Vaccines against epidemic and pandemic influenza

BACKGROUND: Preventative vaccination is the most effective way to control epidemic and, perhaps, pandemic influenza viral infections. However, the immunogenicity and efficacy of influenza vaccines against epidemic strains are suboptimal among older adults. The risk of serious complications from influenza viral infection is compounded by co-morbid conditions among older adults. Furthermore, despite annual influenza vaccination campaigns, the vaccination rates in high risk populations range from 60.5 - 79.2% only [1] . In addition, H5N1 avian influenza viruses have the potential to cause a pandemic. However, H5N1 vaccines currently licensed in the US are poorly immunogenic in high doses in the absence of an adjuvant even in healthy adults. OBJECTIVES: In this review, we address the current status of vaccines against epidemic and avian influenza viruses of pandemic potential. METHODS: We have limited the review to the discussion of technologies and strategies that have progressed to human clinical trials and/or licensure for seasonal and pandemic influenza. RESULTS/CONCLUSION: Improving the immunogenicity of vaccines against avian influenza viruses, as well as aggressive programs to vaccinate high risk populations against seasonal and pandemic influenza, are crucial for our public health efforts in minimizing the impact of influenza epidemics or pandemics.     

Nasal delivery of H5N1 avian influenza vaccine formulated with GenJet™ or in vivo-jetPEI® induces enhanced serological,cellular and protective immune responses

Avian influenza virus infection is a serious public health threat and preventive vaccination is the most cost-effective public health intervention strategy. Unfortunately, currently available unadjuvanted avian influenza vaccines are poorly immunogenic and alternative vaccine formulations and delivery strategies are in urgent need to reduce the high risk of avian influenza pandemics. Cationic polymers have been widely used as vectors for gene delivery in vitro and in vivo. In this study, we formulated H5N1 influenza vaccines with GenJet? or in vivo-jetPEI^®, and showed that these formulations significantly enhanced the immunogenicity of H5N1 vaccines and conferred protective immunity in a mouse model. Detailed analyses of adaptive immune responses revealed that both formulations induced mixed T_H1/T_H2 antigen-specific CD4 T-cell responses, antigen-specific cytotoxic CD8 T-cell and memory B-cell responses. Our findings suggest that cationic polymers merit future development as potential adjuvants for mucosal delivery of poorly immunogenic vaccines.     

Microneedle delivery of trivalent influenza vaccine to the skin induces long-term cross-protection

A painless self-immunization method with effective and broad cross-protection is urgently needed to prevent infections against newly emerging influenza viruses. In this study, we investigated the cross-protection efficacy of trivalent influenza vaccine containing inactivated A/PR/8/34 (H1N1), A/Hong Kong/68 (H3N2) and B/Lee/40 after skin vaccination using microneedle patches coated with this vaccine. Microneedle vaccination of mice in the skin provided 100% protection against lethal challenges with heterologous pandemic strain influenza A/California/04/09, heterogeneous A/Philippines/2/82 and B/Victoria/287 viruses 8 months after boost immunization. Cross-reactive serum IgG antibody responses against heterologous influenza viruses A/California/04/09, A/Philippines/2/82 and B/Victoria/287 were induced at high levels. Hemagglutination inhibition titers were also maintained at high levels against these heterogeneous viruses. Microneedle vaccination induced substantial levels of cross-reactive IgG antibody responses in the lung and cellular immune responses, as well as cross-reactive antibody-secreting plasma cells in the spleen. Viral loads in the lung were significantly (p?<?0.05) reduced. All mice survived after viral challenges. These results indicate that skin vaccination with trivalent vaccine using a microneedle array could provide protection against seasonal epidemic or new pandemic strain of influenza viruses.     

Should expectant mothers be vaccinated against flu? A safety review

Introduction: Pregnant women have a higher risk of serious complications from influenza than non-pregnant women of reproductive age. This increased risk has been noted both during pandemic and inter-pandemic influenza seasons. However, although vaccination against flu is recommended at any trimesters by international and national policies, vaccine coverage remains low in pregnant women, possibly due to patient and healthcare providers’ concern about the safety of the vaccine.

Areas covered: This review addresses the effectiveness and safety of seasonal and adjuvanted and non-adjuvanted pandemic 2009 A/H1N1 influenza vaccine.

Expert opinion: Available data suggest no evidence of an increased risk for any adverse event for both mothers and fetuses after vaccination against flu during pregnancy. These results are important when considering the potential of maternal immunization against flu as a public health intervention to protect both the mother and her infant against serious infectious disease.     

上海地区在校中学生接种甲型H1N1流感疫苗前后抗体水平监测分析

 目的  了解上海地区在校中学生接种甲型H1N1流感疫苗前后的抗体水平;观察甲型H1N1流感疫苗对该人群的免疫保护作用。 方法    应用常规微量血凝抑制试验（micro-hemagglutination inhibition test, HIT）对上海地区在校中学生分3个时间段进行甲型H1N1流感病毒抗体的血清学监测,3个时间段的抗体阳性率比较采用Pearson χ2 检验进行分析。 结果  2009年甲型H1N1流感流行前上海地区在校中学生的血清抗体阳性率仅为1.3%。经过一段时间流行后,血清抗体阳性率升至8.5%。接种甲型H1N1流感疫苗后,血清抗体阳性率升至87.3%。经Pearson χ² 检验分析,3个时间段在校中学生的血清甲型H1N1流感抗体阳性率差异有统计学意义（χ²=243.7,P<0.05）。 结论  在甲型H1N1流感流行前,上海地区在校中学生对其几乎没有免疫力,接种甲型H1N1流感疫苗能为该人群提供较好的免疫保护作用。     

Type II transmembrane serine proteases as potential target for anti-influenza drug discovery

Introduction: The outbreak of an influenza pandemic as well as the continued circulation of seasonal influenza highlights the need for effective antiviral therapies. The emergence of drug-resistant strains further necessitates the development of novel antivirals that target the host factors crucial for viral replication.

Area covered: This review summarizes the current understanding of the structural and functional properties of type II transmembrane serine proteases (TTSPs) as a proteolytic activator of influenza virus infection and discusses their potential as antiviral targets. It also explores the experimental evidence accumulated for inhibitors of TTSPs as novel, broad-spectrum antivirals against various influenza virus subtypes. The review also provides an overview of the properties of small molecules, proteins, and peptides that efficiently inhibit the proteolytic activation of the influenza virus.

Expert opinion: TTSPs activate a wide range of influenza virus subtypes including avian influenza viruses, both in vitro and in vivo, via proteolytic cleavage of influenza hemagglutinin (HA) into infection-competent fusogenic conformation. Other viruses such as SARS-, MERS-coronaviruses and human metapneumoviruses may use the same host cell proteases for activation, implying that TTSP inhibition might be a novel strategy for developing broad-spectrum antiviral agents for respiratory viral infections.     

Grippe A (H1N1) 2009. Revue générale

Influenza A(H1N1) 2009 is an acute contagious respiratory infection caused by influenza A virus subtype H1N1 appeared in 2009 and responsible for a pandemic. The new virus, different from the avian virus H5N1, is a variant containing genes from several known viruses from porcine, avian and human origin. Appeared originally in the northern hemisphere, the epidemic wave reached early most countries, and up to 24% of the population in metropolitan France. It is characterized by a low mortality estimated at 0.04 to 0.2%, and by a benign, or even asymptomatic presentation. However, more severe clinical expression has been observed in some subgroups, carrying or not risk factors (young, pregnant women). The preexisting immunity in a significant proportion of the population, the remarkable stability of the virus, determination of early antigenic characteristics of the virus, the development and rapid availability of suitable vaccines, the efficacy of antiviral drugs, and health care system contributed to the control the morbidity and mortality of the first pandemic wave. Other virological, clinical and epidemiological investigations, are needed to identify all potential risk factors for severity and determine the role of mutation and the diffusion of pandemic and seasonal viruses, which may alter the virulence and transmissibility of influenza A(H1N1)v 2009.     

Long-lasting protective immunity against H7N9 infection is induced by intramuscular or CpG-adjuvanted intranasal immunization with the split H7N9 vaccine

There is an urgent need for efficient vaccines against the highly pathogenic avian influenza A viral strain H7N9. The duration and intensity of the immune response to H7N9 critically impacts the epidemiology of influenza viral infection at the population level. However, the insufficient immunogenicity of H7N9 raises concerns about vaccine efficacy. In this study, we evaluated the impact of immunization routes and the adjuvant CpG on the immune response to a split H7N9 vaccine in mice. Determination of humoral and cellular responses to the vaccine revealed that after four vaccine doses, high titers of H7N9-specific serum IgG, determined by the influenza hemagglutination inhibition (HI) assay, were induced through the intramuscular (i.m.) route and lasted for at least 40 weeks. CpG-adjuvanted immunization increased the levels of long-lived IFN-γ⁺ T cells and raised the Th1-biased IgG2a/IgG1 response ratio. In addition, aside from mucosal IgA, CpG-adjuvanted intranasal (i.n.) immunization elicited serum IgG and cellular responses of a similar duration and intensity to CpG-adjuvanted i.m. immunization. Mouse challenge assays demonstrated that 24 weeks following i.m. immunization without CpG or CpG-adjuvanted immunization through the i.m. or i.n. routes, both offered a high level of protection against H7N9 infection. These results indicate that efficient long-term protection against H7N9 can be achieved via the optimization of vaccination strategies, such as immunization doses, routes, and adjuvants.     

MF59 adjuvanted seasonal and pandemic influenza vaccines

MF59-adjuvanted seasonal trivalent inactivated (ATIV) vaccine licensed since 1997 and MF59-adjuvanted pandemic H1N1 vaccines have been distributed to approximately 80M persons. Addition of the emulsion adjuvant to inactivated vaccine formulations provides for higher levels of antibody to the viral hemagglutinin (HA) in less responsive older adults, infants and children which, in the case of the pandemic vaccine, allowed only 3.75 μg of the HA to be immunogenic. The adjuvant also stimulates production of more broadly-reactive antibodies against strains that are mismatched to those in the vaccine, a potential advantage in the face of perennial influenza virus antigenic drift. In a field trial, ATIV was 89% efficacious in preventing laboratory-confirmed influenza in 6-<72 month old children, 81% more efficacious than the unadjuvanted control split vaccine while, in older adults, ATIV reduced community-acquired pneumonia and influenza hospitalizations in adults >65 years old by 23% compared to unadjuvanted vaccine, in an observational study. The effectiveness of MF59 adjuvanted split pandemic H1N1 vaccine was 74% overall. Unadjuvanted pandemic vaccine was poorly immunogenic in HIV-infected persons, whereas their responses to MF59-adjuvanted vaccine were similar to those of healthy controls. Analyses of the clinical trials and pharmacovigilance databases and observational studies have shown that while MF59-adjuvanted influenza vaccines are more locally reactogenic, they have not been associated with an increased risk for various adverse effects (AE) of special interest, including unsolicited neurological or autoimmune events.     

Therapeutic targeting of adenosine receptors in inflammatory diseases

A novel H7N9 avian influenza A virus (IAV) emerged in China in early 2013 causing > 450 cases of respiratory illness and 175 deaths within a 20-month period. Though avian viruses infect humans infrequently, the lack of human immunity to these viruses raises the possibility of a pandemic if they were to acquire the ability to transmit efficiently. Despite the fact that IAV pathogenicity results from the cytopathic effects and tissue damage caused by both viral replication and an overly robust immune response, current IAV therapeutics only target the viral proteins. This has led to the emergence of drug resistance due to the high mutation rates of viruses. The growing obsolescence of our current influenza therapeutics underscores the need for alternative treatment strategies. One promising area of research is the use of drugs that target the host response to IAV infection. This article describes how gene expression profiling can be used to predict drugs that reverse the destructive effects of the host response to H7N9 and other pathogenic influenza viruses.     

A/H5N1 prepandemic influenza vaccine (whole virion, vero cell-derived, inactivated) [Vepacel®

The influenza A subtype H5N1 virus is a likely causative agent for the next human influenza pandemic. Pandemic influenza vaccine production can begin only after a novel pandemic virus emerges. Cell-based vaccine production has advantages over conventional egg-based methods, allowing more rapid large-scale vaccine production. A reliable Vero cell culture system is available for pandemic and prepandemic influenza vaccine production. Prepandemic influenza vaccines are an important component of influenza pandemic preparedness plans, as their targeted use in the pandemic alert period or early in a pandemic is likely to mitigate the consequences of an influenza outbreak. Vepacel? is a prepandemic influenza vaccine (whole virion, Vero cell-derived, inactivated) containing antigen of H5N1 strain A/Vietnam/1203/2004 and is approved for use in the EU. Clinical immunogenicity studies with the vaccine have demonstrated good rates of functional neutralizing antibody responses against the vaccine strain (A/Vietnam/1203/2004), meeting established immunogenicity criteria for seasonal influenza vaccines, and cross-reactivity against H5N1 strains from other clades. In phase I/II and III studies, a heterologous (A/Indonesia/05/2005) booster vaccine administered to healthy adult and elderly volunteers 6-24 months after the two-dose priming vaccine (A/Vietnam/1203/2004) regimen induced good immunogenic responses against both H5N1 strains, demonstrating strong immunological memory. Broadly similar, albeit less robust, responses were observed in two special risk cohorts of immunocompromised and chronically ill patients. In general, adverse events observed in clinical immunogenicity studies with H5N1 vaccine (A/Vietnam/1203/2004) were similar to those reported with non-adjuvanted, inactivated, seasonal influenza vaccines.     

Oseltamivir for treatment and prophylaxis of influenza infection

Background: Influenza infection is a global problem affecting millions of people worldwide, despite efficacious vaccines. Treatment and prophylaxis against influenza have been successful using antiviral medications such as adamantanes and neuraminidase inhibitors. Objective: To review the antiviral agents and specifically the neuraminidase inhibitor, oseltamivir, for use in treatment and prophylaxis of influenza infection. Methods: This review focuses on published literature regarding the clinical use of oseltamivir, as well as discussing emerging threats such as avian influenza, antiviral resistance, and strategies such as combination antiviral treatment to mitigate these threats. Results: Oseltamivir is effective in reducing symptom burden in those with influenza A or B infection, and is preventative against developing infection after exposure. Emergence of naturally occurring or post-treatment oseltamivir-resistant influenza as well as an avian influenza pandemic may limit its future use as a monotherapeutic antiviral treatment agent.     

Recent Patents on development of nucleic acid-based antiviral drugs against seasonal and pandemic influenza virus infections

Influenza viruses are etiological agents of deadly flu that continue to pose global health threats, and have caused global pandemics that killed millions of people worldwide. The global crisis involving the avian H5N1 influenza provides compelling reasons to accelerate fast track development of novel antiviral drugs against the potential pandemic virus. The availability of neuraminidase inhibitors such as oseltamivir (tamiflu) improves our ability to defend against influenza viruses, but the incidences of tamiflu-resistance are rising rapidly. Nucleic acid-based antiviral drugs are promising classes of experimental antiviral drugs that have been shown in pre-clinical studies to be effective against seasonal and avian influenza viruses. The potency and versatility of these drugs make them potential candidates to be used in seasonal and pandemic influenza scenarios. The review will assess the recent patents, research and development of antisense oligonucleotides, small interfering RNA, immunomodulating RNA for the prevention and treatment of influenza infection.     

Vaccination antigrippe A (H1N1) : analyse rétrospective 2009

The occurrence of the influenza A (H1N1) pandemic was the opportunity to set an appropriate vaccination campaign, effective and well tolerated within the shortest period of time. Thanks to a strong experience in the development of seasonal influenza vaccines and recent experimental knowledge on potential vaccines against H5N1 strain, pharmaceutical companies developed a new vaccine suited for the pandemic A H1N1 California July 2009 strain. This vaccine was produced with and without adjuvant, taking into account safety controls and evolution of scientific knowledge. Nevertheless, this campaign got a poor reception from the general and medical population due to the concomitant spread of the pandemics, an insufficient communication program, organization that was felt as unsuited, too complex and not well understood. Despite that, effectiveness and tolerance of the vaccination campaign have been observed with may be a positive effect on the epidemic.     

基于流感病毒保守抗原的广谱流感疫苗研究进展

流感是由流感病毒感染引起的严重急性呼吸道传染病,接种流感疫苗是预防流感最经济、安全且有效的措施。目前广泛应用的传统流感疫苗的保护效果受到疫苗株与流行株表面抗原匹配程度的明显影响,难以有效应对因流感病毒发生抗原漂移或抗原转换而产生的无法预料的流行或大流行。因而开发能够诱导广谱和持久免疫的广谱流感疫苗是新型流感疫苗研发的重要方向。流感病毒基质、核蛋白和血凝素茎部结构域作为流感病毒的保守抗原,是当前广谱流感疫苗的主要靶抗原。此文就近年来基于流感病毒保守抗原的广谱流感疫苗的抗原选择、免疫保护制剂、临床研究进展做一综述。     

Inactivated influenza vaccines: recent progress and implications for the elderly

The current public health strategy for the containment of influenza is annual vaccination, which is recommended for the elderly and for those in risk factor categories that present the highest morbidity and mortality. However, because the immune response in the elderly is known to be less vigorous than in younger adults, research in the last decade has focused on improving the immune response to vaccination and increasing the protection of aged populations. The decreased efficacy of vaccines in the elderly is due to several factors, such as a decrease in the number of Langerhans cells, the limited capacity of dendritic cells to present antigen, defects in the expression of Toll-like receptors and the reduced expression of MHC class I and II molecules. Also, production of mature naive T cells by the thymus decreases with age. Among several approaches proposed to address the need for more immunogenic vaccines compared with conventional agents, the most well proven is the use of adjuvants. The first licensed adjuvant, aluminium-based mineral salts (alum), introduced in the 1920s, remains the standard worldwide adjuvant for human use and it has been widely used for almost a century. However, the addition of alum adjuvant to a split or subunit influenza vaccine has induced only marginal improvements. Other adjuvants have been developed and approved for human use since 1997; in particular, MF59, an oil-in-water adjuvant emulsion of squalene, which is able to increase immunogenicity of seasonal, pre-pandemic and pandemic subunit vaccines while maintaining acceptable safety and tolerability profiles. More recently, another oil-in-water emulsion, AS03, has been approved as a component of pre-pandemic H5N1 and pandemic H1N1 2009 vaccines. Besides adjuvants, several other strategies have been assessed to enhance antibody response in the elderly and other less responsive subjects, such as high-dose antigen vaccines, carrier systems (liposomes/virosomes) and the intradermal route of immunization. In particular, the potential of intradermal vaccination is well documented and the recent availability of an appropriate injection system, which combines simplicity, safety and ease of use, has allowed evaluation of the tolerability, safety and immunogenicity of the intradermal influenza vaccine in large numbers of subjects. Data that emerged from large clinical trials showed an improved immunogenicity compared with that of standard vaccine. Observational studies or comparisons between adjuvanted, intradermal or high-dose versus conventional vaccines are needed to evaluate whether the greater immunogenicity observed in a number of recent studies is correlated with greater protection against influenza and influenza-related complications and death.     

季节性流感疫苗接种对大流行流感的影响研究

加拿大研究发现,季节性流感疫苗接种增加2009年大流行甲型流感(H1N1)感染的危险性,而澳大利亚研究未能证实这个发现.雪貂实验结果表明,以前的季节性流感感染能防御大流行甲型流感(H1N1),但以前的季节性流感疫苗接种则不能.模型研究显示,流感感染可导致对不同亚型的暂时性免疫.这些观察可以解释加拿大和澳大利亚的不一致发...     

Progress in structure-based drug design against influenza A virus

Introduction: The 2009-H1N1 influenza pandemic has prompted new global efforts to develop new drugs and drug design techniques to combat influenza viruses. While there have been a number of attempts to provide drugs to treat influenza, drug resistance has been a major problem with only four drugs currently approved by the FDA for its treatment.

Areas covered: In this review, the drug-resistant problem of influenza A viruses is discussed and summarized. The article also introduces the experimental and computational structures of drug targeting proteins, neuraminidases, and of the M2 proton channel. Furthermore, the article illustrates the latest drug candidates and techniques of computer-aided drug design with examples of their application, including virtual in silico screening and scoring, AutoDock and evolutionary technique AutoGrow.

Expert opinion: Structure-based drug design is the inventive process for finding new drugs based on the structural knowledge of the biological target. Computer-aided drug design strategies and techniques will make drug discovery more effective and economical. It is anticipated that the recent advances in structure-based drug design techniques will greatly help scientists to develop more powerful and specific drugs to fight the next generation of influenza viruses.     

Antiviral activity of the MEK-inhibitor U0126 against pandemic H1N1v and highly pathogenic avian influenza virus in vitro and in vivo

The emergence of the 2009 H1N1 pandemic swine influenza A virus is a good example of how this viral infection can impact health systems around the world in a very short time. The continuous zoonotic circulation and reassortment potential of influenza A viruses (IAV) in nature represents an enormous public health threat to humans. Beside vaccination antivirals are needed to efficiently control spreading of the disease. In the present work we investigated whether the MEK inhibitor U0126, targeting the intracellular Raf/MEK/ERK signaling pathway, is able to suppress propagation of the 2009 pandemic IV H1N1v (v = variant) as well as highly pathogenic avian influenza viruses (HPAIV) in cell culture and also in vivo in the mouse lung. U0126 showed antiviral activity in cell culture against all tested IAV strains including oseltamivir resistant variants. Furthermore, we were able to demonstrate that treatment of mice with U0126 via the aerosol route led to (i) inhibition of MEK activation in the lung (ii) reduction of progeny IAV titers compared to untreated controls (iii) protection of IAV infected mice against a 100× lethal viral challenge. Moreover, no adverse effects of U0126 were found in cell culture or in the mouse. Thus, we conclude that U0126, by inhibiting the cellular target MEK, has an antiviral potential not only in vitro in cell culture, but also in vivo in the mouse model.     

大流行流感疫苗研发和质量管理中一些问题的探讨

季节性流感疫苗是公认的预防流行性感冒的有力武器,主要预防人流感病毒同型变异株造成的流行和感染.而大流行流感通常由新的流感病毒亚型引起,因此,大流行流感疫苗是一种全新的预防性疫苗.比较季节性流感和大流行流感的产生原因,进而从毒种制备、生产基质、抗原含量、佐剂、免疫效果评价、质控方法、生物安全等各个方面阐述大流行流感疫苗研制中面临的技术问题,同时介绍国外在质量管理方面的技术法规.