E RECOMBINANT PROTEIN

One of the main problems in the area of influenza prophylaxis and pandemic prevention is the development of cross-reactive vaccines, i.e. vaccines directed against all subtypes of human influenza viruses. Such vaccines are being developed in many countries for more than 10 years. A number of vaccines are presently undergoing clinical trials. We created Uniflu candidate vaccine based on recombinant HBc4M2e protein consisting of 4 tandem-connected copies of the highly conserved ectodomain of M2 protein of the influenza A virus. These 4 copies were genetically fused to the carrier protein, namely hepatitis B core antigen. Commercially available Derinat was used as adjuvant in the candidate vaccine. Preclinical studies on laboratory animals (mice, ferrets) demonstrated that immunization with Uniflu leads to significantly higher level of specific immunoglobulins in the blood and bronchoalveolar lavages. Moreover, it produces immunoglobulins belonging to subtype IgG2a that is the most important mediator of antibody-dependent cytotoxicity. The vaccine under review stimulates the proliferation of T-lymphocytes, as well as the formation of CD4+ and CD8+ T-cells synthesizing ɣ-IFN. When infected with the lethal doses (5 LD50) of influenza A viruses of the subtypes H1N1, H2N2, H3N2, and H1N1pdm09, immunized animals typically developed mild form of illness. This kept them alive in 90-100% of cases, which demonstrated almost complete protection from death. Replication of the virus in the lungs of immunized mice was reduced by 1.8-4.8 log10. High immunogenicity of the vaccine, and reduced clinical symptoms following experimental infection, were demonstrated in ferrets as well. The developed recombinant vaccine Uniflu has high specific activity and cross-protection. Uniflu can be proposed as pre-pandemic vaccine, provided that it passes clinical trials.

Immunocapture isotope dilution mass spectrometry in response to a pandemic influenza threat

As a result of recent advances in mass spectrometry-based protein quantitation methods, these techniques are now poised to play a critical role in rapid formulation of pandemic influenza vaccines. Analytical techniques that have been developed and validated on seasonal influenza strains can be used to increase the quality and decrease the time required to deliver protective pandemic vaccines to the global population. The emergence of a potentially pandemic avian influenza A (H7N9) virus in March of 2013, prompted the US public health authorities and the vaccine industry to initiate production of a pre-pandemic vaccine for preparedness purposes. To this end, we evaluated the feasibility of using immunocapture isotope dilution mass spectrometry (IC-IDMS) to evaluate the suitability of the underlying monoclonal and polyclonal antibodies (mAbs and pAbs) for their capacity to isolate the H7 hemagglutinin (HA) in this new vaccine for quantification by IDMS. A broad range of H7 capture efficiencies was observed among mAbs tested by IC-IDMS with FR-545, 46/6, and G3 A533 exhibiting the highest cross-reactivity capabilities to H7 of A/Shanghai/2/2013. MAb FR-545 was selected for continued assessment, evaluated by IC-IDMS for mAb reactivity against H7 in the H7N9 candidate vaccine virus and compared with/to reactivity to the reference polyclonal antiserum in allantoic fluid, purified whole virus, lyophilized whole virus and final detergent-split monovalent vaccine preparations for vaccine development. IC-IDMS assessment of FR-545 alongside IC-IDMS using the reference polyclonal antiserum to A/Shanghai/2/2013 and with the regulatory SRID method showed strong correlation and mAb IC-IDMS could have played an important role in the event a potential surrogate potency test was required to be rapidly implemented.

Development of a candidate influenza vaccine based on virus-like particles displaying influenza M2e peptide into the immunodominant region of hepatitis B core antigen: Broad protective efficacy of particles carrying four copies of M2e

A long-term objective when designing influenza vaccines is to create one with broad cross-reactivity that will provide effective control over influenza, no matter which strain has caused the disease. Here we summarize the results from an investigation into the immunogenic and protective capacities inherent in variations of a recombinant protein, HBc/4M2e. This protein contains four copies of the ectodomain from the influenza virus protein M2 (M2e) fused within the immunodominant loop of the hepatitis B virus core antigen (HBc). Variations of this basic design include preparations containing M2e from the consensus human influenza virus; the M2e from the highly pathogenic avian A/H5N1 virus and a combination of two copies from human and two copies from avian influenza viruses. Intramuscular delivery in mice with preparations containing four identical copies of M2e induced high IgG titers in blood sera and bronchoalveolar lavages. It also provoked the formation of memory T-cells and antibodies were retained in the blood sera for a significant period of time post immunization. Furthermore, these preparations prevented the death of 75-100% of animals, which were challenged with lethal doses of virus. This resulted in a 1.2-3.5 log10 decrease in viral replication within the lungs. Moreover, HBc particles carrying only "human" or "avian" M2e displayed cross-reactivity in relation to human (A/H1N1, A/H2N2 and A/H3N2) or A/H5N1 and A(H1N1)pdm09 viruses, respectively; however, with the particles carrying both "human" and "avian" M2e this effect was much weaker, especially in relation to influenza virus A/H5N1. It is apparent from this work that to quickly produce vaccine for a pandemic it would be necessary to have several variations of a recombinant protein, containing four copies of M2e (each one against a group of likely influenza virus strains) with these relevant constructs housed within a comprehensive collection Escherichia coli-producers and maintained ready for use.

Assessing the use of antiviral treatment to control influenza

Vaccines are the cornerstone of influenza control policy, but can suffer from several drawbacks. Seasonal influenza vaccines are prone to production problems and low efficacies, while pandemic vaccines are unlikely to be available in time to slow a rapidly spreading global outbreak. Antiviral therapy was found to be beneficial during the influenza A(H1N1)pdm09 pandemic even with limited use; however, antiviral use has decreased further since then. We sought to determine the role antiviral therapy can play in pandemic and seasonal influenza control using conservative estimates of antiviral efficacy, and to assess if conservative but targeted strategies could be employed to optimize the use of antivirals. Using an age-structured contact network model for an urban population, we compared the transmission-blocking ability of a conservative antiviral therapy strategy to the susceptibility-reducing effects of a robust influenza vaccine. Our results show that while antiviral therapy cannot replace a robust influenza vaccine, it can play a role in reducing attack rates and eliminating outbreaks, and could significantly reduce public health burden when vaccine is either unavailable or ineffective. We also found that antiviral therapy, by treating those who are infected, is naturally a highly optimized strategy, and need not be improved upon with expensive targeted campaigns.

Quantification of viral proteins of the avian H7 subtype of influenza virus: an isotope dilution mass spectrometry method applicable for producing more rapid vaccines in the case of an influenza pandemic

Vaccination is the most effective means to prevent influenza and its serious complications. Influenza viral strains undergo rapid mutations of the surface proteins hemagglutinin (HA) and neuraminidase (NA) requiring vaccines to be frequently updated to include current circulating strains. It is nearly impossible to predict which strains will be circulating in the next influenza season. It is, therefore, imperative that the process of producing a vaccine be streamlined and as swift as possible. We have developed an isotope dilution mass spectrometry (IDMS) method to quantify HA and NA in H7N7, H7N2, and H7N9 influenza. The IDMS method involves enzymatic digestion of viral proteins and the specific detection of evolutionarily conserved target peptides. The four target peptides that were initially chosen for analysis of the HA protein of H7N2 and H7N7 subtypes were conserved and available for analysis of the H7N9 subtype that circulated in China in the spring of 2013. Thus, rapid response to the potential pandemic was realized. Quantification of a protein is performed by employing multiple peptides to ensure that the enzymatic digestion of the protein is efficient in the region of the target peptides, verify the accuracy of the measurement, and provide flexibility in the case of amino acid changes among newly emerging strains. The IDMS method is an accurate, sensitive, and selective method to quantify the amount of HA and NA antigens in primary liquid standards, crude allantoic fluid, purified virus samples, and final vaccine presentations.

Influenza vaccines: T-cell responses deserve more attention

Currently licensed influenza vaccines rely predominantly on the induction of strain-matched hemagglutination inhibition antibody responses. These vaccines have a proven record of safety and efficacy in preventing influenza-induced illness and complications. However, they do not confer protection to all vaccinated individuals, and the protection they afford is short-lived, particularly in older adults. Hemagglutination inhibition titers induced by these vaccines are considered correlates of protection, but recent data demonstrate that this is not always the case. It is clear that better insight is needed into the immune responses that correlate with protection against human influenza. Influenza vaccines that can induce cross-reactive cellular immune responses (CD4(+) and/or CD8(+) T-cell responses) might correct some of the shortcomings of currently used influenza vaccines. In the future, the use of infection-permissive and disease-modifying vaccines that allow for the induction of cross-reactive T-cell responses may become a valuable complement to the administration of trivalent inactivated influenza vaccines.

Swine flu. Mexico's handling of A/H1N1 in comparative perspective

Emerging infectious diseases (EIDs) pose international security threats because of their potential to inflict harm upon humans, crops, livestock, health infrastructure, and economies. Despite the scale of this threat, there are inherent limitations in preventing and controlling EIDs, including the scope of current disease surveillance efforts. All of this leads to the following questions in the context of Mexico's recent swine flu experience: What were the cultural, political, and economic challenges to Influenza A/H1N1 virus response in Mexico? By way of comparison, what can we learn from the U.S. experience in 1976 with A/New Jersey/76 (Hsw1N1), later referred to as H1N1? This article explores the comparative political economy of Mexico's handling of influenza virus A/H1N1 outbreak in 2009. Research provides notable observations-based on the strengths and weaknesses of each country's response--that can be used as a starting point of discussion for the design of effective EIDs surveillance programs in developing and middle-income countries. In the U.S., the speed and efficiency of the 1976 U.S. mobilization against H1N1 was laudable. Although the U.S. response to the outbreak is seldom praised, the unity of the scientific and political communities demonstrated the national ability to respond to the situation. Mexico's strongest characteristics were its transparency, as well as the cooperation the country exhibited with other nations, particularly the U.S. and Canada. While Mexico showed savvy in its effective management of public and media relations, as the article details, political, economic, and cultural problems persisted.

Determination of H5N1 vaccine potency using reference antisera from heterologous strains of influenza

Please cite this paper as: Vodeiko and Weir (2011). Determination of H5N1 vaccine potency using reference antisera from heterologous strains of influenza. Influenza and Other Respiratory Viruses 6(3), 176–187.

Background  Standardization of inactivated influenza vaccines by hemagglutinin (HA) content is performed by the single radial immunodiffusion (SRID) method. Regulatory agencies prepare, calibrate, and distribute SRID reagent standards necessary for testing of seasonal influenza vaccines, and a similar process is used to produce potency reagents for candidate pandemic influenza vaccines that are manufactured for emergency stockpiles.

Objectives  Because of the concerns in generating a timely strain‐specific potency antiserum for an emerging pandemic virus, we evaluated the feasibility of using heterologous potency reference antiserum as a replacement for a strain‐specific (homologous) antiserum in the SRID potency assay for stockpiled H5N1 vaccines.

Results  The results indicate that a heterologous H5N1 antiserum can be used to determine the accurate potency of inactivated H5N1 influenza vaccines. Additionally, when H5N1 vaccine was subjected to an accelerated stability protocol, both homologous and heterologous antisera provided similar measurements of vaccine potency decline. Limitations to the heterologous antiserum approach to potency determination were shown by the inability of antiserum to recent seasonal H1N1 viruses to work in an SRID assay with the 2009 pandemic H1N1 A/California/07/2009 antigen.

Conclusions  The data demonstrate the feasibility of using heterologous antiserum for potency determination of at least some candidate vaccines in case of a shortage or delay of homologous antiserum. Further, the results suggest the prudence of stockpiling a broad library of potency reagents including many strains of influenza viruses with pandemic potential to provide an added measure of assurance that reagent production would not be a bottleneck to vaccine production during a pandemic.

Quantification of immunoreactive viral influenza proteins by immunoaffinity capture and isotope-dilution liquid chromatography-tandem mass spectrometry

An immunocapture isotope dilution mass spectrometry (IC-IDMS) method was developed to quantify antibody-bound influenza hemagglutinins (HA) in trivalent influenza vaccines (TIV). Currently, regulatory potency requirements for TIV require HA quantification based on the single radial immunodiffusion (SRID) assay, which is time-consuming, laborious, and requires production of large quantities of reagents globally. In IC-IDMS, antiserum to the HA of interest captured viral proteins that were in the correct conformation to be recognized by the antibodies. The captured proteins were digested, and evolutionarily conserved tryptic peptides were quantified using isotope-dilution liquid chromatography-tandem mass spectrometry. IC-IDMS relies on antibody-antigen binding similar to SRID but incorporates the accuracy and precision of IDMS. Polyclonal antibodies (pAb-H3) prepared by injection of sheep with purified H3 HA captured 82.9% (55.26 fmol/μL) of the total H3 HA (66.69 fmol/μL) from the commercial TIV and 93.6% (57.23 fmol/μL) of the total H3 HA (61.14 fmol/μL) in purified virus. While other HA (H1, B), neuraminidase (N1, N2, NB), viral matrix proteins, and nucleoproteins were also captured by this antiserum, our results were not affected due to the specificity of the mass spectrometer. IC-IDMS is an accurate, precise, sensitive, and selective method to measure antibody-bound HA in purified virus and commercial vaccines.

Physicians' recommendations to their patients concerning a novel pandemic vaccine: a cross-sectional survey of the 2009 influenza A/H1N1 pandemic in Japan

OBJECTIVES

Striking a balance between the rapid availability of a novel vaccine while ensuring its safety, quality, and efficacy is a major challenge during a pandemic. We aimed to elucidate physicians' attitudes regarding the novel vaccine during the influenza A/H1N1 pandemic of 2009, and to determine factors that affected their vaccination recommendations to patients.

METHODS

Of a random sample of 1,000 general practitioners (GPs) in Japan, 515 participated in the cross-sectional anonymous survey conducted just before the novel vaccine was available (between 28 September and 18 October 2009).

RESULTS

A total of 453 GPs (88.3%) replied that they intended to receive the new vaccine themselves; however, only 177 GPs (34.6%) intended to proactively recommend it to their patients. The anticipated cost of the vaccine negatively influenced the intention to vaccinate themselves and their recommendations to patients (P < 0.001, χ (2) test). Results of multivariate logistic regression analysis showed that physicians with experience in influenza A/H1N1 patient contacts [1-20 contacts, odds ratio (OR) = 7.49 (95% confidence interval [CI]: 1.73-32.36), P = 0.007; >20 contacts, OR = 8.03 (95% CI: 1.77-36.50), P = 0.007, compared with no contacts] were more likely to recommend the vaccine to patients, whereas those with knowledge of the fear on the causal association between Guillain-Barré syndrome (GBS) cases and the 1976 swine flu vaccination in the USA were less likely to recommend the vaccine [OR = 0.66 (95% CI: 0.45-0.97), P = 0.036].

CONCLUSIONS

Results of our survey indicate that physicians experience a moral conflict regarding recommending the novel vaccine to patients, which may be the result of their own experience with the disease, knowledge of vaccine side-effects, and cost.

Progress in the development of pandemic influenza vaccines and their production technologies

This article analyzes the current situation in the field of construction and production of pandemic influenza vaccines. The main task of protecting the population against influenza pandemics requires state-of-the-art approaches to the construction of influenza vaccines to be based on reassortment and genetic engineering techniques, including the analysis of primary structures of influenza viral genes, synthesis and cloning of the main viral genes, reverse genetics techniques, and banks of plasmids bearing basic viral genes. Reassortant technologies are now giving way to new approaches for objective reasons. The state-of-the-art technologies provide safety not only at the laboratories where vaccine viruses are constructed but also make the production process wholly safe. We are using the following approaches to the development of industrial production: use of nanoparticles and nanoemulsions as functional adjuvants, construction of totally-safe strains for live attenuated influenza vaccines with deletions of molecular determinants of pathogenicity, application of protein and chemical chaperones to provide self-assembly of haemagglutinin molecules of the H1N1v-2009 virus, and impregnation of whole-virion preparations with nanoparticles to enhance antigenicity.

Platycodin d improves the immunogenicity of newcastle disease virus-based recombinant avian influenza vaccine in mice

The development of an effective influenza vaccine is urgently important for controlling outbreaks of the highly pathogenic avian influenza virus (HPAIV) and reducing the impact of pandemics. The use of an adjuvant in such a vaccine can significantly contribute to improve the immunogenicity. To explore a novel and safe adjuvant for improving the potency of influenza vaccines, platycodin D (1), a saponin from the root of Platycodon grandiflorum, was evaluated for the adjuvant potentials on the specific cellular and humoral immune responses to Newcastle disease virus-based recombinant avian influenza vaccine (rL-H5) in mice. Compound 1 significantly promoted the concanavalin A (Con A)-, the lipopolysaccharide (LPS)-, and the antigen-induced splenocyte proliferation and enhanced the serum antigen-specific IgG, IgG1, IgG2a, and IgG2b antibody titers (P<0.05, P<0.01, or P<0.001) in mice immunized with rL-H5. The mRNA expressions of Th1/Th2 cytokines (IFN-gamma and IL-10) and transcription factors (T-bet and GATA-3) in splenocytes were also markedly up-regulated by 1, compared with the control group immunized with rL-H5 alone (P<0.01 or P<0.001). In addition, 1 remarkably increased the killing activities of natural killer (NK) cells from splenocytes in the immunized mice (P<0.05), which may have important implications for the vaccination against the avian influenza virus. We concluded that 1 could improve the immunogenicity of the rL-H5 vaccine by enhancing both humoral and cellular immune responses in mice, and that 1 is a promising adjuvant for influenza vaccines.

Influenza vaccines: from surveillance through production to protection

Influenza is an important contributor to population and individual morbidity and mortality. The current influenza pandemic with novel H1N1 has highlighted the need for health care professionals to better understand the processes involved in creating influenza vaccines, both for pandemic as well as for seasonal influenza. This review presents an overview of influenza-related topics to help meet this need and includes a discussion of the burden of disease, virology, epidemiology, viral surveillance, and vaccine strain selection. We then present an overview of influenza vaccine-related topics, including vaccine production, vaccine efficacy and effectiveness, influenza vaccine misperceptions, and populations that are recommended to receive vaccination. English-language articles in PubMed published between January 1, 1970, and October 7, 2009, were searched using key words human influenza, influenza vaccines, influenza A, and influenza B.

Rapid typing and subtyping of vaccine strains of the influenza virus with high resolution mass spectrometry

The application of high-resolution mass spectrometry to type and subtype strains of the influenza virus within recent recommended vaccine formulations is described. Proteolytic digests of whole virus or separated hemagglutinin antigen generate conserved signature peptides of unique mass that can be used to characterise each component virus in a rapid and direct manner by the detection of their ions alone. The approach is demonstrated for two type A strains and one type B strain of human influenza viruses present in recommended seasonal vaccines in the northern and southern hemispheres from 2007 through 2010.

A prime-boost vaccination of mice with heterologous H5N1 strains

We evaluated the priming effect of an H5N1 pandemic vaccine in a mouse model to investigate strategies for influenza pandemic vaccination. For priming, an alum-adjuvanted inactivated whole H5N1 vaccine (NIBRG-14, clade 1) was used. As booster vaccines, several formulations of Indo05/05/2005(H5N1)PR8-IBCDC-RG2 vaccines (clades 2-1)were evaluated, including split, whole, alum-adjuvanted split, and alum-adjuvanted whole vaccines. Any type of booster vaccination elicited a significant HI antibody response despite the difference in antigenicity between the priming and booster vaccines. The split vaccine elicited a much stronger booster response than the alum-adjuvanted whole vaccine. When the mice were primed with the H1N1 or H3N2 vaccines, this did not affect the booster response to the H5N1 vaccine. These results indicated that an alum-adjuvanted whole vaccine is able to confer immunological memory to haemagglutinin even if the primed and boosted vaccine strains are in different clades and, once vaccinated, a split vaccine is preferred to evoke recall responses.

Yearly licensing studies from 1997 to 2007 of the inactivated whole virus seasonal influenza vaccine fluval--a useful approach to pandemic vaccine development even in less well developed countries?

Objective  Seasonal vaccination has been consistently shown to significantly reduce morbidity and mortality because of influenza epidemics, even in healthy, working adults. Here we report the results of the yearly licensing studies of the past 11 influenza seasons (1997–2007) with a trivalent, inactivated whole virus vaccine with an aluminum phosphate adjuvant system.

Methods  Sixty healthy volunteers per age group (18–60 years and 60 years and older) were enrolled to receive vaccination each year, thus, a total of 1080 subjects were studied. Serum antibody titers were measured by hemagglutination inhibition (HI).

Results:  The vaccine met the criteria for licensing each year, meaning seroprotection (achievement of an HI titer of >1:40 in >70% of subjects); seroconversion, i.e. a >4‐fold increase in HI antibody titer, or reaching a titer of >1:40, in >40% of subjects; and an increase in geometric mean titers by >2·5‐fold. Side effects were rare and mild. The same method was used to produce a pre‐pandemic vaccine against influenza A (H5N1), which has been shown to be safe and immunogenic in humans.

Conclusions  We conclude that the method presented is safe, effective and may serve as a useful approach to seasonal and pandemic vaccine production even in less well‐developed countries by means of technological transfer.

Controlling pandemic influenza through vaccination programs

Despite its high impact on global mortality, morbidity and cost, seasonal influenza has been regarded as a self-limiting and controllable disease process. With the recent outbreaks of human infection owing to the virulent H5N1 avian influenza virus, the occurrence of the next flu pandemic appears to be closer than ever. With the lessons learnt from the three pandemics of the last century, we are preparing for this. Although not totally preventable, it appears to be possible to decrease the morbidity and mortality from influenza during a pandemic by taking appropriate and timely public health measures. This article aims to summarize the problem at hand and the possible tools available to at least offset the potentially massive impact of such a pandemic.

Baculovirus-derived hemagglutinin vaccine protects chickens from lethal homologous virus H5N1 challenge

Since outbreaks of highly pathogenic avian influenza (HPAI) in both human and poultry from 2003, it is critical to have effective vaccines. A cDNA fragment coding the entire hemagglutinin (HA) gene derived from an H5N1 strain (A/duck/China/E319-2/03) was cloned and expressed using the baculovirus system. Two weeks after receiving two doses of recombinant HA (rHA) vaccines, chickens develop high antibody response for hemagglutination inhibition (HI) at titer 7.2 log(2). Challenge studies revealed that vaccinated chickens with HI titers greater than 3 log(2) could have immunoprotection against the same HPAI H5N1 strain virus challenge through intranasal route. Additionally, HI titer of 5 log(2) determined whether the live viruses could not be detected from oropharyngeal, cloacal discharge or in tissues. This result suggests that the rHA expressed from baculovirus system could be a candidate for the development of a safe and efficient subunit vaccine for HPAI (H5N1).

Quantification of influenza virus hemagglutinins in complex mixtures using isotope dilution tandem mass spectrometry

Influenza vaccination is the primary method for preventing influenza and its severe complications. Licensed inactivated vaccines for seasonal or pandemic influenza are formulated to contain a preset amount of hemagglutinin (HA), the critical antigen to elicit protection. Current methods to establish the HA concentration of vaccines rely on indirect measurements that are subject to considerable experimental variability. We present a liquid chromatography-tandem mass spectrometry (LC/MS/MS) method for the absolute quantification of viral proteins in a complex mixture. Through use of an isotope dilution approach, HA from viral subtypes H1, H3, H5, and B was determined both directly and rapidly. This method can be applied to purified virus preparations, to monovalent bulk concentrates, or to trivalent inactivated influenza vaccines with improved speed, sensitivity, precision, and accuracy. This LC/MS/MS approach may substantially increase the reliability of methods used to quantitate the amount of antigen in seasonal and pandemic influenza vaccines and reduce the time and effort to deliver influenza vaccines for public health use during the next influenza pandemic.

A clinical trial of a whole-virus H5N1 vaccine derived from cell culture

BACKGROUND

Widespread infections of avian species with avian influenza H5N1 virus and its limited spread to humans suggest that the virus has the potential to cause a human influenza pandemic. An urgent need exists for an H5N1 vaccine that is effective against divergent strains of H5N1 virus.

METHODS

In a randomized, dose-escalation, phase 1 and 2 study involving six subgroups, we investigated the safety of an H5N1 whole-virus vaccine produced on Vero cell cultures and determined its ability to induce antibodies capable of neutralizing various H5N1 strains. In two visits 21 days apart, 275 volunteers between the ages of 18 and 45 years received two doses of vaccine that each contained 3.75 microg, 7.5 microg, 15 microg, or 30 microg of hemagglutinin antigen with alum adjuvant or 7.5 microg or 15 microg of hemagglutinin antigen without adjuvant. Serologic analysis was performed at baseline and on days 21 and 42.

RESULTS

The vaccine induced a neutralizing immune response not only against the clade 1 (A/Vietnam/1203/2004) virus strain but also against the clade 2 and 3 strains. The use of adjuvants did not improve the antibody response. Maximum responses to the vaccine strain were obtained with formulations containing 7.5 microg and 15 microg of hemagglutinin antigen without adjuvant. Mild pain at the injection site (in 9 to 27% of subjects) and headache (in 6 to 31% of subjects) were the most common adverse events identified for all vaccine formulations.

CONCLUSIONS

A two-dose vaccine regimen of either 7.5 microg or 15 microg of hemagglutinin antigen without adjuvant induced neutralizing antibodies against diverse H5N1 virus strains in a high percentage of subjects, suggesting that this may be a useful H5N1 vaccine. (ClinicalTrials.gov number, NCT00349141.)

Human infection with highly pathogenic H5N1 influenza virus

Highly pathogenic H5N1 influenza A viruses have spread relentlessly across the globe since 2003, and they are associated with widespread death in poultry, substantial economic loss to farmers, and reported infections of more than 300 people with a mortality rate of 60%. The high pathogenicity of H5N1 influenza viruses and their capacity for transmission from birds to human beings has raised worldwide concern about an impending human influenza pandemic similar to the notorious H1N1 Spanish influenza of 1918. Since many aspects of H5N1 influenza research are rapidly evolving, we aim in this Seminar to provide an up-to-date discussion on select topics of interest to influenza clinicians and researchers. We summarise the clinical features and diagnosis of infection and present therapeutic options for H5N1 infection of people. We also discuss ideas relating to virus transmission, host restriction, and pathogenesis. Finally, we discuss vaccine development in view of the probable importance of vaccination in pandemic control.

Epidemiology of pandemic influenza: use of surveillance and modeling for pandemic preparedness

Along with continual enhancement of current influenza surveillance programs, pandemic preparedness also involves application of current surveillance techniques to past pandemics to identify their viruses and patterns, as well as estimation of the potential burden of future pandemics. Although mortality surveillance has been in place in selected locations for more than a century, the recent development of molecular diagnostics has shed new light on the origin and structure of the viruses responsible for the past 3 pandemics, allowing for comparisons with new viruses identified through ongoing viral surveillance. Models previously used to estimate hospitalizations and mortality associated with past epidemics and pandemics have evolved to estimate the burden and required surge capacity of future pandemics of different severities.

Resistance to anti-influenza drugs: adamantanes and neuraminidase inhibitors

Development of effective drugs for the treatment or prevention of epidemic and pandemic influenza is important in order to reduce its impact. Adamantanes and neuraminidase inhibitors are two classes of anti-influenza drugs available for influenza therapy currently. However, emergence of resistance to these drugs has been detected, which raises concerns regarding their widespread use. In this review, resistance to the adamantanes and neuraminidase inhibitors will be discussed in relation to both epidemic and pandemic influenza viruses.

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.

Susceptibility of highly pathogenic A(H5N1) avian influenza viruses to the neuraminidase inhibitors and adamantanes

Since 2003, highly pathogenic A(H5N1) influenza viruses have been the cause of large-scale death in poultry and the subsequent infection and death of over 140 humans. A group of 55 influenza A(H5N1) viruses isolated from various regions of South East Asia between 2004 and 2006 were tested for their susceptibility to the anti-influenza drugs the neuraminidase inhibitors and adamantanes. The majority of strains were found to be fully sensitive to the neuraminidase inhibitors oseltamivir carboxylate, zanamivir and peramivir; however two strains demonstrated increased IC50 values. Sequence analysis of these strains revealed mutations in the normally highly conserved residues 116 and 117 of the N1 neuraminidase. Sequence analysis of the M2 gene showed that all of the A(H5N1) viruses from Vietnam, Malaysia and Cambodia contained mutations (L26I and S31N) associated with resistance to the adamantane drugs (rimantadine and amantadine), while strains from Indonesia were found to be a mix of both adamantane resistant (S31N) and sensitive viruses. None of the A(H5N1) viruses from Myanmar contained mutations known to confer adamantane resistance. These results support the use of neuraminidase inhibitors as the most appropriate class of antiviral drug to prevent or treat human A(H5N1) virus infections.

Distinct contributions of vaccine-induced immunoglobulin G1 (IgG1) and IgG2a antibodies to protective immunity against influenza

Vaccination represents the most effective form of protection against influenza infection. While neutralizing antibodies are typically measured as a correlate of vaccine-induced protective immunity against influenza, nonneutralizing antibodies may contribute to protection or amelioration of disease. The goal of this study was to dissect the individual contributions of the immunoglobulin G1 (IgG1) and IgG2a antibody isotypes to vaccine-induced immunity against influenza virus. To accomplish this, we utilized an influenza vaccine regimen that selectively enhanced IgG1 or IgG2a antibodies by using either DNA or viral replicon particle (VRP) vectors expressing influenza virus hemagglutinin (HA) (HA-DNA or HA-VRP, respectively). After HA-DNA vaccination, neutralizing antibodies were detected by both in vitro (microneutralization) and in vivo (lung viral titer) methods and were associated with increased IgG1 expression by enzyme-linked immunosorbent assay (ELISA). Vaccination with HA-VRP did not strongly stimulate either neutralizing or IgG1 antibodies but did induce IgG2a antibodies. Expression of IgG2a antibodies in this context correlated with clearance of virus and increased protection against lethal influenza challenge. Increased induction of both antibody isotypes as measured by ELISA was a better correlate for vaccine efficacy than neutralization alone. This study details separate but important roles for both IgG1 and IgG2a expression in vaccination against influenza and argues for the development of vaccine regimens that stimulate and measure expression of both antibody isotypes.

Potential benefits and limitations of various strategies to mitigate the impact of an influenza pandemic

The recent avian influenza outbreaks underscore the importance of improving our preparedness for an impending influenza pandemic. Various strategies, including pharmaceutical interventions (such as vaccines and antivirals) and nonpharmaceutical interventions (such as quarantine, isolation, and social distancing) may be implemented to mitigate the impact of a pandemic. It is necessary to understand the potential benefits and limitations of each strategy to determine the most appropriate strategies to be implemented. In this article, each strategy is reviewed to define its potential benefits and limitations during a pandemic. Vaccines are probably the most effective measure to reduce morbidity and mortality. However, vaccines are not likely to be available at an early stage of a pandemic. The supply of vaccines is most likely to be insufficient due to limited worldwide production capacity. Antivirals, particularly neuraminidase inhibitors, are expected to be effective against a pandemic influenza strain and are the only available pharmaceutical intervention until enough vaccines are produced. Shortage of supply and high cost is still a major limiting factor in amassing large stockpiles of neuraminidase inhibitors. The possible emergence of resistant strains should also be considered. Nonpharmaceutical interventions can be effective in preventing the spread of the virus under certain conditions. The effectiveness of nonpharmaceutical interventions depends on how influenza viruses are transmitted. There are still significant gaps in the scientific evidence of the way in which influenza viruses are transmitted. Further studies should be conducted to define the basic transmission patterns of influenza viruses.

Removing Barriers to Global Pandemic Influenza Vaccination

This article clarifies the regulatory issues surrounding influenza pandemic vaccine for the larger policy community and describes the need for regulatory harmonization. Vaccination would save lives in an influenza pandemic, but a lack of global manufacturing capacity will leave most of the world without access to vaccine. Capacity can be expanded if governments harmonize their regulatory policies. This article details the regulatory approaches taken by the United States, the European Union, and Japan for pandemic vaccine development, three regions that produce the majority of the world's seasonal influenza vaccine. They should quickly converge on regulatory requirements, intellectual property considerations, the use of recombinant DNA techniques for vaccine production, and technical issues about the composition of pandemic vaccine.

A new European perspective of influenza pandemic planning with a particular focus on the role of mammalian cell culture vaccines

Sixteen EU scientists and doctors were interviewed about pandemic planning using psychometric methods applied to a scientific problem for the first time. Criticism was aimed at countries which have no plan whatsoever, the majority of nations. Many such countries have not invested in scientific infrastructure and public health. Amongst the 15 or so published pandemic plans a lack of detail was identified. Of particular need was investment into avian virus vaccine stocks (H1-15), prepared licenses of vaccine and pre purchase and agreed distribution, investment into stocks of antivirals, antibiotics and masks. Most but not all members of the group predicted a global outbreak within 5 years, most probably starting in SE Asia. However it was recognised that a pandemic could start anywhere in the world which had juxtaposition of young people, chickens, ducks and pigs. Mammalian cell culture production using wild type virus with the production factory at category III levels of security was exemplified. Antivirals would be essential to ameliorate the first wave of infection although significant quantities of cell grown vaccine could be produced if, as in 1918, 1957 and 1968 there is a long period between the first virus isolation and person to person spread. The wider scientific community is more energised than previously for very serious preparations to be in place way before the outbreak begins as this is a major public health problem, completely dwarfing concerns about bioterrorism.

Avian influenza: an omnipresent pandemic threat

BACKGROUND

Humans have faced 3 major influenza pandemics in the 20th century. In recent years, it has become evident that domestic poultry play an important role in the generation of novel influenza strains with the capacity to cross the species barrier and infect and kill humans at an alarming rate. There is particular concern that avian influenza viruses of the H5N1 subtype could cause a pandemic.

METHODS

A better understanding of the genetic factors that lead to interspecies transmission is essential to prevent the emergence of influenza pandemics. In addition, the stockpiling of antiviral drugs and development of vaccines against potentially pandemic viruses must be considered under the umbrella of pandemic plans.

RESULTS

The world is ill-prepared to face an influenza pandemic. Only a handful of countries have developed influenza pandemic plans, and even fewer are developing vaccines or stockpiling antiinfluenza drugs to ameliorate the impact of a potential pandemic. Currently the major undertaking in several at risk nations is to implement effective control measures to stop the spread of the virus at its source, that is, avian species. These measures include the culling of domestic poultry to contain the virus, a practice that could eventually bring these countries to a financial and social breaking point.

CONCLUSIONS

Avian influenza disease is preventable in humans and birds with the concerted effort of governments and poultry producers, large and small, to improve biosecurity and education programs. Pandemic plans can reduce the impact of the pandemic; however, preventing avian influenza in poultry can avert a pandemic altogether.

Two Doses of Parenterally Administered Split Influenza Virus Vaccine Elicited High Serum IgG Concentrations which Effectively Limited Viral Shedding upon Challenge in Mice

We have previously found that whole influenza virus vaccine induced a more rapid and stronger humoral response, particularly after the first dose of vaccine, than split virus vaccine in mice. In this study, we have evaluated the protective efficacy of whole and split influenza virus vaccines in mice using a nonlethal upper respiratory tract challenge model. We have also investigated the immunological correlates associated with no or very little viral shedding after viral challenge. Vaccination resulted in reduced viral shedding and shortened the duration of infection by at least 2 days. After one dose of vaccine, whole virus vaccine generally resulted in less viral shedding than split virus vaccine. In contrast, two doses of split virus vaccine, particularly the highest vaccine strengths of 15 and 30 microg HA, most effectively limited viral replication and these mice had high concentrations of prechallenge influenza-specific serum IgG. The vaccine formulation influenced the IgG2a/IgG1 ratio, and this IgG subclass profile was maintained upon challenge to some extent, although it did not influence the level of viral shedding. The concentration of postvaccination serum IgG showed an inverse relationship with the level of viral shedding after viral challenge. Therefore, serum IgG is an important factor in limiting viral replication in the upper respiratory tract upon challenge of an antigenically similar virus.

Whole influenza virus vaccine is more immunogenic than split influenza virus vaccine and induces primarily an IgG2a response in BALB/c mice

The aim of this study was to compare the kinetics and the magnitude of the humoral immune response to two different influenza vaccine formulations, whole and split virus vaccines. BALB/c mice were immunized intramuscularly with one or two doses (3 weeks apart) of 7.5, 15 or 30 microg of haemagglutinin of monovalent A/Panama/2007/99 (H3N2) split or whole virus vaccine. The two vaccine formulations induced similar kinetics of the antibody-secreting cells response; however, differences in the magnitude were observed in the spleen and bone marrow. Vaccination with whole virus vaccine generally elicited a quicker and higher neutralizing antibody response, particularly after the first dose of vaccine. The two vaccine formulations gave different immunoglobulin G (IgG) subclass profiles. Split virus vaccine stimulated both IgG1 and IgG2a antibodies suggestive of mixed T-helper 1 (Th1) and Th2 response, whereas whole virus vaccine induced mainly an IgG2a antibody response, which is indicative of a dominant Th1 response. The increased immunogenicity of whole virus vaccine in a naïve population could reduce the vaccine concentration needed to provide protective immunity.

Poor immune responses to influenza vaccination in infants

Twenty-two and 37 infants and young children received two doses of influenza HA vaccine before the 2001-2002 influenza season and before the 2002-2003 season, respectively. Two or three serial specimens were obtained, before and 1 month after the first vaccination as well as 1 month after the second vaccination. Infants showed a significantly poor HI antibody rise and lymphocyte response compared with young children aged > or =12 months. Time kinetics of the lymphoproliferative responses to influenza antigen among young children varied whereas their activities in infants were typically negative before immunization and increased after vaccination. Infants responded poorly to HA influenza vaccine compared with young children.

Responsiveness to a pandemic alert: use of reverse genetics for rapid development of influenza vaccines

BACKGROUND

In response to the emergence of severe infection capable of rapid global spread, WHO will issue a pandemic alert. Such alerts are rare; however, on Feb 19, 2003, a pandemic alert was issued in response to human infections caused by an avian H5N1 influenza virus, A/Hong Kong/213/03. H5N1 had been noted once before in human beings in 1997 and killed a third (6/18) of infected people. The 2003 variant seemed to have been transmitted directly from birds to human beings and caused fatal pneumonia in one of two infected individuals. Candidate vaccines were sought, but no avirulent viruses antigenically similar to the pathogen were available, and the isolate killed embryonated chicken eggs. Since traditional strategies of vaccine production were not viable, we sought to produce a candidate reference virus using reverse genetics.

METHODS

We removed the polybasic aminoacids that are associated with high virulence from the haemagglutinin cleavage site of A/Hong Kong/213/03 using influenza reverse genetics techniques. A reference vaccine virus was then produced on an A/Puerto Rico/8/34 (PR8) backbone on WHO-approved Vero cells. We assessed this reference virus for pathogenicity in in-vivo and in-vitro assays.

FINDINGS

A reference vaccine virus was produced in Good Manufacturing Practice (GMP)-grade facilities in less than 4 weeks from the time of virus isolation. This virus proved to be non-pathogenic in chickens and ferrets and was shown to be stable after multiple passages in embryonated chicken eggs.

INTERPRETATION

The ability to produce a candidate reference virus in such a short period of time sets a new standard for rapid response to emerging infectious disease threats and clearly shows the usefulness of reverse genetics for influenza vaccine development. The same technologies and procedures are currently being used to create reference vaccine viruses against the 2004 H5N1 viruses circulating in Asia.

Vaccination for pandemic influenza: a six point agenda for interpandemic years

BACKGROUND

The demand for influenza vaccine is driven by recognition of its health and economic benefits. Vaccine reduces all cause mortality in the elderly by 30 to 50% and prevents > or =30% of hospital admissions for influenza-related respiratory disease, heart disease and stroke. However, because most influenza vaccine (85%) is produced in only eight countries, adequate production and equitable distribution of vaccine throughout the world will pose a serious challenge when the next influenza pandemic appears.

METHODS

This article reviews a six point agenda for pandemic vaccination that should be undertaken during interpandemic years. The agenda includes preparing vaccine seed strains using reverse genetics, determining the characteristics of a pandemic vaccine and vaccination schedule, considering global registration of pandemic vaccines, increasing vaccination in interpandemic years, documenting the epidemiology of vaccine use and addressing political issues that will affect the global supply of pandemic vaccines.

CONCLUSIONS

Planning for pandemic vaccination must begin during the interpandemic period to ensure a vaccine supply that will be adequate to meet demand in all countries. This will require the skills not only of experts in virology, epidemiology and public health but also those in politics, economics and law. The task will be complex, but its promised benefits will be immense.

Are we ready for pandemic influenza?

During the past year, the public has become keenly aware of the threat of emerging infectious diseases with the global spread of severe acute respiratory syndrome (SARS), the continuing threat of bioterrorism, the proliferation of West Nile virus, and the discovery of human cases of monkeypox in the United States. At the same time, an old foe has again raised its head, reminding us that our worst nightmare may not be a new one. In 2003, highly pathogenic strains of avian influenza virus, including the H5N1 and H7N7 subtypes, again crossed from birds to humans and caused fatal disease. Direct avian-to-human influenza transmission was unknown before 1997. Have we responded to these threats by better preparing for emerging disease agents, or are we continuing to act only as crises arise? Here we consider progress to date in preparedness for an influenza pandemic and review what remains to be done. We conclude by prioritizing the remaining needs and exploring the reasons for our current lack of preparedness for an influenza pandemic.

Pandemic influenza and the global vaccine supply

Use of influenza vaccine is increasing, especially in developing countries. Yet most of the world's influenza vaccine is produced by companies located in 9 developed countries. When the threat of an influenza pandemic appears, the traditional approach to providing interpandemic vaccines will not be able to meet the global demand for pandemic vaccine. Several steps must be taken to address this problem, including the use of reverse genetics to prepare seed strains for vaccine production, the undertaking of clinical studies to define the characteristics of candidate "pandemic-like" vaccines and vaccination schedules, the development of procedures for global vaccine registration, the expansion of recommendations and reimbursement for interpandemic vaccination, the country-specific reporting of vaccine use and forecasts of future vaccine needs, and the negotiation of political agreements that will ensure the adequate production and equitable distribution of pandemic vaccine throughout the world.