A comparison of live and killed influenza-virus vaccines. Report to the Medical Research Council's Committee on Influenza and other Respiratory Virus Vaccines

Vaccines for preventing influenza in healthy children

BACKGROUND

The consequences of influenza in children and adults are mainly absenteeism from school and work. However, the risk of complications is greatest in children and people over 65 years of age. This is an update of a review published in 2011. Future updates of this review will be made only when new trials or vaccines become available. Observational data included in previous versions of the review have been retained for historical reasons but have not been updated because of their lack of influence on the review conclusions.

OBJECTIVES

To assess the effects (efficacy, effectiveness, and harm) of vaccines against influenza in healthy children.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 12), which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE (1966 to 31 December 2016), Embase (1974 to 31 December 2016), WHO International Clinical Trials Registry Platform (ICTRP; 1 July 2017), and ClinicalTrials.gov (1 July 2017).

SELECTION CRITERIA

Randomised controlled trials comparing influenza vaccines with placebo or no intervention in naturally occurring influenza in healthy children under 16 years. Previous versions of this review included 19 cohort and 11 case-control studies. We are no longer updating the searches for these study designs but have retained the observational studies for historical purposes.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed risk of bias and extracted data. We used GRADE to rate the certainty of evidence for the key outcomes of influenza, influenza-like illness (ILI), complications (hospitalisation, ear infection), and adverse events. Due to variation in control group risks for influenza and ILI, absolute effects are reported as the median control group risk, and numbers needed to vaccinate (NNVs) are reported accordingly. For other outcomes aggregate control group risks are used.

MAIN RESULTS

We included 41 clinical trials (> 200,000 children). Most of the studies were conducted in children over the age of two and compared live attenuated or inactivated vaccines with placebo or no vaccine. Studies were conducted over single influenza seasons in the USA, Western Europe, Russia, and Bangladesh between 1984 and 2013. Restricting analyses to studies at low risk of bias showed that influenza and otitis media were the only outcomes where the impact of bias was negligible. Variability in study design and reporting impeded meta-analysis of harms outcomes.Live attenuated vaccinesCompared with placebo or do nothing, live attenuated influenza vaccines probably reduce the risk of influenza infection in children aged 3 to 16 years from 18% to 4% (risk ratio (RR) 0.22, 95% confidence interval (CI) 0.11 to 0.41; 7718 children; moderate-certainty evidence), and they may reduce ILI by a smaller degree, from 17% to 12% (RR 0.69, 95% CI 0.60 to 0.80; 124,606 children; low-certainty evidence). Seven children would need to be vaccinated to prevent one case of influenza, and 20 children would need to be vaccinated to prevent one child experiencing an ILI. Acute otitis media is probably similar following vaccine or placebo during seasonal influenza, but this result comes from a single study with particularly high rates of acute otitis media (RR 0.98, 95% CI 0.95 to 1.01; moderate-certainty evidence). There was insufficient information available to determine the effect of vaccines on school absenteeism due to very low-certainty evidence from one study. Vaccinating children may lead to fewer parents taking time off work, although the CI includes no effect (RR 0.69, 95% CI 0.46 to 1.03; low-certainty evidence). Data on the most serious consequences of influenza complications leading to hospitalisation were not available. Data from four studies measuring fever following vaccination varied considerably, from 0.16% to 15% in children who had live vaccines, while in the placebo groups the proportions ranged from 0.71% to 22% (very low-certainty evidence). Data on nausea were not reported.Inactivated vaccinesCompared with placebo or no vaccination, inactivated vaccines reduce the risk of influenza in children aged 2 to 16 years from 30% to 11% (RR 0.36, 95% CI 0.28 to 0.48; 1628 children; high-certainty evidence), and they probably reduce ILI from 28% to 20% (RR 0.72, 95% CI 0.65 to 0.79; 19,044 children; moderate-certainty evidence). Five children would need to be vaccinated to prevent one case of influenza, and 12 children would need to be vaccinated to avoid one case of ILI. The risk of otitis media is probably similar between vaccinated children and unvaccinated children (31% versus 27%), although the CI does not exclude a meaningful increase in otitis media following vaccination (RR 1.15, 95% CI 0.95 to 1.40; 884 participants; moderate-certainty evidence). There was insufficient information available to determine the effect of vaccines on school absenteeism due to very low-certainty evidence from one study. We identified no data on parental working time lost, hospitalisation, fever, or nausea.We found limited evidence on secondary cases, requirement for treatment of lower respiratory tract disease, and drug prescriptions. One brand of monovalent pandemic vaccine was associated with a sudden loss of muscle tone triggered by the experience of an intense emotion (cataplexy) and a sleep disorder (narcolepsy) in children. Evidence of serious harms (such as febrile fits) was sparse.

AUTHORS' CONCLUSIONS

In children aged between 3 and 16 years, live influenza vaccines probably reduce influenza (moderate-certainty evidence) and may reduce ILI (low-certainty evidence) over a single influenza season. In this population inactivated vaccines also reduce influenza (high-certainty evidence) and may reduce ILI (low-certainty evidence). For both vaccine types, the absolute reduction in influenza and ILI varied considerably across the study populations, making it difficult to predict how these findings translate to different settings. We found very few randomised controlled trials in children under two years of age. Adverse event data were not well described in the available studies. Standardised approaches to the definition, ascertainment, and reporting of adverse events are needed. Identification of all global cases of potential harms is beyond the scope of this review.

Preexisting Immunity, More Than Aging, Influences Influenza Vaccine Responses

Background.  Influenza disproportionately impacts older adults while current vaccines have reduced effectiveness in the older population. Methods.  We conducted a comprehensive evaluation of cellular and humoral immune responses of adults aged 50 years and older to the 2008-2009 seasonal trivalent inactivated influenza vaccine and assessed factors influencing vaccine response. Results.  Vaccination increased hemagglutination inhibition and neutralizing antibody; however, 66.3% of subjects did not reach hemagglutination inhibition titers ≥ 40 for H1N1, compared with 22.5% for H3N2. Increasing age had a minor negative impact on antibody responses, whereas prevaccination titers were the best predictors of postvaccination antibody levels. Preexisting memory B cells declined with age, especially for H3N2. However, older adults still demonstrated a significant increase in antigen-specific IgG(+) and IgA(+) memory B cells postvaccination. Despite reduced frequency of preexisting memory B cells associated with advanced age, fold-rise in memory B cell frequency in subjects 60+ was comparable to subjects age 50-59. Conclusions.  Older adults mounted statistically significant humoral and cell-mediated immune responses, but many failed to reach hemagglutination inhibition titers ≥40, especially for H1N1. Although age had a modest negative effect on vaccine responses, prevaccination titers were the best predictor of postvaccination antibody levels, irrespective of age.

Hemagglutination inhibiting antibodies and protection against seasonal and pandemic influenza infection

Objectives

Hemagglutination inhibiting (HI) antibodies correlate with influenza vaccine protection but their association with protection induced by natural infection has received less attention and was studied here.

Methods

940 people from 270 unvaccinated households participated in active ILI surveillance spanning 3 influenza seasons. At least 494 provided paired blood samples spanning each season. Influenza infection was confirmed by RT-PCR on nose/throat swabs or serum HI assay conversion.

Results

Pre-season homologous HI titer was associated with a significantly reduced risk of infection for H3N2 (OR 0.61, 95%CI 0.44–0.84) and B (0.65, 95%CI 0.54–0.80) strains, but not H1N1 strains, whether re-circulated (OR 0.90, 95%CI 0.71–1.15), new seasonal (OR 0.86, 95%CI 0.54–1.36) or pandemic H1N1-2009 (OR 0.77, 95%CI 0.40–1.49). The risk of seasonal and pandemic H1N1 decreased with increasing age (both p < 0.0001), and the risk of pandemic H1N1 decreased with prior seasonal H1N1 (OR 0.23, 95%CI 0.08–0.62) without inducing measurable A/California/04/2009-like titers.

Conclusions

While H1N1 immunity was apparent with increasing age and prior infection, the effect of pre-season HI titer was at best small, and weak for H1N1 compared to H3N2 and B. Antibodies targeting non-HI epitopes may have been more important mediators of infection-neutralizing immunity for H1N1 compared to other subtypes in this setting.

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The determinants of influenza immunity were examined in an unvaccinated cohort.

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The risk of H3N2 and B infection decreased with increasing pre-season HI titer.

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Pre-season HI titer had less effect on H1N1 infection.

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H1N1 immunity increased with age and seasonal H1N1 induced pandemic H1N1 immunity.

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The contribution of non-HI antibodies to immunity may be relatively high for H1N1.

The antigenic evolution of influenza: drift or thrift?

It is commonly assumed that antibody responses against the influenza virus are polarized in the following manner: strong antibody responses are directed at highly variable antigenic epitopes, which consequently undergo 'antigenic drift', while weak antibody responses develop against conserved epitopes. As the highly variable epitopes are in a constant state of flux, current antibody-based vaccine strategies are focused on the conserved epitopes in the expectation that they will provide some level of clinical protection after appropriate boosting. Here, we use a theoretical model to suggest the existence of epitopes of low variability, which elicit a high degree of both clinical and transmission-blocking immunity. We show that several epidemiological features of influenza and its serological and molecular profiles are consistent with this model of 'antigenic thrift', and that identifying the protective epitopes of low variability predicted by this model could offer a more viable alternative to regularly update the influenza vaccine than exploiting responses to weakly immunogenic conserved regions.

Sequential seasonal H1N1 influenza virus infections protect ferrets against novel 2009 H1N1 influenza virus

Individuals <60 years of age had the lowest incidence of infection, with ~25% of these people having preexisting, cross-reactive antibodies to novel 2009 H1N1 influenza. Many people >60 years old also had preexisting antibodies to novel H1N1. These observations are puzzling because the seasonal H1N1 viruses circulating during the last 60 years were not antigenically similar to novel H1N1. We therefore hypothesized that a sequence of exposures to antigenically different seasonal H1N1 viruses can elicit an antibody response that protects against novel 2009 H1N1. Ferrets were preinfected with seasonal H1N1 viruses and assessed for cross-reactive antibodies to novel H1N1. Serum from infected ferrets was assayed for cross-reactivity to both seasonal and novel 2009 H1N1 strains. These results were compared to those of ferrets that were sequentially infected with H1N1 viruses isolated prior to 1957 or more-recently isolated viruses. Following seroconversion, ferrets were challenged with novel H1N1 influenza virus and assessed for viral titers in the nasal wash, morbidity, and mortality. There was no hemagglutination inhibition (HAI) cross-reactivity in ferrets infected with any single seasonal H1N1 influenza viruses, with limited protection to challenge. However, sequential H1N1 influenza infections reduced the incidence of disease and elicited cross-reactive antibodies to novel H1N1 isolates. The amount and duration of virus shedding and the frequency of transmission following novel H1N1 challenge were reduced. Exposure to multiple seasonal H1N1 influenza viruses, and not to any single H1N1 influenza virus, elicits a breadth of antibodies that neutralize novel H1N1 even though the host was never exposed to the novel H1N1 influenza viruses.

Vaccines for preventing influenza in healthy children

BACKGROUND

The consequences of influenza in children and adults are mainly absenteeism from school and work. However, the risk of complications is greatest in children and people over 65 years of age.

OBJECTIVES

To appraise all comparative studies evaluating the effects of influenza vaccines in healthy children, assess vaccine efficacy (prevention of confirmed influenza) and effectiveness (prevention of influenza-like illness (ILI)) and document adverse events associated with influenza vaccines.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3) which includes the Acute Respiratory Infections Group's Specialised Register, OLD MEDLINE (1950 to 1965), MEDLINE (1966 to November 2011), EMBASE (1974 to November 2011), Biological Abstracts (1969 to September 2007), and Science Citation Index (1974 to September 2007).

SELECTION CRITERIA

Randomised controlled trials (RCTs), cohort and case-control studies of any influenza vaccine in healthy children under 16 years of age.

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 75 studies with about 300,000 observations. We included 17 RCTs, 19 cohort studies and 11 case-control studies in the analysis of vaccine efficacy and effectiveness. Evidence from RCTs shows that six children under the age of six need to be vaccinated with live attenuated vaccine to prevent one case of influenza (infection and symptoms). We could find no usable data for those aged two years or younger.Inactivated vaccines in children aged two years or younger are not significantly more efficacious than placebo. Twenty-eight children over the age of six need to be vaccinated to prevent one case of influenza (infection and symptoms). Eight need to be vaccinated to prevent one case of influenza-like-illness (ILI). We could find no evidence of effect on secondary cases, lower respiratory tract disease, drug prescriptions, otitis media and its consequences and socioeconomic impact. We found weak single-study evidence of effect on school absenteeism by children and caring parents from work. Variability in study design and presentation of data was such that a meta-analysis of safety outcome data was not feasible. Extensive evidence of reporting bias of safety outcomes from trials of live attenuated influenza vaccines (LAIVs) impeded meaningful analysis. One specific brand of monovalent pandemic vaccine is associated with cataplexy and narcolepsy in children and there is sparse evidence of serious harms (such as febrile convulsions) in specific situations.

AUTHORS' CONCLUSIONS

Influenza vaccines are efficacious in preventing cases of influenza in children older than two years of age, but little evidence is available for children younger than two years of age. There was a difference between vaccine efficacy and effectiveness, partly due to differing datasets, settings and viral circulation patterns. No safety comparisons could be carried out, emphasising the need for standardisation of methods and presentation of vaccine safety data in future studies. In specific cases, influenza vaccines were associated with serious harms such as narcolepsy and febrile convulsions. It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months of age in the USA, Canada, parts of Europe and Australia. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes, and directly comparing vaccine types are urgently required. The degree of scrutiny needed to identify all global cases of potential harms is beyond the resources of this review. This review includes trials funded by industry. An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry-funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favourable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in the light of this finding.

Vaccines for preventing influenza in healthy children

BACKGROUND

The consequences of influenza in children and adults are mainly absenteeism from school and work. However, the risk of complications is greatest in children and people over 65 years old.

OBJECTIVES

To appraise all comparative studies evaluating the effects of influenza vaccines in healthy children; assess vaccine efficacy (prevention of confirmed influenza) and effectiveness (prevention of influenza-like illness) and document adverse events associated with influenza vaccines.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 3); OLD MEDLINE (1950 to 1965); MEDLINE (1966 to September 2007); EMBASE (1974 to September 2007); Biological Abstracts (1969 to September 2007); and Science Citation Index (1974 to September 2007).

SELECTION CRITERIA

Randomised controlled trials (RCTs), cohort and case-control studies of any influenza vaccine in healthy children under 16 years of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Fifty-one studies with 294,159 observations were included. Sixteen RCTs and 18 cohort studies were included in the analysis of vaccine efficacy and effectiveness. From RCTs, live vaccines showed an efficacy of 82% (95% confidence interval (CI) 71% to 89%) and an effectiveness of 33% (95% CI 28% to 38%) in children older than two compared with placebo or no intervention. Inactivated vaccines had a lower efficacy of 59% (95% CI 41% to 71%) than live vaccines but similar effectiveness: 36% (95% CI 24% to 46%). In children under two, the efficacy of inactivated vaccine was similar to placebo. Variability in study design and presentation of data was such that a meta-analysis of safety outcome data was not feasible. Extensive evidence of reporting bias of safety outcomes from trials of live attenuated vaccines impeded meaningful analysis.

AUTHORS' CONCLUSIONS

Influenza vaccines are efficacious in children older than two but little evidence is available for children under two. There was a marked difference between vaccine efficacy and effectiveness. No safety comparisons could be carried out, emphasizing the need for standardisation of methods and presentation of vaccine safety data in future studies. It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months old in the USA and Canada. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required.

Vaccines for preventing influenza in healthy children

BACKGROUND

In children and adults the consequences of influenza are mainly absences from school and work, however the risk of complications is greatest in children and people over 65 years old.

OBJECTIVES

To appraise all comparative studies evaluating the effects of influenza vaccines in healthy children; assess vaccine efficacy (prevention of confirmed influenza) and effectiveness (prevention of influenza-like illness) and document adverse events associated with receiving influenza vaccines.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005); OLD MEDLINE (1966 to 1969); MEDLINE (1969 to December 2004); EMBASE (1974 to December 2004); Biological Abstracts (1969 to December 2004); and Science Citation Index (1974 to December 2004). We wrote to vaccine manufacturers and a number of corresponding authors of studies in the review.

SELECTION CRITERIA

Any randomised controlled trials (RCTs), cohort and case-control studies of any influenza vaccine in healthy children under 16 years old.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Fifty-one studies involving 263,987 children were included. Seventeen papers were translated from Russian. Fourteen RCTs and 11 cohort studies were included in the analysis of vaccine efficacy and effectiveness. From RCTs, live vaccines showed an efficacy of 79% (95% confidence interval (CI) 48% to 92%) and an effectiveness of 33% (95% CI 28% to 38%) in children older than two years compared with placebo or no intervention. Inactivated vaccines had a lower efficacy of 59% (95% CI 41% to 71%) than live vaccines but similar effectiveness: 36% (95% CI 24% to 46%). In children under two, the efficacy of inactivated vaccine was similar to placebo. Thirty-four reports containing safety outcomes were included, 22 including live vaccines, 8 inactivated vaccines and 4 both types. The most commonly presented short-term outcomes were temperature and local reactions. The variability in design of studies and presentation of data was such that meta-analysis of safety outcome data was not feasible.

AUTHORS' CONCLUSIONS

Influenza vaccines are efficacious in children older than two years but little evidence is available for children under two. There was a marked difference between vaccine efficacy and effectiveness. That no safety comparisons could be carried out emphasizes the need for standardisation of methods and presentation of vaccine safety data in future studies. It was surprising to find only one study of inactivated vaccine in children under two years, given recent recommendations to vaccinate healthy children from six months old in the USA and Canada. If immunisation in children is to be recommended as public-health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required.

Receptor specificity of influenza virus influences severity of illness in ferrets

Weanling ferrets were inoculated intranasally with either wild-type or receptor-variant clones of influenza A/Memphis/102/72 to determine if changes in receptor specificity influence virulence of influenza virus infection. Over the 5 days after inoculation, receptor-variant inoculated ferrets had a lower mean elevation in body temperature, greater weight gain and less sneezing than the wild-type group. Influenza virus was recovered from the lungs of fewer receptor-variant infected ferrets (5/12 vs 11/12) and in lower titers than in wild-type infected ferrets at 5 days after inoculation. The viruses recovered from lung homogenates retained the same receptor specificity as the inoculum. Serum hemagglutination inhibition titers for the two groups were similar. These findings suggest that the receptor-variant clone is less virulent but elicits a similar immunogenic response compared with the wild-type clone.

Peptide and protein drugs: II. Non-parenteral routes of delivery

In this second part of a two-part review, the absorption and delivery of peptide and protein drugs via non-parenteral routes are discussed. Approaches considered include the absorption enhancers, iontophoretic methods, the use of absorption inhibitors and prod rugs.

Sequential infection or immunization of ferrets with a series of influenza A (H3N2) strains (report to the Medical Research Council's Sub-Committee on influenza Vaccines (CDVIP/IV))

Previous studies of boys at Christ's Hospital school have indicated that annual immunization with influenza virus vaccines did not significantly reduce the total incidence of influenza infection compared to unimmunized subjects. In view of the implications of this result, a similar study was conducted in ferrets to clarify these findings. Groups of ferrets were immunized or infected with a series of influenza A (H3N2) viruses over an 18-month period, and the immunity to subsequent live virus challenge was measured after each virus or vaccine exposure. The results indicated that live virus infection gave a more solid immunity than immunization with inactivated vaccine; and the serum haemagglutination-inhibiting antibody response was greater following immunization than following infection. In addition, differences in immunity could not be explained by measurements of cross-reacting and specific antibody, since the incidence of these antibodies was similar in both infected and immunized animals. The results do not suggest an explanation for the different levels of immunity induced following infection or immunization or the results obtained from the Christ's Hospital study. However, the relative contribution of various immune responses to virus or virus antigen is discussed, and it is suggested that the difference in immunity may lie in the ability of live virus infection to stimulate local antibody.

Distribution of influenza viruses in Northern Greece during 1972-1983

Observations on the circulation of influenza viruses in Northern Greece during the winters of 1972/3 to 1982/3 are presented. Influenza A viruses were detected every winter with the exception of those of 1973/4 and 1981/2, when neither type A nor type B was isolated. The strains of type A isolated during the study period were similar to those circulating world-wide over the same time scale. Influenza B viruses were isolated only during the winters of 1972/3 and 1979/80; influenza A viruses were also circulating in the community at those times. The B strains detected were similar to those recorded world-wide during the period of study.

Cross-protection in mice infected with influenza A virus by the respiratory route is correlated with local IgA antibody rather than serum antibody or cytotoxic T cell reactivity

Mice previously infected with an aerosol of A/Rec 31 influenza virus were strongly protected against an aerosol challenge with A/Vic influenza as judged by lung virus titers recovered 2 days after the challenge infection. Such complete homotypic immunity was not achieved by priming with live Rec 31 virus injected i.v. or UV-inactivated Rec 31 virus administered s.c. together with Al(OH)3 and saponin. The reason for the superior protective effect of the natural infection was investigated. The protection induced by respiratory infection with Rec 31 virus was specific for influenza A viruses. It was not correlated with specific serum hemagglutination inhibition antibody titer or cross-reactive cytotoxic T (Tc) cell reactivity. Moreover, the transfer of splenic and lymphoid T cell populations with strong secondary Tc activity did not significantly reduce lung virus titers in recipient mice 3 days after infection. The protection however occurred in parallel with the presence of cross-reactive IgA antibody in the lung washings. It thus appears that local secretory IgA plays a causal role in the prevention of cross-infection by influenza A virus. Serum antibody and Tc cells, on the other hand, may be crucial for recovery from such infection. All mice primed with live Rec 31 virus, administered i.v. or by aerosol and expressing equally high levels of Tc reactivity, survived a lethal challenge with A/PR8 virus. The same challenge, however, killed half of the mice immunized s.c. with inactivated Rec 31 virus which induced only a low level of Tc reactivity.

Advantage of live attenuated cold-adapted influenza A virus over inactivated vaccine for A/Washington/80 (H3N2) wild-type virus infection

The efficacy of live attenuated cold-adapted (ca) reassortant influenza virus vaccine against experimental challenge with homologous wild-type virus 5 to 8 weeks after vaccination was compared with that of licensed inactivated vaccine in 81 seronegative (haemagglutination-inhibition antibody titre less than or equal to 1:8) college students. At a dose of 10(7.5) 50% tissue culture infectious dose (TCID50) (70 HID50, human 50% infectious doses) the live virus vaccine, given intranasally, completely protected against illness caused by wild-type virus, whereas the inactivated vaccine, administered intramuscularly, provided 72% protection. Wild-type virus was recovered from only 13% of live virus vaccinees (10(7.5) TCID50 dose of ca virus) compared with 63% of inactivated virus vaccinees and the few infected live virus vaccinees shed 1000 times less wild-type virus than did infected inactivated virus vaccinees or unvaccinated controls. This striking reduction in virus shedding suggests that influenza transmission may be more efficiently interrupted with live than with inactivated virus vaccination.

In vivo and in vitro hamster models in the assessment of virulence of recombinant influenza viruses

The virulence of five wild-type influenza A viruses and 14 recombinant viruses, prepared from the cold adapted A/Ann Arbor/6/60 virus and various wild-type viruses, was studied by two methods. Firstly, the viruses were inoculated into hamsters, and the titres present in the lungs and turbinates at 1, 3 and 4 days post-infection were measured. Secondly, the effect of five wild-type and ten recombinant viruses on the ciliated epithelium of in vitro hamster tracheal organ cultures was examined. The results obtained were assessed with reference to the known virulence of the viruses for human volunteers. The results showed that virus strains virulent for man grew to higher titres in hamster lungs and turbinates than attenuated strains; and that virulent strains destroyed the ciliary activity of hamster tracheal organ cultures more quickly and to a greater extent than attenuated strains. Comparison of the results with the known virulence of viruses tested for man suggests that the reduced ability of virus to grow in hamster lung tissue and the relatively little effect on ciliary activity may be used as markers of virus attenuation; however, the growth of virus in hamster turbinates overlaps for virulent and attenuated strains and therefore was not considered a useful marker of virulence.

A comparison of live and inactivated influenza A (H1N1) virus vaccines. 1. Short-term immunity

Groups of volunteers were immunized subcutaneously with one of three inactivated influenza virus A/USSR/77 (H1N1) vaccine preparations; a whole virus vaccine, a surface-antigen subunit adsorbed vaccine, or an aqueous surface-antigen subunit vaccine. The reactions to immunization were recorded, and the antibody response was measured 1 month later. A fourth group of volunteers were inoculated intranasally with live attentuated A/USSR/77 (H1N1) influenza virus; the reactions and antibody response of these volunteers were also measured. One month after immunization, the incidence of infection by challenge with homologous live attentuated virus was determined for all groups of volunteers. The results showed that all four vaccines used were relatively non-reactogenic, and that inactivated vaccines induced higher titres of serum antibody than the live attenuated vaccine. All the vaccines induced significant protection against challenge virus infection which was directly related to the level of serum HI antibody response.

A comparison of live and inactivated influenza A (H1N1) virus vaccines. 2. Long-term immunity

Groups of volunteers were immunized with one of three influenza virus vaccines, and the resistance to challenge infection with attenuated influenza A (H1N1) virus was measured 8 months later. The vaccines were aqueous subunit influenza A/USSR/77 (H1N1) vaccine, aqueous subunit influenza B/Hong Kong/73 vaccine, or attenuated influenza virus A (H1N1) vaccine. The B virus vaccine was included as a control to assess the incidence of natural A virus infection during the study period. A proportion of the B virus vaccinees had pre-existing A (H1N1) virus antibody and were used to study the immunity conferred by natural infection to the live virus challenge. The serum antibody responses were measured at 1 and 8 months after immunization. The results showed that all the vaccines induced serum HI antibody in a proportion of the volunteers; however, after 1 month, higher titres of serum antibody were found in volunteers given inactivated A vaccine than in those given live attenuated A virus vaccine. Eight months post-immunization the titres of serum antibody in volunteers given inactivated vaccine had declined significantly, but there were no changes in the antibody titres of those given live virus vaccine. The incidence of infection by the challenge virus at 8 months post-immunization was directly related to the serum antibody titres 1 month post-immunization; no evidence was obtained to suggest that those given live virus vaccine had a more solid immunity than those given inactivated vaccine.

Interference following dual inoculation with influenza A (H3N2) and (H1N1) viruses in ferrets and volunteers

The effects of simultaneous inoculation with two attenuated influenza A viruses was studied in ferrets and volunteers. Groups of ferrets were inoculated with an influenza A (H3N2) or (H1N1), virus or a combination of both viruses: the temperature response, serum and local antibody response, and the change in nasal wash protein concentration was determined. The results showed that both viruses were attenuated for ferrets, and that inoculation with both viruses together did not cause clinical reactions. Serological studies on paired serum samples obtained from ferrets showed that both viruses when given separately infected all the inoculated animals; however, dual infection resulted in all ferrets being infected with the influenza A (H3N2) virus strain, but this infection interfered with infection by the influenza A (H1N1) strain. Similar investigations were carried out in volunteers. Again, the clinical reactions and temperature response of volunteers to infection by one or other of the viruses showed both strains to be attenuated for man even when given together. In addition, no adverse clinical reactions were seen in volunteers inoculated with both viruses simultaneously. Serum antibody studies showed that infection by influenza A (H1N1) virus interfered with infection by the influenza A (H2N2) virus strain. These results show evidence of interference by influenza A viruses; however, the direction of interference was one-way, and differed for ferrets and for volunteers.

Infant rat model of attenuation for recombinant influenza viruses prepared from cold-adapted attenuated A/Ann Arbor/6/60

The pathogenicity of 6 wild-type influenza A viruses and 21 recombinant strains prepared from wild-type viruses and cold-adapted A/Ann Arbor/6/60 virus for infant rats was determined. Thus, the titers of virus present in the turbinates and lungs of virus-infected animals was measured serially for 5 days after intranasal infection, and the ability of virus strains to promote subsequent systemic bacterial infection by Haemophilus influenzae was measured at 48 h after virus infection. The results obtained were assessed with reference to the genetic constitution of the virus strains and to virus virulence for volunteers. The results showed that virulent viruses grew to relatively high titers in rat turbinates and significantly promoted systemic infection by H. influenzae. In contrast, attenuated strains grew to lower titers and failed to promote systemic H. influenzae infection. For the strains tested, the results showed clear differences for attenuated and virulent strains, and the model was a reliable indication of virulence for humans. Although the virulent strains tended to grow to higher titers in rat lungs than did attenuated strains, exceptions were found, and this measurement could not reliably discriminate virulent and attenuated virus strains. The results suggest that infant rats can be used to assess the virulence of cold-adapted recombinant influenza virus strains, and thus, they can facilitate the development of such strains for vaccine production.

Transmissibility of influenza viruses in hamsters

The growth characteristics of a series of influenza A viruses in the turbinates and lungs of hamsters was measured: in addition, the susceptibility of hamsters to infection by these viruses was also determined. These two criteria were used to give estimates of the growth potential of influenza viruses in hamsters, and the results were related to the incidence of transmission of virus from inoculated hamsters to cage-contacts. The results showed that strains of influenza virus reported as virulent for man tended to grow to higher titres in hamster nasal washings and lungs; were more infective for hamsters when inoculated by the intranasal route; and showed a high incidence of spread to cage-contacts. The methods could provide valuable measurements of virus attenuation and transmissibility for man, and the further exploitation of these techniques could facilitate the production and licensing of live, attenuated influenza virus vaccines.

Characterization and clinical evaluation of live influenza A vaccine prepared from a recombinant of the A/USSR/92/77 (H1N1) and the cold-adapted A/Ann Arbor/6/60 (H2N2) strains

Live influenza vaccine was prepared after genetic recombination of the A/USSR/92/77 (H1N1) strain with the cold-adapted A/Ann Arbor/6/60 (H2N2) strain. The recombinant contains the genes coding for the HA and NA proteins from the A/USSR/92/77 (H1N1) strain and the genes coding for the P1, P2, P3, NP, M and NS proteins from the A/Ann Arbor/6/60 (H2N2) strain. To assess the properties of this vaccine, it was administered under double-blind conditions to 14 healthy volunteers, while another 14 healthy volunteers received placebo. The vaccine virus appeared to be sufficiently attenuated. No febrile reactions were observed. The vaccinees showed an increase in mean serum haemagglutination-inhibiting antibody level from 19 to 73 after two vaccinations. From nasal swabs and antibody responses, it was concluded that the vaccine virus showed no transmission to the placebo group under conditions of close contact. Also, the vaccine virus was found to be genetically stable. It is concluded that this live influenza virus vaccine meets the requirements for safe use in humans. However, several problems still exist which may impede a general use of life influenza vaccines.

A clinical trial with Alice/R-75 strain, live attenuated serum inhibitor-resistant intranasal bivalent influenza A/B vaccine

A clinical trial was conducted with Alice/R-75 strain live attenuated intranasal influenza A/B vaccine. With double blind control 88 adult volunteers were administered 2 doses of Alice/R-75 vaccine, 93 volunteers received one dose of Alice/R-75 vaccine and one dose placebo solution and 94 subjects were administered 2 doses of placebo solution. Twenty-three other subjects received Alice strain monovalent influenza A vaccine. For comparison, data from 21 subjects who received monovalent intranasal R-75 strain influenza B in two doses is included. The vaccine was generally well tolerated. Four-fold serum hemagglutination-inhibiting (HAI) antibody titer rises to A/England/42/72 occurred in 39% of the monovalent Alice strain vaccines; in contrast 18% of those given 2 doses of bivalent Alice/R-75 vaccine and 11% of those given 1 dose of bivalent vaccine had similar four-fold HAI antibody titer rises. HAI antibody titer rises to influenza B/Hong Kong/72 occurred in 38% of R-75 strain monovalent vaccinees, 14% of Alice/R-75 2-dose vaccinees and 11% of Alice/R-75 one dose vaccinees. An epidemic of influenza at onset of the study made evaluation of the efficacy of the vaccine impossible.

A contribution of cellular immunity to protection against influenza in man

The degree of lymphocyte transformations and leukocyte migration inhibition (LMI) in the presence of inactivated A/Scotland/74 (H3N2) influenza virus vaccine was measured in blood samples collected from 56 medical student volunteers. At the same time the volunteers were skin tested, using the same vaccine. Using the antigenically similar WRL 105 (H3N2), recombinant influenza virus, the level of haemagglutination-inhibiting (HI) antibodies in serum, and neutralizing antibodies in nasal washings collected from the volunteers, were also determined. Each volunteer was then inoculated with live, attenuated WRL 105 influenza virus vaccine and infections demonstrated by virus isolations and serology. Correlations between the ability to infect the volunteers and the various parameters of humoral and cellular immunity were then determined. The results showed a good correlation between the level of serum HI antibody and infection. Thus 16 of 20 volunteers with serum HI antibody titres of 1:10, but only 6 of 20 volunteers with antibody levels of 1:30, showed evidence of infection. No direct correlation was observed between any of the other parameters measured and infection by WRL 105 virus. However, when the LMI and serum HI antibody levels were considered together, a contribution of cellular immunity, as measured by the LMI test, could be found. Of 19 volunteers with low serum HI antibody and low LMI levels, 16 were infected, whereas of 13 volunteers with low HI antibody, but with high LMI levels, only 6 showed evidence of infection with WRL 105 influenza virus.

Studies with live attenuated influenza virus in chronic bronchitis

The use of live, recombinant virus for immunisation against influenza produced a number of respiratory illnesses, some severe, in patients with chronic obstructive airways disease. These patients are probably more susceptible to the influenza virus than are normal subjects. Special care will be needed in testing these viruses on patients with respiratory disease.

Immunity to attenuated influenza virus WRL 105 infection induced by heterologous, inactivated influenza A virus vaccines

Groups of student volunteers were immunized with one of five different inactivated influenza virus vaccines. The concentration of virus in the various vaccines differed by both the international unitage test and by the concentration of haemagglutinin, as measured by the single radial diffusion test; the results of the two methods of standardization showed no correlation. The serum HI response to immunization was variable; volunteers given A/England/72 showed a 16.6-fold increase in homologous serum antibody titre whilst volunteers given A/Hong Kong/68 vaccine showed a 4.2-fold increase. The variable response of volunteers to immunization could not be explained by the varied concentration of virus in the vaccines, as measured by either test, the titres of serum HI antibody present before immunization, or a combination of these two factors.The ability to infect volunteers with WRL 105 virus 4 weeks after immunization with heterologous, inactivated virus vaccine was directly related to the degree of cross-reactivity between the haemagglutinins of this vaccine virus and WRL 105 virus. Thus, the greatest number of infections by the challenge virus were seen in volunteers given A/Hong Kong/68 vaccine, less were observed in volunteers given A/England/72 vaccine, and least were found in groups given A/Port Chalmers/73 or A/Scotland/74 vaccine. However, compared with the incidence of infection in volunteers given B/Hong Kong/73 vaccine, all the heterologous influenza A vaccine gave some immunity to challenge infection.

The potential advantages and requirements of live attenuated influenza virus vaccines

Live attenuated influenza A virus vaccines are potentially the most efficient and effective method of immunization against epidemic influenza, and offer the only feasible means of mass vaccination at a socially acceptable cost. The advantage of live virus vaccines are described and compared with killed virus vaccines in terms of immune responses, protection and commercial production. The most frequently considered methods of attenuation and their individual drawbacks are discussed with speculation on the future development and rationale of master vaccine strains. Recommended minimal requirements of master vaccine strains and candidate live vaccines are presented as a basis for their eventual evaluation by licensing authorities.

Longer term effects of live influenza vaccine in patients with chronic pulmonary disease

WRL 105 strain live influenza vaccine or placebo was given to patients with chronic bronchitis in a double-blind study. The twenty-one vaccinated and twenty-three placebo-treated patients made daily self-assessments of the severity of symptoms of cough, breathlessness, tightness, wheeze, and sputum production in the following 20 weeks. Symptom scores in the first 2 weeks after vaccination or treatment with placebo were used to calculate a baseline range for each patient. Comparison of symptoms in the two groups in the baseline period showed that symptoms were more often reported by vaccinated than by placebo-treated patients but the differences were not statistically significant. One patient who responded serologically to vaccination had a moderately severe influenzal illness starting on the day after vaccination. Comparison of symptom scores during the 18-week surveillance period with baseline values showed that symptoms of breathlessness, tightness, wheeze and cough were significantly more common in vaccinated than in placebo-treated patients and that antibiotic usage was more common in the vaccinated group.

Influenza immunization: serologic and clinical responses in military units

Two inactivated influenza-virus vaccines were tested and compared in three army training units in Israel. The serological responses to the vaccines and the side-effects were assessed. The vaccines contained the influenza strains which were prevalent in 1974: A2/Port Chalmers/1/73 and B/Hong Kong/8/73. One of the vaccines also contained A2/England/42/72. Both vaccines caused a more than three-fold rise in geometric mean titers against influenza A strains, and about a twofold rise in geometric mean titers against influenza B/Hong Kong/5/73. Approximately 75%-80% of the vaccinees acquired protective hemagglutination-inhibition antibody titers against influenza A strains, while less than 30% acquired protective titers against B strains. In general, there were no significant differences between the serological responses to the two vaccines. More than 50% of the vaccinees experienced at least one systemic side-effect (50.3% with one vaccine and 61.0% with the other). The average number of side-effects per person was between 1.78 and 2.11. However, these side-effects were generally of short duration and caused minimal disability. On the whole, the two vaccines did not differ significantly with regard to the side-effects they caused.

Clinical and serologic effects of live attenuated serum inhibitor-resistant influenza B vaccine in seronegative adults

The clinical effects, nasal and serum antibody responses, and virus excretion of a live attenuated serum inhibitor-resistant influenza B virus vaccine, R75, was evaluated in 43 seronegative healthy adults by a random double-blind study. Symptom responses were minimal and were not significantly different between vaccine and placebo groups. No fevers, abnormalities in physical examination or laboratory testing developed during 4 weeks of observation. Among vaccinees, 10 (48%) developed serum hemagglutination-inhibition (HI) antibodies, 16 (76%) developed serum neutralization (N) antibodies and 4 (19%) developed nasal N antibodies. The GMT responses from study day 0 to day 28 were 4.0 to 10.4 for serum HI, 1.8 to 9.8 for serum N, and 1.0 to 1.4 for nasal N. There were no significant titer changes in the placebo group. No virus excretion was detected. Although there are some questions concerning the relationship of antibody levels to protection, the low antibody responses in this study are an indication that R75 is not sufficiently immunogenic.

WRL 105 strain (H3N2) live attenuated influenza vaccine: acceptability, reactivity, and antibody response in normal, bronchitic, and geriatric volunteers

The acceptability, reactivity, and antibody responses of recombinant WRL 105 strain, live, attenuated influenza virus vaccine administered intranasally were studied in seventeen normal adults, and in seventeen bronchitic and twenty-one geriatric volunteers. The effect on peak flow and 1-second forced expiratory volume (F.E.V.1) on the 3rd, 5th, and 7th days after vaccination was measured in the bronchitic and normal groups. Seroconversion occurred in 80% to tht homologous virus, in 40.6% to A/Victoria/3/75, and in 26.5% to A/England/864/75 in subjects with pre-vaccination haemagglutination inhibition titres of less than 1/40. A fourfold or greater increase in homologous anti-neuraminidase antibody was found in 48% of twenty-seven infected subjects when measured by a new elution inhibition technique. The frequency and nature of symptoms were similar in both infected and non-infected groups. No significant changes in F.E.V.1 occurred, but on days 5 and 7 there was a decrease in peak flow measurements in both infected and non-infected groups when assessed as the percentage change of the pre-vaccination value.

A clinical trial of WRL 105 strain live attenuated influenza vaccine comparing four methods of intranasal vaccination

A single intranasal dose of 10(7-0) EID50 recombinant WRL 105 strain live attenuated influenza vaccine was administered intranasally to 193 volunteers either as nose drops or by one of three spray devices which produced sprays of differing physical characteristics. In volunteers with homologous haemagglutinating inhibiting antibody titres of less than or equal to 20 before vaccination, seroconversion rates varied widely from 80% following the administration of drops to 71%, 57% and 28% with the three spray devices. In the week following vaccination 16 (22%) of 74 volunteers who were found to show a fourfold or greater antibody response to took analgesics to control symptoms in comparison with 4 (7%) of 58 volunteers who exhibited no serological response to vaccination (P less than 0-05). However, neither the occurrence of upper respiratory nor systemic symptoms were significantly different in these two groups and the degree of attenuation of the recombinant WRL 105 strain appears to be acceptable for future use.

Assessment of vaccine efficacy by challenge studies in man

The only final test of the potency of a vaccine is its ability to protect against exposure in an epidemic. Laboratory tests for control purposes attempt to predict this capacity. It is suggested that challenging small groups of volunteers with attenuated influenza virus is a good index of immunity which could be used to check and refine present tests and to evaluate new ones.

Protective efficacy of a live, attenuated, influenza virus vaccine ('Alice' strain)

Animal studies have indicated the high degree of efficacy and broad protection of ‘Alice’ vaccine against various heterologous H₃N₂ influenza virus strains.

Similarly, challenge studies carried out in volunteers have confirmed the high degree of efficacy of ‘Alice’ vaccine versus homologous and heterologous influenza A virus strains.

Clinical and serologic effects of Alice strain live attenuated influenza A (H3N2) virus vaccine in an adult population

Alice strain live attenuated influenza A (H3N2) virus was evaluated in prison volunteers. By random double blind allocation, 94 volunteers received Alice strain vaccine (AS) intranasally and 97 received placebo. The vaccine was well tolerated, and there was no serious morbidity. The number, type, duration, and severity of symptoms was not significantly different between the vaccine and placebo groups. Seventy-five per cent of vaccines with initial HAI titers less than or equal to 1:8 had 4 fold or greater titer responses on day 30. Placebo recipients experienced no titer changes. The GMT among vaccinees increased from 23.5 prior to vaccination 59.7 30 days later. Surveillance activities failed to document influenza A (H3N2) infection in the volunteer population during a 6 month follow-up period. Additional studies on the protective effects of the vaccine are required before efficacy can be determined.

Comparative trials of live attenuated and detergent split influenza virus vaccines

Comparative clinical trials of live attenuated and detergent-split subunit influenza virus vaccines were undertaken with 1048 volunteers in Western Australia. Volunteers were divided into three main groups, each of which received either live virus vaccine or a saline control administered intranasally, or subunit vaccine injected subcutaneously. No differences were recorded between the three groups in their post-vaccination symptoms. Serum samples were collected at various times up to 50 weeks after vaccination, and antibody titres were measured by haemagglutination-inhibition (HI) tests and, for 231 volunteers, by virus neutralization tests. The two vaccines were almost equivalent in inducing seroconversion in vaccinees with pre-trial HI titres of 96 or less, but the subunit vaccine stimulated a higher geometric mean HI antibody titre. The longevity of the HI antibody response was greater for the live virus vaccine. The height of the response and the longevity of neutralizing antibody were the same for both vaccines. Both vaccines provided a high degree of protection against epidemic A/England/42/72 influenza, and some protection against A/Port Chalmers/1/73 influenza.

Recombinant WRL 105 strain live attenuated influenza vaccine. Immunogenicity, reactivity, and transmissibility

The immunogenicity, reactivity, and transmissibility of recombinant WRL 105 (H3N2) (A/Okuda/57XA/Finland/4/74) strain live attenuated influenza virus vaccine were studied in adult male volunteers in a residential community in rural England. Thirteen volunteers received a single dose of 10(7.0) E.I.D.50 recombinant WRL 105 vaccine administered as nose drops, and twelve volunteers received placebo. Nine (82%) of eleven volunteers with initial antibody titres of less than or equal to 1/96 showed a significant antibody response to vaccination, but there was no evidence of transmission of vaccine virus to those who received placebo. The incidence and nature of reactions were similar in those who received vaccine and placebo. The vaccine was shown to confer protection against natural infection with a strain exhibition antigenic characteristics equivalent to those of A/Scotland/840/74.

The efficacy of live and inactivated vaccines of Hong Kong influenza virus in an industrial community. A report to the Medical Research Council Committee on influenza and other respiratory virus vaccines

Intranasal vaccines of inactivated or living attentuated A2/Hong Kong influenza viruses were compared for clinical acceptability, serological effects and protective efficiency against natural epidemic influenza in a large industrial and clerical population.Neither vaccine resulted in any significant untoward side-effects. The serum haemagglutination-inhibiting (HI) antibody response within 1 month of vaccination was similar with both vaccines; approximately 50% of those with little or no pre-vaccination antibody developed 4-fold or greater rises in titre. The effect of the antigenic potency of the vaccines and the prior immunological experience of the population is discussed. Volunteers given live vaccine showed a 2.2-fold lower incidence of clinical influenza than those given killed vaccine in a natural epidemic 16 months after vaccination.

Immune response to vaccination with a live influenza virus (H3N2) vaccine ("Ann" strain)

A live attenuated influenza virus ("Ann" strain) derived from A/England/878/69 was given intranasally to a group of volunteers, most of whom had already circulating antibodies against H(3)N(2) viruses at the time of inoculation. There was a fourfold or higher increase of circulating hemagglutination-inhibiting antibodies in those volunteers who had relatively low initial titers. The response was lower in those with initially higher serum titers. The pattern of the serum neutralizing antibody response was very similar. The geometric means of the antineuraminidase antibodies were 67 and 118 pre- and postvaccination, respectively. All subjects showed a rise in local neutralizing antibodies in their nasal secretions with geometric means of 4 and 17 pre- and postvaccination, respectively. The levels of local antineuraminidase antibodies also rose in most subjects. In addition to the response to the homologous virus type, the antibody formation to the recent A/England/42/72 was measured in the sera and nasal secretions of some subjects. There was a clearcut response in most of the sera and in all of the secretions examined. The stimulation of circulating lymphocytes was measured in 6 volunteers. All volunteers showed a temporary stimulation. The stimulation index ranged between 2.5 and 28.5.

The role of serum haemagglutination-inhibiting antibody in protection against challenge infection with influenza A2 and B viruses

The intranasal inoculation of volunteers with living partially attenuated strains of influenza A and B viruses offers a new opportunity to determine the protective effect of serum haemagglutin-inhibiting antibody against a strictly homologous virus, under conditions where the time and dosage of the infective challenge can be controlled, the scoring of proven infections can be more precise and higher rates of infection can be achieved than in most natural epidemics.In 1032 adult volunteers, whose serum HI antibody titre was determined immediately before virus challenge, there was a consistent inverse quantitative relationship between the HI titre and the likelihood of infection. The PD 50 (50% protective dose) of HI antibody was 1/18-1/36, but an unusual finding was that volunteers with no detectable pre-challenge antibody often seem to be less susceptible to infection than those with pre-challenge antibody in low titre.In one group of volunteers challenged with an influenza B strain there was no evidence that pre-challenge antibody titres against viral neuraminidase had any significant protective effect against challenge infection.

Antibody responses and resistance to challenge in volunteers vaccinated with live attenuated, detergent split and oil adjuvant A2-Hong Kong-68 (H 3 N 2 ) influenza vaccines. A report to the Medical Research Council Committee on Influenza and other Respiratory Virus Vaccines

Forty-nine subjects were vaccinated with either live attenuated, detergent split, or oil adjuvant A2/Hong Kong influenza vaccines, or a saline influenza B vaccine as control. Respiratory symptoms occurred more frequently in subjects who received the live vaccine but in total there was little difference between the symptoms in the four groups. Antibody titres in nasal washings and serum were measured by haemagglutination inhibition, neuraminidase inhibition and virus neutralization tests. The oil adjuvant vaccine stimulated larger antibody responses than the other procedures. Six weeks after vaccination the volunteers were challenged with partially attenuated live A2/Hong Kong influenza virus administered intranasally. The live attenuated and oil adjuvant vaccines provided the best protection against challenge.

Attenuation of human influenza A viruses

The attenuation of two human influenza A viruses has been carried out, using the selection of inhibitor-resistant strains and multiple passages at low temperatures. A virus related to A2/Tokyo/3/67 was obtained in an inhibitor-resistant form. When this was compared with the inhibitor-sensitive strain in a volunteer trial it was relatively non-pathogenic. The second virus, A2/Hongkong/1/68, was subjected to much longer treatment, but nevertheless remained slightly sensitive to serum inhibitor. When given to volunteers it was less pathogenic than before but attenuation was incomplete. A2/Hongkong/1/68 was also modified by passage at low temperatures. Many of these passages are apparently necessary for full attenuation.All attenuated viruses were infective and antigenic.