Influenza A and Inactivated Trivalent Influenza Virus Vaccines in Older Adults with Chronic Diseases

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1 JOURNAL OF CLINICAL MICROBIOLOGY, Sept. 1986, p /86/ $02.00/0 Copyright 1986, Americn Society for Microbiology Vol. 24, No. 3 Sfety of nd Serum Antibody Response to Cold-Recombinnt Influenz A nd Inctivted Trivlent Influenz Virus Vccines in Older Adults with Chronic Diseses GEOFFREY J. GORSE, 2* ROBERT B. BELSHE,"2 AND NANCY J. MUNN2'3 Section of Infectious Diseses1 nd Section of Pulmonry Diseses,3 Deprtment of Medicine, Huntington Veterns Administrtion Medicl Center, nd Mrshll University School of Medicine,2 Huntington, West Virgini Received 7 Februry 1986/Accepted 5 June 1986 Forty older dults with chronic diseses were vccinted intrnslly with either influenz A/Cliforni/lO/78 (HlNl) (CR37) or influenz A/Wshington/897/80 (H3N2) (CR48) virus. No cliniclly significnt morbidity or decrement in pulmonry function occurred postvccintion. Two (15%) recipients of CR37 virus nd twelve (44%) recipients of CR48 virus becme infected with vccine virus, s indicted by fourfold rise in serum hemgglutintion inhibition ntibody titer; fourfold rise in serum immunoglobulin G (IgG) or IgA ntibody titer, indicted by enzyme-linked immunosorbent ssy; isoltion of vccine virus from nsl wshings; or ll of these. Within 1 yer fter cold-recombinnt vccine virus vccintion, 18 vccinees received inctivted trivlent influenz virus vccine prenterlly. Of the vccinees, 13 (72%) developed fourfold rise in serum ntibody titer to HlNl ntigen nd 16 (89%) developed fourfold rise in serum ntibody titer to H3N2 ntigen. We conclude tht dministrtion of these cold-recombinnt vccine viruses to older dults with chronic diseses ws sfe, but tht serum ntibody response rtes were lower thn those chieved with subsequently dministered inctivted influenz virus vccine given prenterlly. However, the higher seroconversion rtes ttined by using the inctivted trivlent influenz virus vccine do not necessrily men tht it is more efficcious in preventing infection or severe illness or both due to nturl wild-type influenz A virus. Before ech respirtory disese seson, it is recommended tht popultions t high risk for complictions resulting from influenz virus infection be immunized ginst the prevlent strins of influenz viruses (11, 12). The purpose of this immuniztion is to reduce mortlity nd morbidity from influenz illness nd pneumoni (either primry virl or secondry bcteril pneumoni). Among those recommended to receive influenz vccine re persons over the ge of 65 yers nd ptients with chronic lung, hert, or metbolic disese. Despite documented need for influenz immuniztion in these popultions, complince my be low nd the efficcy of inctivted influenz virus vccine my be lower in the elderly thn in younger persons (26). The fourfold rte of serologic response to inctivted virus prenterl vccines hs rnged from 70 to 90%, nd in certin elderly subpopultions the response rte hs been s low s 21% (4, 8, 9, 16-18, 21, 26, 28, 31). Previous influenz virus vccintion ppers to decrese the rte of serologic response to subsequent vccintion s well (8). Intrnslly dministered live-ttenuted, cold-recombinnt (CR) influenz A virus vccines offer potentilly more desirble nd effective pproch to immuniztion ginst influenz A virus infection. CR virus vccines do not require prenterl injection nd offer the theoreticl dvntge of stimulting secretory immunoglobulin A (IgA) ntibody production t the nturl portl of entry (31). Neutrlizing IgA ntibody nd, to lesser extent, IgG ntibody re present in nsl wsh specimens tken from volunteers who re resistnt to chllenge with influenz A. The ntihemgglutinin serum IgA ntibody level my correlte with the production of secretory IgA in the respirtory trct, perhps due to the escpe of loclly produced IgA ntibody from the nsl mucos into the systemic circultion (10, 24). * Corresponding uthor. Clements et l. (14) reported tht protection ginst wildtype virus chllenge in young dults ws greter fter vccintion with influenz A/Wshington/897/80 (H3N2) (CR48) virus thn fter prenterl inctivted trivlent influenz virus vccine. The CR virus vccine lso reduced the titer of wild-type virus shed in respirtory secretions compred with the inctivted virus vccine. Worsening of chronic irwys disese is potentil hzrd with widespred use of live-ttenuted virus vccine. This hs not, however, been cliniclly pprent in previously reported series in which persons with chronic bronchitis, sthm, or chronic obstructive pulmonry disese (COPD) were vccinted with other live-ttenuted or CR virus strins (1, 19, 22). To further investigte influenz A virus vccintion in high-risk dults, we studied the sfety of nd serum ntibody responses to intrnslly dministered CR influenz A virus vccines. Subsequently, mny dults hve undergone vccintion with prenterlly dministered, inctivted trivlent influenz virus vccine; we report their responses to inctivted virus vccine fter live-ttenuted virus vccintion. MATERIALS AND METHODS Vccines. The CR influenz A/Clifornill0/78 (H1N1) virus nd influenz A/Wshington/897/80 (H3N2) virus vccines were derived from cold-dpted influenz A/Ann Arbor/6/60 virus by H. F. Mssb (University of Michign), by methods previously described (15). The resulting CR HlNl vccine (CR37, lot no. E167) hd titer of % tissue culture infective doses (TCID5os) per ml, nd the CR H3N2 vccine (CR48, lot no. E179) hd titer of 108 TCID50s per ml in Mdin-Drby cnine kidney cells. The vccine viruses contin six genes tht code for internl proteins from the donor cold-dpted strin, nd the genes tht code for hemgglutinin (HA) nd neurminidse were derived from 336

2 VOL. 24, 1986 influenz A/Cliforni/10/78 (HlNl) virus nd influenz A/Wshington/897/80 (H3N2) virus, respectively. In ddition to being cold-dpted, the vccine viruses were temperture sensitive (restrictive temperture, 39 C). Dilution of vccine virus ws mde in Leibowitz medium (L-15) without ph indictor nd resulted in n inoculum of HlNl vccine virus of either (10-fold dilution) or (undiluted s provided by the Ntionl Institute of Allergy nd Infectious Diseses, Bethesd, Md.) TCID50s nd of n inoculum of H3N2 vccine virus of either (10-fold dilution) or (undiluted s provided by the Ntionl Institute of Allergy nd Infectious Diseses) TCID50s per 0.5-ml dose. The zonl-purified whole virion, inctivted trivlent influenz virus vccine vilble for the influenz seson (influenz A/Chile/1/83 [HlNl], influenz A/Philippines/2/82 [H3N2], nd influenz B/USSR/83 [Connught Lbortories, Swiftwter, P.]), ws dministered prenterlly. Selection of ptients. Volunteers were mbultory nd not institutionlized. They were recruited from outptient clinics nd were 43 to 73 yers of ge. Initil groups of livettenuted virus vccinees did not hve history of pulmonry disese which ws severe enough to require phrmcologic therpy. After it ws cler tht these initil volunteers did not experience cliniclly detectble lower-respirtory symptoms nd signs, persons with vrious degrees of COPD nd other chronic diseses were identified by screening the pulmonry function lbortory logbook nd outptient clinic records for recruitment in subsequent studies. Becuse CR37 (HlNi) virus ws not shed in nsl secretions of the initil volunteer groups, subsequent vccinees with chronic diseses received CR48 (H3N2) virus. All potentil vccinees underwent complete history, physicl exmintion, nd screening lbortory procedures tht included ssessing levels of ntibody to Hi nd H3 HA, urinlysis, complete nd differentil blood cell counts, lnine mino nd gmm glutmyltrnsferse level determintions, nd chest roentgenogrms. Pulmonry function testing (PFT) tht consisted of bsic spirometry performed in the clinicl PFT lbortory using Series 5000 Pulmo-Lb (Gould, Dyton, Ohio) ws done before nd fter live-ttenuted virus vccintion in vccinees with history of pulmonry disese nd other chronic diseses in the subsequent studies. Spirometry ws not performed before nd fter prenterl dministrtion of inctivted virus vccine. Volunteers were not selected on the bsis of prevccintion level of ntibody to Hi nd H3 HA or on the bsis of prenterl inctivted influenz virus vccintion before previous influenz seson; most older dults in the generl popultion hve hd significnt prior experience with influenz viruses. Criteri used to exclude potentil volunteers included the following: life-thretening crdic dysrhythmis, concomitnt ntineoplstic chemotherpy, n bsolute neutrophil count of <1,000 cells per mm3, cliniclly unstble COPD or crdiovsculr disese, nd known llergy to eggs, neomycin, or mphotericin B. Clinicl studies. The protocol for clinicl studies ws pproved by the Institutionl Review Bords of the Huntington Veterns Administrtion Medicl Center nd of Mrshll University. After informed consent ws obtined, volunteers were plced in the supine position, nd the vccine ws dministered intrnslly in totl volume of 0.5 ml (0.25 ml in ech nostril). Volunteers (see Results section for numbers of volunteers in ech group) were vccinted with either CR influenz A/Cliforni/10/78 (H1N1) (CR37) or influenz A/Wshington/897/80 (H3N2) (CR48) virus vccines. The frequency of previous vccin- INFLUENZA A VACCINES IN OLDER ADULTS 337 tion with inctivted trivlent influenz virus vccine in previous yers llowed us to retrospectively nlyze the influence of inctivted virus vccine on subsequent livettenuted virus vccintion. Mny volunteers received inctivted virus vccine within 5 to 12 months fter they received live-ttenuted virus vccine. This llowed us to prospectively evlute the influence of live-ttenuted virus vccine on subsequent ntibody response to inctivted virus vccine. Recipients of CR influenz A virus vccines were observed dily for symptoms nd signs of dverse rections relted to infection with vccine virus (e.g., runny nose, sore throt, cough, erche, red eyes, fever, congestion, incresed shortness of breth, nd usculttory pulmonry chnges) on dys 1 to 5 nd on dys 7, 14, nd 28 postvccintion. Stndrd spirometry ws performed in the clinicl PFT lbortory pre- nd 10 to 14 dys postvccintion with the CR48 (H3N2) influenz A virus vccine in 21 individuls but not with the CR37 (HlNl) virus vccinees. The forced expirtory volume (FEV1), forced vitl cpcity (FVC), nd FEV1/FVC (percent) were determined (2, 3). The degree of obstruction to irflow ws ctegorized on the bsis of the FEV1/FVC (percent), nd n FEV1/FVC of -70% ws defined s norml. Mild obstruction ws defined s n FEV1/FVC of 60 to 69%, moderte obstruction ws defined s 45 to 59%, nd severe obstruction ws defined s n FEV1/FVC of 45%. Severl spirometric trils were done, nd the best effort ws reported. When the trils were inconsistent, the test ws discrded nd repeted. Isoltion of viruses. Nsl wsh specimens (5 ml of vel infusion broth in ech nostril) were obtined before vccintion with CR virus vccine nd on dys 1 to 5 nd on dy 7 postvccintion. Specimens were trnsported on wet ice to the lbortory for inocultion onto tissue culture cells. A portion of ech specimen ws frozen t -70 C, nd portion ws inoculted onto primry rhesus monkey kidney or Mdin-Drby cnine kidney cells with trypsin overly nd onto MRC-5 cells nd incubted t 34 C for 14 dys. Virus isoltes were identified s previously described (7). When influenz A virus ws isolted, it ws reinoculted onto rhesus monkey kidney or Mdin-Drby cnine kidney cells nd incubted t 39 C to ssess the presence of revertnt virus, i.e., virus tht hd regined the bility to replicte t 39 C. In ddition, when influenz A virus ws isolted, portion of the frozen clinicl specimen ws thwed nd inoculted onto tissue culture cells in seril 10-fold dilutions from n undiluted stte to 1:10,000 dilution to quntitte virl shedding. Serologicl tests. Serum specimens were obtined from ech vccinee before nd 28 dys fter dministrtion of CR37 (HlNi), CR48 (H3N2), or the inctivted trivlent influenz virus vccine. These specimens were stored t -20 C until testing for ntibody to HlNi or H3N2. Hemgglutintion inhibition (HAI) ntibodies were mesured by using whole virus homologous to the two CR virus vccine strins in stndrd microtiter ssy (32). Ech CR vccine virus strin ws grown in the llntoic cvity of eggs, nd the HA ws extrcted nd purified by previously described methods (27), including nonionic detergent solubiliztion, density grdient centrifugtion, nd ffinity chromtogrphy. A one-step enzyme-linked immunosorbent ssy (ELISA) previously described by Murphy et l. (24, 25) ws used to detect nti-influenz virus serum immunoglobulin titer nd immunoglobulin isotype. The sequence of regents from the solid phse onwrd consisted of

3 338 GORSE ET AL. purified HA, humn serum (in seril 1:4 dilutions), nd got nti-humn immunoglobulin serum (nti-igg or nti-iga) conjugted with lkline phosphtse (Miles Scientific, Div. Miles Lbortories, Inc., Nperville, Ill.) nd substrte (p-nitrophenyl phosphte disodium; Sigm Chemicl Co., St. Louis, Mo.). The yellow chromogen produced by clevge of the substrte ws mesured by A405 on multichnnel spectrophotometer (Dyntech Industries, Inc., McLen, V.). The ELISA titers were clculted by conventionl positive-over-negtive method in which the endpoint ws the highest dilution tht gve positive-over-negtive rtio of -2 Ṡttisticl methods. Sttisticl tests were performed on n Apple IIE computer using the Stts Plus progrm. Sttisticl tests included Fisher's exct test or chi-squre nlysis with the Ytes correction for two-by-two comprisons. Student's t test ws used to compre the men numericl mesurements of the vccine popultions. The Mnn-Whitney test ws used to compre the fold increse in reciprocl ntibody titer to vccintion with CR37 (HlNl) versus inctivted virus vccine HlNl ntigen nd with CR48 (H3N2) versus inctivted virus vccine H3N2 ntigen. The Mnn-Whitney test lso ws used to compre prevccintion reciprocl ntibody titers of ptients who demonstrted fourfold seroresponse to vccintion with titers of nonseroresponders. RESULTS Chrcteristics of the vccine study popultions. A totl of 13 volunteers received CR37 (H1N1) virus intrnslly. The initil eight persons were vccinted with TCID50s. Becuse virus ws not shed in nsl wshings from these individuls nd becuse no dverse effects were noted, five other volunteers were vccinted with the undiluted virus preprtion (107.1 TCID50s). A totl of 27 volunteers subsequently received CR48 (H3N2) virus intrnslly. Initilly, one volunteer ws vccinted with TCID50s. When virus ws not shed in nsl wshings of this volunteer or in those of the CR37 (HlNl) volunteers nd when no dverse effects were noted, 26 persons were vccinted with TCID50s per dose (undiluted preprtion). Ten of the CR37 (HlNl) vccinees nd eight of the CR48 (H3N2) vccinees received the inctivted trivlent influenz virus vccine prenterlly 5 to 12 months fter receiving the CR virus vccintion. The men ge ws not significntly different mong the vccinee groups (Tble 1). Underlying diseses included COPD in 24 vccinees, gstrointestinl diseses (usully cirrhosis or peptic ulcer disese) in 12, hypertension in 10, crdiovsculr disese in 6, neoplstic disese in 2, dibetes mellitus in 2, nd restrictive pulmonry disese in 1 vccinee. We obtined ech vccinee's history of influenz virus vccintion before his or her enrollment in the current study. Four of the CR37 (HlNl) vccinees hd received TABLE 1. Vccine Numbers nd ges of individuls who received ech vccine vccinees ge (yr) Age rnge (yr) CR37 (HlNl) ± CR48 (H3N2) ± Either CR ± Inctivted virus ± Of these vccinees, 10 hd received CR37 (HlNl) virus nd 8 hd received CR48 (H3N2) virus before receiving the inctivted virus vccine. TABLE 2. PFTs done prevccintion nd 10 to 14 dys postvccintion in 21 older dults given CR48 (H3N2) virus vccine Prevccintion PFT (FEV1/FVC) result (%) J. CLIN. MICROBIOL. No. of ptients with the following postvccintion PFT results (no. infected with vccine virus) < (1) (3) 3 (1) 2(1) (1) 0 4 (2) 0 < (1) 2 PET results re s follows: 270, norml; 60 to 69, mild obstruction to irflow; 45 to 59, moderte obstruction; <45, severe obstruction. inctivted influenz virus vccine t some time in previous yers, one hd not, nd this informtion ws not known for the remining eight vccinees. Of the CR48 (H3N2) vccinees, 14 hd received inctivted influenz virus vccine t some time in previous yers, 11 hd not, nd this informtion ws not known for the remining 2 vccinees. Postvccintion follow-up for possible CR vccine virusrelted complictions. Morbidity during the first 7 dys postvccintion occurred in five CR virus vccinees, who developed upper-respirtory-trct symptoms (e.g., rhinitis nd sore throt). Only one of these five persons hd become infected with the vccine virus. Conjunctivitis developed in two CR vccinees, neither of whom hd become infected with the vccine virus; virl cultures of conjunctivl swb specimens did not yield virus. One CR virus vccinee required hospitliztion for suprventriculr tchycrdi. He hd not become infected with vccine virus nd hd history of suprventriculr rrhythmis predting vccintion. A CR48 (H3N2) vccinee who hd developed fourfold rise in IgG ntibody titer nd who shed vccine virus on dys 2 nd 3 postvccintion developed n influenzlike clinicl illness 10 months fter live-ttenuted virus vccintion, nd wild-type influenz A virus H3N2 ws isolted from nsl swb culture t tht time. None of the vccinees developed incresed dyspne postvccintion. Of the 21 CR48 (H3N2) vccinees who underwent PFT, 2 experienced worsening in FEV1/FVC from one ctegory of irflow obstruction to nother nd 5 experienced n improvement in FEV1/FVC from one ctegory to nother (Tble 2). Of the 10 infected vccinees, 1 experienced worsening in FEV1/FVC from one ctegory to nother nd 5 experienced n improvement. A lrger proportion of vccinees who becme infected with CR48 (H3N2) virus experienced n improvement or no chnge in FEV1 postvccintion (9 of 10 infected vccinees) compred with those vccinees who did not become infected with vccine virus (2 of 11 noninfected vccinees) (P = , Fisher's exct test, one-tiled). Differences in mens of FEV1 nd FEV1/FVC for vrious vccinee groups before nd fter vccintion with CR48 (H3N2) were not significnt (Tble 3). The men FEV1/FVC for ll vccinee groups ws 60 to 63%, borderline between moderte nd mild irflow obstruction; the men vlues for the group of vccinees over 65 yers of ge were somewht lower but not significntly so compred with those of other groups (P ws not significnt). Infection s indicted by nsl shedding of CR virus. None of the volunteers vccinted with CR37 (HlNl) virus shed virus in nsl wshings. Two CR48 (H3N2) virus vccinees shed vccine virus (101.0 TCID50s/ml t 34 C incubtion, no virl growth t 39 C incubtion) on dy 2 or 3 fter inocultion with CR vccine or on both dys. One of these two

4 VOL. 24, 1986 INFLUENZA A VACCINES IN OLDER ADULTS 339 TABLE 3. Men FEV, nd FEV,/FVC (%) (sstndrd devition) for ptients before nd fter vccintion with CR48 (H3N2) virus FEV1 (liters) FEV1/FVC (%) Ptient Ptien groupno. of AFEV, % FV/FVCC1 ptients Pre- Post- AFEV1b (%) Pre- Post- (%) vccintion vccintion vccintion vccintion All CR48 (H3N2) ± ± ± ± ± ± 6.2 virus vccinees tested 265 Yrs old ± ± ± ± ± ± 5.7 <65 Yrs old ± ± ± ± ± ± 6.4 Infected' with CR ± ± ± ± ± ± 5.9 (H3N2) virus Not infected with ± ± ± ± ± ± 5.5 CR48 (H3N2) virus Dt re shown for ll ptients who underwent PFT. b Men of pre- minus postvccintion FEV1 (± stndrd devition) for ech vccinee group pre- nd postvccintion. c Men of pre- minus postvccintion FEV1/FVC (± stndrd devition) (%) for ech vccinee group pre- nd postvccintion. dincludes ll vccinees with evidence of infection with the CR48 (H3N2) vccine virus, including nsl shedding of vccine virus, fourfold rise in serum IgG or IgA titer, fourfold rise in HAI ntibody titer, or ll of these. persons lso developed fourfold rise in ELISA serum IgG ntibody titer; the other did not hve fourfold rise in ny serum ntibody mesured. Serologic response to CR virus or inctivted trivlent virus vccine dministered within 1 yer fter CR virus vccintion. Significntly fewer CR37 (HlNl) virus vccinees mnifested fourfold increses in HAI ntibody to Hi HA compred with inctivted virus vccinees (Tble 4; P = 0.05, Fisher's exct test, one-tiled). The one CR37 (HlNi) virus vccinee who developed HAI ntibody hd received the higher dose of CR37, 107 l TCID50s. Significntly fewer CR48 (H3N2) virus vccinees mnifested fourfold HAI ntibody increses to H3 HA (ll seroresponders received the higher dose, TCID50s) compred with inctivted virus vccinees (Tble 4; X2 = 6.5, P < 0.05). Men fold increses in HAI ntibody titer to Hi nd H3 HA were significntly greter mong inctivted virus vccine recipients thn mong CR37 or CR48 virus vccinees (Tble 5; Mnn-Whitney test, z = -2.1, P = 0.03 nd z = -2.2., P = 0.03, respectively). As mesured by IgG ELISA, significntly fewer CR37 (HiN1) virus vccinees mnifested fourfold ntibody response to Hi thn did inctivted virus vccinees (Tble 4; P < 0.001, Fisher's exct test, one-tiled), nd the men fold increse in IgG ntibody to Hi ws significntly higher fter inctivted trivlent influenz virus vccine thn fter livettenuted virus vccine (Tble 5; Mnn-Whitney test, z = -2.6, P = 0.011). Although lrger proportion of vccinees seroresponded to CR48 virus thn to CR37 virus, CR48 (H3N2) virus vccinees mnifested fourfold increses in IgG ntibody (ll seroresponders received the TCID50S of virus) significntly less often thn did recipients of inctivted virus vccine (Tble 4; x2 = 8.9, P < 0.01). The men fold increse in IgG ntibody to H3 HA ws significntly greter fter inctivted virus vccine (Tble 5; Mnn- Whitney test, z = -2.5, P = 0.01). As mesured by IgA ELISA, 1 (inoculum of TCID50s) of 13 CR37 (HlNi) virus vccinees mnifested serum IgA ntibody response to Hi. The proportion of CR48 (H3N2) virus vccinees mnifesting fourfold serum IgA ntibody response (ll seroresponders received TCID50S of virus) ws not significntly different from tht of inctivted virus vccinees (Tble 4). The men fold increses in serum IgA ntibody to Hi nd H3 HA were not significntly different mong the vccine groups (Tble 5). A significnt positive ssocition between fourfold rise in IgA nd IgG titers occurred in recipients of CR48 (H3N2) virus. Of 7 vccinees with fourfold serum IgA ntibody titer rise, 5 lso hd rise in IgG ntibody titer; of 20 without fourfold serum IgA ntibody titer rise, only 4 hd rise in IgG ntibody titer (P = 0.023, Fisher's exct test, onetiled). One of the CR37 (H1N1) virus nd two of the CR48 (H3N2) virus vccinees developed fourfold rises in IgA ntibody titer without n ccompnying rise in either HAI or IgG ntibody titer or isoltion of virus from nsl wsh specimen. None of the inctivted virus vccine recipients developed fourfold rise in serum IgA ntibody titer without concomitnt rise in serum IgG ntibody titer. By ny criterion of infection, i.e., fourfold rise in serum HAI, IgG, IgA ntibody titer, isoltion of vccine virus from nsl wshings, or ll of these, 2 (15%) of the 13 CR37 (H1N1) virus vccinees nd 12 (44%) of the 27 CR48 (H3N2) virus vccinees becme infected with vccine virus. This TABLE 4. Numbers of ptients with fourfold ntibody responses to CR or inctivted influenz virus vccine No. of ptients with fourfold ntibody Vccine type/ntibody rise/no. tested mesured Hi ntigen H3 ntigen CR37 (H1N1) HAI 1/13 IgG 0/13b,c IgA 1/13 Any of the bove 2/13d CR48 (H3N2) HAI 3/27E IgG 9127C f IgA 7/27 Any of the bove 11/279 Inctivted virus HAI 7/18 9/18' IgG 11/18b 15/18f IgA 3/18 4/17 Any of the bove 13/18d 16/189 p = 0.05; Fisher's exct test, one-tiled. b p < 0.001; Fisher's exct test, one-tiled. c p = 0.017; Fisher's exct test, one-tiled. dp = 0.002; Fisher's exct test, one-tiled. 'X2 = 6.5; P < 0.05 with the Ytes coffection. fx2 = 869; P < 0.01 with the Ytes correction. 9 X2= 8.52; P = with the Ytes correction.

5 340 GORSE ET AL. J. CLIN. MICROBIOL. TABLE 5. Serum HAI ntibody nd serum IgG nd IgA ntibody responses (ELISA) to CR or inctivted influenz virus vccine Hi ntigen H3 ntigen Vccine type/ntibody Reciprocl ntibody titer Reciprocl ntibody titer mesured (geometric men) Men fold (geometric men) Men fold increse (± SD) increse (± SD) Prevccintion Postvccintion Prevccintion Postvccintion CR37 (HlNl) virus HAI ±0.9 NTb NT IgG 3,294 3, ± 0c NT NT IgA NT NT CR48 (H3N2) virus HAI NT NT ± 1.5d IgG NT NT 1,089 2, ± 13.6e IgA NT NT ± 1.8 Inctivted trivlent influenz virus HAI ± ± 1.9d IgG 3,995 10, ± 3.5c,f 1,011 4, ± 8.3e.f IgA ± ± 8.0 Mnn-Whitney test, z = -2.1, P = b NT, Not tested. c Mnn-Whitney test, z = -2.6, P = d Mnn-Whitney test, z = -2.2, P = e Mnn-Whitney test, z = -2.5, P = f Mnn-Whitney test, z = -1.7, P = my be low estimte of the proportion of infected individuls, becuse dditionl vccinees my hve developed isolted rises in nsl wsh secretory IgA ntibody titer without other evidence of vccine virus infection. Fourfold rises in serum HAI, IgG, or IgA ntibody titer or in ll three mong the 18 recipients of the inctivted influenz virus vccine were more frequent to both Hi (P = 0.002, Fisher's exct test, one-tiled) nd H3 HA (X2 = 8.52, P = 0.003) thn they were mong the CR virus vccinees (Tble 4). Seroresponse s function of prevccintion ntibody titer. Becuse prevccintion ntibody titer my hve influenced response to the vccines, we compred reciprocl prevccintion ntibody titers s function of subsequent seroresponse to vccintion. Prevccintion HAI ntibody titer did not pper to influence HAI ntibody response to live-ttenuted virus vccine; reciprocl geometric men HAI titers of nonseroresponders compred with those of seroresponders to ech of the live-ttenuted virus vccines were not significntly different. However, prevccintion reciprocl geometric men HAI titer to H3 mong the nonseroresponders who received inctivted virus vccine ws significntly higher thn mong seroresponders (47.0 versus 21.8; z = 2.56, P = 0.01, Mnn-Whitney test). Among CR48 virus vccine recipients, the prevccintion reciprocl IgG ELISA geometric men titer of nonseroresponders ws higher thn tht of seroresponders (2,011 versus 319; z = 2.37, P = 0.017). Among the inctivted virus vccine recipients, high ELISA IgG ntibody ws correlted with bsence of ELISA ntibody response (nonseroresponders versus seroresponders to Hi ntigen, 7,071 versus 2,530, z = 2.22, P = 0.025; H3 ntigen, 7,113 versus 475, z = 2.55, P = 0.011, Mnn-Whitney test). No significnt differences were found in prevccintion reciprocl geometric men IgA ELISA titers compring the nonseroresponders nd seroresponders. No significnt differences occurred in prevccintion reciprocl geometric men HAI, IgG, or IgA ntibody titers between nonseroresponders to CR37 (HlNl) virus nd nonseroresponders to the Hi ntigen of the inctivted virus vccine or between nonseroresponders to CR48 (H3N2) virus nd the H3 ntigen of inctivted virus vccine. In ddition, there were no significnt differences by the sme mesures mong seroresponders to CR48 (H3N2) virus nd the H3 ntigen of the inctivted virus vccine. Effect of history of influenz virus vccintion on seroresponse to CR48 (H3N2) virus vccine. Of the 27 CR48 (H3N2) virus vccine recipients, 25 were ble to give vccine history tht ws believed to be relible before this study. Fourteen recipients hd been vccinted in previous yer with inctivted influenz virus vccine, nd 11 hd never been vccinted for influenz. Of the 14 vccine recipients with history of inctivted virus vccintion, 5 becme infected with the live-ttenuted CR48 (H3N2) vccine virus, nd 9 did not. This ws not significntly different from the 7 of the 11 who becme infected with vccine virus nd gve history of no previous influenz vccintion. Effect of CR virus on subsequent seroresponse to inctivted virus vccine. Infection with the CR vccine viruses my hve primed the response to subsequent inctivted virus vccine dministrtion. Of the eight persons who did not become infected with CR37 (HiN1) virus who subsequently received the inctivted virus vccine, five hd seroresponse to both Hi nd H3 ntigens nd three responded only to the H3 ntigen. Of the two persons who becme infected with CR37 (HiNi) virus nd subsequently received inctivted virus vccine, both developed seroresponse to both the Hi nd H3 ntigens. Of the four persons who did not become infected with CR48 (H3N2) virus nd who subsequently received inctivted virus vccine, two seroresponded to both Hi nd H3 ntigen nd two did not serorespond to either ntigen. Of the four persons who becme infected with CR48 (H3N2) virus nd who subsequently received inctivted virus vccine, ll seroresponded to both Hi nd H3 ntigens. In summry, ll 6 persons who becme infected with CR virus nd 7 of 12 persons who did not become infected with CR virus hd seroresponse to subsequent inctivted virus vccine homologous ntigen (P = 0.09, Fisher's exct test, one-tiled).

6 VOL. 24, 1986 DISCUSSION The two CR influenz A virus vccines used in this study were sfe when dministered intrnslly to older dults with chronic diseses. Significnt chnges in PFTs did not occur fter dministrtion of these vccines. Our sfety dt confirm previous reports by the Medicl Reserch Council Advirsory Group (1, 22) (PFT done t 7 to 21 dys postvccintion) tht live-ttenuted influenz virus vccines do not cutely chnge the pulmonry function of dults with chronic obstructive irwys disese. Kv nd Litinen (19) hve lso found no chnge in specific irwy conductnce mong ptients with sthm who received live-ttenuted influenz A virus vccines. Although trnsient spirometric chnges in the first 10 dys postvccintion re not ruled out by our dt, testing PFTs t 10 to 14 dys postvccintion would probbly revel spirometric chnges s result of influenz A virus infection in persons with COPD. Smith et l. (30) demonstrted reductions in FEV1 nd FVC lsting for up to 6 months fter nturl influenz A virus infection in ptients with COPD. They did not comment on whether decrements in pulmonry function were more severe in the first 1 to 2 weeks fter the onset of clinicl signs nd symptoms of infection, however. It might be expected tht infection with live-ttenuted influenz A virus is less likely to cuse pulmonry function decrements, since experimentl wild-type influenz A virus infection does not result in bnormlities mong helthy dults, wheres nturl infection does (20). When detected, the chnges occurred t both 3 nd 10 dys postvccintion. The sme studies hve not been done in ptients with underlying COPD. Prenterl dministrtion of inctivted trivlent influenz virus vccine 5 to 12 months fter CR virus vccintion resulted in significntly higher rtes of fourfold serum ntibody increses compred with the rtes of fourfold ntibody increses fter the intrnsl dministrtion of CR vccine viruses. It is possible tht the response rtes to the inctivted virus vccine were enhnced by the ptients' exposure to the CR vccine virus within the previous yer. However, the rtes of seroresponse to inctivted virus vccine in our ptients were similr to those reported in the literture for this type of noninstitutionlized older dult (4, 8, 9, 16-18, 21, 26, 28, 29, 31). Alterntively, it is likely tht the preexisting experience with other influenz A virus serotypes prevented infection with CR virus but did not prevent serologic response to the inctivted virus vccine. As in seronegtive children (5, 6), the CR48 (H3N2) vccine virus ws more infectious in our older dult popultion thn ws the CR37 (H1N1) vccine virus. This my reflect n ctul difference in the infectivity of the two viruses. No definite explntion for this difference is vilble, since the infectivity of these two vccine viruses is determined theoreticlly by the six genes provided by the common prent virus strin (influenz A/Ann Arbor/6/60). Most previous studies of older, seropositive dults report the serologic response to influenz A vccine in terms of the HAI ntibody titer. Our trivlent virus vccine recipients demonstrted n HAI response rte comprble to tht seen in other series (9, 21). However, the IgG ntibody (ELISA) response to vccintion demonstrted higher proportion of fourfold rises in these sme vcinees. It is not known whether n ELISA-determined IgG ntibody titer rise corresponds directly to subsequent protection from wild-type virus chllenge. The CR48 (H3N2) virus vccinee who developed nturl influenz A virus infection 10 months INFLUENZA A VACCINES IN OLDER ADULTS 341 postvccintion hd low ELISA IgG nd IgA ntibody titers to H3 ntigen t 28 dys postvccintion (1:80 nd 1:20, respectively). Although this IgG ntibody titer represented fourfold rise compred with prevccintion, the level ttined ws still low in comprison with pre- nd postvccintion ntibody titers of other CR48 recipients. As expected, the rtes of serologic response to the two CR virus strins in this study were lower thn those in studies of seronegtive children or dults. Belshe et l. (5, 6) reported vccine virus infection rtes of 60 to 79% fter vccintion with CR37 (HlNl) virus nd up to 100% fter CR48 (H3N2) virus vccintion of seronegtive children. Approximtely one-hlf of seropositive children becme infected with CR37 or CR48 virus (6). Clements et l. (14) reported n HAI rise in 94% of young dults who were seronegtive prior to vccintion with commercil inctivted trivlent influenz virus vccine, compred with 44% response rte mong seronegtive young dults who were vccinted with CR48 (H3N2) virus (107.5 TCID50s). If serum ntibody, nsl wsh ntibody, nd virus shedding re ll considered, the percentge of seronegtive young dults infected with CR37 (HlNl) virus nd with CR48 (H3N2) virus ws 88 to 96% (13, 14, 23). The Medicl Reserch Council Advisory Group (22) reported 31% HAI serologic response rte to CR48 (H3N2) virus (107 50% egg infective doses) mong previously seropositive dults with chronic bronchitis. This is higher response rte thn ws found in our CR48 (H3N2) virus recipients, s mesured by HAI response, but similr to the 33% rte of ELISA serum IgG fourfold rises in our ptients. Rtes of fourfold rises in serum IgA ntibody titer were not significntly different mong the vccine groups. Three of our CR virus recipients but none of our inctivted virus vccine recipients developed fourfold rises in serum IgA ntibody titer without ccompnying chnges in serum HAI or IgG ntibody titer. Additionl CR vccinees my hve become infected, nd they demonstrted this only by rises in locl secretory IgA ntibody titer. Murphy et l. (24) did not detect serum IgA response in ll young children who developed nsl wsh secretory IgA ntibody response fter becoming infected with cold-dpted influenz A virus vccines. Clements et l. (14) found higher rte of nsl wsh secretory IgA ntibody rises mong seronegtive young dults who received intrnsl CR48 (H3N2) virus compred with the response fter prenterl dministrtion of inctivted virus vccine (69 versus 31%). For these resons, determintion of nsl wsh IgA ntibody levels in our ptients will provide further importnt informtion regrding the locl immune response to CR virus vccine nd my increse the totl number of infected vccinees detected. The higher seroconversion rtes ttined by using the inctivted trivlent influenz virus vccine do not necessrily men tht it is more efficcious in preventing infection or severe illness or both due to nturl wild-type influenz A virus. Differences in the stimultion of secretory humorl immunity nd of cellulr immunity (e.g., cytotoxic T cells nd enhnced lymphokine production) produced by the vrious vccines my be more importnt determinnts of protection ginst nturl chllenge nd recovery from infection. Furthermore, response to live-ttenuted influenz A virus vccine my seprte vccinees with previous influenz A virus experience into two groups, those who re susceptible to wild-type influenz A virus infection nd those who re lredy immune to nturl chllenge. Perhps protection from infection by CR virus vccintion correltes with protection from nturlly cquired wild-type influenz

7 342 GORSE ET AL. A virus. If infection cused by CR virus vccine induces protection ginst wild-type influenz A virus nd if dults who fil to become infected fter CR virus vccintion re immune to nturlly cquired influenz A virus, CR virus vccine my hve superior efficcy when compred with inctivted virus vccine. Our sfety nd ntigenicity tests provide the foundtion for further studies with these promising live-ttenuted influenz virus vccines. ACKNOWLEDGMENTS This work ws supported in prt by the Vetern's Administrtion Medicl Reserch nd in prt by the Ntionl Institute of Allergy nd Infectious Diseses contrct no. 1-AI We cknowledge the technicl ssistnce of Virgini Evns, Betty Burk, nd Julie Brtrm in conducting this investigtion. LITERATURE CITED 1. Advisory Group on Pulmonry Function Tests in Reltion to Live Influenz Virus Vccines A study of live influenz virus vccine in ptients with chronic bronchitis. Br. J. Dis. 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