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Serology: Screening for Vaccine Preventable Diseases Alison M Kesson Infectious Diseases and Microbiology.
History of Vaccination
Vaccination • Immunisation against viral diseases is a triumph of modern science and a triumph of community cooperation and organisation.
Effect of Vaccination on Populations • Smallpox eradicated in 1977 • Poliomyelitis – eradicated from the western hemisphere and many areas • Measles • Rubella • Hepatitis B
Smallpox - Variola • Eradication of smallpox in 1977 • 180 years after Jenner showed cowpox infection prevented subsequent infection by smallpox •
Poliomyelitis • Estimated that without eradication, more than ten million new cases of polio worldwide would manifest themselves between 2005 and 2040.
What vaccine preventable diseases are there?
Bacterial VPDs • • • • • •
Tetanus Diphtheria Pertussis Pneumococcus Meningococcus Haemophilus influenzae B • Tuberculosis
• • • • • •
Typhoid Cholera Botulism Anthrax Plague Q fever
Viral VPDs – routine schedule • • • • • • • •
Polio 1,2,3 Hepatitis B virus Measles Mumps Rubella Varicella zoster virus Rotavirus Influenza A and B
VPDs - other • • • • • •
Hepatitis A virus Respiratory syncytial virus Rabies Smallpox Yellow fever Japanese encephalitis
What is a vaccine?
Background • Vaccination or immunisation is the induction or provision of immunity against an infectious disease. • The immunological basis for vaccination depends upon two central properties of the adaptive immune system; antigen specificity and memory. • The effectiveness of a vaccine is directly related to its ability to induce immunological memory.
Vaccination • Active vaccination is induction of host immune response by administration of antigen – long lasting - years. • Passive vaccination is provision of antibody which provides protective immunity over a relatively short period – weeks to months.
• Vaccines are preparations administered orally or parenterally, which stimulate a specific protective immune response in the recipient without themselves causing diseases. • Vaccines prevent disease (protective immunity) but do not necessarily prevent infection (sterilising immunity). • Viral vaccines are either live (attenuated) or killed. • Attenuated vaccines do not cause disease in immunocompetent individuals.
Vaccine protection • With protection actual infection may occur and generate a booster response. The infection will be quickly aborted due to immunological memory of vaccine-induced immunity not necessarily located at viral entry e.g. inactivated polio vaccine.
What is the immunological response?
The “Primary Response” • The “primary response” occurs after first exposure to an antigen - after a latent period of approx 7 to 10 days circulating antibodies first appear in the blood. • Ig M antibodies with low affinity appear first and may fix complement, making cell lysis and phagocytosis possible. • Later antibodies are of IgG with higher affinity. • The switch for IgM to IgG requires T cell cooperation.
The “Primary Response” • As the titre of IgG rises (after the second week) the titre of IgM falls. • IgG antibodies are produced in large amounts and function in neutralisation, antibodydependent cellular cytotoxicity (ADCC) and fixation of complement. • The antibody titre usually reaches a peak at about 2 to 6 weeks after infection and then gradually falls.
The “Secondary Response” • After a second exposure to the same antigen, a heightened memory immune response occurs usually by 4 to 5 days and depends upon proliferation of both B and T cells e.g. measles and varicella. • This provides immunity and protection against disease.
Mucosal Immunity • Many pathogens replicate on the mucosal surfaces before host invasion and may induce secretory IgA in the respiratory and GIT mucous membranes (e.g. rubella, polio, influenza). • IgA is often neutralising, fixes complement (alternative pathway) and lyses some organisms.
Protection • Some measured immune responses may not themselves confer protective immunity but are correlated with protection and remain as useful markers of protective immunity e.g. IgG to rubella, influenza • Parenteral and inactivated vaccines rarely induce mucosal IgA responses.
How do we detect vaccination or infection?
Diagnosis of Infection • Diagnosis of a viral infection – Demonstration of the virus – Demonstration of viral antigen or nucleic acid.
• This is in the acute phase of diseases 5-20 days after exposure. • Demonstration of virus in tissue from affected organs is usually of diagnostic significance • Exceptions may be adenovirus and enterovirus due to GIT excretion
• Respiratory Syncitial Virus
Ref: White and Fenner 1994
Detection of Disease • Detection of specific antibody has a temporal but not a causal association • Positive or negative predictive value of result depends on the clinical picture and the prevalence of disease in the population.
Diagnosis of Infection • Detection of IgM antibodies • Detection of a rising titre of antibodies in paired specimens • Detection of a single high titre • Detection of antigen • Difficult to distinguish reactivation from primary infection – IgM usually more marked in primary infection.
Diagnosis of Infection • All laboratory findings have to be interpreted in relation to clinical symptoms and signs. • The clinician must provide adequate history. • The laboratory should comment on findings and advise regard further testing.
How do we detect immunity or past infection?
Measurement of Immunity • Response to a vaccine is usually determined by measuring the appearance and/or concentration of specific antibodies in serum. • Measles, mumps, rubella hepatitis B, varicella – circulating antibodies correlate with clinical protection, but only measures the humoral arm of immune response. • Evaluation of persisting antibody has been used to determine duration of vaccine-induced immunity.
Measurement of Immunity • Absence of detectable antibody is not always correlated with lack of protection e.g. VZV, HBV • Antibody levels often fall with time (e.g. measles, rubella, HBV) however, revaccination usually leads to a rapid IgG response with little IgM response indicating persisting protective immunity.
Measurement of Immunity • With some vaccines determining the level of antibody is important to imply protection e.g. rubella. • Detection of CMI which would be very helpful is a research tool only.
Detection of Vaccine Protection • Laboratory testing to determine immunity (IgG) is usually different to determining infection (IgM or IgA). • Most serology performed on serum. • Anticoagulants added to blood often interfere with assays especially complement fixation. • A rise in antibody titre may be due to primary infection, reinfection or reactivation.
Methods Available • A variety of methods is available – – – – – –
• Choice of test depends on the virus, the clinical problem – infection or immunity. • Demonstration of seroconversion or rising titre requires paired specimens 1-3 weeks apart.
• Complement Fixation Titre (CFT)
• Haemagglutination Inhibition titre (HAI)
What is protection? • There is some evidence which can be used to determine that an individual will probably have protection from diseases. • Qualitative detection of IgG e.g. measles, mumps, HAV – Detection of antibody correlates with protection • Quantitative detection of IgG e.g. rubella, HBV
Detection of protection • • • • • • • •
Polio 1,2,3 Hepatitis B virus Measles Mumps Rubella Varicella zoster Rotavirus Influenza A & B
= = = = = = = =
Neutralising antibody titre HBsAb = >10 IU / mL Measles IgG detected Mumps IgG detected Rubella = >10 IU / mL ?? Varicella zoster IgG detected ? Not available CFT not predictive of protection. Use HAI or Neut.
Detection of protection • Hepatitis A virus • Respiratory syncytial virus • Rabies
• Yellow fever
• Japanese encephalitis =
Hepatitis A IgG (Total Ab) CFT not predictive of protection. Rabies antibody – or about to die Evidence of vaccination within 3 years Capture IgM –sensitive (CF, HI) Neutralisation to sort out X-reactions (specific) Protection ??
Case 1 • Term female infant born to P2G1 mum • Wt 1.9kg • Apgars 51, 75 • Palpable rash