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VACCINE &

VACCINATION
STB2153 Virology &Immunology
Semester 2 2016_17
Vaccination
Active immunity produced by vaccine

Immunity and immunologic memory


similar to natural infection but
without risk of disease
Vaccination
Vaccines are one of the most important tools
we have to protect the health of children
Immunization is one of the most important
ways parents can protect their children
against serious diseases
We now have the means to protect our
nations children against more than 13
diseases that in the past caused great
suffering, disability and premature death.
Vaccines are
Highly Cost Effective
For every $1 spent*:
DTaP saves. . . . . . . . . . . . . . . . $27.00
MMR saves . . . . . . . . . . . . . . . $26.00
Perinatal Hep B saves . . . . . . . $14.70
Varicella saves . . . . . . . . . . . . . $ 5.40
Inactivated Polio (IPV) saves. . $ 5.45

*direct and indirect savings


(including work loss, death, and disability)
Childhood Immunization
Program Successes
Vaccine-preventable diseases
at an all time low
Record high coverage rates
Measles is no longer endemic in
the U.S. and Western Hemisphere
Rubella Eliminated
Number of Vaccines in the Routine
Childhood Immunization Schedule
1985 (7) 1995 (10) 2005 (13)
Measles Measles Measles
Rubella Rubella Rubella
Mumps Mumps Mumps
Diphtheria Diphtheria Diphtheria
Tetanus Tetanus Tetanus
Pertussis Pertussis Pertussis
Polio Polio Polio
Hib (infant) Hib (infant)
HepB HepB
Varicella Varicella
Pneumococcal Disease
Influenza
Meningococcal
Comparison of 20th Century Annual
Morbidity and Current Morbidity,
Vaccine-Preventable Diseases (pre-1990 Vaccines)
20th Century Percent
Disease Annual Morbidity 2004* Decrease

Smallpox 48,164 0 100%


Diphtheria 175,885 0 100%
Measles 503,282 37 99.99%
Mumps 152,209 236 99.84%
Pertussis 147,271 18,957 87.13%
Polio (paralytic) 16,316 0 100%
Rubella 47,745 12 99.97%
Congenital Rubella Syndrome 823 0 100%
Tetanus 1,314 27 97.95%


Source: CDC. MMWR April 2, 1999. 48: 242-264 Numbers in yellow indicate
* Provisional 2004 Data at or near record lows in 2004
Comparison of Pre-Vaccine Era
Estimated Annual Morbidity and Current
Morbidity,
Vaccine-Preventable Diseases (post-1990
Vaccines)
Pre-Vaccine Era
Estimated Annual Percent
Disease Morbidity 2003 Decrease

Hepatitis A 117,333 32,711 72.1%

Hepatitis B (acute) 66,232 21,030 68.2%

Hib (invasive) 20,000 40 99.8%

Pneumococcus (invasive) 63,067 39,800 36.9%

Varicella 4,085,120 817,024 80.0%

Influenza (<5 years) N/A N/A ---

Meningococcus (invasive) 2,183 N/A ---

N/A = not available


Table 2: New immunisation schedule
Immuni Age (months) Age
sation (years)
0 1 2 3 4 5 6 12 18 6

BCG No
scar
Hep B
DPT DT
OPV
HIB
Measles
*
MMR
Vaccine development

Properties of good candidate:


Organism causes significant illness
Organism 1 serotype
Organism no oncogenic potential
Antibodies block infection /
systemic spread
Vaccine heat stable
The Rotavirus vaccine
Estimated 440,000 to 870,000 deaths annually due
to rotavirus
Nature of protective immunity well-documented;
mechanisms unknown
Timeline
1973-Rotavirus first isolated
1984-Efficacy of live attenuated rotavirus vaccines
demonstrated
August 1998-Wyeth vaccine licensed (>80% effective)
July 1999-Wyeth vaccine withdrawn due to intussusception
(risk 1/2500 to 1/11,000
2005-Merck and Glaxo-Smith-Kline vaccines still under
evaluation safety tests will involve 63,000 to 68,000
subjects(!)
Principles of Vaccination
Active Immunity
Protection produced by the person's own
immune system
Usually permanent

Passive Immunity
Protection transferred from another
person or animal
Temporary protection that wanes with
time
Passive Immunity
Transfer of antibody produced by one
human or other animal to another
Temporary protection
Transplacental most important
source in infancy
Passive Immunization
IgG - immediate protection - no memory

Standard Igs (human, animals) Non-specific


Pooled plasma from donors
Igs vs. many common viruses

Human hyperimmune serum (high titre)


Specific
From donor c. high titre Abs to specific virus
Against specific (single) virus
Passive Immunization

Mims C et al. Medical Microbiology. 1998.


Active immunization
Penetrate cells
- intracell. Ag
Formulations: processing to
1. Live pathogens attenuatedsurface of cells
- cytotoxic T cell
2. Killed micro-orgs response

3. Microbial extracts
4. Vaccine conjugates
5. Toxoids

Do not enter host cells:


1ary B cell-mediated
humoral response
Vaccine components
Attenuate Killed Microbial
d pathogen extract /
pathogen product
Bacteri Typhoid (PO) Typhoid fever B. pertussis Ag
BCG (M. bovis) Cholera *Hib
al
(Salmonella) Pertussis Diphtheria
Disease Plague (Y. pestis) (Tox.)
s Anthrax *Meningococcal
*Pneumococcal
Tetanus (Tox.)

Viral Measles Polio (Salk) Hep. B


Mumps Hep. A
Disease
Rubella Influenza
s Chickenpox Rabies
Polio (Sabin - Japanese
When Is It Safe to
Immunize?
Mild illness
Disease exposure
Antibiotic therapy
Breast Feeding
Premature birth
Most allergies
Family history of
vaccine reaction
Vaccine Reactions

Local Reactions

Systemic
Reactions

Allergic Reactions

Emotional
Problems with vaccines
Localized - at site of injection
Anaphylaxis to Ag or non-microbial
content vaccine (eggs)
Contamination with pathogen
Reversion of attenuation
Lack of efficacy if another concurrent
infection (rubella & polio vaccine)
Organisms with lots of serotypes
Autism and Vaccines
Theory posed that
MMR vaccine might
play a role in autism
Weight of scientific
evidence does not
support
American Academy of
Pediatrics Review and
Institute of Medicine
Review conclude no
association
Inactivated Vaccines
Whole

viruses
bacteria
Fractional

protein-based
toxoid
subunit

polysaccharide-based
pure
conjugate
Live Attenuated Vaccines
Severe reactions possible

Interference from circulating


antibody

Fragile must be stored and handled


carefully
Live Attenuated Vaccines
Attenuated (weakened) form of the
"wild" virus or bacterium
Must replicate to be effective
Immune response similar to natural
infection
Usually effective with one dose*
Live Attenuated Vaccines
Viral Viral
measles,
rubella, mump,
varicella/zoster, vaccinia,
yellow fever, rotavirus,
oral polio
intranasal
Bacterial BCG, influenza,
oral typhoid
Inactivated Vaccines
Cannot replicate
Generally not as effective as live
vaccines
Less interference from circulating
antibody than live vaccines
Generally require 3-5 doses
Immune response mostly humoral
Antibody titer may diminish with time
Inactivated Vaccines

Whole-cell vaccines
Viral polio, hepatitis A,
rabies, influenza
Bacterial pertussis, typhoid
cholera, plague
Inactivated Vaccines

Fractional vaccines
Subunit hepatitis B, influenza,
acellular pertussis,
human papillomavirus,
anthrax, Lyme

Toxoid diphtheria, tetanus


Vaccines
Advantages of inactivated vaccines
Gives sufficient humoral immunity if boosters given
No mutation or reversion
Can be used with immuno-deficient patients
Sometimes better in tropics

Disadvantages of inactivated vaccines


Many vaccinees do not raise immunity
Boosters needed
No local immunity (important)
Higher cost
Shortage of monkeys (polio)
Failure in inactivation and immunization with virulent virus
Recombinant Vaccine
Recombinant vaccines are created by utilizing bacteria or yeast to
produce large quantities of a single viral or bacterial protein.
Contains only part of a microorganism (i.e., the vaccine is not
whole).

Such vaccines are typically safer than whole vaccines because


they (ideally) contain only those parts that induce a good immune
response and not those parts that can lead to complications or
side effects

Recombinant vaccines are typically less effective than whole


vaccines, especially live-attenuated vaccines, since at best
recombinant vaccines induce an incomplete immune response
against a pathogen. only inducing humoral immunity
DNA Vaccines
What is a DNA Vaccine?
A DNA Vaccine is essentially a DNA sequence
that can be used as a vaccine.
This sequence of DNA is taken from bacterial or
viral genes, which codes for a protein that is
essential for their growth or replications.
The sequence is then injected into a cell of a
person, the protein is produced, and
an immunity is developed against the infectious
organisms.
In this way the DNA sequence acts as a vaccine.
Application of gene Transfer in
Healthcare

ex vivo in vivo
1) purification Direct application:
of target cells
viral vectors
2) gene transfer
non-viral vector

3) re-infusion naked DNA


of modified cells
Characteristics of immunization
with DNA Vacccine
Antigenacity as in natural infection
Activation of CD8+ CTLs (antigen is
presented on MHC class I)
Can insert more than one antigen per
vector
Delivery Vectors are easily developed
Production and distribution of vectors are
easily developed
Clinical Trials
HIV-1 (env,rev,gag,pol, nef)

HSV-1 (gD,gB,ICP-27)

Preventive Malaria parasite (CSP)

Influenza A virus (HA,M1,NP)

HBV (HBsAG)

tumour vaccines (tumour-specific Ags)

Therapeutic HIV-1 (env, tat, nef, multi-


epitope)
Components of DNA Vaccine
The magnitude of CMI and humoral responses
is generally modest when DNA is used alone.
Primate studies and preliminary results of
human trials suggest that more potent
specific immune responses could be induced
by:
combining DNA with adjuvants,
boosting with a recombinant viral vector or
protein, or
by both adjuvanting and boosting.
Components of DNA Vaccine
Example:DNA vaccines developed for human
HIV vaccine trials:
DNA plasmid prime + recombinant modified vaccinia
Ankara (MVA) boost
DNA plasmid with cytokine (interleukin-2) adjuvant
DNA plasmid with nonionic blocked copolymer
adjuvant, w/wo recombinant adenovirus boost
DNA plasmid prime + recombinant fowlpox virus boost
DNA plasmid prime with cytokine (interleukin-12)
adjuvant + recombinant gp140 protein boost
DNA vaccines

Antiviral and antibacterial


Cancer immunotherapy
(traditional vaccines are better
when available)

Passive Active
to increase initiates an immune
the pre-existing immune response
response against an unrecognised
to the cancer or poorly antigenic tumor
How is a DNA Vaccine made?
DNA is isolated
-The DNA sequence which would code for a specific protein is isolated from
the genome of the infectious organism.

Eukaryotic promoter and terminator are


added
-Bacteria and viruses have different promoters for transcription than do eukaryotes.
The eukaryotic cells of a human would not respond to the promoter region from a
prokaryote. So, a eukaryotic promoter must be added so that a human cell can
begin transcription. A terminator is also necessary so that the exact sequence for
the protein is copied and nothing more.

DNA is integrated into a plasmid vector


2
Plasmid is transformed
into bacteria
-A bacteria such asE. coli can be used
and the plasmid then becomes part of
the bacterias DNA.
Bacterial growth occurs
-Many more copies of the plasmid
containing the infectious organisms
DNA must be produced, so growth of
the bacteria is necessary.
Plasmid DNA is purified
from the bacteria
-All of the other bacterial DNA and debris
are separated from the plasmid.

2
Common Vectors for Gene
Therapy
How does it work?

Plasmid vectors are injected into muscle


cells
-Muscle cells are most commonly used because they are able to take
up the plasmids more easily than most other cells.
Cells uptake the plasmid
-The plasmids with the DNA sequence inside them are accepted into
the nucleus of the muscle cells.
The gene is expressed inside the cells
-Transcription occurs and the mRNA coding for the infectious
organisms protein is created.

2
How does it work?
The infectious organisms protein is produced
Translation of the mRNA occurs and the protein is now
actively being produced in the muscle cells of the person .
The immune system responds to the foreign
protein
The immune system recognizes the proteins are incorrect
and attacks them with killer T cells and memory B cells.
A lasting immune protection is created and
maintained
Memory B cells create antibodies for the specific proteins,
and thus the person is protected from the proteins and
consequently the infectious organism itself.
DNA vaccines
Gene for antigenic protein

Vaccine plasmid Host cell

(1)
Antigenic
(2) protein

mRNA (4) Free Ag


Nucleus of
host cell Cleavage
(3)

Antigenic
Cellular Fragment MHC 1 peptide
DNA of antigenic
peptide
T cell response Humoral response
DNA for pathogen specific antigen

gene
(DNA)
I II III IV V

RNA

2
antigen
(protein)
Current attempts with naked DNA
vaccination in infectious diseases
Tuberculosis

Lyme disease
HIV
Helicobacter pylori
hepatitis B and C
Influenza Malaria
Papilloma T cells recognise liver cell
Cytomegalovirus with malarial parasite inside

Produce IFN-gamma

IFN-gamma stimulate
antigen presentation
T cells recognise liver cell
with malarial parasite inside
Important: too much IFN-gamma
is also too bad. Produce IFN-gamma
(it is pro-inflammatory)
IFN-gamma stimulate
antigen presentation
DNA Vaccines vs. Traditional Vaccines

Uses only the DNA from Uses a weakened form of


the infectious organism the actual infectious
material
Produces the proteins
that would be created by Allows for the infectious
the infectious organism organism to actually
invade cells in the body
Avoids the risks of using
the actual infectious Creates possible risk of the
organism vaccine being fatal
Creates a lasting immune Infectious organism could
response possibly revert to the wild-
type form
Lower cost, easy to
manage and use Creates an immune
response that may vary in
effectiveness depending on
the person 1&3
Nature of Immune Response

In
contrast to conventional
vaccines, DNA vaccines elicit cell-
mediated as well as antibody-
mediated immune responses.
The cell-mediated response
The plasmid is taken up by an antigen-
presenting cell (APC) like a dendritic cell.
The gene(s) encoding the various components
are transcribed and translated.
The protein products are degraded into
peptides.
These are exposed at the cell surface nestled in
MHC class I molecules where they serve as a
powerful stimulant for the development of cell-
mediated immunity.
The antibody-mediated response
If the plasmid is taken up by other cells (e.g.
muscle cells),
the proteins synthesized are released and can
be engulfed by antigen-presenting cells
(including B cells).
In this case, the proteins are degraded in the
MHC class II pathway and presented to helper T
cells.
These secrete lymphokines that aid B cells to
produce antibodies [View].
Safety Problem
tumor induction
due to chromosomal integration
tolerance
due to long-term presentation of antigen
adverse reactions and immunopathology
due to co-administration of cytokine and/or immun
stimulatory genes
auto-immune reactions
correlated with the induction of anti-DNA antibodies
biologic activity (apart from immunogenicity)
of the expressed antigen
The Long and Winding
Road to an AIDS
Vaccine
Adults and children estimated to be
living with HIV as of end 2004
Western & Central Eastern Europe
Europe & Central Asia
North America 610 000 1.4 million
1.0 million [480 000 760 000] [920 000 2.1 million] East Asia
[540 000 1.6 million] 1.1 million
Caribbean North Africa & Middle East [560 000 1.8 million]
440 000 540 000
[230 000 1.5 million] South & South-East Asia
[270 000 780 000]
7.1 million
Sub-Saharan Africa [4.4 10.6 million]
Latin America 25.4 million Oceania
1.7 million [23.4 28.4 million]
35 000
[1.3 2.2 million]
[25 000 48 000]

Total: 39.4 (35.9 44.3)


million
DNA Vaccines and HIV
HIV could be prevented using DNA Vaccines
-By isolating the gene for a protein produced by HIV, a DNA
Vaccine could be created and immunity for the protein and
thus HIV, could be established.
Many experiments have been done
-Researchers have attempted to create many varying DNA
Vaccines, but none have been entirely successful in humans .
Envelope gene
-A specific gene of HIV that could be used to create a DNA
Vaccine for HIV.

4
AIDS Vaccine Approaches
Recombinant subunit
vaccines
Poxviruses
Adenoviruses
DNA vaccines
Whole inactivated HIV
Peptide-based vaccines
Live attenuated HIV
Steps in the Development of an
AIDS Vaccine
Design of candidate vaccine
Which HIV proteins?
How to deliver?
Testing of immune responses
Mice & rabbits>Monkeys
Efficacy testing
Key role of nonhuman primate studies
Human clinical trials
Phase I>Phase IIPhase III
Delivery path
FDA, WHO, Financing, Infrastructure and
immunization
Lessons learned from
Macaque AIDS Vaccine
Studies
Ability of live attenuated SIV vaccines to
provide potent protection against challenge
Difficulty in inducing sterile protection
against SIV
Importance of CD8+ T lymphocyte
responses in controlling SIV replication
Lack of efficacy of standard envelope
vaccines in inducing protection against SIV
Lessons learned from
Macaque AIDS Vaccine
Studies
Improved efficacy of combination SIV
vaccines in inducing protection against
SIV challenge
Ability of live attenuated AIDS vaccines
to cause disease
Preclinical studies of
safety/immunogenicity of recombinant
adenovirus vaccines
Human Clinical Trials
Phase I
Initial safety trials, also provides info on immune responses
10-30 volunteers
8-12 months for completion
Phase II
Provide expanded information on safety and immunogenicity
50-500 volunteers, generally including at-risk-populations
18-24 months
Phase III
Definitive tests of vaccine efficacy in at-risk-populations
5,000-10,000 volunteers
36 months
Human Clinical Trials of AIDS
Vaccines
Phase I (n>70) Phase II (n=5) Phase III (n=3)

Adenoassociated virus (AAV) Adenovirus gp120


Adenovirus Gag (Merck) ALVAC/rgp12
Adeno + ALVAC boost
ALVAC/rgp120 0
ALVAC
Gag/Pol/Env
DNA
(Aventis/Vaxgen)
DNA+MVA
DNA + MVA
Lipopeptides
Gag (IAVI/KAVI/MRC)
Modified vaccinia Ankara
(MVA)
Recombinant protein
(subunit)
Vaccinia
Venezulan Encephalitis
Virus (VEE)
Goals of an HIV Vaccine
Sterile protection
Difficult to achieve
Most viral vaccines protect against disease not infection
Delay in disease progression
Most realistic goal
Escape from immune responses likely over time
What will effect on transmission be?
increased survival or
increased risk behavior may increase transmission rates
Decrease transmission rates
Results of Phase III Vaxgen
Trials
North America Thai
Vaccine gp120B/B
Population NAmMSM/women gp120B/D
Power 30%efficacy ThaiIVDU
Subjects 5403 30%efficacy
Vaccine/Placebo 2:1 2546
Infectionrate 1:1
Vaccine 6.7% 9.1%
Placebo 7.1% 9.1%

No evidence for vaccine efficacy in either trial


Financial Considerations
for AIDS Vaccine
Development
Cost
of vaccine development is
enormous
$100 to $800 million
Riskbenefit ratios of vaccines
different from those of therapeutics
Who will pay?
What will we do with a partially
effective AIDS vaccine?

Effectiveness may vary depending on


Genetic subtype of vaccine
Geographic area
Sex
Small protective effect may be offset by
increases in risk-taking behavior
Hope for the Future

Vaccines more effective in inducing CTL


responses now in phase IIB trials

Approaches to address sequence diversity

Strategies to improve induction of


neutralizing antibodies
Vaccines more effective in
inducing CTL responses
currently under evaluation*
Merck (Merck 018/HVTN 050)
Adenovirus vector Clade B Gag
International trial with 5 sites, 435 patients
IAVI/MRCPhase I/II
DNA vaccineGag +CTL epitopes with MVA boost
United Kingdom/Kenya/Uganda
Vaccine Research Center (VRC)Phase I
DNA vaccineClade B Gag, A, B & C Env
NIH VRC & HVTN Uganda
phase III results not likely until 2007-2009

*For full listing see www.iavi.org


Influenza Vaccines for pre-
pandemic uses

FluBlk: A
Recombinant
Hemagglutinin
Protein Vaccine for
Influenza

Manon Cox

VRBPAC
February 27, 2007 A Vaccine Company for the 21st Century

Making products where speed, cost and safety matters


FluBlk - Next Generation
Vaccine for Influenza

Trivalent recombinant HA (rHA) antigen


vaccine
Produced in vitro via insect cell culture
technology
Cloned from WHO/CDC recommended strains
Easier to produce, no eggs, no live viruses, no
bio-containment required, no preservatives
FluBlk - Next Generation Vaccine
for Influenza

FluBlk rHA Antigens:


Highly purified (>95%)
Correct 3-D structure
Biologically active
Hemagglutinin activity
Induces protective immune responses
HAI antibodies
Neutralizing antibodies
Year Strain Impact+ Location
1997 H5N1 18 (6) Hong Kong
1998 H9N2 5 China
1999 H9N2 2 Hong Kong
2002 H7N2 1 US Virginia
2003 H5N1 4 (4) Asia
H7N7 89 (1) Netherlands
H9N2 1 Hong Kong
2004 H5N1 46 (32) Asia
H7N3 2 Canada
2005 H5N1 97 (42) Asia
2006 H5N1 114 (79) Asia/Middle
East/ Africa?
FluBlk Phase II/III Field Study
Commercial dose
Efficacy: 100% (even against drifted H3 strain)
Effectiveness:
54% reduction (p 0.05) in CDC-ILI vs. placebo
Efficacious and effective without neuraminidase
Highly immunogenic
H3 component - high and long lasting titers
Protective levels for all antigens for at least 6 months
FluBlk protects against drifted strains
Challenges
Introducing new vaccines
Establishing and maintaining a
steady vaccine supply
Vaccine financing
Reducing remaining racial/ethnic
disparities in coverage
Addressing unfounded fears about
vaccine safety
Estimated Vaccination Coverage* Among Children
19-35 Months of Age by Race/Ethnicity US,
National Immunization Survey, 2000-2004
4:3:1:3:3

* Estimate=NA (Not Available) if the unweighted sample size for the numerator was <30 or (CI half width)/Estimate >0.5 or (CI half width)>10
Self-reported by respondent. Individual racial groups do not include Hispanic children. Children of Hispanic ethnicity may be of any race
4 or more doses of DTP, 3 or more doses of poliovirus vaccine, 1 or more doses of any MCV, 3 or more doses of Hib, and 3 or more doses of HepB
Children Receiving Autism Services
by Quarter, California, 2002-2005

California Department of Developmental Services


Estimated Vaccination Coverage with Individual
Vaccines Among Children 19-35 Months of Age,
National Immunization Survey, 2002 & 2003
2000 2001 2002 2003 2004
Vaccine % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)

DTP/DT/DTaP
3 doses 94.1 (0.5) 94.3 (0.5) 94.9 (0.6) 96.0 (0.5) 95.9 (0.5)
4 doses 81.7 (0.8) 82.1 (0.8) 81.6 (0.9) 84.8 (0.8) 85.5 (0.8)
Poliovirus 89.5 (0.6) 89.4 (0.7) 90.2 (0.7) 91.6 (0.7) 91.6 (0.7)

Hib 3 doses 93.4 (0.5) 93.0 (0.6) 93.1 (0.6) 93.9 (0.6) 93.5 (0.6)

MMR 1 dose 90.5 (0.6) 91.4 (0.6) 91.6 (0.7) 93.0 (0.6) 93.0 (0.6)
Hepatitis B 3
90.3 (0.6) 88.9 (0.7) 89.9 (0.7) 92.4 (0.6) 92.4 (0.6)
doses
Varicella 1 dose 67.8 (0.9) 76.3 (0.8) 80.6 (0.9) 84.8 (0.8) 87.5 (0.7)

PCV
3 doses -- -- 40.8 (1.1) 68.1 (1.0) 73.2 (1.0)
4 doses -- -- -- 35.8 (1.0) 43.4 (1.1)
New Approach

Vaccine production:
Viral or bacterial genes inserted into
plant chromosomes to make transgenic
plants or transgenic animals.
Products can be harvested or the
plant can be used as foods