Viral Immunization

4th Year Medical, 2006/2007

Prof. Widad Al-Nakib, FRCPath.

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 Principle of Immunization

• The principle of vaccination is to induce a

"primed" state in the vaccinated subject
so that, following exposure to a pathogen,
a rapid secondary immune response is
generated leading to the accelerated
elimination of the organism and protection
from clinical disease. Success depends on
the generation of memory T and B cells
and the presence in the serum of
neutralizing antibody
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 What makes a Good Vaccine?

1. Ability to elicit the appropriate immune response for

the particular pathogen:
– Tuberculosis - cell mediated response
– most bacterial and viral infections - antibody
2. Long term protection
ideally life-long
3. Safety
vaccine itself should not cause disease
4. Stable
retain immunogenicity, despite adverse storage
conditions prior to administration
5. Inexpensive

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 Different Types of Virus Vaccines

• Live whole virus vaccines

• Killed whole virus vaccines
• Subunit vaccines;- purified or
recombinant viral antigen
• Recombinant virus vaccines
• Anti-idiotype antibodies
• DNA vaccines

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‘Kids Get Vaccinated’

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‘Teenagers Get Vaccinated’

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 Live-Attenuated Viral Vaccines

• Live virus vaccines are prepared from

attenuated strains that are almost or completely
devoid of pathogenicity but are capable of
inducing a protective immune response. They
multiply in the human host and provide
continuous antigenic stimulation over a period of
time, Primary vaccine failures are uncommon
and are usually the result of inadequate
storage or administration. Another possibility
is interference by related viruses as is
suspected in the case of oral polio vaccine in
developing countries

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Use of a Related Virus from Another Animal as
Live Vaccines
(Hetrologous Vaccines)

• Both cowpox virus and vaccinia virus are

closely related to variola virus, the causitive
agent of smallpox. The eighteenth centuary
physician, Edward Jenner observed that
milkmaids who had been infected with cowpox
virus were immune to smallpox. Widespread use
of vaccinia virus as a vaccine has lead to the
world-wide eradication of smallpox.

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 Use of Partially Attenuated Virus by an
Unnatural Route as a Live Vaccine

• The virulence of the virus is often reduced

when administered by an unnatural route.
This principle is used in the immunization
of military recruits against adult respiratory
distress syndrome using enterically
coated live adenovirus type 4, 7 and
(21).

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 Passage of the Virus in an “Unnatural
Host" or Host Cell as Live Vaccine
• The major vaccines used in man and animals
have all been prepared this way. After
repeated passages, the virus is administered to
the natural host. The initial passages are made
in healthy animals or in primary cell cultures.
There are several examples of this approach:
the 17D strain of yellow fever was developed
by passage in mice and then in chick embryos.
Polioviruses were passaged in monkey kidney
cells and measles in chick embryo fibroblasts.
Human diploid cells are now widely used
such as the WI-38 and MRC-5

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 Development of Temperature Sensitive
Mutants as Live Vaccines

• As previously described but passaging the

virus under reduced temperature.
• Good example; the live –attenuated
polio virus vaccines

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Inactivated (Killed) Whole Virus Vaccines

• The virus is simply inactivated. The outer virion coat

should be left intact but the replicative function should be
destroyed. To be effective, non-replicating virus
vaccines must contain much more antigen than live
vaccines that are able to replicate in the host.
Preparation of killed vaccines may take the route of heat
or chemicals. The chemicals used include
formaldehyde or beta- propiolactone. The traditional
agent for inactivation of the virus is formalin. Excessive
treatment can destroy immunogenicity whereas
insufficient treatment can leave infectious virus capable
of causing disease.
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 Live vs Killed Vaccines
Feature Live Dead
Dose Low High
No. of doses Single Multiple
Need for adjuvant No Yes

Duration of Many years Short

immunity
Antibody IgG, IgA IgG
response
CMI Good Poor
Reversion to Possible Not possible
virulence 13
 Potential Safety Problems

• Live vaccines
• Underattenuation
• Mutation leading to reversion to virulence
• Preparation instability
• Contaminating viruses in cultured cells
• Heat lability
• Should not be given to
immunocompromized or pregnant patients
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 Potential Safety Problems

• Killed vaccines
• Incomplete inactivation
• Increased risk of allergic reactions due to
large amounts of antigen involved

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 Present Problems with Vaccine
Development Include
Failure to grow large amounts of organisms
in laboratory
Crude antigen preparations often give poor
protection. eg. Key antigen not identified
Live vaccines of certain viruses can
(1) induce reactivation,
(2) be oncogenic in nature

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 Subunit Vaccines

• As the technology for growing viruses to high titres in

cell cultures advanced, it became practicable to purify
virus and viral antigens. It is now possible to identify the
peptide sites encompassing the major antigenic
sites of viral antigens, from which highly purified
subunit vaccines can be produced. Increasing
purification may lead to loss of immunogenicity, and this
may necessitate coupling to an immunogenic carrier
protein or adjuvant, such as an aluminum salt. Examples
of purified subunit vaccines include the HA vaccines for
influenza A and B, and HBsAg derived from the
plasma of carriers

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 Recombinant Viral Proteins Vaccines

• Virus proteins have been expressed in

bacteria, yeast, mammalian cells, and viruses.
E. Coli cells were first to be used for this
purpose but the expressed proteins were not
glycosylated, which was a major drawback since
many of the immunogenic proteins of viruses
such as the envelope glycoproteins, were
glycosylated. Nevertheless, in many instances, it
was demonstrated that the non-glycosylated
protein backbone was just as immunogenic.
Recombinant hepatitis B vaccine is the only
recombinant vaccine licensed at present.

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 Synthetic Peptides

• The best known example is foot and mouth disease,

where protection was achieved by immunizing animals
with a linear sequence of 20 aminoacids. Synthetic
peptide vaccines would have many advantages. Their
antigens are precisely defined and free from
unnecessary components which may be associated
with side effects. They are stable and relatively cheap
to manufacture. Furthermore, less quality assurance is
required. Changes due to natural variation of the virus
can be readily accommodated, which would be a great
advantage for unstable viruses such as influenza

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 Anti-idiotype Antibodies Vaccines

• The ability of anti-idiotype antibodies to mimic

foreign antigens has led to their development
as vaccines to induce immunity against viruses,
bacteria and protozoa in experimental animals.
Anti-idiotypes have many potential uses as viral
vaccines, particularly when the antigen is difficult
to grow or hazardous. They have been used to
induce immunity against a wide range of viruses,
including HBV, rabies

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 DNA Vaccines

• Dubbed the new technology the "third revolution" in vaccine

development—in par with the development of subunit vaccines.
The first clinical trials using injections of DNA to stimulate an
immune response against a foreign protein began for HIV in
1995. Four other clinical trials using DNA vaccines against
influenza, herpes simplex virus, T-cell lymphoma, and an
additional trial for HIV were started in 1996.
• The technique that is being tested in humans involves the
direct injection of plasmids - loops of DNA that contain
genes for proteins produced by the organism being
targeted for immunity. Once injected into the host's muscle
tissue, the DNA is taken up by host cells, which then start
expressing the foreign protein. The protein serves as an
antigen that stimulate an immune responses and
protective immunological memory
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 Adjuvants

• Used to potentiate the immune response

• Functions to localize and slowly release antigen at or
near the site of administration.
• Functions to activate APCs to achieve effective
antigen processing or presentation
• Materials that have been used include;-
• Aluminum salts
• Mineral oils
• Mycobacterial products, eg. Freund's adjuvants

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Immunostimulating Complexes (ISCOMS)

• An alternative vaccine vehicle

• The antigen is presented in an
accessible, multimeric, physically well
defined complex
• Composed of adjuvant (Quil A) and
antigen held in a cage like structure
• Adjuvant is held to the antigen by lipids
• Can stimulate CMI
• Mean diameter 35nm
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‘Measles Attack’

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 Measles Mumps Rubella (MMR) Vaccine
• Live attenuated vaccines prepared in cell-cultures of
human fibroblast given as part of the childhood
vaccination program
• Measles immunizations aimed at preventing the more
serious complications of measles such as pneumonia in
young children under 15 months of age in developing
countries such as in Africa and measles encephalitis in
well developed countries.
• Mumps immunization is aimed at preventing the more
serious complications of mumps including meningitis
• Rubella immunization is aimed at preventing rubella
infection in early pregnancy and hence congenital rubella
syndrome.
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‘Poliomyelitis’

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 Polio Virus Vaccines
• Two highly effective vaccines containing all 3 strains of
poliovirus are in general use:
• The killed virus vaccine (Salk, 1954) is used mainly in
Sweden, Finland, Holland and Iceland.
• The live attenuated oral polio vaccine (Sabin, 1957) has
been adopted in most parts of the world; its chief
advantages being: low cost, the fact that it induces mucosal
immunity and the possibility that, in poorly immunized
communities, vaccine strains might replace circulating wild
strains and improve herd immunity. Against this is the risk
of reversion to virulence (especially of types 2 and 3) and
the fact that the vaccine is sensitive to storage under
adverse conditions.
• The inactivated Salk vaccine is recommended for children
who are immunosuppressed

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 Hepatitis B Virus Vaccines

• Two vaccines are in current use: a serum derived

vaccine and a recombinant vaccine. Both contain
purified preparations of the hepatitis B surface protein.
• The serum derived vaccine is prepared from hepatitis B
surface protein, purified from the serum of hepatitis B
carriers. This protein is synthesised in vast excess by
infected hepatocytes and secreted into the blood of
infected individuals..
• A second vaccine, produced by recombinant DNA
technology, has since become available. Vaccine is
administration to individuals who are at high risk of
exposure to hepatitis B, namely: infants of hepatitis B
carrier mothers, health care workers, homosexual men
and intravenous drug abusers.

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 Hepatitis A Virus Vaccine

• A vaccine for hepatitis A has been

developed from formalin-inactivated, cell
culture-derived virus.
Two doses, administered one month
apart, appear to induce high levels of
neutralising antibodies. The vaccine is
recommended for travellers to third world
countries, and indeed all adults who are
not immune to hepatitis A
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 Yellow Fever Virus Vaccine

• The 17D strain is a live attenuated

vaccine developed in 1937. It is a highly
effective vaccine which is administered to
residents in the tropics and travellers to
endemic areas. A single dose induces
protective immunity to travellers and
booster doses, every 10 years, are
recommended for residents in endemic
areas.
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 Rabies Virus Vaccine

• No safe attenuated strain of rabies virus has yet

been developed for humans. Vaccines in current
use include:
• The neurotissue vaccine - here the virus is
grown in the spinal cords of rabbits, and then
inactivated with beta-propiolactone. There is
a high incidence of neurological complications
following administration of this vaccine due to a
hypersensitivity reaction to the myelin in the
preparation and largely it has been replaced by
• A human diploid cell culture-derived vaccine
(also inactivated) which is much safer.
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 Rabies Virus Vaccines

There are two situations where vaccine is given:

a) Post-exposure prophylaxis, following the bite of a

rabid animal:
A course of 5-6 intramuscular injections, starting on the
day of exposure. Hyperimmune rabies globulin may also
administered on the day of exposure.
b) Pre-exposure prophylaxis is used for protection of
those whose occupation puts them at risk of infection
with rabies; for example, vets, abbatoir and laboratory
workers.
This schedule is 2 doses one month apart ,and a booster
dose one year later. (Further boosters every 2-3 years
should be given if risk of exposure continues).

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 Influenza Virus Vaccine

• Repeated infections with influenza virus are common due

to rapid antigenic variation of the viral envelope
glycoproteins. Antibodies to the viral neuraminidase
and haemagglutinin proteins protect the host from
infection.
• However, because of the rapid antigenic variation, new
vaccines, containing antigens derived from influenza
strains currently circulating in the community, are
produced every year.
Surveillance of influenza strains now allows the inclusion
of appropriate antigens for each season.The vaccines
consist of partially purified envelope proteins of
inactivated current influenza A and B strains.

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 Varicella-Zoster Virus Vaccine

Alive attenuated strain of varicella zoster •

virus has been developed. It is not
licensed in in many countries for general
use, but is used in some oncology unitsto
protect immuno-compromised children
who have not been exposed to wild-type
varicella zoster virus. Such patients may
develop severe, life threatening infections
if infected with the wild type virus
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Efficacy of Current Vaccines

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 New Rotavirus Vaccines Licensed

• Two new vaccines have recently been

licensed
• “Rotarix” (GlaxoSmithKline), monovalent,
live, oral human 89-12 strain
• “RotaTeq” (Merck), pentavalent, live, oral
human-bovine reassortants

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 Rotavirus Vaccine

• Concern about the emergence of

“new” serotypes and “reassortants”
strains require constant monitoring
and surveillance.
• Updating of the new vaccine with the
“new” strains could be important to
maintain efficacy

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The ‘New’ HSV Vaccine is Efficacious in Reducing
Genital Herpes in Susceptible Women

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 The ‘New” HPV vaccines

• Two ‘new’ vaccines against HPV have completed initial

double blind –placebo controlled trials
• ‘Bivalent’ recombinant vaccine (against HPV-16 & 18)
(GlaxoSmithKline)
• ‘Quadravalent’ recombinant vaccine (against HPV-16 &
18 and also HPV-6 &11 (Merck)
• Both vaccines showed 90-100 % protection against
persistent infections or disease caused by these HPV
strains in women after follow-up of a period of over 2
years.

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 Passive Immunization

Passive immunisation is the transfer of immunity to

a host by means of immunoglobulins (preformed
antibodies). These immunoglobulins are typically
prepared by cold ethanol fractionation as a 16%
solution of gamma globulin from large pools of serum
obtained from the blood donations of at least 1000
donors.
Immunoglobulin from immune individuals can be used
as prophylaxis to prevent viral infections in
exposed, but non immune individuals. It works by
binding to extra-cellular virions and preventing them
from attaching to and entering susceptible cells.
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 Passive immunization

"Normal" Immune globulin

This is a pooled product, prepared from the serum of
normal blood donors. It contains low titers of
antibody to a wide range of human viruses. It is
mainly used as prophylaxis against:
• Hepatitis A virus infection,
• Parvovirus infection, and
• Enterovirus infections (in neonates).
• HIV-infected babies.

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 Passive Immunization
Hyper-immune globulin
Immunoglobulin may be prepared from the serum of
selected individuals who have high titers of antibody to
particular viruses.
Examples include:
• Zoster immune globulin
Prevention of Varicella in immunocompromised children and
neonates.
• Human Rabies immune globulin
Post-exposure prophylaxis in an individual who has been
bitten by a rabid animal.
• Hepatitis B immune globulin
Non-immune individual who has been exposed to HBV.
• RSV immune globulin
Treatment of respiratory syncytial virus infections in the very
young. 43
 Viral Vaccination Schedules- Kuwait
Vaccination Schedule Vaccine
2nd day after birth HBV (I.M.)/OPV-1
2nd month HBV/OPV-1
4th month OPV-1,2,3
6th month HBV/OPV-1,2,3/MMR
12 month MMR (S.C.)
18 month OPV-1,2,3
2.5 years OPV
3.5-4 years MMR
Adulthood ?Boosters 44