Summary of a clinical trial with liposome-adjuvanted influenza A virus vaccine in elderly adults.

In a randomized, double-blinded study, 77 elderly seropositive volunteers were immunized with either liposome-adjuvanted or control subvirion vaccine containing 15 micrograms/dose of haemagglutinin from influenza A/Taiwan/1/86 (H1N1) virus. The liposome vaccine was well-tolerated but elicited serologic responses that were no different in frequency or magnitude from those induced by the control vaccine. Less than 20% of subjects in either group mounted a 4-fold or greater rise in antibody titer. Peripheral blood anti-influenza A cytotoxic T lymphocyte activity was enhanced to a greater extent by the liposome vaccine than by the control subvirion vaccine. It remains unclear whether liposome-adjuvanted formulations would have an advantage over conventional influenza vaccines for routine annual reimmunization of targeted high-risk populations.

Influenza virus vaccination of patients with chronic lung disease.

STUDY OBJECTIVES: To evaluate the safety of, and mucosal and systemic immune responses induced by two influenza virus vaccine regimens in subjects with COPD. DESIGN: Single-center, blinded, randomized, prospective clinical trial evaluating two vaccine regimens. SETTING: Outpatient clinics of St. Louis Department of Veterans Affairs Medical Center. PARTICIPANTS: Volunteers (age range, 42 to 88 years) had preexisting COPD with severe obstruction to airflow on average, were male, and were not receiving immunosuppressive medication. INTERVENTIONS: Twenty-nine volunteers were randomly assigned to receive either bivalent live attenuated influenza A virus vaccine (CAV) or saline solution placebo intranasally. All subjects also received an i.m. injection of trivalent inactivated influenza virus vaccine (TVV) simultaneously. MEASUREMENTS AND RESULTS: Clinical status and pulmonary function measured by spirometry did not change significantly after vaccination. Using hemagglutinins (H1 and H3 HA) which more closely resembled those in CAV, mean levels of anti-HA immunoglobulin A (IgA) antibodies in nasal washings increased significantly after vaccination with CAV and TVV compared to prevaccination, but they did not increase significantly after TVV and intranasal placebo. Mean levels of influenza A virus-stimulated interleukin-2 and -4 produced by peripheral blood mononuclear cells in vitro increased significantly after administration of the combination vaccine regimen and to a lesser extent after TVV and intranasal placebo compared to respective prevaccination levels. The timing of the cytokine response appeared different following CAV and TVV compared to TVV and intranasal placebo. CONCLUSIONS: Intranasally administered CAV was safe when given with i.m. administered TVV and there may be an immunologic advantage to administration of the combination vaccine regimen compared to TVV with intranasal placebo.

Cognitive impairment in patients with obstructive sleep apnea and associated hypoxemia.

Twenty-six patients with sleep apnea had neuropsychologic testing prior to nocturnal sleep study in a sleep disorders clinic. The cognitive functioning of patients who had sleep apnea with associated hypoxemia was compared to nonhypoxemic patients with sleep apnea. The patients who had sleep apnea with hypoxemia had more severe cognitive impairment than those with sleep apnea without hypoxemia. The hypoxemic patients with sleep apnea had significantly poorer cognitive functioning on four of eight tests (p less than 0.05). In addition, the patients who had sleep apnea with hypoxemia had mean performance scores in the impaired range on measures of attention, concentration, complex problem-solving, and short-term recall of verbal and spatial information. In contrast, the patients who had sleep apnea without hypoxemia had no mean performance score in the impaired range. The degree of hypoxemia during sleep and wakefulness significantly correlated with the degree of overall cognitive impairment as rated by a neuropsychologist; however, measures of sleep fragmentation did not significantly correlate with overall cognitive impairment in patients with sleep apnea. We conclude that patients who have sleep apnea with associated hypoxemia have cognitive impairment which is more severe than those with sleep apnea without hypoxemia.

Influenza A virus-specific cytotoxic T lymphocyte activity declines with advancing age.

OBJECTIVE: To investigate whether influenza A-specific cytotoxic T lymphocyte (CTL) activity is reduced in elderly compared with younger adults. DESIGN: Case series comparing outcomes in young and elderly cohorts. SETTING: Saint Louis University Division of Geriatric Medicine. PARTICIPANTS: Healthy adult outpatients and staff members aged < 50 (young) or > or = 65 (elderly) years. METHODS: Peripheral blood mononuclear cells were assayed for CTL activity by a 51chromium release assay following 1 week of in vitro stimulation with influenza A/PR/8/34 (H1N1) virus. MEASUREMENTS: Percent specific lysis of autologous and allogeneic influenza virus-infected target cells. MAIN RESULTS: Specific lysis of autologous A/PR-infected targets was significantly lower in elderly compared to young subjects (P < 0.01), and exceeded 10% in a significantly lower proportion of elderly compared with younger subjects (P < 0.05), but was not influenced by a history of vaccination within the preceding 12 months. Cytotoxic effectors were class I human leukocyte antigen (HLA)-restricted and displayed heterosubtypic cross-reactivity but were unable to lyse influenza B-infected targets. CONCLUSIONS: These results demonstrate an age-related decline of influenza A virus-specific CTL activity and suggest that CTL responses to inactivated virus vaccine are of short duration.

Reduced infectivity of cold-adapted influenza A H1N1 viruses in the elderly: correlation with serum and local antibodies.

OBJECTIVE: To compare young and elderly adults in terms of their immune responses and rates of infection following intranasal vaccination with a live attenuated influenza virus. DESIGN: Time series, comparing outcomes in young and elderly convenience sample. METHOD: Retrospective laboratory analysis of serum and nasal wash specimens collected during prior studies in which young or elderly volunteers had been inoculated with cold-adapted influenza A/Kawasaki/86 (H1N1) reassortant virus. SETTING: Johns Hopkins Center for Immunization Research. PARTICIPANTS: Healthy young and elderly adults with pre-vaccination serum hemagglutination inhibition (HAI) antibody titers less than or equal to 1:8. OUTCOME MEASUREMENTS: Antibody responses in serum and nasal washes. MAIN RESULTS: The proportion of vaccinees who developed any serum or local antibody response was higher in young compared with elderly subjects (20/20 vs 5/14, P less than 0.0005). Resistance to infection with cold-adapted virus correlated with pre-vaccination levels of serum immunoglobulin G (IgG), serum IgA, and nasal wash IgA antibody to whole virus antigen. Age was highly correlated with a lack of response to vaccine by simple regression, but not when data were adjusted for pre-existing antibody levels. CONCLUSIONS: Cold-adapted reassortant influenza A H1N1 viruses achieve lower rates of infection in elderly than young adults, primarily due to age-related differences in preexisting levels of immunity which may not be reflected by HAI titer.

Hepatitis B virus vaccination for older adults.

OBJECTIVE: To compare in adults more than 50 years old the tolerability and immunogenicity of vaccination with recombinant hepatitis B surface antigen (HBs) compared with vaccination with recombinant hepatitis B protein PreS2 + S, and to investigate the safety and immunogenicity of a fourth vaccine dose in poor and non-responders. DESIGN: Randomized, double-blind prospective study. SETTING: General clinical research center for outpatient evaluation and vaccination. SUBJECTS: Adults older than age 50 who were in general good health and with no known risk factors for acquiring or serologic evidence of hepatitis B virus infection. INTERVENTION: Subjects were randomized to receive 10 mcg HBs (Recombivax, Merck, Sharp and Dohme), 12 mcg PreS2 + S, or 24 mcg PreS2 + S vaccine at 0, 1, and 6 months. Poor and non-responders (anti-Hbs < 10 mIU/mL at month 9 and/or 12) were encouraged to receive a fourth vaccine injection. MEASUREMENTS: Diary records of temperature and local and systemic reactions following each vaccination were maintained by all subjects. Anti-HBs levels were measured by radioimmunoassay before the first injection, at 1, 2, 3, 6, 7, 9, and 12 months after for all subjects, and 1 month after the fourth injection for the group of poor and non-responders. MAIN RESULTS: Twenty men and nine women (mean age +/- SD, 66 +/- 8.0 years) were enrolled. Ten subjects received HBs vaccine, nine received 12 mcg PreS2 + S vaccine, and 10 received 24 mcg PreS2 + S vaccine. One subject in the HBs group dropped out, and data were analyzed for the remaining 28 subjects. There were no differences in rates of side effects reported by each of the three groups. Overall, minor local adverse reactions occurred in 12 (40%) after at least one of the first three vaccinations. Systemic side effects occurred in five (17%) after the first vaccination, in one after the second, but in none after the third. The 24-mcg PreS2 + S vaccine was not more immunogenic than the HBs vaccine, and the 12-mcg PreS2 + S vaccine was judged inadequate. Nineteen of 22 (86%) poor and non-responders received a fourth vaccination. Minor local adverse reactions were reported by six (32%), and none reported a systemic side effect. For the 12 subjects receiving a fourth injection of HBs or 24 mcg PreS2 + S vaccine, the proportion of responders 1 month following the fourth injection was greater than for 1 month following the third injection (11 of 12 [92%] versus 12 of 19 [63%], respectively, P < .05). CONCLUSION: For adults more than 50 years of age who have low anti-HBs levels after three vaccine injections, a fourth injection is well tolerated and results in improved immunogenic response.

Influenza, pneumonia, tetanus: how effective is vaccination?

The rationale for immunizing older adults with influenza, pneumococcal, and tetanus-diphtheria vaccines is derived largely from epidemiological data indicating a heightened susceptibility to these illnesses within this population. The authors provide supportive information relevant to the routine use of these vaccines in adults aged 65 or older.

Effect of age on serum immunoglobulin G subclass antibody responses to inactivated influenza virus vaccine.

We previously reported an age-associated impairment of serum immunoglobulin G (IgG) antibody responses to inactivated influenza virus vaccine. The present study extends these observations by examining the IgG subclass distribution of vaccine responses measured by enzyme linked immunosorbent assay in healthy adults aged < 40 (young), 40-64 (middle-aged), and > or = 65 (elderly) years. Serological responses in all age groups showed antibodies that were predominantly IgG1 and secondarily IgG3. Influenza antigen-specific IgG4 titers did not change following vaccination, and antibodies of the IgG2 subclass were not detected in any serum specimens. Aging was associated with a significant impairment of IgG1, but not of IgG3, antibody production. Relative differences in the magnitude and frequency of response between IgG1 and IgG3 subclasses, which were present in young and middle-aged adults (viz., IgG1 > IgG3), were less apparent in the elderly. This observation was confirmed in a second analysis of IgG subclass-specific responses in a separate cohort of elderly vaccinees. These results suggest that the age-related impairment of humoral responses to inactivated influenza virus vaccine is primarily accounted for by differences in IgG1 antibody production, and that IgG3 antibodies make up a larger proportion of the overall serologic response in the elderly than they do in younger persons.

Increased immunogenicity of inactivated influenza virus vaccine containing purified surface antigen compared with whole virus in elderly women.

Thirty-eight elderly female subjects (aged 80 +/- 7 years, mean +/- standard deviation) were randomized to immunization with trivalent inactivated influenza virus vaccine containing either purified surface antigen (n = 18) or whole virus (n = 20) components from A/Texas/36/91 (H1N1), A/Beijing/353/89 (H3N2), and B/Panama/45/90 strains. Humoral and cellular immune responses were assessed by measuring serum hemagglutination inhibition antibodies and cytotoxic T lymphocyte (CTL) activity at 0 and 3 weeks postvaccination. Serological responses to both of the type A vaccine strains following immunization with surface antigen vaccine (SAV) were significantly more frequent and greater in magnitude than those induced by whole-virus vaccine. Antibody responses to the B/Panama component were modest and did not differ significantly between the two vaccines. Persons given SAV, but not those given whole-virus vaccine, had a small but significant increase in mean percent specific lysis of influenza A (H1N1) virus-infected autologous targets by peripheral blood mononuclear cells which were stimulated in vitro with influenza A (H1N1) virus. The H1N1-stimulated cytotoxic effectors induced by SAV were CD8+ and were not cross-reactive against H3N2-infected targets. Influenza B virus-specific CTL responses were not observed with either vaccine. These results suggest that currently available subunit influenza virus vaccines may offer an advantage over inactivated whole-virus preparations for inducing humoral and cellular immune responses in the elderly, although the CTL response may be too limited to be of physiological significance.

Vaccine-induced antibodies to heterologous influenza A H1N1 viruses: effects of aging and "original antigenic sin".

Prototype influenza A H1N1 viruses representing antigenically distinct Hsw1, H0, and H1 hemagglutinin variants that circulated during the early 1900s were used to measure cross-reactive serum hemagglutination inhibition antibodies elicited by contemporary inactivated virus vaccines in adults aged < 40 (young), 40-64 (middle-aged), or > or = 65 (elderly) years. Elevated titers of antibodies to Hsw1 and H0 antigens were present both before and after vaccination in higher proportions of middle-aged and elderly than young adults, whereas antibodies to more recent H1 antigens were prevalent in all age groups. Vaccine responses to heterologous H1N1 viruses were consistently reduced in frequency and magnitude with advancing age. Also, within each age group, antibody responses tended to diminish against progressively older heterologous antigens. These results confirm previous seroepidemiological surveys but suggest that preferential orientation of secondary antibodies toward priming epitopes ("original antigenic sin") is not responsible for the age-related impairment of antibody responses to influenza vaccine.

Effect of age on cytotoxic T lymphocyte memory as well as serum and local antibody responses elicited by inactivated influenza virus vaccine.

Healthy seropositive adults aged < 40 (n = 15), 40-64 (n = 15), and > or = 65 (n = 17) years were parenterally immunized with trivalent subvirion influenza virus vaccine, and their cellular and humoral immune responses were compared. Vaccination resulted in a significant enhancement of class I human leukocyte antigen-restricted influenza A cross-reactive cytotoxic T lymphocyte (CTL) memory. Elderly subjects had significantly lower baseline and peak postvaccination mean percentages of specific lysis of influenza A virus-infected autologous targets but nonetheless mounted CTL responses to vaccine that were comparable in magnitude to those of younger adults. Serologic responses and nasal IgG responses to each of 3 vaccine strains were reduced in magnitude and frequency with advancing age. Parenteral immunization was ineffective at inducing nasal wash IgA antibodies. Between 2 and 12 weeks after vaccination, serum and nasal antibody titers decreased modestly, although the rate of decline was comparable between age groups. The ability of elderly adults to mount CTL responses after influenza vaccination suggests that T cell effector mechanisms may be an important determinant of vaccine-induced protection against serious illness in this age group.

Age-related changes in LFA-1 expression, cell adhesion, and PHA-induced proliferation by lymphocytes from senescence-accelerated mouse (SAM)-P/8 and SAM-R/1 substrains.

Accelerated senescence-prone mice of the SAM-P/8jf series were compared with senescence-resistant SAM-R/1 controls in terms of age-related changes in phytohemagglutinin (PHA) proliferative responses and lymphocyte function-associated antigen-1 (LFA-1) utilization by non-adherent splenocytes. Advancing age was associated with a reduction in cell proliferative responses to PHA in both substrains, although the rate of decline was significantly more rapid in the senescence-prone animals. Conversely, in both substrains there was a progressive age-related increase in the proportion of splenocytes expressing high levels of LFA-1, and a parallel increase in the degree of LFA-1-dependent cell aggregation induced by phorbol ester. Age-matched SAM-P/8jf and SAM-R/1 mice did not differ in terms of LFA-1 expression or LFA-1-dependent cell aggregation. Two-color cytofluorometric analysis demonstrated the enhanced expression of LFA-1 expression by cells bearing the Pgp-1hi phenotype characteristic of memory lymphocytes. These results suggest that age-associated changes in lymphocyte adhesion are attributable to alterations in the relative numbers of memory cells expressing high levels of LFA-1, but are unlikely to contribute to the reduced proliferative response to mitogen in aged mice.

Neuraminidase-specific antibody responses to inactivated influenza virus vaccine in young and elderly adults.

Little information is available on the potential role of antibody to influenza virus neuraminidase (NA) in vaccine-induced immunity. In the present study, serologic responses to the N1Texas/91 and N2Beijing/92 NA components of trivalent inactivated influenza virus vaccine were measured by NA inhibition (NI) and enzyme-linked immunosorbent assay (ELISA), and the results for adults aged 18 to 45 (young) or > or = 65 (elderly) years were compared. The two age groups had comparable rates (32 to 50%) of NI response. In contrast, ELISA immunoglobulin G (IgG) antibody responses to N1 and N2 NAs occurred in 70 to 71 and 67 to 83%, respectively, of young subjects but in only 3 to 18 and 18 to 35%, respectively, of elderly subjects. prevaccination mean ELISA IgG and IgA NA antibody titers were generally lower for the young adults than they were for the elderly, whereas the corresponding NI titers were comparable. In young adults, plaque size-reducing NA antibody increases were positively associated with ELISA but not with NI antibody increases. There were no apparent age-related differences in the immunoglobulin isotype distribution of the anti-NA response, with IgG being the dominant class and IgG1 the dominant subclass of serum antibody. Anti-hemagglutinin antibody responses to H1Texas/91 and H3Beijing/92 were greater in magnitude and frequency than the corresponding NA-specific responses to N1Texas/91 and N2Beijing/92 when measured by hemagglutination inhibition and NI, respectively, but not when measured by ELISA. The discordance between NI and ELISA for measurement of NA-specific vaccine responses may reflect the relative insensitivity of NI in discriminating differences when initial antibody titers are low.

In previously immunized elderly adults inactivated influenza A (H1N1) virus vaccines induce poor antibody responses that are not enhanced by liposome adjuvant.

In a randomized, double-blinded study, 77 healthy elderly seropositive volunteers (95% of whom had received influenza vaccine within the prior 5 years) were immunized with either monovalent liposome-adjuvanted or control subvirion vaccine containing inactivated influenza A/Taiwan/1/86 (H1N1) virus. The experimental vaccine was well-tolerated but elicited serologic responses that were no different in frequency or magnitude from those induced by the control vaccine. Less than 20% of subjects in either group mounted a fourfold or greater rise in antibody titer. Sixty-three elderly subjects who had participated in the liposome vaccine trial were reimmunized 18 weeks later with licensed trivalent subvirion vaccine, and their serologic responses were compared with those of 26 young adults. Significant rises in hemagglutination inhibition (HAI) antibody titers to the A/Texas/36/91 (H1N1), A/Beijing/32/92 (H3N2) and B/Panama/45/90 components occurred in 10%, 76% and 56% of elderly vaccinees, respectively, compared to 92% (p < 0.0001), 100% (p < 0.005) and 88% (p < 0.005) of young vaccines, respectively. Age differences in seroresponse rates to the H1N1 subtype antigen were significant even when comparing young and old adults with identical prevaccination HAI antibody titers. These data confirm prior observations suggesting that previously immunized elderly persons have impaired serologic responses to influenza vaccines, particularly against recently circulating H1N1 subtype antigens. It remains unclear whether liposome-adjuvanted formulations would have an advantage over conventional influenza vaccines for routine annual reimmunization of targeted populations.

Systemic and local antibody responses in elderly subjects given live or inactivated influenza A virus vaccines.

Intranasal live attenuated cold-adapted (ca) influenza A/Kawasaki/9/86 (H1N1) reassortant virus and parenteral inactivated influenza A/Taiwan/1/86 (H1N1) virus were given alone or in combination to 80 ambulatory elderly subjects. An enzyme-linked immunosorbent assay was used to measure hemagglutinin-specific (HA) antibodies in serum and nasal wash specimens collected before vaccination and 1 and 3 months later. Serum immunoglobulin G (IgG) and nasal wash IgA HA responses were elicited in 56 and 20%, respectively, of 25 inactivated-virus vaccinees and in 67 and 48%, respectively, of 27 recipients of both vaccines but in only 36 and 25%, respectively, of 28 vaccinees given live virus alone. Inactivated virus, administered alone or with live virus vaccine, induced higher titers of serum antibody than did the live virus alone. In contrast, nasal IgA HA antibody was elicited more often and in greater quantity by the vaccine combination than by either vaccine alone. Despite these differences, the peak titers of local antibody mounted by each group of vaccinees were similar. By 3 months postvaccination, serum IgG and nasal IgA HA antibody titers remained elevated above prevaccination levels in 50 and 17%, respectively, of the inactivated-virus vaccinees and in 46 and 23%, respectively, of recipients of both vaccines but in only 19 and 7%, respectively, of the live-virus and systemic antibodies, if vaccinees. The finding that live ca influenza A virus induced short-lived local and systemic antibodies, if confirmed, suggests that live virus vaccination may not be a suitable alternative or adjunct to inactivated virus vaccination for the elderly.

Effect of age on the human high affinity interleukin 2 receptor of phytohaemagglutinin stimulated peripheral blood lymphocytes.

High affinity interleukin 2 receptors (HA-IL-2R) on mitogen- or antigen-stimulated T cells have been shown to efficiently bind interleukin 2 (IL-2) and to transduce the activation signal(s) that facilitate proliferation. This study was initiated to determine whether the impaired proliferative response of T cells from elderly individuals can be attributed to the defective expression of HA-IL-2R. While cells from both young and old individuals had statistically insignificant differences in the number of HA-IL-2R per membrane IL-2R-positive cell and these receptors displayed similar binding affinities with 125I-IL-2, there were consistently fewer cells and fewer cells expressing HA-IL-2R in the cell cultures from elderly individuals. The magnitude of the age-associated impairment in cell proliferation was decreased, but remained present, when Percoll fractionated lymphoblasts, as compared to peripheral blood lymphocytes (PBL), were cultured in the presence of exogenous interleukin 2 (IL-2). The results demonstrate that a significantly larger percentage of lymphocytes from elderly individuals do not respond to mitogenic stimulation and, probably due to stimulus stress, die in culture. As a consequence there are fewer functionally competent cells expressing the HA-IL-2R in cultures from elderly individuals, which in turn contributes to the age-related defect in the lymphocyte proliferative response.

Phorbol myristate acetate and calcium ionophore A23187-stimulated human T cells do not express high-affinity IL-2 receptors.

Phorbol myristate acetage (PMA) and Ca2+ ionophore A23187 mimic early signal transduction pathways and activate purified human T cells to secrete large quantities of interleukin-2 (IL-2) and to proliferate. Despite producing 50-100-fold more IL-2 than phytohaemagglutinin (PHA)-activated peripheral blood lymphocytes (PBL), PMA/A23187-stimulated human T cells proliferate less than cells activated by PHA. Washing the cells to remove PMA/A23187 was found to increase cellular proliferation two to five-fold. High-affinity IL-2R (HA-IL-2R) were found to be expressed by human T cells that had been washed 24 hr after PMA/A23187 stimulation and recultured without stimulus for an additional 48 hr, but not by T cells constantly exposed to PMA/A23187 for 72 hr. Radioligand binding studies with [125I]IL-2 demonstrated that while the alpha (p55) and beta (p70-75) subunits of HA-IL-2R were both present on the constant PMA/A23187-stimulated T cells, they did not appear to associate to form functional HA-IL-2R. This defect in the expression of bio-active HA-IL-2R on constant PMA/A23187-stimulated human T cells seems to account for their low proliferative response.