Influenza
Conditions
Keywords
Fluad, MF59, Fluzone, HDFlu, Influenza, Vaccine
Brief summary
The purpose of this research study is to better understand the immune response to the Adjuvanted Subunit flu vaccine (MF59) and the High Dose flu vaccine (HDFlu) in people 65 years of age and older. The research team will be studying why immune response diminishes as people get older in both men and women. The ultimate goal is to understand how flu immunity develops after vaccination. This information may lead to the development of more effective flu vaccines in the future.
Detailed description
The overall goal of this proposal is to determine how vaccine type, sex, and gene expression influence both innate and T helper cell immune responses using systems biology and bioinformatics as tools to comprehensively assess the human transcriptome. We will evaluate sex-dependent immune responses to two unique influenza vaccines in a population of older adults; the recently FDA-licensed MF59-adjuvanted influenza subunit vaccine and the high-dose split virion influenza virus vaccine. The influence of sex on immune response to vaccination has been observed across multiple vaccines (including standard dose influenza vaccines, but the mechanisms are unknown, it affects all age groups regardless of hormonal status, and existing studies focus almost exclusively on humoral immune responses. Relatively little is known about the effect of sex on innate and T helper responses following vaccination and we are unaware of any studies evaluating the effect of sex on immune responses to adjuvanted influenza vaccine. The presence of adjuvant (MF59Flu) or higher antigen (Ag) dose leads to greater immunogenicity through mechanisms that have not been fully deciphered and are likely to be different. Further, a direct comparison of innate and T helper immune responses between adjuvanted and high dose influenza vaccines has not been reported. The study design will include 200 generally healthy individuals (ages ≥65) who meet all inclusion criteria. 100 subjects will receive each vaccine with equal sex representation in each subgroup (a factorial design for sex by vaccine type). Subjects will undergo venipuncture for blood samples (\ 100 mL each, sufficient for the proposed assays) before vaccination and at three timepoints after vaccination (Day 1, Day 8, Day 28). The clinical characterization of our study subjects will include demographic information, height, weight, BMI, waist circumference, medications, and medical conditions that do not meet exclusion criteria (see Protection of Human Subjects). We will also quantify blood leukocyte populations (CBC, WBC differential). Immunosenescence and cytomegalovirus (CMV) infection can affect influenza vaccine-induced immune responses. We will evaluate whether CMV seropositivity or other measures of immunosenescence are associated with immune response and whether they interact with vaccine type/sex. We will monitor/characterize transcriptional changes (mRNA and miRNA) as well as measures of immune function (cytokine secretion, leukocyte surface phenotype, hemagglutination inhibiting antibody titer, and memory B cell ELISPOT) at each time point.
Interventions
DRUGFluad Vaccine
FLUAD is an inactivated influenza vaccine indicated for active immunization against influenza. disease caused by influenza virus subtypes A and type B contained in the vaccine. FLUAD is. approved for use in persons 65 years of age and older.
FLUZONE® HIGH-DOSE vaccine is indicated for people 65 years of age and older to help prevent influenza disease caused by influenza A and B strains contained in the vaccine.
Sponsors
National Institute of Allergy and Infectious Diseases (NIAID)
Mayo Clinic
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
BASIC_SCIENCE
Masking
NONE
Intervention model description
Eligible subjects who consent and enroll will be randomly assigned to receive either the Fluad Vaccine or Fluzone High-Dose vaccine.
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* Male or female adults ages 18-40 or of 65 and or older at the time of enrollment * Eligible to receive Fluad® (MF59Flu) or Fluzone® (HDFlu) if age 65 or older * No history of anaphylactic reaction to gelatin, neomycin, or other vaccine component * Not pregnant * No immunosuppression or immunodeficiency * No acute illness at time of vaccination * Determined by medical history and clinical judgment to be eligible for the study, by being generally healthy, with no autoimmune or immunosuppressive conditions and having stable current medical conditions (subjects with preexisting stable disease, defined as disease not requiring significant change in therapy or hospitalization for worsening disease 12 weeks before receipt of study vaccine, will be eligible. A change in dose or therapy within a category (e.g., change from one nonsteroidal anti-inflammatory drug to another) is allowed. A change to a new therapy category (e.g., surgery or addition of a new pharmacological class) is only allowed if it is not caused by worsening disease. A change to a new therapy category caused by worsening disease is considered significant and therefore ineligible for enrollment. * Patients with diabetes mellitus are eligible for inclusion if they have had a hemoglobin A1c measurement of \<8.0 within the past 6 months prior to enrollment. These hemoglobin A1c measurements are recommended at least twice yearly by the American Diabetes Association (ADA), and the target levels here are representative of the goals of the ADA. These hemoglobin A1c levels will ensure that these participants have good glycemic control. (American Diabetes Association. American Diabetes Association Position Statement: Standards of Medical Care in Diabetes- 2015. Diabetes Care 2015;38(Suppl. 1): S1-S94) * Able to follow study procedures in the opinion of the investigator * Expected to be available for the duration of the study * Weighs \>110 lbs
Exclusion criteria
* Known or suspected immunodeficiency or receiving treatment with immunosuppressive therapy including cytotoxic agents or systemic corticosteroids (e.g., for cancer, HIV, or autoimmune disease). If systemic corticosteroids have been administered short term for treatment of an acute illness, subjects will be included if corticosteroid therapy (inhaled, intranasal, and intra-articular corticosteroid therapy is permitted) has been discontinued for at least 30 days. * Serious chronic medical conditions including metastatic malignancy, severe chronic obstructive pulmonary disease requiring supplemental oxygen, end-stage renal disease with or without dialysis, clinically unstable cardiac disease, or any other disorder that, in the investigator's opinion, precludes the subject from participating in the study. Diabetic patients will be excluded if they do not have a hemoglobin A1c measurement within the past 6 months or if they had a hemoglobin A1c measurement of an A1c \>8.0 * Receipt of any blood products, including immunoglobulin, within 6 months of study enrollment. * Current anticoagulant therapy or a history of bleeding diathesis that would contraindicate intramuscular (IM) injection. (Note: antiplatelet drugs such as aspirin and clopidogrel are permitted.) * Receipt of any vaccines within the past 30 days prior to enrollment * Receipt of the current seasonal influenza vaccine other than in this study * Acute illness within the last 30 days * Blood donation within the last 58 days prior to study enrollment * Any medical condition that would, in the opinion of the investigator, interfere with the evaluation of the study objectives * Pregnant patients will be excluded * Any condition (e.g. allergic reaction, Guillain-Barre Syndrome) that precludes their receipt of the influenza vaccine
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Memory B Cell ELISPOT | Day 28 | Number of influenza-specific Ab producing memory B cells. Spot Forming Units (SFUs) are the frequency of Ab secreting B cells in an ELISPOT assay. |
| Innate Cell IFNa2a Production | Baseline, Day 1 | Cytokine secretion (interferon alpha 2a) after in vitro stimulation with influenza virus |
| T Cell Gene Expression | Baseline, Day 28 | Gene expression counts. The number shown is the total number of RNA molecules whose sequence matches a human gene. This is a measure of how much gene expression is occurring in the cells in each subject's blood sample. |
| T Cell miRNA Expression | Baseline, Day 8, Day 28 | Next generation sequencing of purified T cells' miRNA |
| Innate IFNAR1 Cell Gene Expression | Baseline, Day 8 | IFNAR1 gene counts (the number of molecules of RNA whose sequence matches the interferon alpha receptor 1 gene that were present in the subject's blood sample). |
| Innate Cell miRNA Expression | Baseline, Day 1, Day 8 | Next generation sequencing of purified innate cells' miRNA |
| Hemagglutination Inhibition Ab Titer | Baseline and Day 28 | Reciprocal of the serum dilution exhibiting no hemagglutination (the larger the number, the more agglutinating antibodies the subject has. A titer of equal to more than 1:40 and above is considered a protective antibody titer) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| T Cell Phenotype | Day 28 | Flow cytometry analysis of T cells. The results show the percentage of specific white blood cell types are present in each subject's blood sample. Reported as a % of the total peripheral blood mononuclear cells. |
| Innate Cell Phenotype | Day 1 (stim) | Flow cytometry analysis of innate cells. The results show the percentage of classical monocytes in each subject's blood sample. The data are reported as a percentage of the peripheral blood mononuclear cells. |
| CMV Serostatus | Baseline | Serum CMV-specific IgG level. Number reported as Sample Index (the optical density in an ELISA). The Sample Index is a semi-quantitative measure of how much CMV-specific IgG antibodies are in each subject's blood sample. The values range from 0 to 4. Values between 0 and 3 are relative measures of the amount of antibody (0 = no antibody, 1 = a low level of antibody, 3 = a high level of antibody). Values from 3-4 all reflect high levels of antibody but typically exceed the linear range of the assay and cannot be used to quantify exact amounts of antibody. |
| CD4/CD8 Ratio | Day 28 | Flow cytometry analysis of T cells. The results show the ratio of CD4+ T cells compared to CD8+ T cells present in each subject's PBMCs. |
| T Cell ELISPOT Response | Day 28 | influenza-specific, IFNg producing, memory T cells. Spot Forming Units (SFUs) are the frequency of IFN-g secreting T cells in an ELISPOT assay. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Fluad Vaccine Subjects receive a single dose of the Fluad influenza vaccine.
Fluad Vaccine: FLUAD is an inactivated influenza vaccine indicated for active immunization against influenza. disease caused by influenza virus subtypes A and type B contained in the vaccine. FLUAD is. approved for use in persons 65 years of age and older. | 120 |
| Fluzone Vaccine Subjects receive a single dose of the Fluzone High-Dose influenza vaccine.
Fluzone High-Dose: FLUZONE® HIGH-DOSE vaccine is indicated for people 65 years of age and older to help prevent influenza disease caused by influenza A and B strains contained in the vaccine. | 121 |
| Total | 241 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Lost to Follow-up | 3 | 4 |
Baseline characteristics
| Characteristic | Fluad Vaccine | Total | Fluzone Vaccine |
|---|---|---|---|
| Age, Continuous | 71.7 years | 71.5 years | 71.4 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 2 Participants | 4 Participants | 2 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 118 Participants | 237 Participants | 119 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 1 Participants | 1 Participants | 0 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 119 Participants | 240 Participants | 121 Participants |
| Region of Enrollment United States | 120 participants | 241 participants | 121 participants |
| Sex: Female, Male Female | 78 Participants | 152 Participants | 74 Participants |
| Sex: Female, Male Male | 42 Participants | 89 Participants | 47 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 120 | 0 / 121 |
| other Total, other adverse events | 31 / 120 | 22 / 121 |
| serious Total, serious adverse events | 0 / 120 | 0 / 121 |
Outcome results
Primary
Hemagglutination Inhibition Ab Titer
Reciprocal of the serum dilution exhibiting no hemagglutination (the larger the number, the more agglutinating antibodies the subject has. A titer of equal to more than 1:40 and above is considered a protective antibody titer)
Time frame: Baseline and Day 28
Population: The number of samples analyzed is less than the study cohort total because some of the serum samples failed in the HAI assay. These failures were either: results did not meet QC, sample degraded and failed to function in the assay properly.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Fluad Vaccine | Hemagglutination Inhibition Ab Titer | Day 0 | 40 Titer |
| Fluad Vaccine | Hemagglutination Inhibition Ab Titer | Day 8 | 40 Titer |
| Fluad Vaccine | Hemagglutination Inhibition Ab Titer | Day 28 | 80 Titer |
| Fluzone Vaccine | Hemagglutination Inhibition Ab Titer | Day 0 | 40 Titer |
| Fluzone Vaccine | Hemagglutination Inhibition Ab Titer | Day 8 | 80 Titer |
| Fluzone Vaccine | Hemagglutination Inhibition Ab Titer | Day 28 | 80 Titer |
Comparison: Null Hypothesis: HAI Day 28 - HAI Day 0 for Fluad = HAI Day 28 - HAI Day 0 for Fluzone Alternative Hypothesis: HAI Day 28 - HAI Day 0 for Fluad NE HAI Day 28 - HAI Day 0 for Fluzonep-value: 0.062Wilcoxon (Mann-Whitney)
Primary
Innate Cell IFNa2a Production
Cytokine secretion (interferon alpha 2a) after in vitro stimulation with influenza virus
Time frame: Baseline, Day 1
Population: The number of samples analyzed is less than the study cohort total because some of the serum samples failed in the assay. These failures were either: results did not meet QC, sample degraded and failed to function in the assay properly.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Fluad Vaccine | Innate Cell IFNa2a Production | Day 1 Stimulated | 107.5846 pg/mL |
| Fluad Vaccine | Innate Cell IFNa2a Production | Day 0 Stimulated | 112.3650 pg/mL |
| Fluzone Vaccine | Innate Cell IFNa2a Production | Day 0 Stimulated | 131.4214 pg/mL |
| Fluzone Vaccine | Innate Cell IFNa2a Production | Day 1 Stimulated | 134.9071 pg/mL |
Primary
Innate Cell miRNA Expression
Next generation sequencing of purified innate cells' miRNA
Time frame: Baseline, Day 1, Day 8
Population: Data was not collected or analyzed
Primary
Innate IFNAR1 Cell Gene Expression
IFNAR1 gene counts (the number of molecules of RNA whose sequence matches the interferon alpha receptor 1 gene that were present in the subject's blood sample).
Time frame: Baseline, Day 8
Population: The number of samples analyzed is less than the study cohort total because some of the serum samples failed in the assay. These failures were either: results did not meet QC, sample degraded and failed to function in the assay properly.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Fluad Vaccine | Innate IFNAR1 Cell Gene Expression | Baseline | 1516 Gene counts |
| Fluad Vaccine | Innate IFNAR1 Cell Gene Expression | Day 8 | 1450 Gene counts |
| Fluzone Vaccine | Innate IFNAR1 Cell Gene Expression | Baseline | 1572.5 Gene counts |
| Fluzone Vaccine | Innate IFNAR1 Cell Gene Expression | Day 8 | 1562 Gene counts |
Primary
Memory B Cell ELISPOT
Number of influenza-specific Ab producing memory B cells. Spot Forming Units (SFUs) are the frequency of Ab secreting B cells in an ELISPOT assay.
Time frame: Day 28
Population: A subset of the total participants' samples were tested to determine the scientific value of this outcome. Based on pre-specified optimization analyses the assay results were highly variable and would not be informative, therefore the assay was not run on all participant samples. Results are reported for the participants' samples that were tested for optimization analyses.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Fluad Vaccine | Memory B Cell ELISPOT | 5.7 SFUs per 200,000 cells |
| Fluzone Vaccine | Memory B Cell ELISPOT | 16.3 SFUs per 200,000 cells |
Primary
T Cell Gene Expression
Gene expression counts. The number shown is the total number of RNA molecules whose sequence matches a human gene. This is a measure of how much gene expression is occurring in the cells in each subject's blood sample.
Time frame: Baseline, Day 28
Population: The number of samples analyzed is less than the study cohort total because some of the serum samples failed in the assay. These failures were either: results did not meet QC, sample degraded and failed to function in the assay properly.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Fluad Vaccine | T Cell Gene Expression | Day 0 | 36019037 Total gene counts |
| Fluad Vaccine | T Cell Gene Expression | Day 28 | 34319023 Total gene counts |
| Fluzone Vaccine | T Cell Gene Expression | Day 0 | 36566557 Total gene counts |
| Fluzone Vaccine | T Cell Gene Expression | Day 28 | 35360483 Total gene counts |
Primary
T Cell miRNA Expression
Next generation sequencing of purified T cells' miRNA
Time frame: Baseline, Day 8, Day 28
Population: Data was not collected or analyzed
Secondary
CD4/CD8 Ratio
Flow cytometry analysis of T cells. The results show the ratio of CD4+ T cells compared to CD8+ T cells present in each subject's PBMCs.
Time frame: Day 28
Population: This outcome requires data from outcome #9. As outcome #9 was determined to be non-informative and was not run on the entire cohort, we do not have the necessary data to calculate this outcome on the entire cohort. Results are reported for the participants' samples for whom outcome #9 was reported from the optimization analyses.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Fluad Vaccine | CD4/CD8 Ratio | 2.92 Ratio |
| Fluzone Vaccine | CD4/CD8 Ratio | 1.69 Ratio |
Secondary
CMV Serostatus
Serum CMV-specific IgG level. Number reported as Sample Index (the optical density in an ELISA). The Sample Index is a semi-quantitative measure of how much CMV-specific IgG antibodies are in each subject's blood sample. The values range from 0 to 4. Values between 0 and 3 are relative measures of the amount of antibody (0 = no antibody, 1 = a low level of antibody, 3 = a high level of antibody). Values from 3-4 all reflect high levels of antibody but typically exceed the linear range of the assay and cannot be used to quantify exact amounts of antibody.
Time frame: Baseline
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Fluad Vaccine | CMV Serostatus | 2.018 Sample Index |
| Fluzone Vaccine | CMV Serostatus | 2.709 Sample Index |
p-value: 0.29Wilcoxon (Mann-Whitney)
Secondary
Innate Cell Phenotype
Flow cytometry analysis of innate cells. The results show the percentage of classical monocytes in each subject's blood sample. The data are reported as a percentage of the peripheral blood mononuclear cells.
Time frame: Day 1 (stim)
Population: A subset of the total participants' samples were tested to determine the scientific value of this outcome. Based on pre-specified optimization analyses the assay results were highly variable and would not be informative, therefore the assay was not run on all participant samples. Results are reported for the participants' samples that were tested for optimization analyses.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Fluad Vaccine | Innate Cell Phenotype | 70.1 Percentage |
| Fluzone Vaccine | Innate Cell Phenotype | 93.1 Percentage |
Secondary
T Cell ELISPOT Response
influenza-specific, IFNg producing, memory T cells. Spot Forming Units (SFUs) are the frequency of IFN-g secreting T cells in an ELISPOT assay.
Time frame: Day 28
Population: A subset of the total participants' samples were tested to determine the scientific value of this outcome. Based on pre-specified optimization analyses the assay results were highly variable and would not be informative, therefore the assay was not run on all participant samples. Results are reported for the participants' samples that were tested for optimization analyses.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Fluad Vaccine | T Cell ELISPOT Response | 14.4 SFUs per 200,000 cells |
| Fluzone Vaccine | T Cell ELISPOT Response | 17.4 SFUs per 200,000 cells |
Secondary
T Cell Phenotype
Flow cytometry analysis of T cells. The results show the percentage of specific white blood cell types are present in each subject's blood sample. Reported as a % of the total peripheral blood mononuclear cells.
Time frame: Day 28
Population: A subset of the total participants' samples were tested to determine the scientific value of this outcome. Based on pre-specified optimization analyses, it was determined that results did not capture vaccination-specific responses and would not be useful for the clinical trial, therefore the assay was not run on all participant samples. Results are reported for the participants' samples that were tested for optimization analyses.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Fluad Vaccine | T Cell Phenotype | CD3+ T cells | 44.31 Percentage |
| Fluad Vaccine | T Cell Phenotype | CD4+ T cells | 18.41 Percentage |
| Fluad Vaccine | T Cell Phenotype | CD8+ T cells | 8.73 Percentage |
| Fluzone Vaccine | T Cell Phenotype | CD3+ T cells | 42.5 Percentage |
| Fluzone Vaccine | T Cell Phenotype | CD4+ T cells | 17.98 Percentage |
| Fluzone Vaccine | T Cell Phenotype | CD8+ T cells | 10.28 Percentage |