tatjana plješa , md, phd institute of virology, vaccines and sera –torlak belgrade, serbia

Effect of the inclusion of Effect of the inclusion of „„contemporary” contemporary” B. B.

pertussis pertussis strains in the strains in the vaccine composition on vaccine composition on temporal trends in temporal trends in B. B. pertussis pertussis populationpopulationTatjana PlješaTatjana Plješa, MD, PhD, MD, PhD

Institute of Virology, Vaccines and Institute of Virology, Vaccines and Sera –TorlakSera –Torlak

Belgrade, SerbiaBelgrade, Serbia

Pertussis or whooping cough has persisted andPertussis or whooping cough has persisted and resurged in the face of vaccination and has resurged in the face of vaccination and has becomebecome one of the most prevalent vaccine-one of the most prevalent vaccine-preventable diseasespreventable diseases in Western countries with in Western countries with estimated infection frequenciesestimated infection frequencies of 1–9%of 1–9% (Mooi et (Mooi et al, 2013)al, 2013)

Bordetella pertussis Bordetella pertussis poses a threat to infants poses a threat to infants thatthat have not been (completely) vaccinated and have not been (completely) vaccinated and forfor whom pertussis is a severe, life-threatening, whom pertussis is a severe, life-threatening, diseasedisease (de Greeff, 2010) (de Greeff, 2010)

.

Pertusis - Pertusis - one of the leading causes of one of the leading causes of vaccine preventable deaths in the world vaccine preventable deaths in the world

todaytoday

Pertusis - Pertusis - one of the leading causes of one of the leading causes of vaccine preventable deaths in the world vaccine preventable deaths in the world

todaytoday

WHO, 2013.WHO, 2013.

Estimated casesEstimated cases 16. 000. 16. 000. 000000

Estimated Estimated deathsdeaths 8989. . 000000

Vaccine Vaccine coveragecoverage 8844%%

Argentina (Hozbor et al., 2009)

Canada (Skowronski et al., 2002; Ntezayabo et al., 2003)

USA (Yih et al., 2000; CDC, 2002a; CDC, 2003a; Tanaka et al., 2003)

Australia (McIntyre et al., 2002; Spokes and Gilmour, 2011)

Netherland (de Melker et al., 2000)

Israel (Moerman et al., 2006)

Spain (Crespo et al., 2011)

Finland (Elomaa et al., 2005)

UK (Litt et al., 2009) etc.

Resurgence in Resurgence in countries with long countries with long vaccination history and high coveragevaccination history and high coverage

??

Better education and awareness about disease (He and Mertsola, 2008)

Better diagnostic methods & improved reporting (He and Mertsola, 2008)

Waning of adaptive immunity through time (Wendelboe et al, 2005)

Adaptation to the vaccine induced immunity (He and Mertsola, 2008)

WCVs induce longer lasting immunity than ACVs, the switch from WCVs to ACVs may have aggravated the pertussis problem (Gustafsson, 2006; Sheridan, 2012)

Antigenic divergence of Ptx and Prn (He and Mertsola, 2008; Mooi et al, 2013)

Resurgence of pertussis –possible Resurgence of pertussis –possible reasons reasons

B. pertussis B. pertussis virulence factor show polymorphismsvirulence factor show polymorphisms

Wide spread antigenic divergence between Wide spread antigenic divergence between

circulating isolates and vaccine strains circulating isolates and vaccine strains

Alleles changes from vaccine to non-vaccine types Alleles changes from vaccine to non-vaccine types

– every 15-30 years– every 15-30 years

Polimorphism of nucleotidesPolimorphism of nucleotides

Pertussis toxin Pertactin

5 types of PtxA:5 types of PtxA:

PPtxA1, txA1, PtxPtxA2, A2, PtxPtxAA4, PtxA5 and Ptx4, PtxA5 and PtxAA88 ((MooiMooi

et al., 20et al., 201010).).

Predominant in isolates – PtxA1 and PtxA2 Predominant in isolates – PtxA1 and PtxA2 (Mooi et al., 2013)(Mooi et al., 2013)

Most vaccines – PtxA1, PtxA2 and PtxA4 Most vaccines – PtxA1, PtxA2 and PtxA4 (Litt (Litt

et al., 2009)et al., 2009)

TohamaTohama (widely use (widely use acelular acelular vaccine strain)vaccine strain) - -

PPtxA2txA2

Polimorphism of pertussis Polimorphism of pertussis toxintoxin

13 different pertactin allels 13 different pertactin allels

Alleles changes from vaccinAlleles changes from vaccinee to non-vaccin to non-vaccinee

types – every 15-30 yearstypes – every 15-30 years

Predominant in isolates: Prn1, Predominant in isolates: Prn1, Prn2Prn2 and Prn3 and Prn3 (Mooi et al., 2010)(Mooi et al., 2010)

Vaccine strains : Prn1, Prn7 and Prn10 Vaccine strains : Prn1, Prn7 and Prn10 (Mooi (Mooi

et al., 2010)et al., 2010)

PolimorphismPolimorphism of pertactinof pertactin

Average pertussis incidence in 26 European Average pertussis incidence in 26 European countriescountries

Kanitz E. ESCAIDE, 2011Kanitz E. ESCAIDE, 2011

Kanitz E. ESCAIDE, 2011Kanitz E. ESCAIDE, 2011

Pertussis incidence in European countriesPertussis incidence in European countries

Island

Spain

Ireland SwedenNorway

Netherland

Estonia

SloveniaSlovakia

wP-containing:wP-containing:Inactivated whole Inactivated whole bacterial cellbacterial cell

Different strainsDifferent strains

Isolates as Isolates as vaccine strainsvaccine strains

Both celular and Both celular and humoral immune humoral immune responseresponse

Th1 type & Th17Th1 type & Th17

aP-containing:aP-containing:PT ; PT & FHA; PT ; PT & FHA; PT, FHA & PRN; PT, FHA & PRN; PT, FHA, PRN, PT, FHA, PRN, Fim2 & Fim3Fim2 & Fim3

Tohama vaccine Tohama vaccine strainstrain

Humoral imune Humoral imune responseresponse

Th2 type & Th17Th2 type & Th17

Vaccine typesVaccine types

Vaccine safetyVaccine safety

Although local and systemic reactogenicity are Although local and systemic reactogenicity are

more commonly associated with wP-containing more commonly associated with wP-containing

vaccines, both aP-containing and wP-vaccines, both aP-containing and wP-

containing vaccinescontaining vaccines have excellent safety have excellent safety

records. records. WHO, Weekly epidemiological record, No. 30, 25 july

2014

HiggsHiggs et al., 2012 et al., 2012

Institute for Virology, Vaccine and Sera Torlak

Pertussis incidence in the Republic of Serbia Pertussis incidence in the Republic of Serbia 1965-20111965-2011

Pertussis in SerbiaPertussis in Serbia

Notifiable Notifiable infectious diseaseinfectious disease

DiagnosisDiagnosis -- culture culture and serologyand serology

Trends


Incid

en

ce

Incid

en

ce

Pertussis vaccine in Pertussis vaccine in SerbiaSerbia

VVaccination since 1957accination since 1957 Current vaccine compositionCurrent vaccine composition -- since since

19851985 Four vaccine strains:Four vaccine strains:• 8/84 (Fim2)8/84 (Fim2)• 1772/57 and 2047/51772/57 and 2047/577 (Fim2,3) (Fim2,3)• 23/81 (Fim323/81 (Fim3)) Acellular vaccine can be administred in Acellular vaccine can be administred in

private practice (last 10 years)private practice (last 10 years) Acellular vaccine in the imunization Acellular vaccine in the imunization

calendar from 2014calendar from 2014



In Serbia, for more than 50 In Serbia, for more than 50

years, vaccine strains have years, vaccine strains have

been changed regularly to been changed regularly to

coincide with isolates coincide with isolates

circulating in the susceptible circulating in the susceptible

population.population.

Study of antigenic divergenceStudy of antigenic divergenceof B. pertussis of B. pertussis in Serbiain Serbia

Identification of serotypes and Identification of serotypes and genotypes of genotypes of B. pertussisB. pertussis vaccine vaccine strains and strains and circulatingcirculating isolates isolates between 1953 and 2011between 1953 and 2011..

Comparision with circulating and Comparision with circulating and vaccine strains in other vaccine strains in other European European countries, USA and Australia. countries, USA and Australia.

4 vaccine strains:4 vaccine strains:

(2047/57, 1772/57, 23/81 and 8/84)(2047/57, 1772/57, 23/81 and 8/84)

7777 clinical isolatesclinical isolates::

I.I. 1953 1953 tto 19o 196060 (n= (n=2121))

II.II. 19196161 t to 19o 197979 (n= (n=99))

III.III. 19819800 t to o 19891989 (n= (n=3434))

IV.IV. 1990. to 2011 (n=13)1990. to 2011 (n=13)


Serotyping Serotyping – – monoclonal antibodies against monoclonal antibodies against

Fim2 and Fim3 by slide agglutination testFim2 and Fim3 by slide agglutination test**

GGenotyping enotyping -- LightCycler PCRLightCycler PCR && PFGE PFGE** : :

• Ptx S1 subPtx S1 subunitunit(ptxA) (ptxA)

• Prn Prn

PFGE profPFGE profilesiles –– pulsed-field gel pulsed-field gel

electrophoresis*electrophoresis*

**Advani et al., 2004, Mooi et al., 2000Advani et al., 2004, Mooi et al., 2000


StrainStrain FimFim Prn Prn PtxA PtxA IsolatedIsolated Added in Added in vaccinevaccine

1772/571772/57 2,32,3 11 22 19571957 1972 1972

2047/57 2047/57 2,32,3 11 22 19519577 19681968

23/81 23/81 33 11 11 19811981 1985 1985

8/848/84 22 22 11 19841984 1985 1985

Vaccine strainsVaccine strains


B. pertussisB. pertussis serotypes serotypes


ptxAptxA genotypes genotypes


Pertactin genotypesPertactin genotypes


SummarySummary

Isolation Isolation

periodperiod

No. of No. of

iisolatessolates

ptxA ptxA prn prn serotserotypeype

ptxA1ptxA1 ptxA2ptxA2 prn1prn1 prn2 prn2 prn3 prn3 prn 11prn 11Fim2Fim2 Fim2,3Fim2,3 Fim3Fim3

1953.-1960.1953.-1960. 2121 00 2121 2121 00 00 00 88 1313 00

1961.-1979.1961.-1979. 99 44 55 99 00 00 00 00 66 33

1980.-1989.1980.-1989. 3434 3131 33 2727 11 33 33 2222 00 1212

1990.-2011.1990.-2011. 1313 1010 33 44 55 11 33 77 33 33

SummSumm 7777 4545 3232 6161 66 44 66 3737 2222 1818


**22Mooi et al., 2013 Mooi et al., 2010 He et al., 2009 Litt et al., 2009 Elomaa et al., 2005.

**11Dakic et al., 2010. Pljesa et al., 2014 .

VVaaccine strainsccine strains Circulating strainsCirculating strains

SSerbiaerbia*1*1 EEuropeurope*2*2 SSerbiaerbia*1*1 EEuropeurope*2*2

prnprn pprn1rn1 and and prn2prn2

prn1prn1 or or prn7prn7

prn1, prn1, prn11prn11

prn2prn2,, prn3prn3

ptxAptxA ptxA1ptxA1 and and ptxA2ptxA2

ptxA2 ptxA2 or or ptxA4ptxA4 ptxA1ptxA1 ptxA1ptxA1

Vaccine strains in Serbia - Vaccine strains in Serbia - 44 different PFGE profiles different PFGE profiles


PFGE profiles of vaccine strainsPFGE profiles of vaccine strains

PFGEprofile Strain Group


DendDendrrogram ogram of of B. pertussis B. pertussis

strainsstrains Isolates - 22 Isolates - 22

different PFGE different PFGE profilesprofiles

43% - 43% - unique unique Serbian profiles Serbian profiles (BpSBR)(BpSBR)

PFGE Strain Year of isolation


PFGE profiles of PFGE profiles of B. pertussis B. pertussis strainsstrains

Change in PFGE profiles was observed over time

5 common profiles - 2/3 of isolates (BpSR23, BpFINR1,

BpFINR9, BpSBR6 and BpSBR5)

All PFGE profiles, observed in 1950s disappeared

since then (except BpSR23)

The profile BpSR23 was found in all the study periods

95% of isolates belonged to two clusters, having a

high similarity with a minimum of 78% overall

relatedness


Vaccine strains – all 3 serotypes (Fim2, Vaccine strains – all 3 serotypes (Fim2, Fim3 & Fim2.3)Fim3 & Fim2.3)After the introduction of vaccination – After the introduction of vaccination – the the frequency of serotype Fim2.3 decreasedfrequency of serotype Fim2.3 decreasedFim2Fim2 has been the most prevalent has been the most prevalent serotype during the study period.serotype during the study period.

In most other countries - In most other countries - Fim2 Fim2 predominate in unvaccinated populationpredominate in unvaccinated population & & displaced by Fim3 strains when vaccination displaced by Fim3 strains when vaccination is introducedis introduced (Hallander et al, 2005) (Hallander et al, 2005)

Serbia vs. Serbia vs. other countriesother countries-Serotyping--Serotyping-


3 vaccine strains 3 vaccine strains (2047/57, 1772/57 (2047/57, 1772/57 && 23/81) 23/81) -- prn1 prn1 and 1 vaccine strain (and 1 vaccine strain (8/848/84)) -- prn2 prn2

Isolates - Isolates - prn1, prn2, prn3 i prn11prn1, prn2, prn3 i prn11

Frequency of Frequency of prn2 genotprn2 genotype – very low and ype – very low and appearance were late (compared to other appearance were late (compared to other countries)countries)

Dominant – prn1 and Dominant – prn1 and prn11prn11

The prn2 is by far the most prevalent type in The prn2 is by far the most prevalent type in modern isolatesmodern isolates (Advani et al., 2004; Elomaa et al., (Advani et al., 2004; Elomaa et al., 2005; Heikkinen et al., 2008; Mooi et al., 2013)2005; Heikkinen et al., 2008; Mooi et al., 2013)

The prn11 - only in Australia and China, in 1980s The prn11 - only in Australia and China, in 1980s (Byrne et al., 2006; Zhang et al., 2010)(Byrne et al., 2006; Zhang et al., 2010)

Serbia vs. Serbia vs. other countriesother countries-Prn genotyping- -Prn genotyping-


The low frequency of prn2 The low frequency of prn2 strains and their relatively late strains and their relatively late emergence in Serbia may be emergence in Serbia may be due to the fact that the due to the fact that the vaccine contains an isolate vaccine contains an isolate having prn2 allelehaving prn2 allele (introduced (introduced in vaccine composition 1985) !in vaccine composition 1985) !

Serbia vs. Serbia vs. other countriesother countries-Prn genotyping- -Prn genotyping-


2 vaccine strains (2 vaccine strains (2047/57 2047/57 && 1772/57 1772/57)) -- ptxA2 ptxA2,, 2 2 vaccine strains (vaccine strains (23/81 23/81 && 8/84 8/84)) -- ptxA1. ptxA1.

A shift from ptxA2 to ptxA1 has been observed in A shift from ptxA2 to ptxA1 has been observed in isolates since the late 1960sisolates since the late 1960s

ptxA1 genotptxA1 genotype predominant in ype predominant in 19801980--1989.1989.

The re-appearance of isolates containing ptxA2 The re-appearance of isolates containing ptxA2 was noticed after the two strains harboring ptxA1 was noticed after the two strains harboring ptxA1 were added into the vaccine in 1985were added into the vaccine in 1985..

The high frequency of strains harboringThe high frequency of strains harboring ptxA2 in ptxA2 in 1990-2011 was not comparable to that noticed1990-2011 was not comparable to that noticed in in many other countries (Elomaa et al., many other countries (Elomaa et al., 2005;Cassiday et al., 2000; Weber et al., 2001)2005;Cassiday et al., 2000; Weber et al., 2001)

Serbia vs. Serbia vs. other countriesother countries-PtxA genotyping- -PtxA genotyping-


Specific population of circulating Specific population of circulating B. pertussis B. pertussis strains strains in Serbiain Serbia

TThe profile BpSR23, representing 30% of isolates he profile BpSR23, representing 30% of isolates studiedstudied,, persisted in the persisted in the whole whole study periodstudy period

Only one strain (isolated in 2000) was Only one strain (isolated in 2000) was BpSR11BpSR11

43% of isolates studied 43% of isolates studied showed unique showed unique BpSBR BpSBR profileprofiless

BpSR23 was prevalentBpSR23 was prevalent in Finland and Sweden in in Finland and Sweden in 1970s but not 1970s but not afterafter 1990s 1990s (Elomaa et al., 2005; (Elomaa et al., 2005; Poynten et al., 2004)Poynten et al., 2004)

BpSR11 BpSR11 was found to be predominant in six of the was found to be predominant in six of the eight European countrieseight European countries (Hallander et al., 2007) (Hallander et al., 2007)

Serbia vs. Serbia vs. other countriesother countries-PFGE analysis- -PFGE analysis-


According to the observedAccording to the observed findings, the B. pertussis findings, the B. pertussis population in Serbia is population in Serbia is differentdifferent from other vaccinated from other vaccinated populations, and thispopulations, and this difference may be related to difference may be related to the vaccine the vaccine composition, that composition, that had formulation of had formulation of inclusion of inclusion of “contemporary” strains “contemporary” strains from from population.population.


It has been shownIt has been shown that: that:

variation in Prn affects vaccine efficacy in the mouse modelvariation in Prn affects vaccine efficacy in the mouse model

(King et al., 2001)(King et al., 2001)

the adequate bacterial elimination rates were observed in the adequate bacterial elimination rates were observed in

mice immunized and challenged with the same vaccine type mice immunized and challenged with the same vaccine type

strain (Bottero et al., 2007)strain (Bottero et al., 2007)

the vaccine prepared from a recent isolate provided the the vaccine prepared from a recent isolate provided the

highest mouse protection when compared to those prepared highest mouse protection when compared to those prepared

from the old isolates such as the strain Tohama I (Pereira et from the old isolates such as the strain Tohama I (Pereira et

al., 2005). al., 2005).


Modification of antigens in current Modification of antigens in current vaccines:vaccines:

Possible modifications of the current vaccines Possible modifications of the current vaccines

while maintaining the same antigenic while maintaining the same antigenic

composition include changing of the individual composition include changing of the individual

antigens to match antigensantigens to match antigens of currently of currently

circulating stains of circulating stains of BB.. pertussis pertussis..

MeadeMeade et al, 2014. et al, 2014.

THANK YOU FOR YOUR ATTENTION!THANK YOU FOR YOUR ATTENTION!

This investigation was performed This investigation was performed

through collaboration between through collaboration between

Institute of Virology, VaccineInstitute of Virology, Vacciness and and

Sera, Torlak, Belgrade and Pertussis Sera, Torlak, Belgrade and Pertussis

Reference Laboratory, National Reference Laboratory, National

Institute for Health and Welfare Institute for Health and Welfare

(THL) Turku, Finland(THL) Turku, Finland,, courtesy to courtesy to

Prof.dr Quishe He Prof.dr Quishe He

tatjana plješa , md, phd institute of virology, vaccines and sera –torlak belgrade, serbia

Documents

vaccine composition

vaccine coverage84

pertussis strains

serbia pertussis

bordetella pertussis

vaccine strainsboth

mooi et

ptxa2 mooi