Transcript Document 7658184

Diphtheria, Tetanus, Pertussis
MedCh 401
Lecture 3
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Adjuvant
• Substances that enhance the immune
response
• Two categories:
– vehicles
– immunomodulators
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Adjuvants functioning as vehicles I
• Human use:
– Alum compounds
• Aluminum hydroxide and phosphate
• the only licensed adjuvants in U.S.
– MF59
• Oil and water emulsion
• Marketed in Europe
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Adjuvants functioning as vehicles II
• Animal use:
– Freund’s Complete Adjuvant (CFA)
• dessicated Mycobacterium butyricum, mineral oil
and an emulsifying agent, mannide monooleate
• causes potentially secere local inflammatory lesions, chronic
granulomas, abscesses, and tissue sloughs. Injected into the
murine footpad, it can cause chronic lameness and arthritis;
injected intraperitoneally, it can cause peritonitis
– Freund’s Incomplete Adjuvant
• Mineral oil and Mannide monooleate
• Fewer side effects, adequate for boosting
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Immunomodulatory Adjuvants
• Purified Protein Derivative (PPD)
• Lipopolysaccharide (LPS; bacterial
endotoxin)
• Lipid A - lipid portion of LPS
• Cholera toxin B subunit
• CpG
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Diphtheria vaccine
• Detoxified bacterial, protein toxin
• Injectable, IM administration
• Toxigenic Corynebacterium diphtheriae
(infected with b phage)
• Primarily a childhood disease
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Diphtheria Transmission
• Person-to-person by respiratory droplet
• No animal reservoir
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Manufacturing Process
• Toxigenic strain of C. diphtheriae grown in
Fenton medium with a bovine extract
• After suitable growth, toxin purified from cells by
centrifugation
• Toxoided by incubation with formaldehyde for
several weeks
• Concentrated with ultrafiltration
• Purified by precipitation, dialysis and sterile
filtered
• Adsorbed onto aluminum hydroxide, Al(OH)3
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Excellent Vaccine Efficacy
• Mortality
– 1860-1897 46-196/100,000 people
– Case fatality rates >50% during outbreaks
– 1920
15/100,000 people
• Cases
– 1971 - 1981 - 1,288 in U.S.
– 1980 - 1995 - 41
– occasional in developing countries and Native
populations in U.S. and Canada
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Tetanus Vaccine
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Detoxified bacterial, protein toxin
Clostridium tetani
Injectable dosage form
IM
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Tetanus Transmission
• Not a communicable disease
• The only vaccine-preventable infection
that is not communicable
• Disease acquired through exposure to
bacterial spores in the environment
– inoculation of bacterial spores into body by
puncture or deep cut
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Transmission II
• Neonatal tetanus most common worldwide
• Case fatality increases with age (~50% for
80+ years of age)
• Disease reservoirs
– Soil
– Animal feces
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Tetanus toxins
• Tetanolysin - possible role in establishing
infection at inoculation site
• Tetanospasm
– accumulates intracellularly during log-phase
growth
– released into medium upon autolysis
– Minimum human lethal dose ~ 2.5 ng/kg
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Tetanus disease
• Tetanospasms
– localized - spasm of muscles close to site of
injection; weeks to months duration; rare but
may precede generalized symptoms
– generalized - 80% of cases
• Complications of the spasms:
– fractures of the long bones and vertebrae
– asphyxia from glottic obstruction
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Nervous system effects
• Toxin travels up nerve endings by intraaxonal transport
• Gains entry to neuromuscular junctions by
binding to gangliosides
• Interferes with release of neurotransmitters
from presynaptic inhibitory fibers
• Excitatory reflexes multiply unchecked,
causing spasms
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Tetanus
• Toxin-mediated disease
• Symptoms may progress clinically despite
use of parenteral antibiotics
• Treatment:
– hyperimmune serum
– supportive care
• Recovery may depend on development of
new functional nerve connections
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Manufacturing Process
• Growth of C. tetani in modified Latham
broth in fermenters
• Harvest extracellular toxin by filtration
• Purify
• Detoxify with formaldehyde for ~3 weeks
• Adsorb with Alum adjuvant
• Diafiltration
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Pertussis (Whooping Couth)
• Bordetella pertussis
• Whole cell and acellular vaccines
– traditional and recombinant
• Injectable dosage form
• IM
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Pertussis Transmission
• Person-to-person
• Respiratory droplets
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Pertussis (whooping cough)
• Killed Whole cell – old, not licensed in U.S. or Europe
– still used in developing countries
– relatively cheap
• Acellular (aP) – currently licensed in U.S., Japan and Europe
– some are recombinant
– expensive
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B. pertussis virulence factors
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Pertussis toxin (PT)
Filamentous hemagglutinin (FHA)
Fimbriae (fimbrial agglutinogens) (Fim)
Pertactin (PRN)
Adenylate cyclase
Tracheal cytotoxin
Dermonecrotic or heat-labile toxin
BrkA
Endotoxin (LPS)
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Vaccine Efficacy
• 1914 (Pre-vaccine)
– ~270,000 cases, 10,000 deaths annually
– killed >5 of every 1000 children born in U.S.
• 1976 - 1,010 cases
• 1996 - 7,796
• 2002
– 8,296 cases
– 3.01/100,000 pop.
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Vaccine History
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1914
1948
1991 - 2002
2005
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First whole-cell vaccine (P)
DTP
DTaP for children
Tdap for adults 19-64
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Manufacturing
• B. pertussis cultures grown in modified
Stainer-Scholte broth
• Acellular antigens:
– purified from culture medium (PT and FHA) or
– extracted from cells (PRN, FIM)
• Formaldehyde and/or glutaraldehyde
detoxification of PT
• Aluminum adjuvants
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Manufacturing II
• Novartis-Behring (Chiron) - Recombinant
– Genetically detoxified PT
– Two other components
– Not available in U.S. yet
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DTaP Vaccine Formulations
Component,
per 0.5 ml dose
Diphtheria Toxoid
Tetanus Toxoid
GSK
Infanrix,
Pediarix
25 Lf
10 Lf
AP Inc
(sanofi pasteur)
Tripedia
6.7 Lf
5 Lf
15 Lf
5 Lf
PT, inactivated
25 g
23.4 g
10 g
FHA, inactivated
25 g
23.4 g
5 g
PRN (69kD OMP)
Fimbriae 2
Fimbriae 3
2-phenoxyethanol
(PE), preservative
NaCl
8 g
0
0
3 g
5 g
2.5 mg
0
0.6%
Aluminum adjuvant
<0.625 mg
<0.17 mg
0.33 mg
Formaldehyde,
residual
100 g
<100 g
< 0.02%
Glutaraldehyde,
residual
Polysorbate 80
(Tween 80)
Thimerosal,
preservative
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AP LTd (sanofi pasteur)
Daptacel
4.5 mg
< 0.1%
100 g
0
Trace (single-dose)
25 g/dose (multivial)
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Licensed DTaP Vaccines
A cronym
C o m p on e n ts
M a n ufa c tur e r
D an d T to x o id s
N o v a r ti s B e h r in g
D an d T to x o id s
A P , In c ( sa n o fi p a s t e u r )
D an d T to x o id s
A P , L t d ( s a n o fi p a s t e u r )
A P In c ( s a n o fi p a st e u r )
T D fo r a d u lt s
D an d T to x o id s,
PT, FHA
D an d T to x o id s,
PT, FHA , PRN
D an d T to x o id s
T D fo r a d u lt s
D an d T to x o id s
T D fo r a d u lt s
( n o t a v a il a b l e )
D an d T to x o id s
A P , In c . ( s a n o fi
p a steu r )
A P L t d ( s a n o fi p a s t e u r )
T
T to x o id
A P In c ( s a n o fi p a st e u r )
T a d sorbed
T to x o id
M a ss D P H
T to x o id
T to x o id , r ed u ced D to x o id ,
P T , F H A , P R N , fi m 2 & 3
T to x o id , r ed u ced D to x o id ,
PT, FHA , PRN
A P In c ( s a n o fi p a st e u r )
A P L t d ( s a n o fi p a s t e u r )
D T fo r fu r th e r
m a n u fa c t u r e
DT
T rade
N am e
N on e
DT
D T aP
T r i p e d ia
D T aP
I n fa n r i x
T a d sorbed
T dap
A d acel
T dap
B o o str ix
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G SK
M a ss D P H
G SK
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