Human diploid cell rabies vaccine. Effectiveness of immunization with small intradermal or subcutaneous doses

Fractional dose of intradermal compared to intramuscular and subcutaneous vaccination - A systematic review and meta-analysis

BACKGROUND

Vaccine supply shortages are of global concern. We hypothesise that intradermal (ID) immunisation as an alternative to standard routes might augment vaccine supply utilisation without loss of vaccine immunogenicity and efficacy.

METHODS

We conducted a systematic review and meta-analysis searching Medline, Embase and Web of Science databases. Studies were included if: licensed, currently available vaccines were used; fractional dose of ID was compared to IM or SC immunisation; primary immunisation schedules were evaluated; immunogenicity, safety data and/or cost were reported. We calculated risk differences (RD). Studies were included in meta-analysis if: a pre-defined immune correlate of protection was assessed; WHO-recommend schedules and antigen doses were used in the control group; the same schedule was applied to both ID and control groups (PROSPERO registration no. CRD42020151725).

RESULTS

The primary search yielded 5,873 articles, of which 156 articles were included; covering 12 vaccines. Non-inferiority of immunogenicity with 20-60% of antigen used with ID vaccines was demonstrated for influenza (H1N1: RD -0·01; 95% CI -0·02, 0·01; I2 = 55%, H2N3: RD 0·00; 95% CI -0·01, 0·01; I2 = 0%, B: RD -0·00; 95% CI -0·02, 0·01; I2 = 72%), rabies (RD 0·00; 95% CI -0·02, 0·02; I2 = 0%), and hepatitis B vaccines (RD -0·01; 95% CI -0·04, 0·02; I2 = 20%). Clinical trials on the remaining vaccines yielded promising results, but are scarce.

CONCLUSIONS

There is potential for inoculum/antigen dose-reduction by using ID immunisation as compared to standard routes of administration for some vaccines (e.g. influenza, rabies). When suitable, vaccine trials should include an ID arm.

A Recombinant Rabies Virus Expressing the Marburg Virus Glycoprotein Is Dependent upon Antibody-Mediated Cellular Cytotoxicity for Protection against Marburg Virus Disease in a Murine Model

Marburg virus (MARV) is a filovirus related to Ebola virus (EBOV) associated with human hemorrhagic disease. Outbreaks are sporadic and severe, with a reported case mortality rate of upward of 88%. There is currently no antiviral or vaccine available. Given the sporadic nature of outbreaks, vaccines provide the best approach for long-term control of MARV in regions of endemicity. We have developed an inactivated rabies virus-vectored MARV vaccine (FILORAB3) to protect against Marburg virus disease. Immunogenicity studies in our labs have shown that a Th1-biased seroconversion to both rabies virus and MARV glycoproteins (GPs) is beneficial for protection in a preclinical murine model. As such, we adjuvanted FILORAB3 with glucopyranosyl lipid adjuvant (GLA), a Toll-like receptor 4 agonist, in a squalene-in-water emulsion. Across two different BALB/c mouse challenge models, we achieved 92% protection against murine-adapted Marburg virus (ma-MARV). Although our vaccine elicited strong MARV GP antibodies, it did not strongly induce neutralizing antibodies. Through both in vitro and in vivo approaches, we elucidated a critical role for NK cell-dependent antibody-mediated cellular cytotoxicity (ADCC) in vaccine-induced protection. Overall, these findings demonstrate that FILORAB3 is a promising vaccine candidate for Marburg virus disease.IMPORTANCE Marburg virus (MARV) is a virus similar to Ebola virus and also causes a hemorrhagic disease which is highly lethal. In contrast to EBOV, only a few vaccines have been developed against MARV, and researchers do not understand what kind of immune responses are required to protect from MARV. Here we show that antibodies directed against MARV after application of our vaccine protect in an animal system but fail to neutralize the virus in a widely used virus neutralization assay against MARV. This newly discovered activity needs to be considered more when analyzing MARV vaccines or infections.

[Analysis of determination of rabies virus neutralizing antibody titres in the sera of vaccinated humans.]

INTRODUCTION

Rabies is an infectious disease that is always fatal following the onset of clinical symptoms. The only way to prevent the cases of rabies in humans is timely carried out the rabies post-exposure prophylaxis in accordance with the recommended schedule.

OBJECTIVES

The aim of the study was to characterize the level of immune response in persons that received a post-exposure prophylaxis against rabies, to consider the role of the factors of the formation immune responses to rabies vaccines.

MATERIAL AND METHODS

In the laboratory of viral vaccines of the Scientific Centre for Expert Evaluation of Medicinal Products, the 48 sera of patients that received the post-exposure prophylaxis of rabies after wounds from a rabid or suspected rabid animal has been studied. The titer of virus neutralizing antibodies (VNA) to the rabies virus in the sera of the vaccinated not less than 1:64 (corresponding to a level of VNA at least 0,5 IU /ml) in the mouse neutralization test indicates the effective vaccination.

RESULTS AND DISCUSSION

Our data confirm the absence of statistically significant differences in the level of VNA in the vaccinated persons that received a complete and incomplete (5 doses) course of post-exposure vaccination against rabies. Depending on the level of VNA, all patients are divided into groups with conditionally low, medium and high content of antibodies in sera.

CONCLUSION

It has been shown that in most cases properly administered vaccination contributed to the formation of effective immune response. The lack of a protective level of BHA requires additional administration of the vaccine and analysis of the factors that influenced the ineffectiveness of vaccination. In some patients the determination of rabies virus neutralizing antibody titres is necessary.

Intradermal vaccination using the novel microneedle device MicronJet600: Past, present, and future

Intradermal immunization has become a forefront of vaccine improvement, both scientifically and commercially. Newer technologies are being developed to address the need to reduce the dose required for vaccination and to improve the reliability and ease of injection, which have been major hurdles in expanding the number of approved vaccines using this route of administration. In this review, 7 y of clinical experience with a novel intradermal delivery device, the MicronJet600, which is a registered hollow microneedle that simplifies the delivery of liquid vaccines, are summarized. This device has demonstrated both significant dose-sparing and superior immunogenicity in various vaccine categories, as well as in diverse subject populations and age groups. These studies have shown that intradermal delivery using this device is safe, effective, and preferred by the subjects. Comparison with other intradermal devices and potential new applications for intradermal delivery that could be pursued in the future are also discussed.

Intradermal rabies vaccination: the evolution and future of pre- and post-exposure prophylaxis

Inactivated rabies vaccines have been used to pioneer the immunological and economical advantages of intradermal (ID) administration over 35 years. Vaccine shortages or its prohibitive cost stimulated studies of various doses, frequency and sites of injection. An economical regimen for pre-exposure prophylaxis requires one-tenth of an intramuscular dose, but the early popularity of the method has been stifled by pharmaceutical regulations. There has also been reluctance to use multiple-site post-exposure ID regimens, except in a very few Asian counties. A new four-site ID regimen could overcome many of the problems encountered to date. The time is ripe to make dramatic progress towards efficient use of the current excellent vaccines globally, wherever there is a shortage of vaccine or funds.

Safety and efficacy of novel dermal and epidermal microneedle delivery systems for rabies vaccination in healthy adults

In the present pilot study, intradermal ID delivery systems with a BD microneedle from 1 to 3mm in length, and epidermal delivery (BD skin abrader) through abraded skin surface relative to standard intramuscular injection were evaluated. Circulating neutralizing antibodies were measured against the rabies virus after the Vero cells rabies vaccine was administered at D0, D7, D21 and D49. This clinical evaluation in 66 healthy volunteers shows that ID delivery using BD microneedle technology of 1/4 the IM antigen dose is safe, efficient and reliable, resulting in a protective seroconversion rate. In contrast, the epidermal delivery route did not produce an immune response against the rabies vaccine.

Surgical Infection Society Guidelines for Vaccination after Traumatic Injury

BACKGROUND

Recommendations for vaccination of injured patients against infection are evolving. Newly-recognized infections, safety considerations, changing epidemiology, and redefinition of patient groups at risk are factors that may influence vaccine development priorities and recommendations for immunization. However, recommendations must often be formulated based on incomplete data, forcing reliance on expert opinion to address some crucial questions. These guidelines provide evidence-based recommendations for the prevention or treatment of infectious morbidity and mortality after traumatic injury, such as soft tissue wounds, human or animal bites, or after splenectomy.

METHODS

A panel of experts conducted a thorough review of published literature, as well as information posted on the internet at the websites of the U.S. Centers for Disease Control and Prevention, among others. MEDLINE was searched for the period 1966-2004 using relevant terms including "anthrax," "rabies," "tetanus," "tetanus toxoid," and " splenectomy," in combination with "vaccine" and "immunization." The Cochrane database was searched also. Reference lists were cross-referenced for additional relevant citations. All published reports were analyzed for quality and graded, with the strength of the recommendation proportionate to the quality of the supporting evidence.

RESULTS

Recommendations are provided for pre- and post-exposure prophylaxis of rabies and anthrax. For tetanus prophylaxis, recommendations are provided for prophylaxis of acute wounds stratified y age and prior immunization status, and for immunization of persons at high risk. After splenectomy, it is recommended that all persons ages 2-64 years receive 23- valent pneumococcal vaccine and meningococcal vaccine, with Haemophilus influenzae type B vaccine administered to high-risk patients as well (all are Grade D recommendations). Vaccination should be given two weeks before elective splenectomy (Grade C), or two weeks after emergency splenectomy (Grade D). A booster dose of pneumococcal vaccine is recommended after five years (Grade D); no re- vaccination recommendation is made for meningococcal or Haemophilus influenzae type B vaccine. Recommendations for prophylaxis of splenectomized children under the age of five years are also provided.

CONCLUSION

There are limited data on the use of vaccines after injury. This document brings together a disparate literature of variable quality into a discussion of the infectious risks after injury relevant to vaccine administration, a summary of safety and adverse effects of vaccines, and evidence-based recommendations for vaccination.

Three-year experience with 4-site intradermal booster vaccination with rabies vaccine for postexposure prophylaxis

For booster vaccination of previously immunized persons with potential exposure to rabies, the World Health Organization recommends 2 doses of cell-culture vaccine administered intramuscularly or intradermally on days 0 and 3. We believe that four 0.1-mL intradermal booster doses given on a single day could be used at no risk to the recipient. We studied use of a single booster vaccination on day 0 followed by four 0.1-mL intradermal doses of cell-culture rabies vaccines, and we determined that this is a safe, convenient, and economical regimen for postexposure treatment of previously vaccinated individuals.

Persistence of antibodies in children after intradermal or intramuscular administration of preexposure primary and booster immunizations with purified Vero cell rabies vaccine

BACKGROUND

The use of intradermal (i.d.) injections of purified Vero cell rabies vaccine (PVRV) for preexposure prophylaxis has not been well-established. We studied the safety and immunogenicity of i.d. and intramuscular (i.m.) PVRV injections for primary and booster preexposure immunizations.

METHODS

One of two rabies preexposure PVRV regimens comprising three doses of either 0.1 ml i.d. or 0.5 ml i.m. administered during 28 days was assigned at random to 190 school children. One booster dose was given 1 year later either i.d. or i.m., according to their initial randomization group. Serologic results were available from 155 (82%) children at 1 year after primary immunization and 118 (62%) children at 2 years after booster.

RESULTS

Although children vaccinated i.d. had significantly lower rabies-neutralizing antibody titers after primary immunization as well as after booster than children vaccinated i.m. (P< 0.001 for all time points), there were no significant differences in the percentages of children with adequate titers (> or =0.15 IU/ml) between the i.d. and i.m. groups after both primary and booster immunizations. Mild local reactions were more frequent after i.d. vaccination. Mild or moderate systemic reactions were infrequent and similar after i.d. and i.m. vaccinations. Fever and headache were reported by < or =6%. The reactions after booster were not different from those of post-primary immunization.

CONCLUSIONS

Purified Vero cell rabies vaccine appears to be safe and immunogenic for primary and booster preexposure immunizations. An i.d. PVRV preexposure regimen should be useful especially for rabies-endemic countries with low per capita income.

Safety and immunogenicity of Lyssavac Berna human diploid cell rabies vaccine in healthy adults

A clinical trial testing the safety and immunogenicity of a newly developed human diploid cell rabies vaccine (Lyssavac-HDC) was conducted on subjects at three colleges of veterinary medicine in the United States. Lyssavac-HDC is a sterile lyophilized vaccine containing no antibiotics or preservatives and is administered intramuscularly as a 0.5 ml dose of vaccine containing at least 2.5 i.u. of rabies inactivated antigen per dose. Subjects were given either a three dose pre-exposure series (days 0, 7, and 28), followed by one booster dose of vaccine (day 360); or a five dose simulated post-exposure series of injections (days 0, 3, 7, 14, and 28). All subjects in the post-exposure and pre-exposure groups possessed adequate levels of rabies neutralizing antibody (> or = 5) when tested on day 14 and day 28, respectively. Subjects in the pre-exposure group demonstrated a vigorous anamnestic response after the administration of one booster dose of vaccine on day 360. The type and severity of local and systemic reactions observed were comparable to other primary cell culture rabies vaccines. Significantly, there were no type III hypersensitivity reactions reported in subjects previously immunized with Lyssavac-HDC after the administration of a booster dose of vaccine on day 360.

Immunogenicity achieved by the intradermal hepatitis B vaccination programme for US Army soldiers in Korea

Hepatitis B virus (HBV) infections are a significant threat to the 30,000 US Army soldiers stationed in South Korea. Hepatitis B surface antigen carrier rates in some Korean populations may run as high as 15%, and HBV incidence estimates for US soldiers in Korea have ranged from 0.6 to 6% per year. In response to this threat, on 1 October 1986 the US Army instituted a mandatory three-dose (0, 30-60, and 60+ days), 0.1 ml per dose, intradermal (i.d.) immunization regimen for all soldiers bound for permanent assignments in Korea. Although shown to be immunogenic in experimental studies, the i.d. route had never been attempted on as large a scale as in this operational setting. During September 1987, an evaluation of programme compliance and immune response was conducted. For those who received three doses according to schedule, antibody response was similar to that reported by previous controlled trials that used the i.d. approach. The three-dose i.d. series appeared to provide protective antibody levels in at least 67% of soldiers, but, consistent with previous trials, antibody levels were approximately one-half those obtained following intramuscular vaccination. We conclude that, as a cost-reduction strategy, wide-scale use of intradermal hepatitis B vaccine may be useful in situations characterized by short-term increased HBV infection risk.

Immune complex-like disease in 23 persons following a booster dose of rabies human diploid cell vaccine

Following a routine 0.1 ml booster dose of Merieux rabies human diploid cell vaccine (HDCV), administered intradermally, 23(10.2%) of 226 persons had signs and symptoms compatible with an immune complex-like disease. The disease had its onset from 3-13 days after the injection, lasted 1-5 days, and consisted primarily of urticaria (78.3%), macular rash (65.2%), angiooedema (39.1%), and arthralgia (17.4%). None of the cases were considered severe, and all recovered with no sequelae. There were significant differences in attack rates between men (78.3% of all cases) and women, and between those receiving vaccinations on different days. Similar reactions have been reported following intramuscular booster doses of HDCV. Since the Merieux HDCV is used worldwide, physicians administering HDCV must be aware of these adverse reactions and warn patients. Appropriate therapy should be instituted as warranted by severity of reactions.

Use of post-exposure intradermal rabies vaccination in a rural mission hospital

The efficacy of single site, intradermal human diploid cell rabies vaccine (HDCV) was assessed in patients exposed to rabies, who were treated at a rural mission hospital in central Thailand. Intradermal HDCV, 0.1 ml on days 0, 3, 7 and 14, resulted in protective antibody levels by day 14, with measurable titres present at one year. 98% of 219 patients completed primary vaccination and 84% returned for a one-year booster. No case of rabies has been seen in those vaccinated. Intradermal HDCV in small doses has given results superior to those from vaccination with nervous tissue vaccine with conventional schedules. This intradermal HDCV regimen has proved acceptable to patients, and is suitable for post-rabies-exposure care in developing countries where low cost is essential.

Routine pre-exposure rabies prophylaxis: a reassessment

The rational use of rabies biologics is a difficult challenge. Pre-exposure rabies prophylaxis (PRE-RP) is one important rabies prevention strategy currently recommended by the US Public Health Service for groups considered at high risk of exposure to rabies. However, standard post-exposure rabies prophylaxis (POST-RP) appears equally effective in preventing rabies; PRE-RP still requires a limited vaccination series if a rabies exposure occurs and, at current costs, standard POST-RP may be a less expensive strategy than PRE-RP. For PRE-RP, as with other human rabies prevention strategies, the central problem is to obtain reasonable estimates of actual rabies exposure risks, which provide the rationale for well-designed programs.

Intradermal immunization with human diploid cell rabies vaccine: serological and clinical responses of immunized persons to intradermal booster vaccination

Rabies antibody titers ranged from 0-9.3 IU/mL in 117 human volunteers one year after intradermal vaccination with one or two doses of human diploid cell rabies vaccine (HDCV). At that time, each volunteer received one 0.1-mL booster dose of HDCV intradermally. All 117 volunteers showed good anamnestic responses, with antibody titers rising to 0.5-54.3 IU/mL within seven days of booster injection. Vaccine safety was good; only minor reactions were experienced, all of which resolved spontaneously.