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The Revised Authoritative Guide To Vaccine Legal Exemptions

Comprehensive, authoritative information about vaccine exemptions you can trust, from Alan Phillips, J.D., a leading vaccine rights attorney with years of experience helping clients throughout the U.S. legally avoid vaccines in a wide variety of vaccine-refusal settings. Critical details for parents, students, immigrants, healthcare employees, military personnel and contractors, agencies, attorneys and clientsvirtually anyone concerned with legally avoiding vaccines in the United States. This Guide provides and explains: Important background information about the legal system; How state and federal statutes, regulations, constitutions and legal precedent interact to define the boundaries of your legal exemption rights; How to deal with local authorities and to avoid mistakes that cost others their exemption; Where legal technicalities and practical reality differand what to do about it; More here...

The Revised Authoritative Guide To Vaccine Legal Exemptions Overview

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Selection of Vaccine Adjuvant Candidates for Clinical Trial

The decision to begin human trials of vaccines and adjuvanted vaccines is complex and depends on a number of criteria (85). 1. The vaccine adjuvant candidate must address a public health need, and it must be a logical means to prevent or treat the disease of interest. 2. The vaccine adjuvant must have been designed with a sound scientific rationale. 5. The vaccine adjuvant should be prepared in a practical formulation for phase 1 studies, if possible. Response to a pilot vaccine adjuvant formulation can change after manufacturing scale up or after a more practical formulation is introduced. 6. Unless subsidized by the government, clinical development of a new vaccine adjuvant formulation must attract industrial funding. A company is unlikely to enter into expensive commercial development unless the vaccine adjuvant formulation is protected by worldwide patent or commercial license.

Clinical Framework Required for Trials of Vaccines and Vaccine Adjuvant Formulations

The successful clinical development of a vaccine depends upon an number of clinical components or principles (85,87). Most of these principles are shared by vaccine-adjuvant formulations. They include 2. Inpatient and outpatient facilities for testing vaccines in volunteers, The steps along the clinical development route leading to the use of a licensed vaccine by the public has been nicely summarized by Davenport (87).

Comparative Vaccine Adjuvant Trials 111 Animal Studies

Such comparison trials, adjuvant choice may depend upon other factors. These include cost, commercial availability, reactogenicity, mode of action, and induction of the desired arm of the immune response. Nevertheless, results of comparative trials may fail to identify the best adjuvant or adjuvants. For example, two comparative trials of simian immunodeficiency virus (SIV) vaccines combined with different adjuvants were conducted in macaques (84,89). The results were disappointing in that the mechanism of immunity could not be clearly delineated, and the large number of primates (80 and 98 animals) was still insufficient to allow meaningful statistical comparison of protection between all adjuvant groups.

Induction of Allergy to Nonvaccine or Food Proteins

This is a particularly important test when examining the suitability of an adjuvant for inclusion in an oral vaccine, as there could be a reaction to food proteins (23). With the interest in the oral route as a means of stimulating mucosal immunity, there is a possibility that an adjuvant could induce an allergic response to dietary proteins. In this study, both lactalbumin and gluten failed to elicit an IgE response in the presence of the original Freund's Complete or Incomplete Adjuvants (FCA or FIA) in HAM1 CR mice or Dunkin Hartley guinea pigs. On the other hand, the guinea pigs showed increased IgE production after oral administration of ovalbumin or soy bean protein, both unusual proteins in their normal pellet diet. Such tests are valid only if all of the previous toxicity tests are negative. Ulcerative Freund's Complete Adjuvant (NUFCA) which contains BCG vaccine BP, BNF intradermal (see Note 3). The BCG vaccine for sc injection should not be used as this will cause local...

Vaccine Formulations and Delivery

The ideal attributes for a vaccine are (1) safe for all ages (2) effective, long-lasting immunity (3) requires only a single, or two closely spaced, immunizations (4) provides protection within 2 weeks (5) can be delivered without need of a needle and syringe (6) may be administered in a formulation with other vaccines (7) is stable at high and low temperatures and (8) is inexpensive to produce.63 The initial era of vaccine development was based on the use of killed or attenuated whole organisms as immunogens. Usually these produced reasonable immune responses because of their recruitment of innate immunity, but in some cases they are associated with adverse reactions. Examples of adverse reactions would include the encephalopathic responses to the older formulations of killed Bordetella pertussis vaccine and the allergy to contaminating egg protein of influenza vaccine, which is produced by growing the virus in chicken eggs. To avoid such issues, many newer vaccines use purified...

Alum Precipitated Vaccines

Alum-precipitated vaccines are prepared by in situ precipitation of vaccine antigens with potassium or sodium alum. These antigens are usually in culture medium, employed for growing the organisms, containing anions (phosphate, sulphate, and bicarbonate ions). This is the original method developed primarily for purifying tetanus and diphtheria toxoids (8,15,20). Alum-precipitated toxoids, prepared in this way, were more immunogenic than the soluble formulations and contained a mixture of aluminum compounds, mainly aluminum phosphate and aluminum hydroxide. This product was highly heterogeneous (4) and difficult to manufacture in a consistent and reproducible manner (8,9,12). In 1976, a World Health Organization report (21) described this method as a laboratory procedure which did not define the nature of the material obtained either quantitatively or qualitatively. For these reasons, this product is not very common now. However, this method can be used to prepare aluminum phosphate,...

Vaccine Candidate Selection and Expression

The development of recombinant vaccines against clostridial neurotoxins was pioneered by Helting and Nau52 and Fairweather and colleagues53 using tetanus toxin (TeNT) as the model. They were the first to show that a C-terminal fragment of the TeNT heavy chain, referred to as the fragment C region, was able to protect mice from active challenge with tetanus toxin. The high sequence and structural homology between TeNT and BoNT led scientists at USAMRIID to take a similar approach for BoNT recombinant vaccines. Several overlapping domains of the DNA sequence encoding the heavy chain of BoNT A were isolated by PCR from the C. botulinum NCTC2916 strain. Expression and purification from Escherichia coli indicated that the most promising vaccine candidate encompassed the approximately 50-kDa domain from the C-terminus of the heavy chain (Hc), crude extracts of which were able to protect mice against BoNT challenge.53 54 This suggested that the domain chosen was folding correctly, thus...

MMR and Separate Vaccines

Common side effects of the MMR include a sore arm for 1-2 days. Most effects, however, .occur 1-2 weeks after immunization. These include signs or symptoms of the components of the vaccine. Measles can cause a rash, fever, or upper respiratory infection symptoms. Mumps can cause slight salivary gland swelling. Rubella may present with cervical lymph adenopathies and arthralgia. The MMR vaccine can present with all of the above. All the vaccines can cause febrile seizures and a reversible encephalopathy. The MMR should be delayed for pregnancy or possibility of pregnancy in the patient, for anything more than a minor illness, and if the patient has received gammaglobulin in the past 3 months. Contraindications include anaphylaxis to any of its components or immunodeficiency such as cancer, leukemia, severe HIV immunosuppression, radiation therapy, chemotherapy, and steroids. There is no proof that MMR vaccination causes autism.

Entrapment of Peptide Protein and DNA Vaccines

Materials (all more than 98 pure) required for the preparation of liposome-entrapped vaccines include 2. The water-soluble vaccine (up to 10 mg) in the absence or presence of a coadjuvant (e.g., interleukin(IL-)-2, 12, or 15) is dissolved in 2 mL distilled water (H2O) or 10 mM sodium phosphate buffer pH 7.2 (phosphate buffer PB) as needed. The composition, pH, and molarity of buffer can be varied providing that this does not interfere with vesicle formation or yield of vaccine entrapment. The amount of added vaccine (and coadjuvant) can be increased or decreased proportionally to the total amount of lipid used (see Subheading 2.1.2., Solution 1).

The Virosomal Vaccine Approach

The most significant impediment to the use of synthetic peptides as vaccines has been that they are only weak or nonimmunogenic when injected by themselves into animals (3,4). This property has necessitated the use of carriers, usually large, highly immunogenic proteins, to which the peptides are covalently coupled. These carriers, although helpful in producing an initial antibody response, have no relationship to the pathogen against which the vaccine is designed and therefore do not elicit pathogen-specific T-cell help. Therefore, when an individual who has been vaccinated with a peptide-carrier complex is challenged with the pathogen, a primary rather than a secondary (faster, stronger, higher affinity) response results. Also, booster immunizations often lead to a stronger antibody response to the carrier and a diminishing one to the peptide. In addition, these peptide-carrier complexes must usually be combined with other adjuvants (for example, Freund's) to enhance the response to...

Production of a Commercialized Influenza Virosome Vaccine see Note

At the Swiss Serum and Vaccine Institute, Berne, influenza seed virus solution is inoculated into 11-d-old embryonated hens' eggs from flocks under veterinary control. The inoculated eggs are incubated for a further 50-60 h at 33-35 C, depending on the strain. During this period, they are illuminated for a second time (after 40 h) to eliminate dead eggs. After incubation, the eggs are cooled overnight at 1-4 C they are then opened under laminar flow and the allantoic fluid is aspirated into sterile steel tanks. After centrifugation, the virus suspension is filtered by step filtration, through a filter of 0.65 im and 0.22 im, directly into a new 200-L steel tank. The filtered virus suspension is concentrated about fourfold with a molecular filter system (polysulphone membranes), and then purified and concentrated by sucrose density-gradient ultracentrifugation. The virus-containing fraction is diluted and dialyzed against PBS pH 7.4 to reduce the sugar content to less than 1 ....

The Use of MF59 as a Vaccine Adjuvant

The MF59 emulsion adjuvant was developed with the objective of generating a broad spectrum of recombinant vaccines for human use. The specific aim was to elicit neutralizing titers in humans significantly greater than those obtainable with the alum adjuvants in common usage. An extensive body of preclinical efficacy data has been obtained based on ELISA titers obtained with a variety of subunit antigens in a spectrum of animal model systems. A summary of this data is shown in Table 2. Data are presented as the ratio of serum ELISA titers obtained with MF59 to that obtained with alum formulated vaccine. (In one case (*), where alum vaccines have been shown to be ineffective, the ratio of titers obtained with MF59 to that obtained with antigen alone is presented.) The principal conclusion to be drawn from this data is that MF59 is a significantly more potent adjuvant than the aluminum salts for most of the antigens tested in a variety of animal models. The enhancement of titer typically...

Introduction to virus vaccines

The term vaccination is derived from the Latin word vacca, meaning cow. This is because the original procedure involved the inoculation of material from cowpox lesions into healthy people. Edward Jenner tried the procedure first in 1796 after he noticed that the faces of most milkmaids were unmarked by pocks this was because milkmaids rarely contracted smallpox. They did, however, commonly contract cowpox, so Jenner inoculated material from a milkmaid's cowpox lesion into the arm of an 8-year-old boy. Six weeks later the boy was inoculated with material from a smallpox scab he remained healthy. The immune response against cowpox virus had protected against smallpox virus, the protection resulting from related antigens in the two viruses. A vaccine, therefore, contains material intended to induce an immune response, and this may involve both B cells (which develop into antibody-producing cells) and T cells (responsible for cell-mediated immunity). Both arms of adaptive immunity can be...

Inactivated virus vaccines

Inactivated, or killed, virus vaccines are made by mass producing the virulent virus and then inactivating the infectivity, usually by treatment with a chemical such as formaldehyde (Section 23.5.2.c). The trick lies in finding the combination of chemical concentration and reaction time that completely inactivates the virus, but leaves its antigens sufficiently unchanged that they can still stimulate a protective immune response. Jonas Salk developed a treatment for poliovirus that led to the development of the vaccine that bears his name. The treatment involves suspending virions in formalin (formaldehyde solution) at 37 C for about 10 days. Other examples of killed virus vaccines are those containing inactivated virions of influenza, hepatitis A and foot and mouth disease viruses. Because the virus used to produce an inactivated vaccine is a virulent strain, it is vital that 100 per cent of the infectivity is destroyed in the production process. As discussed in Section 23.4, there...

Synthetic peptide vaccines

Each protein antigen has one or more epitopes. These short amino acid sequences can be synthesized in a machine and it was suggested that the resulting peptides might be used as vaccines. Compared with traditional vaccines it would be easier to ensure the absence of contaminants such as viruses and proteins. A lot of work has been done to try to develop peptide vaccines against foot and mouth disease virus. In this virus there is an important epitope within the virion protein VP1 (Section 14.3.1). Synthetic peptides of this sequence induced reasonable levels of neutralizing and protective antibodies in laboratory animals, but when vaccine trials were done in farm animals the results were disappointing.

Storage and transport of vaccines

Once a vaccine has been manufactured there is a need to preserve its efficacy until it is used. For live vaccines this means preserving virus infectivity for vaccines containing inactivated virions, subunits and virus-like particles it means preserving immunogenicity. The major physical and chemical factors that can reduce the infectivity of a live vaccine were considered in Chapter 23 some of these factors can also reduce the immunogenicity of vaccines. Most vaccines are stored and transported at low temperatures (Figure 24.6) this minimizes losses of infectivity and immunogenicity. Substances that reduce the rate of infectivity loss are included in some vaccines, an example being magnesium chloride in live polio vaccines. Figure 24.6 Low temperature storage of virus vaccines. Photograph courtesy of Novartis Vaccines. Figure 24.6 Low temperature storage of virus vaccines. Photograph courtesy of Novartis Vaccines.

Pneumococcal vaccine is

The recommendation for poliovirus vaccine in infants and children was changed to inactivated vaccine Salk inactivated vaccine (IPV) from live attenuated vaccine Sabin oral vaccine (OPV) for which reason a. Inactivated vaccine is cheaper than attenuated vaccine b. Injection of vaccine is easier than oral administration c. The antibody response is more long lasting with inactivated vaccine d. The chance of vaccine-induced polio illness is unlikely with inactivated vaccine

Preclinical Evaluation of Vaccines Adsorbed onto Aluminum Compounds

To achieve consistency in manufacture of aluminum adjuvants, it is important to characterize these adjuvants for physicochemical and adjuvant properties. Though aluminum adjuvants have been used widely with human vaccines, there are still a number of unanswered questions about their mechanism of action (see Note 5), such as optimal size of the gel particles, degree of adsorp tion of antigens onto adjuvant, amount of gel used as a dose for humans and animals (see Note 3) and even type of aluminum adjuvant that shows better adjuvanticity (see Note 6). During the last several years, physicochemical characteristics of aluminum adjuvants have been studied (7). Though there is no clear understanding between these characteristics and adjuvanticity, most of the regulatory agencies have started requiring information on these characteristics with a view to achieving consistency in manufacture of vaccines adsorbed onto aluminum compounds. The physicochemical characteristics are very useful in...

Virion subunit vaccines

A subunit vaccine contains purified components of virions. In the case of influenza the vaccines contain the haemagglutinin (H) and neuraminidase (N) surface glycoproteins. A typical production method is outlined in Figure 24.3. The infectivity of a batch of influenza virions is inactivated with formaldehyde or P-propiolactone, then the virion envelopes are removed with a detergent, such as Triton X-100. This releases the glycoproteins, which form aggregates of H 'cartwheels' and N 'rosettes'. These structures are purified by centrifugation in a sucrose gradient, and then material from three influenza virus strains is combined to form the vaccine. For protection against influenza the subunit vaccines are preferred over the inactivated vaccines as they cause fewer side-effects, especially in children. The subunit vaccines, however, induce poorer immune responses, so two doses are necessary to provide adequate immunity.

Examples of Modern Vaccine Adjuvants Used in Animals and

Vaccine Adjuvants vs Nonspecific Enhancers of Immunity antigen, are not listed. Thus, adjuvants administered repeatedly as nonspecific enhancers of immune response are largely excluded. Immunopotentiating agents administered to humans separately in time or location from the vaccine may be impractical for vaccinating large numbers of persons, and potentially unsafe because of their physiological effects on the entire body. They may have a role, however, in immunizing a small number of high-risk, immunocompetent individuals, such as renal dialysis patients at risk for hepatitis B or the very elderly at risk of influenza. Examples of such whole body adjuvants used in humans to augment vaccines include Na diethyldithiocarbamate (13), thymosin alpha one (14), loxoribine (15), granulocyte-macrophage stimulating factor (16,17), cimetidine (18), and dehydroepiandrosterone sulfate (19). The results of such trials to date have been disappointing. Several terms used in Table 1 need to be...

Nonclinical Testing of rBV AB PlChia Pastoris Vaccine

Before submission of the IND for rBV A B (Pichia pastoris) vaccine, the proposed vaccine formulation was tested in GLP toxicity studies to establish its safety. Three studies were performed repeat dose toxicity, repeat dose neurotoxicity, and repeat dose immunogenicity. The designs of these three studies were identical. Mice (CD1) received one (day 0), two (day 0 and day 28), or three (day 0, day 28, day 56) doses of vaccine formulated with or without 0.2 (w v) Alhydrogel at serotype-specific antigen concentrations of 0, 1, 2, or 4 g. In each formulation, the concentration of the adjuvant and other excipients was the same as those intended for the Phase 1 clinical trial. For the repeat dose toxicity study, the animals were evaluated through clinical observation, body weight measurement, vaccination site reactogenicity, physical examination, food consumption, clinical pathology (hematology and serum chemistry), terminal organ weight, and macroscopic and microscopic examinations of...

Live attenuated virus vaccines

A live attenuated vaccine contains a mutant strain of a virus that has been derived from a wild-type virulent strain. Vaccines of this type have a number of advantages over most other types of vaccine. One advantage is that there are increasing amounts of virus antigen in the body as the virus replicates. Another is that a wide-ranging immune response is induced that involves B cells, CD4 T cells and CD8 T cells. There are two properties that the vaccine virus must possess. First, its antigens must be identical, or very similar, to those of the wild-type virus so that an immune response against the vaccine virus provides protection from infection with the wild-type virus. Second, the virulence of the wild-type virus must have been attenuated in other words the vaccine virus must have little or no virulence. Most attenuated virus strains have been derived by 'hit and miss' procedures such as repeated passage of wild-type virus in cells unrelated to the normal host. The vaccine strains...

Live recombinant virus vaccines

Recombinant Vaccine Influenza Virus

A recombinant vaccinia virus engineered to contain the gene for the rabies virus G protein has been used to vaccinate wild mammals against rabies. The use of this vaccine was discussed in Section 15.2.1. Figure 24.3 Outline of production method for influenza virus subunit vaccine. Haemagglutinin (H) and neuraminidase (N) are extracted from inactivated influenza virions and purified by sucrose gradient centrifugation. The bands from the gradient are harvested and incorporated into the vaccine.

Final Vaccine Formulation

Vaccine Formats the adjuvant emulsion MF59C.1 in one of two formats either in single containers or in separate vials (admixed prior to administration and therefore referred to as dual vial vaccines). The antigens tested fall into three distinct classes of proteins Antigens of all three types have been successfully formulated into single-vial vaccines after sufficient formulation optimization. These single-container vaccines showed different stability behaviors depending on the nature of the antigen and the susceptibility of the antigen to interact with the adjuvant. Table 1 summarizes much of the stability data obtained for MF59 vaccine formulations at Chiron Corporation. Only two of the antigens, HIV gp120 and CMV gB, were not suitable for single-vial formulation. HIV gp120 has been shown to undergo time-dependent conformational changes in single-container formulations. Such changes are evident by a loss in CD4 binding, a measurement, considered an in vitro surrogate potency...

Mass production of viruses for vaccines

The production of the types of vaccine discussed so far (live attenuated, inactivated, subunit and live recombinant) requires large quantities of virions for most viruses these are produced in cell cultures. John Enders demonstrated in 1949 that poliovirus can be grown in primary monkey cell culture and this led to procedures for the mass production of poliovirus for the Salk and Sabin vaccines. It was subsequently found that some monkey cell cultures used for vaccine production had been harbouring viruses, including simian virus 40 (Section 22.3). It was therefore recommended that human cell cultures should be used for the production of vaccines for human use, though cell lines of monkey origin, such as Vero cells (African green monkey cells), are used for the production of some. Another preference is for the use of diploid cell lines, rather than heteroploid cell lines that have been derived from tumours, as there are perceived risks associated with tumour-derived cells. Examples of...

Development of Pentavalent Botulinum Toxoid Vaccine for Human

In response to adverse events from some of these early toxoid preparations, a more highly processed pentavalent vaccine containing serotype A, B, C, D, and E toxoids was developed at Fort Detrick.31 The neurotoxins were precipitated from C. botu-linum cultures, extracted with calcium chloride and, after further precipitation and extraction steps, sterilized by filtration.32 The neurotoxins were inactivated with 0.6 (v v) formalin over 15 to 25 days at 35 to 37 C and pH 5.5 to 6.5, and formulated with Holts 7 8 aluminum phosphate gel33 at 7 mg mL and 0.01 (w v) thimerosal as preservative. The resultant monovalent toxoids were blended to achieve a variety of formulations for clinical studies to establish suitable and vaccination schedule dosages. The first studies were with serotype A toxoid, which was used at concentrations of 0.34, 1.7, and 10.2 flocculating units per milliliter (Lf mL), using a variety of multidose vaccine schedules. The flocculation test34 was an in vitro method of...

Vaccines Produced in Pichia pastoris

Vaccines produced in Pichia pastoris represent the most advanced recombinant vaccines currently under development. These include rBV A B (P. pastoris), designed to provide protection against BoNT A and BoNT B the primary candidate of the U.S. Department of Defense Joint Vaccine Acquisition Program (DoD-JVAP) a pentavalent vaccine comprising antigens designed to protect against BoNT types A, B, C, E, and F and a heptavalent vaccine designed to provide protection against all known forms of BoNT (A though G). Both are currently funded through the Defense Threat Reduction Agency (DTRA) and the National Institute of Allergy and Infectious Diseases (NIAID). These programs share similar approaches to vaccine candidate selection, similar expression systems, formulation development for purified drug substance (PDS or active pharmaceutical ingredient)) and final drug product (FDP or final dosage form), bioassays for potency, and the same general approach to fermentation and purification. The...

Clinical Testing of rBV AB Pichia pastoris Vaccine

The Phase 1 clinical trial represents the first human experience of the rBV A B (Pichia pastoris) vaccine. The primary objective of the 1 clinical trial is to evaluate the safety, tolerability, and immunogenicity of a two-dose regimen (day 0, day 28) of rBV A B (Pichia pastoris) vaccine at three dosage levels. A secondary objective is to evaluate human neutralizing antibody as a correlate of protective immunity. This will be determined by transfer of sera from the clinical trial volunteers into guinea pigs, and the animals will then be subject to experimental intramuscular challenge with serotype-specific BoNT. This passive transfer model was originally developed for the PBT vaccine as a viable alternative to more conventional Phase 3 clinical testing of botulinum vaccines because the incidence of the disease is extremely low and direct challenge studies in humans are unethical.84 This model requires that human serum containing neutralizing antibodies (measured using a Mouse...

Vaccines

The capacity to elicit protective immunity against infectious agents was first achieved 200 years ago with the utilization of vaccinia (cowpox) by Jenner to protect against smallpox. The word vaccination derives from this first success. Immunization was critical in eradicating smallpox from the world and underlies the approach to the global eradication of other infections, including poliomyelitis. With the vaccines currently recommended by the World Health Organization (WHO) Expanded Programme on Immunization, significant mortality or morbidity from several infections can be prevented in children and adults. Among early childhood diseases, measles accounts for more deaths during childhood than any other vaccine-preventable disease. In 2002, WHO estimated that there were 30 to 40 million cases of measles with more than 700,000 deaths, mostly occurring in developing countries. Thus, at present, delivering available vaccines to at-risk populations is as great a problem as the development...

Varicella Vaccine

This is scheduled for all children 12-18 months of age and all children who have no history of varicella. Children > 12 years of age receiving the vaccine require two doses at least 4-8 weeks apart. Vaccines1 are listed under routinely recommended ages. Bars indicate range of recommended ages for immunization. Anydgsenot given at the recommended age should be given as a catch-up immunization at any subsequent visit when indicated and feasible. (Ovals) indicate vaccines to be given if previously recommended doses were missed or given earlier than the recommended minimum age. Age Vaccine Y

Vaccine Preparation

PMMA nanoparticles can be used in two forms the vaccine antigen can either be incorporated into the nanoparticles or it can be adsorbed to previously formed particles. In the first case, the polymerization is carried out in presence of the antigen. In this case, polymerization has to be performed by gamma-ray irradiation because this type of polymerization can be carried out at room or Adsorption of vaccine antigens can be performed with nanoparticles produced by gamma-irradiation (Subheading 3.2.1.) or by chemical polymerization (Subheading 3.2.2.). Suspensions are mixed with the antigen in the desired concentration and are kept for at least 14 h (18), preferentially under gentle agitation (stirring or shaking). 3. Nonlyophilized empty nanoparticles or nanoparticles rewetted separately from antigen are mixed with the antigen in concentration that give the final vaccine and nanoparticle adjuvant concentrations. 4. Store this mixture at least for 14 h (18) before it is used as a...

Cholera Vaccines

There are currently three licensed cholera vaccines available in various countries around the world. These include the old killed, whole-cell parenteral vaccine, the B subunit killed whole-cell oral vaccine (BS WCV),83,84 and live oral V cholerae O1 strain CVD 103-HgR.85,86 The BS WCV is marketed under the trade name Dukoral (SBL, Stockholm, Sweden), whereas CVD 103-HgR is marketed as Orochol or Mutacol (Berna Biotech, Berne, Switzerland). Neither the nonliving nor the live oral cholera vaccine is presently licensed in the United States. Since the old killed, whole-cell vaccine is reactogenic and confers only partial, short-term protection, there has been little enthusiasm on the part of public health authorities to recommend its widespread use. The two new oral vaccines have distinct advantages over the old parenteral vaccine. They are easy to administer and are more potent in stimulating local intestinal immune responses. These vaccines protect against cholera caused by V cholerae...

Subunit Vaccines

It is becoming increasingly apparent that the natural immune response generated by infection with an organism often does not represent the optimal protective response against that organism (12). Subunit vaccines, consisting of specific components of the pathogen, can be used to direct the immune response to targets that are protective (13). Strain variation of immunologically important sites can be covered by the use of mixtures of peptides, proteins, or nucleic acids that code for them. In addition, less dominant, more highly conserved sites, can be presented more effectively than in the context of the whole organism. Subunit vaccines are also attractive for reasons of safety. Many infectious organisms are too dangerous to risk even an occasional breakthrough in the process of inactivation used to produce a killed vaccine. Live attenuated vaccines can pose risks of reversion to wild type, as well as causing more severe disease in individuals whose immune system is compromised (e.g.,...

Tumor Vaccines

Formation was prevented when these cells were administered to experimental animals. This led to the development of so-called tumor vaccines. In this approach cancer cells transfected with a cytokine-producing gene are administered to animals with established tumors of the same cell line. By inducing specific immunity, an antitumor effect is seen. Connor et al. 54 studied the cytokines IL-2 and interferon-g (IFN-g). Retroviral vectors were used to transfect the bladder cancer cell line MBT-2 with these cytokines and they were then inactivated by X-irradiation. Mice with ortho-topic bladder tumors derived from MBT-2 cells were then vaccinated intraperitoneally with these cell lines (individually or combined), once weekly for 3 weeks. IL-2 vaccination had a significant inhibitory effect on tumor growth, and three of five mice tumors regressed completely. Interferon-g had a less marked effect but still showed antitumor activity. There was no benefit for combined treatment. The same group...

DNA vaccines

The most revolutionary approach to vaccination is the introduction into the vaccinee of DNA encoding an antigen, with the aim of inducing cells of the vaccinee to synthesize the antigen. One advantage of this approach is that there is a steady supply of new antigen to stimulate the immune system, as with live virus vaccines. Because the antigen (a virus protein in this case) is produced within the cells of the vaccinee, it is likely to stimulate efficient T-cell-mediated responses. Figure 24.5 Production of a DNA vaccine. The virus protein gene is inserted into a plasmid, which is then cloned in bacteria. The plasmid is extracted from the bacterial cells, purified and incorporated into a vaccine. A procedure for the production of a DNA vaccine is outlined in Figure 24.5. The antigen-encoding sequence, obtained directly from a DNA virus or by reverse transcription from an RNA virus, is inserted into a plasmid between a strong promoter and a poly(A) signal. The plasmid is replicated in...

Vaccine Formulation

Mix the sterile stock solution of QS-21 with a sterile stock of soluble antigen with the dose of each adjusted to the optimum for the animal to be immunized. A typical effective QS-21 dose is 10-20 g for mice, 25-50 g for guinea pigs or rats, and 50-100 g for rabbits, rhesus monkeys, and baboons. The volume of the vaccine is then adjusted to the final formulation volume (0.2 mL for mice, 0.5-1.0 mL for larger animals) with sterile saline or sterile-buffered saline. Although QS-21 is a relatively mild surfactant that is not expected to denature proteins, extensive studies on the effect of QS-21 on conformation-dependent epitopes have not been carried out. Therefore, assays for such epitopes should be considered. 2. The formulated vaccine should be visually inspected for clarity. Although the stock solution of QS-21 (at 1 mg mL) may have an opalescent appearance upon prolonged storage, it should clarify upon dilution to the concentration typically used in vaccine formulations (50-200 g...

Robert Edelman 1 Introduction

Adjuvants have been used to augment the immune response to antigens for more than 70 years. Ramon first demonstrated that it was possible to increase levels of diphtheria or tetanus antitoxin by the addition of bread crumbs, agar, tapioca, starch oil, lecithin, or saponin to the vaccines (1). In this chapter, an overview is provided of modern vaccine adjuvants as background for more detailed discussions of promising adjuvants in chapters to follow. After a more general discussion of adjuvants including their definition, mechanisms of action, safety, ideal characteristics, impediments to development, and preclinical and clinical regulatory issues, examples will be provided of experimental vaccine adjuvants that have entered clinical trial to enhance a variety of licensed and experimental vaccines in humans. For additional expositions on this complex subject and for a historical perspective, the reader is referred to recent textbooks on vaccine adjuvants (2-4) and a selection of useful...

Mechanisms of Adjuvant Action

To date, most subunit vaccines are poor antigens, whether or not they are natural products, recombinant products, or synthetic peptides. Subunit antigens fail for a variety of reasons, such as incorrect processing by the immune system, rapid clearance, stimulation of inappropriate immune response, and lack of critical B-cell or T-cell epitopes. Potentially, some of these failures can be overcome by administering subunit antigens with adjuvants. It should be remembered, however, that the best adjuvant will never correct the choice of the wrong (nonprotective) epitope. Traditional live vaccines or whole-cell inactivated microbial vaccines are generally better immunogens than subunit vaccines. Live and inactivated whole organisms are structurally more complex than subunit vaccines, and so contain many redundant epitopes that offer more opportunity to bypass genetic restriction of the vaccinee. Such vaccines also provide a larger antigen mass than subunit vaccines, particularly if they...

Specific Immune Mechanisms

Some mechanisms of adjuvant action are discussed below, and which are summarized in Table 2. Vaccine adjuvants can (1) increase the potency of small, antigenically weak synthetic or recombinant peptides. (2) They can enhance the speed, vigor, and persistence of the immune response to stronger antigens. For example, aluminum adjuvants used with licensed pediatric vaccines (e.g., DTP) elicit early and higher antibody response after primary immunization than do unadjuvanted preparations. (3) Adjuvants can increase the immune response to vaccines in immunologically immature, immunosup-pressed, or senescent individuals. (4) Adjuvants can select for, or modulate humeral or cell-mediated immunity, and they can do this in several ways. First, antigen processing can be modulated, leading to vaccines that can elicit both helper T cells and cytotoxic lymphocytes (CTL) (reviewed in 7,43 ). Second, depending upon the adjuvant, the immune response can be modulated in favor of MHC class I or MHC...

Advantages of Adjuvants

Vaccine adjuvants influence the immune response to our benefit in one or more ways (see Table 3). The ability of adjuvants to influence so many parameters of the immune response greatly complicates the process of finding an Modulators of Vaccine Adjuvant Effects effective adjuvant. This is because our knowledge of how any one adjuvant operates on a cellular level is insufficient to support a completely rational approach for matching the vaccine antigen with the proper adjuvant. Consequently, many investigators advocate an empirical approach for antigen selection based on the balance between toxicity, adjuvanticity in animals, and whether one wishes to stimulate a cellular (Th1) response, a humeral (Th2) response, or a balance of the two responses.

Limited Adjuvanticity

Most adjuvants are effective with some antigens, but not others. For example, aluminum compounds failed to augment vaccines against whooping cough (72), typhoid fever (73), trachoma (74), adenovirus hexon antigens (75), influenza hemagglutinin (76), and Haemophilis influenzae type b capsular polysaccharide conjugated to tetanus toxoid (77). It is not always possible to predict compatible and incompatible adjuvant-vaccine combinations early in development, before the late stages of preclinical or early clinical development. This situation is especially common when there are no reliable animal models. Although ovalbumin is often used as a model antigen for preliminary screening, doses used are often too high to discriminate between small differences among adjuvant formulations (78), and no functional antibody assays are available for this nonpathogenic antigen. If possible, initial preclinical studies should be done with the antigen destined for clinical studies at minimal threshold...

Suboptimal Use of Aluminum Adjuvants

Aluminum salts have become the reference preparations for evaluation of new adjuvants for human vaccines. Therefore, it is important that aluminum adjuvants be used optimally to allow correct evaluation of the experimental adjuvant (5,9,79). Aluminum adjuvants are difficult to manufacture in a physi-cochemically reproducible way, and this failure affects immunogenicity. Thus, during the adsorption of antigens on aluminum adjuvants, attention must be paid to the chemical and physical characteristics of the antigen, type of aluminum adjuvant, conditions of adsorption, and concentration of adjuvant

Preclinical and Phase I Clinical Trial Design Issues 101 US Food and Drug Administration Regulations

No detailed or specific guidelines exist in the United States for assessing the safety of adjuvant preparations for use in humans. Only two guidelines refer to adjuvants. The first guideline formally issued by the FDA, which includes adjuvanted vaccines (86), refer to tests of the final container lot of all biological products. These FDA standards are paraphrased in Table 7 for ease of understanding. It is unclear if adjuvants, such as QS-21, which are added to the vaccine immediately before inoculation, are subject to the final container assay. affect adversely the safety or potency of the product. (Code of Federal Regulations, 21 CFR, Part 610.15). Because the definition of satisfactory evidence is rather vague, investigators should interact with the professional staff of the Center for Biologics Evaluation and Research, FDA, in order to reach a consensus definition. Incidentally, aluminum compounds alone are not licensed. Aluminum compounds are not considered to be investigational...

Summary and Conclusion

Interest in vaccine adjuvants is intense and growing, because many of the new subunit vaccine candidates lack sufficient immunogenicity to be clinically useful. In this chapter, I have emphasized modern vaccine adjuvants injected parenterally or administered orally or intranasally with licensed or experimental human vaccines in volunteers. The terms adjuvant, carrier, vehicle, and adjuvant formulation are defined. Every adjuvant has a complex and often a multifactorial immunological mechanism, usually poorly understood in vivo. Adjuvant safety, including the real and theoretical risks of administering vaccine adjuvants to humans, is a critical component that can enhance or retard adjuvant development. In addition to the problem of safety, at least four other issues impede the orderly preclinical development of adjuvanted vaccines. These include inconsistent immunopotentiation by candidate adjuvants, the unreliability of reference aluminum adjuvants, marked variation in response to the...

Duncan E S Stewart Tull 1 Introduction

There are no officially recognized regulations for the design and toxicity testing of adjuvants or adjuvant formulations the former are also referred to as immunomodulators and immunopotentiators. At the Immunological Adjuvants and Vaccines meeting held in Greece in 1988, however, immuno-adjuvant researchers discussed experimental toxicological tests that might be used to monitor new immunomodulators (1). The usefulness of these tests for the range of immunomodulators and adjuvant formulations was examined over a 2-yr period and subsequently, at the next NATO meeting in 1990, further recommendations were made (2). Although as yet, no final agreement has been reached and a variety of tests are still in use. At the Harmonization of regulatory procedures for Veterinary Biologicals meeting in Ploufragan, Brittany, a number of scientists and administrators from the regulatory bodies of the United States of America and the European Community indicated that adjuvants are too reactive for...

Cancer Treatment and Research

Kirsch, Matthias Black, Peter McL. (ed.) Angiogenesis in Brain Tumors. 2003. ISBN 1-4020-7704-1. Keller, E.T., Chung, L.W.K. (eds) The Biology of Skeletal Metastases. 2004. ISBN 1-4020-7749-1. Kumar, Rakesh (ed.) Molecular Targeting and Signal Transduction. 2004. ISBN 1-4020-7822-6. Verweij, J., Pinedo, H.M. (eds) Targeting Treatment of Soft Tissue Sarcomas. 2004. ISBN 1-4020-7808-0. Finn, W.G., Peterson, L.C. (eds.) Hematopathology in Oncology. 2004. ISBN 1-4020-7919-2. Farid, N. (ed) Molecular Basis of Thyroid Cancer. 2004. ISBN 1-4020-8106-5. Khleif, S. (ed) Tumor Immunology and Cancer Vaccines. 2004. ISBN 1-4020-8119-7.

Derek T OHagan and Manmohan Singh 1 Introduction

The biodegradable and biocompatible polyesters, the poly(lactide-coglycolides) (PLG) are the primary candidates for the development of microparticles as vaccines, because they have been used in humans for many years as suture material and as controled-release delivery systems for peptide drugs (3). However, the adjuvant effect achieved by the encapsulation of antigens into PLG microparticles has been demonstrated only relatively recently (Fig. 1) (4-6). Particle size was shown to be an important parameter affecting immunogenicity, because smaller microparticles (< 10 m) were significantly more immunogenic than larger particles (> 10 m) (6,7). The adjuvant effect of microparticles can also be enhanced by their coadministration with additional adjuvants (5). Recent studies have shown that microparticles also exert an adjuvant effect for cell-mediated immunity, including the induction of cyto-toxic T cell (CTL) responses following both systemic and mucosal administration (8,9). The...

Jrg Kreuter 1 Introduction

Nanoparticles are solid particles ranging in size from 1 to 1000 nm (1 m). They consist of macromolecular materials and can be used therapeutically or prophylactically, for example, as adjuvants in vaccines or drug carriers, in which the active principle (drug or biologically active material) is dissolved, entrapped, or encapsulated, or to which the active principle is adsorbed or chemically attached (1-3). One of the first areas of application of nanoparticles was their employment as adjuvants for vaccines. The most frequent method for the preparation of nanoparticles for this purpose was, and still is, emulsion polymerization. The polymers that can be employed for this process include poly(methyl methacrylate) (4-6), polyacrylamide (7), and poly(alkyl cyano-acrylates) (8,9). Among these polymers, poly(methyl methacrylate) proved to be by far the most optimal and suitable material (10,11). Nanoparticles made from polyacrylamide or poly(alkyl cyanoacrylate) possess the disadvantage...

Liposomes Background Research

Liposomes are vesicles made up of one or more concentric lipid bilayers alternating with aqueous spaces (12). The lipid components are usually phospholipids or other amphiphiles such as nonionic surfactants, often supplemented with cholesterol and other charged lipids. Bilayers can be in a fluid or rigid state at ambient temperature (Ta), depending on the nature of the amphiphile. The fluid state is achieved with amphiphiles that have a gel-liquid crystalline transition temperature (Tc) the temperature at which the acyl chains melt below Ta, whereas the rigid state requires amphiphiles with a Tc above Ta. Owing to their ability to entrap water- and lipid-soluble molecules in their aqueous and lipid phases, respectively, liposomes have been used since 1970 (17) as a delivery system for a great variety of pharmacologically active agents in therapeutics (12). Drug delivery with liposomes or other systems can circumvent many of the problems associated with direct drug use, for instance,...

Reinhard Glck 1 Introduction

Immunization is the most effective defense mechanism against microbial infections today. Although highly effective vaccines are currently available for a number of infectious diseases, vaccine formulations can still be improved in a number of important areas. Issues of safety, stability, delivery, and combining vaccines to several pathogens need to be addressed. For many diseases, a greater understanding of microbial pathogenesis and the basis for protective immunity is still needed. The ability to induce antigen-specific humoral and cell-mediated immunity is crucial to the development of effective prophylactic and therapeutic vaccines. In the past, vaccine development was mainly empirical, and based on attempts to mimic natural infection. Vaccinology has entered a new era, which might be linked to rational drug design vs brute force screening. The development of new or improved vaccines will rely on a sophisticated understanding of the molecular biology, mechanisms of pathogenesis,...

Preparation of Oligonucleotides Containing Cationic Virosomes see Note

Virosomes are prepared as described for the production of commercial IRIV-hepatitis A vaccine. Instead of PC and PE the cationic N- 1-(2,3-dioleyloxy) propyl -N,N,N-trimethyl-ammonium methylsulfate (DOTAP) is added to the influenza envelope glycoproteins (HA and NA) and phospholipids. Encapsulation of oligonucleotides into DOTAP-virosomes is performed as follows cat-ionic virosomes are added to each of the following oligodeoxy-nucleotide phosphorothioates (OPTs) antisense FITC.OPT, sense FITC-OPT, and FITC-OPT. These OPTs are dissolved and the solutions are then treated by sonica-tion for 2 min at 26 C. Nonencapsulated OPT are separated from the virosomes by gel filtration on a High Lead Superdex 200 column (Pharmacia, Uppsala, Sweden). The column is equilibrated with sterile PBS. The void volume fractions containing the DOTAP virosomes with encapsulated OPT is eluted with PBS and collected.

Prospects for the Future

Because it is not clear which (if any) animal species or strain correlates with human immunity (54), products that show promise in an animal system need to be tested in humans for both safety and immunogenicity. Virosomes have been extensively given to humans of all ages in the context of vaccine formulations. Therefore, such efforts should prove exciting for the successful application of the molecular approach to new and improved vaccines. There are several ways to increase adjuvant activity over that observed with alum, the only adjuvant in approved products licensed by the FDA (56) and which is far from ideal (i) by developing an adjuvant vaccine formulation that is more dispersable, therefore improving transfer of antigens to draining lymph nodes (ii) by using immunostimulants that help to trap and activate appropriate cells within these lymph nodes (iii) by providing for a physical or chemical association of these immunostimulants with vaccine antigens so that both are delivered...

Protective Immune Responses

The vast majority of infectious diseases are caused by pathogens that infect mucosal surfaces or use them as portals of entry. Mucosal immune responses are the first line of defense against these pathogens that are inhaled, ingested, or sexually transmitted. However, some agents may be able to breach these defenses, and go on to cause systemic disease. Therefore, vaccines against these agents may need to induce both mucosal and circulating immune responses for optimal protection (1-3). From Methods in Molecular Medicine, Vol. 42 Vaccine Adjuvants Preparation Methods and Research Protocols Edited by D. T. O'Hagan Humana Press, Inc., Totowa, NJ

Cochleate Delivery Vehicles

Cochleate delivery vehicles are unique vaccine carrier and delivery formulations composed of simple, natural materials (phosphatidylserine and calcium) (14-19). Multiple cochleate administrations can be given to the same animal without adverse side effects, as they are nontoxic, noninflammatory, and biodegradable (14). Cochleates are stable phospholipid-calcium precipitates, which are structurally distinct from liposomes (Fig. 1). There are substantial and critical differences between the composition and properties of liposomes and cochleates. Liposomes at physiological temperatures are comprised of fluid bilayer membranes with aqueous space contained within the compartments bounded by the lipid bilayers (20). The fluid lipid bilayer is susceptible to attack from harsh environmental conditions, such as extremes of pH, or the presence of enzymes that digest lipid.

Mechanistic Approaches to Adjuvant Design

A variety of approaches have been utilized in searching for adjuvants that would be useful for clinical application to human disease prevention. Both alum, the principal adjuvant licensed for use in conjunction with human vaccines, and polylactide-coglycolide (PLG) microspheres have been reported to provide a depot that release antigen over an extended period of time (2). A From Methods in Molecular Medicine, Vol. 42 Vaccine Adjuvants Preparation Methods and Research Protocols Edited by D. T. O'Hagan Humana Press, Inc., Totowa, NJ

Adjuvant Reactogenicity

Limiting reactogenicity of adjuvanted vaccines to a tolerable level for widespread administration to humans has been a critical problem in transition from animal models to the clinic. The first priority in formulation of MF59 was to ensure safety, thus a very conservative formulation based upon low-risk components has been utilized. Clinical testing with both influenza and herpes simplex virus (HSV) vaccines in more than 18,000 subjects have demonstrated minimal reactogenicity of these formulations and the adjuvant has been approved for both commercial use and for further testing in both infants and pregnant women.

Pharmaceutical Feasibility

The advanced state of development of MF59 offers the potential user significant advantages. MF59s manufactured under GMP conditions at a scale commensurate with commercial use as part of an adjuvanted influenza vaccine (Fluad). Extensive characterization of raw materials, development of a reproducible manufacturing process and derivation of suitable conditions for long-term stability have been achieved during the product development cycle. MF59 has shown excellent compatibility with a variety of subunit antigens, all of which have been formulated by a simple mixing of the antigen with the adjuvant. This simple approach allows final formulation to be performed in the clinic and reduces the need for extensive stability studies on early-phase candidate vaccines. On selected vaccines, storage stability in the presence of MF59 has also been established demonstrating the feasibility of long-term compatibility of antigens with MF59 on a case-by-case basis.

Manufacturing Process for 50lScale Production of MF59

Here we describe the manufacturing process for sterile clinical grade MF59C.1 having defined release specifications and demonstrated long-term stability. The 50l scale manufacturing process for MF59C.1 is shown in Fig. 1. Briefly, polysorbate 80 is dissolved in WFI and combined with aqueous sodium citrate-citric acid buffer solution. Separately, sorbitan trioleate is dissolved in squalene. These two solutions are combined together and processed in an inline homogenizer to yield a coarse emulsion. The coarse emulsion is fed into a microfluidizer, where it is further processed to obtain a stable submicron emulsion. The coarse emulsion is passed through the interaction chamber of the microfluidizer repeatedly until the desired particle size is obtained. The bulk emulsion is filtered through a 0.22- m filter under nitrogen to remove large droplets, yielding MF59C.1 adjuvant emulsion bulk that is filled into glass bottles. For vaccine antigens that have demonstrated long-term...

Assurance of Clinical Safety

Summary of Subjects Receiving MF59 and Vaccine Antigens through March 1999 in Chiron-Sponsored Programs Summary of Subjects Receiving MF59 and Vaccine Antigens through March 1999 in Chiron-Sponsored Programs Subtotal Vaccine Antigens with MF59 vaccine. Adjuvants, by definition, increase immunological responsiveness, which may result in immune reactivity to epitopes other than those necessary for protection as well as giving rise to side effects associated with generation of the response. The MF59 formulation has been restricted to components that are not individually immunostimulatory. The principal component, squalene, is a naturally occurring intermediate in cholesterol synthesis that is widely distributed in nature and is the primary component of shark liver oil. The MF59 emulsion is immunostimulatory and the safety of each vaccine formulated with the adjuvant must be demonstrated under controlled clinical conditions. Chiron has tested MF59 under such controlled clinical conditions...

Use of MPL Adjuvant Formulations

The formulations prepared as aforementioned are considered stock preparations of MPL at 1.0 mg mL and as such, require dilution for use with antigens. It is the intent of the following to provide general guidelines for the use of these preparations as adjuvants for vaccine antigens in experimental animal models. 1. An effective adjuvant dose of either MPL formulation with a vaccine antigen must be determined experimentally by the investigator. Using mice in our laboratory, we have found that MPL doses that range between 5-50 g have been useful with soluble protein or peptide antigens, as well as with polysaccharide-protein conjugates. 4. To use the MPL o w emulsion (1.0 mg mL MPL-10 oil) stock formulation, add the antigen as a solution in DPBS, such that the stock o w emulsion is diluted either 1 10 or 1 5, which yields a final oil concentration of 1 and 2 , respectively. The concentration of MPL will be either 100 or 200 g mL. For mouse studies, we inject 0.05-0.25-mL volumes of the...

Granulocyte Macrophage Colony Stimulating Factor GMCSF

Seattle, WA) have been reported with both protein and peptide-based vaccines (15), this cytokine has been extensively studied as a gene therapy approach with either DNA vaccines or as cytokine-secreting transduced tumor cells (16,17). These studies demonstrated that local administration of GM-CSF in combination with an antigen source, particularly in poorly immunogenic murine syngeneic tumor models, can stimulate potent, specific, and long-lasting antitumor immunity.

David C Neujahr and David S Pisetsky 1 Introduction

Although the role of bacterial DNA in stimulating normal host defense is uncertain, the immunological properties of this molecule are nevertheless highly relevant to emerging vaccine technologies. Thus, bacterial DNA has adjuvant properties. These properties, which have been most clearly demonstrated in the murine system, include the induction of cytokines interferon gamma, alpha, beta tumor necrosis factor alpha interleukin 6, 12, and 18 (IFN-y, IFN-o p, TNF-a, IL-6, IL-12, IL-18) as well as the direct stimulation of murine B cells (3-6). The basis of DNA stimulation has been assessed using three major sources of DNA natural DNA, synthetic phosphodiester oligo-nucleotides (Po oligos), and phosphorothioate oligonucleotides (Ps oligos). Ps compounds are DNA derivatives in which one of the nonbridging oxygens in the phosphodiester backbone is replaced by a sulfur atom. This substitution leads to nuclease resistance, as well as changes in other physical properties of DNA such as melting...

Jason A Neidleman Gary Ott and Derek OHagan 1 Introduction

From Methods in Molecular Medicine, Vol. 42 Vaccine Adjuvants Preparation Methods and Research Protocols Edited by D. T. O'Hagan Humana Press, Inc., Totowa, NJ In this chapter, the ability of LT mutants to induce CTL in combination with yeast-derived human immunodeficiency virus (HIV) p55 and p24 gag will be discussed. The procedure for assaying CTL activity in immunized mice will be provided. In this procedure, mice are immunized according to a standard schedule and splenocytes are harvested and prepared for stimulation. The splenocytes are restimulated and assayed by 51chromium release to determine the ability of the vaccine of interest to elicit a p55 gag-specific CTL response.

Center for Biologics Evaluation and Research Cber Fda

The CBER, FDA, Rockville, MD is responsible for regulating vaccines and other biologics in the United States. In addition to meeting the general standards before public release (Table 7), each vaccine and adjuvant are tested for safety on a case by case basis, preferably with the help and guidance of the CBER as noted before. Such guidance, informal in nature but quite helpful, was published in 1993 in response to the needs of HIV-1 vaccine development (52). The principles laid down by that publication can be adapted to the needs of other vaccines. It is recommended that as a general principle, all novel (nonaluminum) vaccine adjuvant formulations be discussed earlier rather than later in preclinical development with the staff of the CBER. The principles are summarized in the next few paragraphs. These and other preclinical and clinical trial study design issues have been discussed in some detail (52,53). 1. Extensive experience with aluminum compounds have shown them to be safe....

General Adjuvant Properties

QS-21 stimulates strong antibody- and cell-mediated responses in animals. QS-21 has been shown to stimulate strong antibody responses to T-dependent protein antigens in mice (3-5), guinea pigs (6), rhesus monkeys (7), and baboons (8). Antibody responses induced by QS-21-adjuvanted vaccines were shown to be higher than antibody responses with aluminum hydroxide-adjuvanted vaccines and were similar to those obtained with Freund's com-plete-adjuvanted (FCA) vaccines (3,6). QS-21 is also a strong adjuvant for From Methods in Molecular Medicine, Vol. 42 Vaccine Adjuvants Preparation Methods and Research Protocols Edited by D. T. O'Hagan Humana Press, Inc., Totowa, NJ Fig. 1. Influence of QS-21 on mouse IgG subclasses. Balb c mice (five per group) were immunized with KLH (2.5 g) without adjuvant, with 20 g QS-21, 2.5 g aluminum hydroxide or the combination of QS-21 aluminum hydroxide. Vaccines were given by sc route on days 0, 14, and 28. Sera was collected at day 42 for analysis of...

Terry Ulrich 1 Introduction

Interest in new methods of potentiating the immune response against vaccine antigens has increased considerably over the past decade. In part, this interest is in response to vaccine initiatives that have established aggressive goals for improving existing vaccines and for developing much-needed new vaccines. Many of the candidate vaccine antigens being developed as part of this effort are synthetic or recombinant subunit structures that are often poorly immunogenic and as such, are unable to elicit protective immune responses in the absence of an adjuvant. Fortunately, our understanding of disease patho-genesis and the immunological mechanisms of protection have increased considerably over the past few years, thus providing an improved rational basis for the development of new adjuvants. From Methods in Molecular Medicine, Vol. 42 Vaccine Adjuvants Preparation Methods and Research Protocols Edited by D. T. O'Hagan Humana Press, Inc., Totowa, NJ Aqueous dispersions of MPL in isotonic...

Erik B Lindblad 1 Introduction

Freund's adjuvants are water-in-mineral oil emulsions (W O emulsions) without heat-killed mycobacteria added (Freund's incomplete adjuvant) or with heat-killed mycobacteria added (Freund's complete adjuvant). Freund's adjuvants are, in a way, historic adjuvants and for many researchers the first and most obvious association to the word adjuvant at all. The adjuvants have been used extensively in experimental immunology owing to their high efficacy, and Freund's incomplete adjuvant has been used for decades in practical veterinary vaccination. Vaccination of humans with Freund's incomplete adjuvant was undertaken in the 1950s and was stopped because of adverse reactions in the mid-1960s. From Methods in Molecular Medicine, Vol. 42 Vaccine Adjuvants Preparation Methods and Research Protocols Edited by D. T. O'Hagan Humana Press, Inc., Totowa, NJ

Historical Background

The first evidence of the use of oil emulsions as adjuvants in vaccine formulations dates back to 1916. At that time, Le Moignic and Pinoy immunized mice with heat-inactivated Salmonella typhimurium in an emulsion of water and vaselin oil, using lanolin as an emulsifier (1). The oil emulsions as adjuvants, however, did not receive much attention before Jules Freund and coworkers (2,3) decades later combined a paraffin (mineral) oil emulsion and heat-killed mycobacteria to produce an extremely potent adjuvant, Freund's complete adjuvant (FCA). FIA has been included in veterinary, as well as human, vaccines. The veterinary vaccines included vaccines against foot-and-mouth disease (5), equine influenza virus (6), hog cholera (7), rabies (8), parainfluenza 3 (9), Newcastle disease (10), and infectious canine hepatitis (11). In cattle, FIA was inefficient in combination with herpesvirus (12). In humans, FIA was used for a period of about two decades, particularly with vaccines against...

Gregory M Glenn Tanya Scharton Kersten and Russell Vassell 1 Introduction

Transcutaneous immunization (TCI), the introduction of antigens using a topical application to intact skin, is a new technology that has both practical and immunological merits. Practically speaking, a needle-free method of vaccine delivery will decrease the risk of needle-borne diseases, reduce the complications related to physical skin penetration, improve access to vaccination by eliminating the need for trained personnel and sterile equipment, and provide a simple means for multivalent or multiple boosting immunization. The immunological implications of TCI are profound as this technique appears to target highly accessible antigen presenting cells (APC) in the skin that can be exploited for a variety of immune outcomes. It has been our experience that TCI can be reliably and reproducibly conducted with a variety of antigens to induce potent and functional immune responses. Thus, this new method may significantly impact both the delivery of vaccines and open new possibilities for...

Sarah C Gilbert 1 Introduction

Adjuvants are available to promote the generation of antibodies to an antigen following immunization. However, many of these adjuvants do not enhance priming of cytotoxic T lymphocytes (CTL). The reason for this lies in the existence of two alternative antigen processing pathways, leading to stimulation of CD4+ T cells, and, in turn, to the generation of antibodies, or stimulation of CD8+ CTL. In general, exogenous proteins enter the antigen presenting cell (APC) by endocytosis. Peptides produced by proteolytic degradation of these proteins bind to major histocompatibility complex (MHC) Class II molecules that travel to the surface of the cell before stimulating CD4+ T cells. Peptides derived from cytoplasmic proteins are translocated into the endoplasmic reticulum and bind to MHC Class I molecules. When these reach the surface of the APC, they prime CD8+ CTL. Thus to generate a CTL response following immunization, it is necessary to feed peptides into the correct processing pathway....

Rajesh K Gupta and Bradford E Rost 1 Introduction

Aluminum compounds, including aluminum phosphate (AlPO4), aluminum hydroxide (Al(OH)3), and alum precipitated vaccines, historically referred to as protein aluminate, are currently the most commonly used adjuvants with human and veterinary vaccines (1-6). These adjuvants are often referred to as alum in the literature, which is misleading because (1) two most widely used adjuvants from this group, aluminum hydroxide and aluminum phosphate, have very different physical characteristics (7) and differ in their adjuvant properties (3,6) and (2) alum, chemically potassium aluminum sulfate (KAl(SO4)2.12H2O), has not been used as an adjuvant as such. Alum was originally used to partially purify protein antigens, mainly tetanus and diphtheria toxoids, by precipitating them in the presence of anions including phosphate, sulphate, and bicarbonate ions resulting in a mixture of compounds, mainly aluminum phosphate and aluminum hydroxide (4,8,9). The amounts of aluminum phosphate and aluminum...

Composition of Mineral Oil Adjuvants

Several pharmacopeias contain a set of specifications for the mineral oil petrolatum or paraffinum liquidum intented for general pharmaceutical use, e.g., as a laxative. However, following the work of Friedewald (19), Henle and Henle (20), and Salk (21,22) leading to a mineral oil-influenza vaccine for humans in the mid-1940s and early 1950s, a special set of requirements was set up for acceptance of the mineral oil preparation for adjuvants. This so-called Tentative Draft, Minimum Requirements for Influenza Vaccines Emulsified in Mineral Oil was prepared by The National Institutes of Health, USA, in 1956

Immunopotentiating Reconstituted Influenza Virosomes

Twenty years after the discovery of the immunological adjuvant properties of liposomes (25) and the ensuing multitude of related animal immunization studies (26), liposomes as adjuvants have come of age (27,28) with the first liposome-based vaccine against hepatitis A being licensed for use in humans. Vaccines based on novasomes (nonphospholipid biodegradable, pausilamellar vesicles formed from single-chain amphiphiles, with or without other lipids) have also been licensed for the immunization of fowl against Newcastle disease virus and avian reovirus (29). The approach adapted for the IRIV vaccines is of particular interest, as it combines several components that are known to contribute to immunostimulation and that are at the same time harmless. Furthermore, influenza A virus has been described as a model system for the study of viral antigen presentation to CTL (37). In the clinical part of this chapter, the potent effect of IRIV designed influenza vaccine on the cellular immune...

Definitions

The discussion of vaccine adjuvants will be facilitated by a definition of terms. The term adjuvant (from the latin, adjuvare help) was first coined by Ramon in 1926 for a substance used in combination with a specific antigen that produces more immunity than the antigen used alone (12). The enormous diversity of compounds that increase specific immune responses to an antigen and thus function as vaccine adjuvants makes any classification system somewhat arbitrary. Adjuvants in Table 1 are grouped according to origin rather than according to mechanism of action, because the mechanism for most adjuvants are incompletely understood. Cox and Coulter (10) have recently classified adjuvants into two broad groups, particulate or nonparticulate. Within each group, an adjuvant may act in one or more of five ways, based on current knowledge namely, immunomodulation, presentation, induction of CD8+ cytotoxic T-lymphocyte (CTL) responses, targeting, and depot generation. These five basic...

Local Reactions

The most frequent adverse side effect associated with adjuvanted vaccines is the formation of local inflammation with signs of swelling and erythema, and symptoms of tenderness to touch and pain on movement. Such reactions occur more frequently in preimmune individuals, or after repeated immunization (24). The inflammation is thought to be the result of formation of inflammatory immune complexes at the inoculation site by combination of the vaccine antigen with preexisting antibodies and complement, resulting in an arthus-type reaction. Such reactions tend to occur more frequently after adjuvanted vaccines than after aqueous vaccines because of the high antibody titers induced by adjuvants. contamination of the vaccine at the time of formulation with reactogenic chemicals and microbial products, (2) instability of the vaccine on storage with breakdown into reactogenic side products, and (3) poor biodegradability of the adjuvanted vaccine resulting in prolonged persistence in the...

Animal Models

Different animal species, and different strains within a species, may behave differently to the same adjuvant. Intraspecies variation in immune response to adjuvants and vaccines is particularly true among mouse strains (9,83). For this reason, preclinical studies in one strain of a single animal species should be interpreted with caution. Again and again, we have discovered that biological differences between animal models and humans have led to the failure of formulations in clinical trials after showing great promise in preclinical studies. Guinea pigs have been used widely for vaccine quality control, and guinea pigs may be the animal of choice for evaluating adjuvant formulations (3), although the absence of reagents to analyze guinea pig cytokines and IgG subclasses may impede full utilization. Recently, a useful rabbit model has been described by FDA and NIH investigators to evaluate the toxicity and adjuvanticity of adjuvant formulations (52). The rabbit model provides a new...

Immunoassays

The induction of protective immunity depended upon the quality rather the quantity of antibody, that is, induction of antibody of the appropriate isotype and fine-epitope specificity. This induction was dependent upon unique, poorly understood interactions between the adjuvant, the antigen, and the host. The conclusions from such experience suggests that the search for an effective vaccine must involve both antigens and adjuvants from the start of preclinical development, and that no adjuvant can be considered a gold standard (8).

Studies in Humans

Two large clinical trials have compared adjuvanted HIV vaccines (62,71) and adjuvanted malaria vaccines (28) in healthy young adult volunteers. These trials illustrate results that can be obtained from comparative adjuvanted vaccine trials in volunteers using similar clinical protocols. In a phase 1, doubleblind, randomized, placebo-controled trial in healthy adults, 50 g of HIV gp120 was combined with one of seven adjuvants (62). The summary of side effects caused by these vaccines and additional HIV vaccine using similar protocols (71) was discussed in Subheading 6.2. Each adjuvanted vaccine was injected into 15 persons at 0, 2, 6, and 18 mo. The adjuvants included aluminum hydroxide, MPL , liposome- encapsulated MPL with aluminum, MF59, MF59 MTP-PE, SAF, and SAF threonyl-MDP. The group that received SAF threonyl-MDP was significantly more likely to experience moderate or severe local and systemic reactions compared to all other groups combined, but this group and the SAF...

Discussion

Manufacturers are expected to provide safety data sheets for their products and these will confirm the lack of toxicity of the product (see Note 4), but the addition of the vaccine candidate antigen may also alter the overall reactivity of the complete vaccine. Therefore, it is unwise to rely completely on manufacturer's specifications alone. Before evaluating the possible toxicity of a new adjuvant formulation, it is assumed that the investigator will have checked for either the innate toxicity of the antigen preparation, e.g., for lipopolysaccharide (endotoxin), or for chemicals used in antigen preparation, e.g., formaldehyde, glutaraldehyde, sodium azide. The inoculation mixture should be prepared aseptically to minimize contamination with endotoxins. In addition, the immunogen itself may have innate adjuvant activity and this should be checked before preparing complex adjuvant formulations. Conjugation of the immunogen to a carrier may impart innate adjuvant activity (see Note 5)....

Aluminum Hydroxide

Currently, the most commonly used method for preparation of aluminum adsorbed vaccines is adsorption of antigens onto preformed aluminum hydroxide or aluminum phosphate gels under controled conditions (3,15). Antigens can also be adsorbed onto these aluminum gels during their preparation (in situ adsorption). These preparations made by adsorption onto preformed gels or by in situ adsorption are usually referred to as aluminum hydroxide or aluminum phosphate adsorbed or adjuvanted vaccines. Tetanus toxoid adsorbed onto pre formed aluminum hydroxide and aluminum phosphate gels had 60 of the potency of vaccine to that adsorbed by in situ method (22). Gels of aluminum phosphate and aluminum hydroxide, of clinical grade, are commercially available. Adsorption onto preformed gels, bought from commercial sources or prepared in-house, is carried out by incubating the gel and the antigen, at optimal pH, with slow stirring for a few hours to overnight (4) at 4 C to room temperature. Though it...

Samir N Khleif

Vaccine Branch, National Cancer Institute Bethesda Naval Hospital Bethesda, MD, U.S.A King Hussein Cancer Center, Amman, Jordan Tumor Immunology and Cancer Vaccines edited by Samir Khleif p. cm. - (Cancer treatment and research 123) Includes indes. ISBN 1-4020-8119-7 e-Book ISBN 1-4020-8120-0 1. Tumors Immunological aspects. 2. Cancer vaccines. I. Khleif, Samir. II. Series. DNLM 1. Cancer Vaccines. 2. Neoplasms immunology. 3. Antigens, Neoplasm. QZ266 T9252 2004 QR188.6.T8615 2004

Conclusions

PMMA nanoparticles are polymeric particulate adjuvants for vaccines. These nanoparticles can easily be manufactured in a reproducible manner in the described particle sizes and with specific surface properties. Scale-up of the production process is also facile (20). PMMA is a material with a good safety record that has been used in humans for more than 50 yr. PMMA nanoparticle adjuvants achieved good antibody responses and good protection against challenge with a number of antigens. Additionally, they also seem to lead to a higher stability of the vaccines containing this type of adjuvant.

Safety

As part of the release testing of materials for use in the first Phase 1 clinical trial of CRL-1005, the formulations were evaluated in the General Safety Test required by the United States Food and Drug Administration for vaccines (20). Because the copolymer and the antigen (PhCG-CTP37-DT) were to be administered im to patients in a 1-mL volume at 4 dose combinations of constant antigen dose and escalating adjuvant doses, the General Safety Test was performed with 0.5-mL and 5.0-mL volumes of the following human doses in mice and guinea pigs, respectively The data summarized above support the safety and lack of toxicity of copolymer adjuvant CRL-1005. The copolymer is not inherently pyrogenic and aqueous clinical materials have been repeatedly manufactured with undetectable endotoxin concentrations. In addition, the General Safety Tests in mice and guinea pigs indicated that large doses of the vaccine formulations have low toxicity. Finally, the preclinical study in rabbits and the...

DNA Cochleates

Cochleates are also highly effective carriers for DNA vaccines (16-19, and in preparation). Cochleates have been used to mediate the in vivo delivery and expression of a plasmid coding for the env, tat, and rev genes of HIV-1 (16,17, and in preparation). Induction of gp160 (env) specific splenocyte proliferation and cytotoxic lymphocyte activity was observed following oral, as well as im, administration of DNA-cochleate formulations. The cochleates induced superior responses compared to naked DNA or DNA encapsulated in fusogenic proteoliposomes (17). Strong cytolytic and proliferative responses were induced to a single im injection of 3 or 17 g encochleated DNA. Whereas 50 g naked DNA generated little or no cytolytic or proliferative activity. Oral delivery, by swallowing cochleates at 0 and 4 wk, led to responses that were equivalent to those achieved intramuscularly. In contrast, a larger dose of naked DNA swallowed yielded no measurable proliferative or cytolytic responses (16,17,...

Summary

Ment of preventive and therapeutic vaccines. Current work focuses on the development of cochleates as safe and efficient protein- and nucleotide-based vaccines for the induction of mucosal and systemic immunity in humans and animals. Applications in gene therapy and drug delivery are also being developed (26,27).

LC Dialysis Method

This method for encochleation involves the removal of detergent from a solution of lipid and material to be encochleated, followed by addition of calcium. This method is particularly suited to the formulation of vaccines containing membrane proteins with intact transmembrane regions (see Notes 1, 5, 6 below for more details and references), or peptides with hydrophobic tails (see Note 7 below and ref. 29).

Adjuvant Potency

The success of any vaccine adjuvant formulation is dependent upon fulfillment of several requirements. The most important of these are potency, tolerable reactogenicity, and pharmaceutical feasibility. In order to be protective, the antigen adjuvant formulation must have a specific potency for generation of the appropriate immune function. It is useful to classify adjuvants in terms of their performance regarding the correlation of immunity historically established for a variety of disease models. The generation of neutralizing antibody, present in serum or at mucosal surfaces, has frequently been correlated with protection (1). The presence of specific antibody subtypes and the demonstration of antibody-dependent cellular cytotoxicity are likely to be associated with protection in some cases. Generation of cellular immunity, most particularly, cytotoxic T-lymphocytes (CTLs), has been thought to be contributory to protection in other cases. Finally, generation of specific cytokine...

Source

QS-21 is an immunological adjuvant derived from a natural source the bark of the South American tree Quillaja saponaria Molina. Crude extracts of Quillaja saponaria bark were found to have adjuvant activity in foot-and-mouth disease vaccines in cattle (1). These extracts consisted of a complex mixture of tannins, polyphenolics, and triterpene glycoside saponins. The adjuvant activity was determined to be in the saponin fraction (2). This was later fractionated by high-performance liquid chromatography (HPLC) into at least 23 different triterpene glycoside saponins with a varying range of biological activity for adjuvanticity, surfactant properties, and toxicity (3). QS-21 was identified as a saponin with potent adjuvant activity and low toxicity (3). It can be purified to near homogenity via preparative HPLC. The high level of purity and standardization of the QS-21 saponin adjuvant has enabled evaluation of this compound in clinical trials of experimental vaccines.

Interleukin12 IL12

Because IL-12 is secreted by activated professional APCs, the cytokine can influence T-cell development during antigen priming. This influence has been shown to be preferential toward the development of TH1 cells (5). Therefore, if vaccines are intended to drive the immune response toward a TH1 profile, the addition of IL-12 to the immunization regimen would be beneficial. This has been shown to be true in a model of experimental murine Leishmania (6). Susceptible Balb c mice were injected on days 0 and 10 with soluble Leishmanial antigen (SLA) plus IL-12 protein. The mice were then challenged 14 d later with Leishmania major. The combined immunization regimen conferred protection and was mediated by IFNy. Antigen or IL-12 alone had no protective effect. Therefore, IL-12 can shift T-helper cell phenotype from susceptible TH2 to the resistant TH1 path. Similar results have been shown in a murine model of experimental toxoplasmosis (7). Gene therapy of IL-12 coadministered with a DNA...

Background

From Methods in Molecular Medicine, Vol. 42 Vaccine Adjuvants Preparation Methods and Research Protocols Edited by D. T. O'Hagan Humana Press, Inc., Totowa, NJ CT and the closely related heat labile enterotoxin from Escherichia coli have been extensively studied as adjuvants, providing an enormous fund of knowledge for the development of TCI (1,2). CT is an 86 kDa heterodimeric protein secreted by the bacterium Vibrio cholerae which, when administered perorally or intranasally, induces antibody responses against both itself and coadministered proteins. The strength of the immune enhancement contributed by the use of CT has established CT as the gold standard for mucosal adjuvants (2,3). However, the perceived toxicity of CT and the LT have limited widespread use of these proteins as vaccine components and adjuvants and has led to mucosal strategies using nontoxic mutants (4,5) and purified B-subunits (6,7). Our finding that application of CT to the skin induces robust immune responses...

Aluminum Phosphate

Like aluminum hydroxide, aluminum phosphate is the most widely used adjuvant with routine human vaccines. Most of the vaccine manufacturers throughout the world prepare this adjuvant in-house. Usually, antigens are adsorbed onto a preformed gel, which can be made by several methods (two methods are described in this chapter). Adsorption of antigens is also carried out on freshly prepared aluminum phosphate gel (23). In situ adsorption of antigens onto aluminum phosphate is preferable to aluminum hydroxide, because pH of the solution (disodium phosphate) in which the antigens are suspended for making aluminum phosphate is not as high as of sodium hydroxide used for making aluminum hydroxide. In situ adsorption of antigens on aluminum phosphate has been carried out by suspending purified vaccine antigens in dibasic or tribasic sodium phosphate or phosphate buffer and precipitating with aluminum chloride (3,7,22). This type of reaction can be carried out under controled conditions and...

Hemolysis Test

At very low concentrations, adjuvants should not be hemolytic. This is particularly relevant for the crude, triterpenoid plant saponins, which reportedly destroy erythrocytes if injected intravenously, although this effect may be owing to contaminatory substances (7). The immune stimulating complexes (ISCOMs see Chapter 14) contain a saponin, which is also used to produce the positive 100 lysis of erythrocytes in the method below. It is often stated that such complexes cannot be used in vaccines because of the hemolytic properties of this component, however, no such drastic hemolysis has been detected in the numerous successful studies with ISCOM vaccines in animals. Nevertheless, it is wise to check for the hemolytic activity of a new adjuvant compound either separately, or chemically conjugated to antigen, or in combination with an antigen in the final vaccine formulation. It is obviously very important to check new adjuvant preparations for hemolytic activity against erythrocytes...

Protein Cochleates

Summary of Cochleate Vaccine Studies Summary of Cochleate Vaccine Studies DNA (polynucleotide) vaccines Cochleate vaccine infectious dose challenge with viruses administered parenterally and mucosally has also been achieved (see Table 1 for summary) (14-19, and manuscripts in preparation). For example, cochleate vaccines containing the glycoproteins and lipids from the envelope of influenza virus were given to mice by gradually dispensing liquid into the mouth and allowing it to be swallowed (14, and in preparation). This study demonstrated that high circulating antibody titers could be achieved by simply drinking cochleate vaccines containing influenza virus glycoproteins. The response was boosted by repeated administration and was dose related to the amount of glycoprotein used. Hemagglutination inhibition titers indicated maintenance of the native viral glycoprotein conformation and induction of neutralizing antibodies following cochleate formulation and oral administration. Strong...

Viruses Cause Disease But Are Also Useful as Tools

Viruses are of intense interest because many cause serious illness in humans or domestic animals, and others damage crop plants. During the last century, progress in the control of infectious diseases through improved sanitation, safer water supplies, the development of antibiotics and vaccines, and better medical care have dramatically reduced the threat to human health from these agents, especially in developed countries. This is illustrated in Fig. 1.1, in which the death rate from infectious disease in the United States during the last century is shown. At the beginning of the 20th century, 0.8 of the population died each year from infectious diseases. Today the rate is less than one-tenth as great. The use of vaccines has led to effective control of the most dangerous of the viruses. Smallpox virus has been eradicated worldwide by means of an ambitious and concerted effort, sponsored by the World Health Organization, to vaccinate all people at risk for the disease. Poliovirus has...

Using Local Resources To Meet Needs

Some activities require outside resources (materials, money, or people from somewhere else). For example, a vaccination program is possible only if vaccines are brought in often from another country. Some outside resources, such as vaccines and a few important medicines, can make a big difference in people's health. You should do your best to get them. But as a general rule, it is in the best interest of your people to

Limiting The Distribution Of Tropical Infectious Diseases By Public Health Measures

The distribution of tropical infections can be modified by public health measures. Vaccines, vector control by source reduction and pesticides, treatment, improvement of housing, and drug prophylaxis have been used to limit the distribution of tropical infectious diseases and, at least in the case of smallpox, to eradicate the disease. Several vector-borne diseases, including malaria and yellow fever, were prevalent in the American and Afro-European temperate regions during the 1700s and 1800s. These diseases disappeared outside of the tropics, and some were controlled within the tropics. Sanitation, a raised standard of living, and new technology were primarily responsible. The successes are well-known to most readers. Smallpox was eradicated by 1977 using case finding and vaccination.19 Major cities were freed of urban yellow fever by control of A. aegypti mosquitoes using pesticides and destruction of breeding sites following the methods of General Gorgas.20 Malaria was eliminated...

Unknown Factors Limiting Distribution Absence Of Yellow Fever From Asia

This hypothesis has been tested in the laboratory. Although many of the strains from Asia had reduced ability to become infected,29 the differences were relatively small and did not offer a convincing explanation. Possibly, immunity in humans or primates to dengue or other flaviviruses (serologically related to yellow fever) prevented infection. When challenged with yellow fever virus, monkeys immune to dengue had lower viremia levels than did nonimmune monkeys30 however, flavivirus immunity in Africa and South America is substantial and does not prevent yellow fever transmission on those continents. Thus, the factor(s) limiting the geographic distribution of yellow fever remains unknown. If, as some believe, it is a numbers game, and the introduction of yellow fever virus has not yet coincided with the presence of A. aegypti in sufficient abundance and during the right season to establish an epidemic, then Asia and the rest of the world must maintain...

Infectious Disease Terms

In real epidemics, it is useful to replace the basic reproductive number with the effective reproductive number, denoted R, which is defined as the actual average number of secondary cases infected by a primary case. R is usually less than R0, since it reflects both the impact of control measures instituted over time and the depletion of a susceptible population as previously infected individuals acquire immunity. Herd immunity results when a vaccine not only protects a vaccinated individual from contracting an infection but also prevents that individual from spreading the infection to others.

Army Immunization Program

Military dependents remaining in or traveling in Area I are eligible for immunizations. Those traveling to or living outside Area I are also eligible for immunizations. Infants three months of age or older are required to have begun immunizations prior to travel outside Area I. NOTE Administration of any live virus vaccines, except oral poliovirus vaccine is considered to be medically contraindicated during pregnancy. A temporary waiver should be granted in this situation, and the individual should be advised of the possibility of detention or quarantine while traveling outside Area I. (1) Federal civilian employees of the Armed Forces who are exposed to risk of disease such as tetanus, smallpox, or other infectious diseases associated with their occupation or service with the Armed Forces will be immunized with an appropriate vaccine upon the recommendation of the staff medical officer. These immunizations will be administered at military activities without...

Infectious Mononucleosis

Amantidine or rimantadine for influenza A (zanamivir or oseltamivir for influenza A and B) ventilatory support, antipyretics, and IV fluids. Secondary staphylococcal pneumonia should be treated with parenteral antibiotics yearly vaccination prevents excessive morbidity and mortality, especially among the elderly.

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