Transcutaneous immunization: T cell responses and boosting of existing immunity

Immunomodulation with Enterotoxins for the Generation of Secretory Immunity or Tolerance: Applications for Oral Infections

The heat-labile enterotoxins, such as cholera toxin (CT), and the labile toxins types I and II (LT-I and LT-II) of Escherichia coli have been extensively studied for their immunomodulatory properties, which result in the enhancement of immune responses. Despite superficial similarity in structure, in which a toxic A subunit is coupled to a pentameric binding B subunit, different toxins have different immunological properties. Administration of appropriate antigens admixed with or coupled to these toxins by oral, intranasal, or other routes in experimental animals induces mucosal IgA and circulating IgG antibodies that have protective potential against a variety of enteric, respiratory, or genital infections. These include the generation of salivary antibodies that may protect against colonization with mutans streptococci and the development of dental caries. However, exploitation of these adjuvants for human use requires an understanding of their mode of action and the separation of their desirable immunomodulatory properties from their toxicity. Recent findings have revealed that adjuvant action is not critically dependent upon the enzymic activity of the A subunits, and that the isolated B subunits may exert different effects on cells of the immune system than do the intact toxins. Interaction of the toxins with immunocompetent cells is not exclusively dependent upon their conventional ganglioside receptors. Immunomodulatory effects have been observed on dendritic cells, macrophages, CD4+ and CD8+ T-cells, and B-cells. Numerous factors—including the precise form of the toxin adjuvant, properties of the antigen, whether and how they are coupled, route of administration, and species of animal model—affect the outcome, whether this is enhanced humoral and cellular immunity, or specific induced tolerance toward the antigen.

Recent insights into cutaneous immunization: How to vaccinate via the skin

Technologies and strategies for cutaneous vaccination have been evolving significantly during the past decades. Today, there is evidence for increased efficacy of cutaneously delivered vaccines allowing for dose reduction and providing a minimally invasive alternative to traditional vaccination. Considerable progress has been made within the field of well-established cutaneous vaccination strategies: Jet and powder injection technologies, microneedles, microporation technologies, electroporation, sonoporation, and also transdermal and transfollicular vaccine delivery. Due to recent advances, the use of cutaneous vaccination can be expanded from prophylactic vaccination for infectious diseases into therapeutic vaccination for both infectious and non-infectious chronic conditions. This review will provide an insight into immunological processes occurring in the skin and introduce the key innovations of cutaneous vaccination technologies.

Animal models for cutaneous vaccine delivery

Main challenges in skin vaccination are overcoming the stratum corneum (SC) barrier and targeting the antigen presenting cells (APC) in the epidermis and the dermis. For this purpose many delivery techniques are being developed. In vivo immunogenicity and safety studies in animals are mandatory before moving to clinical trials. However, the results obtained in animals may or may not be predictive for humans. Knowledge about differences and similarities in skin architecture and immunology within a species and between species is crucial. In this review, we discuss variables, including skin morphology, skin barrier function, mechanical properties, site of application and immunology, which should be taken into account when designing animal studies for vaccination via the skin in order to support the translation to clinical trial outcomes.

Non-invasive, epicutaneous immunisation with toxoid in deformable vesicles protects mice against tetanus, chiefly owing to a Th2 response

A non-invasive, intra/transcutaneous immunisation of mice with a suitable combination of tetanus toxoid, ultradeformable vesicle (Transfersome®) carrier, and monophosphoryl lipid A adjuvant targets immuno-competent cells in a body and can protect 100% of the tested mice against an otherwise lethal (50×LD50) parenteral tetanus toxin challenge. The late immune response to the epicutaneously applied tetanus toxoid in such vesicles consists chiefly of circulating IgG1 and IgG2b antibody isotypes, indicative of a specific Th2 cellular response bias. Immunisations by subcutaneous injections moreover protect 100% of mice against a similar, otherwise lethal, dose of tetanus toxin. However, the immune response to transcutaneous and invasive immunisation differs. The latter elicits mainly IgG1 and IgG2b as well as IgG2a antibody isotypes, indicative of a mixed Th1/Th2 response. The cytokine response of the intra/transcutaneously and subcutaneously immunised mice reflects the difference in the organ-specific manner. IFN-γ concentration is appreciably increased in the draining lymph nodes and IL-10 in spleen. Since tetanus is a neutral antigen, both the Th1-specific IFN-γ and the Th-2 specific-IL-10 are observable.

Antigen-loaded nanocarriers enhance the migration of stimulated Langerhans cells to draining lymph nodes and induce effective transcutaneous immunization

This study aims to investigate the efficacy of chitosan nanoparticles (CS-NPs) as a vehicle for transcutaneous antigen delivery in anti-tumor therapy. Ovalbumin (OVA) or gp100 (melanocyte-associated antigen gp100 protein)-loaded CS-sodium tripolyphosphate (TPP)-grafted NPs were prepared by crosslinking low-molecular-weight CS with TPP. Compared with the FITC-OVA solution, the encapsulated fluorescein isothiocyanate (FITC)-OVA-loaded NPs expressed much stronger cellular uptake ability in vitro and higher ability to migrate to lymph nodes in vivo. After transcutaneous administration, OVA-loaded NPs, with imiquimod as an adjuvant, increased the anti-OVA immunoglobulin G titer to levels similar to those induced by the OVA solution. The gp100-loaded NPs promoted the survival of tumor-bearing mice. These results provided evidence of CS-NPs as promising carriers for transcutaneous vaccine delivery, partly contributing to the increased uptake of NPs by skin antigen-presenting cells as well as their enhanced migration to the surrounding lymph nodes.

FROM THE CLINICAL EDITOR

In this study the efficacy of chitosan nanoparticle based vehicles for transcutaneous antigen delivery is investigated in anti-tumor therapy. Authors demonstrate that such nanoparticles may be efficient carriers partly due to their increased uptake by antigen-presenting cells in the skin and their enhanced migration to surrounding lymph nodes.

Epicutaneous/transcutaneous allergen-specific immunotherapy: rationale and clinical trials

PURPOSE OF REVIEW

IgE-mediated allergies, such as allergic rhinoconjunctivitis and asthma, have become highly prevalent, today affecting up to 35% of the population in industrialized countries. Allergen immunotherapy (also called hyposensitization therapy, desensitization or allergen-specific immunotherapy), the administration of gradually increasing amounts of an allergen, either subcutaneously or via the sublingual or oral route is effective. However, only few allergy patients (<5%) choose immunotherapy, as treatment duration is over years and because allergen administrations are associated with local and in some cases even systemic allergic side effects due to allergen accidentally reaching the circulation. Therefore, ideally the allergen should be administered to a site that contains high numbers of potent antigen-presenting cells in order to enhance efficacy and shorten treatment duration, and ideally that site should also be nonvascularized in order to prevent both systemic distribution of the allergen and systemic allergic side effects. The epidermis, a nonvascularized multilayer epithelium that contains high numbers of potent antigen-presenting Langerhans cells, could therefore be an interesting administration route.

RECENT FINDINGS

We have recently reintroduced transcutaneous or epicutaneous allergen-specific immunotherapy (EPIT) as treatment option for IgE-mediated allergies. This method was found efficacious and safe. Few applications of allergens using skin patches with a treatment duration of a few weeks were sufficient to achieve lasting relief.

SUMMARY

This review gives an overview on the history, the rationale, and the mechanisms of transcutaneous/epicutaneous immunotherapy.

Preferential amplification of CD8 effector-T cells after transcutaneous application of an inactivated influenza vaccine: a randomized phase I trial

BACKGROUND

Current conventional vaccination approaches do not induce potent CD8 T-cell responses for fighting mostly variable viral diseases such as influenza, avian influenza viruses or HIV. Following our recent study on vaccine penetration by targeting of vaccine to human hair follicular ducts surrounded by Langerhans cells, we tested in the first randomized Phase-Ia trial based on hair follicle penetration (namely transcutaneous route) the induction of virus-specific CD8 T cell responses.

METHODS AND FINDINGS

We chose the inactivated influenza vaccine - a conventional licensed tetanus/influenza (TETAGRIP) vaccine - to compare the safety and immunogenicity of transcutaneous (TC) versus IM immunization in two randomized controlled, multi-center Phase I trials including 24 healthy-volunteers and 12 HIV-infected patients. Vaccination was performed by application of inactivated influenza vaccine according to a standard protocol allowing the opening of the hair duct for the TC route or needle-injection for the IM route. We demonstrated that the safety of the two routes was similar. We showed the superiority of TC application, but not the IM route, to induce a significant increase in influenza-specific CD8 cytokine-producing cells in healthy-volunteers and in HIV-infected patients. However, these routes did not differ significantly for the induction of influenza-specific CD4 responses, and neutralizing antibodies were induced only by the IM route. The CD8 cell response is thus the major immune response observed after TC vaccination.

CONCLUSIONS

This Phase Ia clinical trial (Manon05) testing an anti-influenza vaccine demonstrated that vaccines designed for antibody induction by the IM route, generate vaccine-specific CD8 T cells when administered transcutaneously. These results underline the necessity of adapting vaccination strategies to control complex infectious diseases when CD8 cellular responses are crucial. Our work opens up a key area for the development of preventive and therapeutic vaccines for diseases in which CD8 cells play a crucial role.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00261001.

Langerhans cells as targets for immunotherapy against skin cancer

Cancer is the second most common cause of death in the world. Treatment of cancer is very challenging and immunotherapy has been developed as a potential way to fight cancer. The main obstacle with immunotherapy is that cancer cells evolve from healthy body cells in response to an accumulation of genetic mutations. As a consequence, the immune system struggles to detect the abnormal cells as they are mainly recognized as self. This implies that equipping the immune system to eliminate cancer cells is tricky, yet represents a very efficient way to constrain the growth of tumors. We became interested in developing immunotherapeutical strategies against skin cancer in the context of our observations that Langerhans cells (LC) are very potent antigen presenting cells and are able to incorporate protein antigens and present them to CD4(+) and CD8(+) T cells in the skin-draining lymph nodes. As a consequence, we developed an immunization strategy through the skin, termed epicutaneous immunization. Protein antigen applied onto barrier-disrupted skin induces long-lasting cytotoxic T-cell responses, potent enough to control and inhibit tumor growth. In this review, we suggest that immunization strategies through the skin could be a promising new approach for the treatment of skin cancer.

Mucosal immune responses induced by transcutaneous vaccines

The skin has been investigated as a site for vaccine delivery only since the late 1990s. However, much has been discovered about the cell populations that reside in the skin, their active role in immune responses, and the fate of trans- cutaneously applied antigens. Transcutaneous immunization (TCI) is a safe, effective means of inducing immune responses against a number of pathogens. One of the most notable benefits of TCI is the induction of immune responses in both systemic and mucosal compartments. This chapter focuses on the transport of antigen into and beyond intact skin, the cutaneous sentinel cell populations that play a role in TCI, and the types of mucosal immune responses that have been generated. A number of in vivo studies in murine models have provided information about the broad responses induced by TCI. Cellular and humoral responses and protection against challenge have been noted in the gastrointestinal, reproductive, and respiratory tracts. Clinical trials have demonstrated the benefits of this vaccine delivery route in humans. As with other routes of immunization, the type of vaccine formulation and choice of adjuvant may be critical for achieving appropriate responses and can be tailored to activate specific immune-responsive cells in the skin to increase the efficacy of TCI against mucosal pathogens.

Transcutaneous delivery and thermostability of a dry trivalent inactivated influenza vaccine patch

A patch containing a trivalent inactivated influenza vaccine (TIV) was prepared in a dried, stabilized formulation for transcutaneous delivery. When used in a guinea pig immunogenicity model, the dry patch was as effective as a wet TIV patch in inducing serum anti-influenza IgG antibodies. When the dry TIV patch was administered with LT as an adjuvant, a robust immune response was obtained that was comparable with or better than an injected TIV vaccine. When stored sealed in a nitrogen-purged foil, the dry TIV patch was stable for 12 months, as measured by HA content, under both refrigerated and room temperature conditions. Moreover, the immunological potency of the vaccine product was not affected by long-term storage. The dry TIV patch was also thermostable against three cycles of alternating low-to-high temperatures of -20/25 and -20/40 degrees C, and under short-term temperature stress conditions. These studies indicate that the dry TIV patch product can tolerate unexpected environmental stresses that may be encountered during shipping and distribution. Because of its effectiveness in vaccine delivery and its superior thermostable characteristics, the dry TIV patch represents a major advance for needle-free influenza vaccination.

Transcutaneous immunization with heat-labile enterotoxin: development of a needle-free vaccine patch

The skin is an attractive target for vaccine delivery. Adjuvants and antigens delivered into the skin can result in potent immune responses and an unmatched safety profile. The heat-labile enterotoxin (LT) from Escherichia coli, which acts both as antigen and adjuvant, has been shown to be delivered to human skin efficiently when used in a patch, resulting in strong immune responses. Iomai scientists have capitalized on these observations to develop late-stage products based on LT. This has encouraged commercial-level product development of a delivery system that is efficient, user-friendly and designed to address important medical needs. Over the past 2 years, extensive clinical testing and optimization has allowed the patch to evolve to a late-stage product. As a strategy for approval of a revolutionary vaccine-delivery system, the singular focus on optimization of LT delivery has enabled technical progress to extend patch-vaccine product development beyond LT. The field efficacy of the LT-based travelers' diarrhea vaccine has validated this approach. The discussion of transcutaneous immunization is unique, in that any consideration of the adjuvant must also include delivery, and the significant advances in a commercial patch application system are described. In this review, we integrate these concepts, update the clinical data and look to the future.

Immunological activation following transcutaneous delivery of HR-gp100 protein

Transcutaneous immunization aims at taking advantage of the skin's immune system for the purpose of immunoprotection. In the present study, we evaluated the potential of topical delivery of a recombinant melanoma protein, HR-gp100, derived from a shortened sequence of the native gp100 gene. The protein was applied on the skin, with and without the addition of two forms of heat labile enterotoxin (nLT and LTB). HR-gp100 fused to Haptide, a cell penetrating 20mer peptide (HR-gp100H) was also tested. Topical HR-gp100 and HR-gp100H application on the ears of mice elicited the production of specific antibodies, and transcutaneous delivery to intact human skin induced dose-dependent LC activation. nLT and LTB also activated LC, but did not further increase the activation induced by HR-gp100. These results show that HR-gp100, an antigenic tumor-derived protein, activates the immune system following transcutaneous delivery, as shown by both Langerhans cell activation and induction of antibody production.

Topical vaccination: the skin as a unique portal to adaptive immune responses

Skin is an ideal tissue for vaccine administration, as it is comprised of immunocompetent cells such as keratinocytes and Langerhans cells and elicits both innate and adaptive immune responses. In this paper, we summarize the immune responses induced by topical vaccination of the skin and review the effects of adjuvants on skin vaccination. We also summarize the existing techniques for skin vaccination. New techniques such as the use of lasers to enhance skin permeability are also discussed, as well as the role of the stratum corneum in skin vaccination. A recent study demonstrating enhanced skin vaccination by using surfactants to extract partial lamellar lipids of the stratum corneum will also be introduced in this review.

Mass vaccination: solutions in the skin

The skin is populated with Langerhans cells, thought to be efficient, potent antigen-presenting cells, that are capable of inducing protective immunity by targeting antigen delivery to the skin. Delivery to the skin may be accomplished by active delivery such as intradermal injection, use of patches or a combination of a universal adjuvant patch with injections. The robust immunity induced by skin targeting can lead to dose sparing, novel vaccines and immune enhancement in populations with poorly responsive immune systems, such as the elderly. Vaccine delivery with patches (transcutaneous immunization), may allow self-administration, ambient temperature stabilization and ease of storage for stockpiling, leading to a new level of efficient vaccine distribution in times of crisis such as a bioterror event or pandemic influenza outbreak. The use of an adjuvant (immunostimulant) patch with injected vaccines has been shown in clinical studies to enhance the immune response to an injected vaccine. This can be used for dose sparing in pandemic influenza vaccines in critically short supply or immune enhancement for poor responders to flu vaccines such as the elderly. Transcutaneous immunization offers a unique safety profile, as adjuvants are sequestered in the skin and only delivered systemically by Langerhans cells. This results in an excellent safety profile and allows use of extremely potent adjuvants. The combination of the skin immune system, safe use of potent adjuvants and ease of delivery suggests that skin delivery of vaccines can address multiple unmet needs for mass vaccination scenarios.

Epicutaneous immunization converts subsequent and established antigen-specific T helper type 1 (Th1) to Th2-type responses

Epicutaneous immunization is a potential novel technique for topical vaccine delivery. It targets the immunologically rich milieu of the skin while having the advantage of being a non-invasive immunization procedure. By disrupting the stratum corneum of the epidermis a natural adjuvant effect can be achieved through activation of resident Langerhans cells. This negates the normal need for co-application of noxious adjuvants. Epicutaneous immunization on barrier-disrupted skin induces potent antigen-specific systemic immunity with a strong T helper type 2 (Th2) bias. We show here that epicutaneous immunization enhances the vigour of a subsequent T-cell response to the same antigen. The induced systemic Th2 response prevents the development of Th1 responses induced through injection of antigen in complete Freund's adjuvant (CFA). Prior epicutaneous immunization results in reduced production of antigen-specific interferon-gamma and immunoglobulin G2a (IgG2a) and enhanced interleukin-4, IgG1 and IgE responses to immunization with CFA. Moreover, epicutaneous immunization converts an established Th1 response to a Th2 response, as demonstrated by the specific reduction of interferon-gamma and IgG2a and the enhancement of interleukin-4 and IgE. This Th2 dominance of epicutaneous immunization may have direct therapeutic application as an immune-modulating procedure in Th1-dominant diseases such as autoimmune rheumatoid arthritis, type 1 diabetes, Hashimoto's thyroiditis and multiple sclerosis.

Transcutaneous immunization with inactivated influenza virus induces protective immune responses

The recent outbreaks of highly pathogenic avian influenza in Asia and spread of the disease worldwide highlight the need to redefine conventional immunization approaches and establish effective mass vaccination strategies to face global pandemics. Transcutaneous immunization (TCI) is a novel route for vaccination, which uses the topical application of vaccine antigens on the skin. In this study, we investigated the potential of TCI using inactivated whole influenza virus. We found that TCI with whole inactivated influenza virus induced influenza virus-specific antibodies with hemagglutination inhibition and neutralizing activities as well as cellular immune responses, even without an adjuvant, and conferred protective immunity to virus challenge. Co-administration with cholera toxin (CT), a potent adjuvant for TCI, significantly enhanced immune responses against the influenza virus antigen. To enhance penetration of the skin barrier to the particulate influenza viral antigens, we tested the effects of the potential penetration enhancers/immunomodulators oleic acid (OA) and retinoic acid (RA). Pretreatment of mouse skin with OA elicited increased levels of influenza virus-specific binding and neutralizing antibodies to levels equivalent to those induced by intranasal immunization with inactivated influenza virus. OA and RA treatments differentially affected the pattern of cytokine production upon stimulation with influenza viral antigen and provided enhanced protection. These results reveal a promising perspective for the application of transcutaneous immunization to prevent influenza epidemics as well as a range of other infectious diseases.

Transcutaneous immunization in mice: Induction of T-helper and cytotoxic T lymphocyte responses and protection against human papillomavirus-induced tumors

Previous reports have shown that transcutaneous immunization (TCI) with proteins or peptides in combination with adjuvants efficiently induces specific cellular and humoral immune responses. However, depending on the kind of skin pretreatment, induction of cellular immune responses was restricted to generation of either specific cytotoxic T lymphocytes (CTLs) or T-helper (Th) cells. In this study, we induced antigen-specific CTL responses together with the appropriate Th responses by TCI of C57BL/6 mice. We applied ovalbumin protein or an ovalbumin-derived fusion peptide containing a CTL and Th epitope together with a combination of cholera toxin (CT) and CpG oligodeoxynucleotide (CpG) onto cold wax-depilated and hydrated bare skin. TCI with the ovalbumin fusion peptide induced more robust CTL and Th responses than that with ovalbumin protein. The fusion peptide in combination with the nontoxic CT derivative CTA1-D2D1 and CpG induced an antigen-specific CTL response, albeit less efficiently than in combination with complete CT. Further, we compared the potency of HPV-16 E7 oncoprotein-derived peptides containing single (CTL) or multiple (CTL + Th + B cell) epitopes to induce effective CTL responses. Strong E7-specific CTL responses were detected only after TCI with the E7 multiepitope peptide. This peptide was also shown to protect mice against tumor growth after challenge with HPV-16 E7-positive tumor cells. TCI with E7 protein and CT/CpG led to formation of an E7-specific humoral immune response.

Immunization without needles

Most current immunization procedures make use of needles and syringes for vaccine administration. With the increase in the number of immunizations that children around the world routinely receive, health organizations are beginning to look for safer alternatives that reduce the risk of cross-contamination that arises from needle reuse. This article focuses on contemporary developments in needle-free methods of immunization, such as liquid-jet injectors, topical application to the skin, oral pills and nasal sprays.

Heat labile enterotoxin of E. coli: a potential adjuvant for transcutaneous cancer immunotherapy

Escherichia coli heat labile enterotoxin (LT) has been shown to penetrate intact skin and to activate adaptive immunity. A nontoxic mutant, nLT, and its B subunit (LTB), have been evaluated separately for their potential use as a tool for transcutaneous delivery of antigens for cancer immunotherapy. We have shown that FITC-labeled nLT is taken up by human dendritic cells (hDC) in vitro and in mouse skin, and induces maturation and activation of hDC in vitro. hDC matured with nLT enhanced nonspecific melanoma antigen uptake and presentation to autologous CD8+ T cells. In mouse in vivo studies, nLT or LTB were applied on the skin either mixed with recombinant gp100 or genetically fused with a multiepitope polypeptide (MEP). Fused LTB-MEP induced antibody production that was dependent on LTB cell binding. We conclude that LT derivatives may be useful for the transcutaneous delivery of tumor antigens for cancer immunotherapy.

Induction and recall of immune memory by mucosal immunization with a non-toxic recombinant enterotoxin-based chimeric protein

Previous reports have suggested that peroral delivery of antigens chemically coupled to non-toxic recombinant enterotoxin B subunits, such as the cholera toxin B subunit (CTB), induces tolerance to the antigen that may be abrogated by the toxic enzyme activity of intact enterotoxins, such as cholera toxin (CT). The aim of this study was to examine the immunogenicity of a genetically coupled protein composed of the saliva-binding region (SBR) of the Streptococcus mutans surface antigen AgI/II and the non-toxic A2 and B subunits of CT (SBR-CTA2/B) compared with that of recombinant SBR admixed with CT (SBR + CT) and SBR chemically coupled to recombinant CTB (SBR-CTB) following peroral delivery by intragastric (i.g.) immunization. The results showed that i.g. immunization with SBR-CTA2/B, like SBR + CT, induced antigen-specific serum immunoglobulin G (IgG) and salivary IgA antibodies, and sensitized splenic T cells. Comparison studies with SBR-CTB produced serum IgG but not salivary IgA titres and failed to sensitize splenic cells. Immunization with SBR-CTA2/B via the intranasal route also primed for the recall of antigen-specific memory antibody responses 6 months later. These findings show that SBR-CTA2/B is an immunogenic, not tolerogenic, chimeric protein that can induce and recall antigen-specific memory responses upon mucosal immunization.

Skin localization of cow's milk proteins delivered by a new ready-to-use atopy patch test

PURPOSE

Atopy patch tests (APTs) allow the detection of delayed allergies at the skin level. The localization of beta-lactoglobulin delivered into the skin by an innovative ready-to-use APT (E-patch was investigated and the efficacy and safety of this device were assessed.

METHODS

The E-patch containing beta-lactoglobulin was placed for 24 h in contact with hairless rat skin mounted in a Franz diffusion cell. Transdermal passage was monitored by measurement of beta-lactoglobulin A-[methyl-(14)C] or by two-site enzyme immunoassay. An iterative skin stripping allowed measurement of the beta-lactoglobulin penetrating the first external skin layers.

RESULTS

After 24 h, 92% of beta-lactoglobulin remained on the skin. The iterative skin strippings showed a 135-fold higher concentration of beta-lactoglobulin in the stratum corneum than that found in the epidermis-dermis. Analysis of the solution in the receiver compartment by radioactivity assays or immunoassays indicates that intact protein did not cross the skin.

CONCLUSIONS

The E-patch system allows native beta-lactoglobulin to concentrate in the stratum corneum, in the vicinity of immunological cells, but does not lead to its systemic delivery. Therefore, it is suggested that this delivery system creates ideal conditions for promoting a positive topical response with reduced risk of systemic anaphylactic reactions caused by the native form of the beta-lactoglobulin A.

Vaccines: past, present and future

The vaccines developed over the first two hundred years since Jenner's lifetime have accomplished striking reductions of infection and disease wherever applied. Pasteur's early approaches to vaccine development, attenuation and inactivation, are even now the two poles of vaccine technology. Today, purification of microbial elements, genetic engineering and improved knowledge of immune protection allow direct creation of attenuated mutants, expression of vaccine proteins in live vectors, purification and even synthesis of microbial antigens, and induction of a variety of immune responses through manipulation of DNA, RNA, proteins and polysaccharides. Both noninfectious and infectious diseases are now within the realm of vaccinology. The profusion of new vaccines enables new populations to be targeted for vaccination, and requires the development of routes of administration additional to injection. With all this come new problems in the production, regulation and distribution of vaccines.

Improved immune responses to influenza vaccination in the elderly using an immunostimulant patch

The elderly have greater morbidity and mortality due to influenza, and respond poorly to influenza vaccination compared to younger adults. This study was designed to determine if the adjuvant heat-labile enterotoxin from Escherichia coli (LT), administered as an immunostimulant (IS) patch on the skin with influenza vaccination, improves influenza immune responses in the elderly. Three weeks following vaccination, hemagglutination inhibition (HAI) responses in LT IS patch recipients showed improvement over those of elderly receiving vaccine alone, as demonstrated by significance or trends in fold rise [A/Panama (P = 0.004), A/New Caledonia (P = 0.09)], seroconversion [A/New Caledonia (63% versus 40%, P = 0.01), A/Panama (54% versus 36%, P = 0.08)] and seroprotection [26%, 20% and 16% greater for the patch group for A/New Caledonia, A/Panama and B/Shandong strains, respectively]. The data suggest that an LT IS patch may further enhance influenza vaccine immune responses in the elderly.

Transcutaneous immunization with a 40-kDa outer membrane protein of Porphyromonas gingivalis induces specific antibodies which inhibit coaggregation by P. gingivalis

This study seeks to assess the potential of a 40-kDa outer membrane protein of Porphyromonas gingivalis (40k-OMP) as a transcutaneous vaccine against chronic periodontitis. Transcutaneous immunization (TCI) of mice with 40k-OMP alone elicited 40k-OMP-specific IgG antibody (Ab) responses in both serum and saliva. When administered with cholera toxin (CT) as adjuvant, TCI with 40k-OMP not only elevated IgG Abs as noted above, but also induced IgA responses in serum but not in saliva. Salivary IgG from mice given 40k-OMP alone or 40k-OMP plus CT showed higher binding levels to the 40k-OMP than did that of non-immunized mice. Ab-forming cell (AFC) analysis revealed high numbers of 40k-OMP-specific IgG AFCs in the spleen but low numbers in the salivary glands of mice given 40k-OMP alone or 40k-OMP plus CT. Since 40k-OMP-specific IgG inhibited the coaggregation of P. gingivalis vesicles and S. gordonii, TCI with 40k-OMP may be a useful tool in the quest to prevent P. gingivalis infection.

Immunisation against plague by transcutaneous and intradermal application of subunit antigens

We have investigated immunological responses in BALB/c mice following transcutaneous (TC) delivery of fraction 1 (F1) and V subunits from Yersinia pestis in conjunction with an enterotoxin-derived adjuvant (cholera toxin, CT). It was found that two or more TC applications of F1 and V subunits (admixed with cholera toxin) served to elicit significant levels of anti-F1 and V antibodies in the serum of immunised mice. IL-6 secretion from cultured splenocytes derived from immunised mice indicated that a single TC application of F1 and V subunits (admixed with cholera toxin) conferred a cell-mediated response. As compared with intranasal or direct intradermal injection of F1 and V, the numbers of F1/V-specific antibody-forming cells in the spleens of animals immunised by TC application of F1 and V (admixed with CT) was relatively low. It was noted that TC application of F1 and V admixed with CT was very effective for priming responses that were boosted by intranasal or intradermal routes. Similarly, it was found that TC application of F1 and V admixed with CT could be used to efficiently boost pre-existing responses engendered by intradermal injection or intranasal instillation of F1 and V. In order to assess if TC application of F1 and V admixed with CT could protect experimental animals from plague, immunised mice were injected with a virulent strain of Y. pestis. It was found that two TC applications of F1 and V admixed with CT conferred only limited protection against 10(2) MLDs. However, three TC applications of F1 and V admixed with CT conferred solid protection against 10(2) MLDs. Hence we have shown, for the first time, that TC application of F1 and V admixed with CT can protect animals against challenge with a virulent strain of plague causing bacteria. These data suggest that transcutaneous immunisation may be a simple and non-invasive method for immunising individuals against plague.

Modulation of immune responses with transcutaneously deliverable adjuvants

Transcutaneous immunisation is a novel vaccination strategy based on the application of antigen together with an adjuvant onto hydrated bare skin. This simple and non-invasive immunisation procedure elicits systemic and mucosal immune responses and therefore, it provides a viable and cost-effective strategy for disease prevention. For the induction of antigen-specific immune responses the use of adjuvants is critical. They potentiate and modulate the type of immune responses by stimulating the production of cytokines that drive the differentiation of T cells towards the Th1 or Th2-phenotype. These cells mediate protection against different infectious diseases and therefore, their selective induction is important for successful vaccination. In this review we give a brief overview of transcutaneously deliverable adjuvants and we discuss how they modulate immune responses to topically applied antigens.

Potential use of nanoparticles for transcutaneous vaccine delivery: effect of particle size and charge

The aim of this study was to investigate the effect of size and charge on the permeation of nanoparticles through the skin as the first step in designing a transdermal vaccine delivery system. Fluorescent particles ranging in size and charge were applied to the surface of full thickness pig skin in a diffusion chamber and the receptor fluid was assayed to determine permeation. Fluorescence microscopy was used to visualise the skin after experiments. The results showed that only 50 and 500 nm particles that were negatively charged were able to permeate the skin. This provides evidence of the potential of nanoparticles as delivery vectors for antigens and DNA for the purpose of transdermal vaccination protocols. The results would indicate that negative particles with sufficient charge may be ideal carriers for this purpose.

Epicutaneous application of CpG oligodeoxynucleotides with peptide or protein antigen promotes the generation of CTL

Immunostimulatory oligodeoxynucleotides (ODN) are effective adjuvants in the induction of humoral and cellular immune responses when administered parenterally with antigen. The skin has recently become a target organ for the design of non-invasive vaccine technologies. Using ovalbumin (OVA) as a model antigen, we demonstrate that the application of ODN sequences to tape-stripped skin promotes the induction of potent cytotoxic T lymphocyte (CTL) responses to co-administered peptide. Induction of peptide-specific CTL required the presence of CpG motifs within the ODN. CTL afforded tumor protection against a tumor expressing an immunodominant OVA CTL epitope. CTL could also be induced to whole protein administered onto the skin. Differential CpG sequence activity was noted with respect to the induction of CTL to epicutaneous protein with an ODN sequence containing a poly-G motif having an optimal effect. Peptide-specific CTL could be detected in the peripheral blood as early as 6 d after a single immunization. These results highlight the potential of the bare skin as a route for vaccine development and indicate an important role for immunostimulatory ODN as adjuvants to generate functional CTL with the help of the skin immune system.

Targeting dendritic cells for priming cellular immune responses

The cardinal role of dendritic cells (DC) in priming adaptive immunity and in orchestrating immune responses against all classes of pathogens and also against tumors is well established. Their unique potential both to maintain self-tolerance and to initiate protective immune responses against foreign and/or dangerous structures is based on the functional diversity and flexibility of these cells. Tissue DC lining antigenic portals such as mucosal surfaces and the skin are specialized to take up a wide array of compounds including proteins, lipids, carbohydrates, glycoproteins, glycolipids and oligonucleotides, particles carrying such structures and apoptotic or necrotic cells. This process is facilitated by specialized receptors with high endocytic capacity, which provides potential targets for delivering designed molecules. The best route for targeting B- and/or T cell epitopes, however, is still the subject of intense investigation. Immature DC, which reside in various tissues, can be activated by pathogens, stress and inflammation or modified metabolic products, which induce mobilization of cells to draining lymph nodes where they act as highly potent professional antigen presenting cells. This is brought about by the ability to present their accumulated intracellular content for both CD4+ helper (Th) and CD8+ cytotoxic/cytolytic T lymphocytes (Tc/CTL). Engulfed proteins are processed intracellularly and their peptide fragments are transported to the cell surface in the context of major histocompatibility complex encoded class I and II molecules for presentation to Th cells and CTLs, respectively. The T cell priming capacity of DC, however, depends not only on antigen presentation but also on other features of DC. Human monocyte-derived DC provide an excellent tool to study the internalizing, antigen-presenting and T cell-activating functions of DC at their immature and activated differentiation states. These biological activities of DC, however, are highly dependent on their migratory potential from the peripheral non-lymphoid tissues to the lymph nodes, on the expression of adhesion molecules, which support the interaction of DC with T lymphocytes, and the cytokines secreted by DC, which polarize immune responses to Th1-mediated cellular or Th2-mediated antibody responses. These results altogether demonstrate that monocyte-derived DC are useful candidates for in vitro or in vivo targeting of antigens to induce efficient adaptive immune responses against pathogens and also against tumors.

Transcutaneous immunization induces mucosal CTLs and protective immunity by migration of primed skin dendritic cells

Transcutaneous immunization (TCI), the application of vaccines on the skin, induces robust systemic and mucosal antibodies in animal models and in humans. The means by which mucosal immune responses to vaccine antigens are elicited by TCI has not been well characterized. We examined the effect of TCI with an HIV peptide vaccine on the induction of mucosal and systemic CTL responses and protective immunity against mucosal challenge with live virus in mice. Robust HIV-specific CTL responses in the spleen and in the gut mucosa were detected after TCI. The responses were dependent upon the addition of an adjuvant and resulted in protection against mucosal challenge with recombinant vaccinia virus encoding HIV gp160. Although it is clear that adjuvant-activated DCs migrated mainly to draining lymph nodes, coculture with specific T cells and flow cytometry studies with DCs isolated from Peyer's patches after TCI suggested that activated DCs carrying skin-derived antigen also migrated from the skin to immune-inductive sites in gut mucosa and presented antigen directly to resident lymphocytes. These results and previous clinical trial results support the observation that TCI is a safe and effective strategy for inducing strong mucosal antibody and CTL responses.

Transcutaneous immunization and immunostimulant strategies

The skin provides an attractive immune environment for vaccine delivery and a safe and confined anatomic space for the use of potent adjuvants. It has been presumed that LCs as a class of dendritic cells should stimulate potent immune responses when activated by adjuvants, and this theory is beginning to be validated. Progress on simple pretreatment of the skin has led to well-developed, simple-to-use protocols that are not dissimilar from current protocols used to cleanse the skin before injection. Antigen and adjuvant formulation optimization has progressed, leading to phase 2 testing of the technology in formulated, manufacturable patches. Although delivery optimization and product testing is challenging, the major biologic observations underlying TCI and the IS patch have been established clearly in that large protein antigens have been delivered clinically, resulting in robust immune responses in a safe manner. During the next 5 years, the challenge will be to conduct a development program that leads to safe and effective vaccination in the context of specific applications.

Skin permeation, biodistribution, and expression of topically applied plasmid DNA

BACKGROUND

Topical application is emerging as a new route of gene delivery. However, the extent of skin permeation and the in vivo fate of topically applied plasmid DNA are not fully understood.

METHODS

In vitro permeation of plasmid DNA across human skin and keratinocyte layers was tested using Franz diffusion cells. In vivo absorption and biodistribution of topically applied plasmid in mice were determined using quantitative polymerase chain reaction (PCR). The expression levels of plasmid DNA in various tissues were measured by semiquantitative reverse transcription PCR.

RESULTS

In vitro, topically applied DNA was capable of penetrating human skin and keratinocyte layers. Following topical application of plasmid DNA onto murine skin, the levels of plasmid DNA in the serum peaked at 4 hr. At 24 hr post-dose, topically applied DNA existed at higher levels than intravenously administered DNA in almost all tissues, and induced 11.4- and 22-fold higher mRNA expression in muscle and skin, respectively. Moreover, the topical route showed sustained expression of plasmid DNA in the regional lymph nodes over 5 days, whereas the intravenous route did not.

CONCLUSIONS

Taken together, our results show that topically applied plasmid DNA is capable of permeating the skin and being expressed for prolonged periods in various tissues including lymph nodes. This suggests that skin may provide an appealing, noninvasive route of delivery for DNA vaccines and other therapeutic genes.

Antigens onto bare skin: a 'painless' paradigm shift in vaccine delivery

The skin is an attractive route for delivery of vaccines because it is accessible and contains immunocompetent cells. This opens up the possibility that, in the future, vaccines could be administered in a simple, safe and practical way without requiring the use of needles and syringes. This review focuses on the methods developed to deliver vaccines via the intact skin. Candidate vaccine antigens can be delivered topically using particulate delivery systems and patch formulations containing the antigen with an ADP-ribosylating exotoxin as an adjuvant. The duration and type of elicited immune responses depend on the antigen, the adjuvant and the method of delivery. Already, the first clinical trial of transcutaneous delivery of vaccines has demonstrated the proof of the principle. However, despite these successes, there are several challenges ahead to be addressed before vaccines administered with a patch will be available over the counter.

Optimization of epicutaneous immunization for the induction of CTL

The immune system of the skin has recently been exploited for the development of non-invasive vaccine technologies. However, one of the limitations of current vaccine protocols is the inefficient priming of cytotoxic T lymphocytes (CTL). In this study, we report that the application of either an immunodominant class I MHC restricted ovalbumin peptide or whole ovalbumin protein, to tape-stripped skin together with the co-application of the bacterial enterotoxin cholera toxin (CT) induces antigen-specific CTL. Tape-stripping (TS) was found to enhance the magnitude of antibody responses to co-administered protein and to promote the generation of antigen-specific IgG(2a) responses. As well, both cholera toxin and tape-stripping enhanced epidermal dendritic cell (DC) immigration into draining lymph nodes. The adjuvant effect of co-administered cholera toxin and tape-stripping in promoting CTL priming was not dependent on IL-12. Epicutaneous immunization has previously been shown to induce robust antibody responses to administered protein antigen. We now demonstrate the induction of robust and persistent CTL responses to epicutaneously administered protein antigen. Epicutaneous immunization is cheap, simple and effective. These findings suggest the potential use of the skin for the generation of protective immune responses to both viral and tumor challenge.

Immunostimulant patch containing heat-labile enterotoxin from Escherichia coli enhances immune responses to injected influenza virus vaccine through activation of skin dendritic cells

Vaccine strategies, such as influenza virus vaccination of the elderly, are highly effective at preventing disease but provide protection for only the responding portion of the vaccinees. Adjuvants improve the magnitude and rates of responses, but their potency must be attenuated to minimize side effects. Topical delivery of strong adjuvants such as heat-labile enterotoxin from Escherichia coli (LT) induces potent immune responses. We hypothesized that LT delivered alone in an immunostimulating (LT-IS) patch placed on the skin at the site of injection could augment the immune response to injected vaccines. This was based on the observation that topically applied LT induces migration of activated antigen-presenting cells (APCs) from the skin to the proximal draining lymph node (DLN), and that APCs loaded with antigen by injection in the same anatomical region also migrate to the same DLN. We observed that when influenza virus vaccine is injected and an LT-IS patch is placed to target the same DLN, the influenza virus antibody response is enhanced. Similarly, influenza virus-specific T cells isolated from the lungs show increased levels of gamma interferon and interleukin-4 production. An LT-IS patch placed near an injected vaccine also leads to increased levels of hemagglutination inhibition titers, enhanced mucosal immunoglobulin A responses, and enhanced antigen presentation. Although the mechanisms by which an LT-IS patch exerts its enhancing effects need further study, the enhanced immune responses, ability to safely use potent adjuvants, and simplicity of LT-IS patch application address an important unmet need and provide a new immune enhancement strategy.

Transcutaneous immunization and immunostimulant strategies: capitalizing on the immunocompetence of the skin

The skin is an attractive target for vaccine delivery. Topical application of adjuvants results in potent immune responses and good safety profiles. Adjuvants can be coadministered in a patch with vaccine antigens (transcutaneous immunization) or similar delivery format, or administered separately with an injection or IS patch (Iomai), leading to enhanced immune responses. These observations have moved into the clinic, highlighting the likelihood that skin delivery of vaccines will play an important future role in vaccine applications.

Transcutaneous immunization with cholera toxin B subunit adjuvant suppresses IgE antibody responses via selective induction of Th1 immune responses

Topical application of cholera toxin (CT) onto mouse skin can induce a humoral immune response to CT as well as to coadministered Ags. In this study, we examined the nontoxic cell-binding B subunit of CT (CTB) as a potential adjuvant for cutaneous immune responses when coadministered with the prototype protein Ag, OVA. CTB applied onto skin induced serum Ab responses to itself with magnitudes comparable to those evoked by CT but was poorly efficient at promoting systemic Ab responses to coadministered OVA. However, transcutaneous immunization (TCI) with either CT or CTB and OVA led to vigorous OVA-specific T cell proliferative responses. Furthermore, CTB potentiated Th1-driven responses (IFN-gamma production) whereas CT induced both Th1 and Th2 cytokine production. Coadministration of the toxic subunit CTA, together with CTB and OVA Ag, led to enhanced Th1 and Th2 responses. Moreover, whereas TCI with CT enhanced serum IgE responses to coadministered OVA, CTB suppressed these responses. TCI with either CT or CTB led to an increased accumulation of dendritic cells in the exposed epidermis and the underlying dermis. Thus, in contrast to CT, CTB appears to behave very differently when given by the transcutaneous as opposed to a mucosal route and the results suggest that the adjuvanticity of CT on Th1- and Th2-dependent responses induced by TCI involves two distinct moieties, the B and the A subunits, respectively.

Novel ethanol-in-fluorocarbon microemulsions for topical genetic immunization

PURPOSE

Traditionally, vaccines have been administered by needle injection. Topical immunization through the intact skin with either protein- or DNA-based vaccines has attracted much attention recently. We sought to enhance the immune responses induced by DNA-based vaccines after topical application by developing novel ethanol-in-fluorocarbon (E/F) microemulsion systems to aid in the delivery of plasmid DNA (pDNA).

METHODS

Ten different fluorosurfactants were selected or synthesized and screened by pseudo-phase-diagram construction for their ability to form E/F microemulsions. Plasmid DNA was successfully incorporated into E/F microemulsions using several different fluorosurfactants and perfluorooctyl bromide as the continuous fluorocarbon phase. For several reasons, Zonyl FSN-100 (an ethoxylated nonionic fluorosurfactant) was selected for further studies. In vivo studies were performed in mice to assess pDNA expression in skin and immunologic responses after topical application of this system using a luciferase-encoding plasmid (CMV-luciferase) and a CMV-beta-galactosidase-encoding plasmid, respectively.

RESULTS

Plasmid DNA incorporated into E/F microemulsion using FSN-100 as the surfactant was found to be stable. After topical application of this E/F microemulsion system, significant enhancements in luciferase expression and antibody and T-helper type-1 biased immune responses were observed relative to those of "naked" pDNA in saline or ethanol. For example, with the E/F microemulsion system, the specific serum IgG and IgA titers were increased by 45-fold and over 1000-fold, respectively.

CONCLUSION

A novel fluorocarbon-based microemulsion system for potential DNA vaccine delivery was developed.

Strategies for designing vaccines eliciting Th1 responses in humans

There is currently a major interest in designing vaccines capable of eliciting strong cellular immune responses. The induction of cytotoxic and Th1 helper cellular responses is for example highly desirable for vaccines targeting either chronic infectious diseases or cancers (therapeutic vaccines). Similarly, Th1 vaccines would be useful in redirecting inappropriate antigen-specific immune responses in patients with autoimmune diseases and allergies. Importantly, emerging technologies and a better understanding of the physiology of immune responses offer new avenues to rationally design such vaccines. Approaches based on the identification and selection of immunogens containing T cell epitopes can be used, together with epitope-enhancement strategies, to increase binding to MHC, or to improve recognition by T cell receptor complexes. Optimized immunogens can subsequently be presented to the immune system with appropriate vectors allowing to target professional antigen-presenting cells, such as dendritic cells. Such antigen presentation platforms can be used alone or in association, as part of mixed immunization regimens (heterologous prime-boosts), in order to elicit broad immune responses. The rational design of Th1 adjuvants can also benefit from our better understanding of the nature of proinflammatory signals leading to the initiation of both innate and adaptive immune effector mechanisms. Candidate Th1 vaccines (or components such as vectors or adjuvants) will have to be tested in exploratory clinical studies, implying a need for new assays and methods allowing to assess in a qualitative and quantitative manner low-frequency T cell responses in humans.

Effect of transcutaneous immunization with co-administered antigen and cholera toxin on systemic and mucosal antibody responses in sheep

Direct application of antigens to skin together with an adjuvant, a procedure called transcutaneous immunization (TCI), can induce systemic immune responses in mice, humans, cats and dogs. In previous studies we found that cholera toxin (CT) applied topically on unbroken skin induces systemic antibody and lymphocyte proliferative responses in sheep. The current study examined whether concurrent administration of CT and tetanus toxoid (TT) delivered transcutaneously could induce specific antibody responses to both antigens in sheep. Antibodies to both TT and CT were induced by TCI although antibody titres in serum to TT were higher in sheep receiving TT plus alum by intramuscular injection (n=5) than TT plus CT by TCI (n=5). The ratio of IgG1/IgG2 antibody to TT in serum was near unity, and the route of immunization, TCI versus injection, did not influence this ratio. In contrast, the ratio of IgG1/IgG2 antibody differed significantly between the two antigens, TT and CT, delivered by TCI, with a higher proportion of IgG1 antibody in serum to CT than TT. Antibody to TT was detected in lung washes from TCI and injection groups, with IgG1 predominating over IgG2 in both groups. IgA antibodies to CT and TT were detected in sera of CT and TT-immunized groups respectively but in lung washes IgA antibody to TT was detected only in the injection group. Results show that TCI induced systemic antibody responses to CT and the co-administered antigen TT, whereas no evidence was obtained for mucosal IgA responses following TCI.