Background: Poor efficacy and effectiveness of the pandemic H1N1 (pH1N1) component in intranasal live attenuated influenza vaccine (LAIV) has been demonstrated in several studies. The reasons for this are unclear, but may be due to impaired replicative fitness of pH1N1 A/California/07/2009-like (Cal09) LAIV strains. Methods: In an open-label, prospective, observational, phase 4 study, we evaluated the impact of updating the pH1N1 component in the Russian-backbone trivalent LAIV from Cal09 in 2016-17 (n=118) to an A/Michigan/45/2015-like strain (A/17/New York/15/5364, NY15) in 2017-18 (n=126), on shedding and immunogenicity in Gambian children aged 2-4 years old. The study was nested within a larger randomised controlled trial investigating LAIV-microbiome interactions (ClinicalTrials.gov NCT02972957).Findings: Cal09 showed impaired nasopharyngeal shedding compared to H3N2 and influenza B, along with sub-optimal serum antibody and T-cell responses. Following the switch to NY15, a significant increase in pH1N1 shedding was seen, along with improvements in seroconversion and influenza-specific CD4+ T-cell responses. Viral kinetics in vitro mirrored these findings, with NY15 showing greater replicative ability than Cal09 in human nasal epithelial cells.Persistent shedding to day 7 was independently associated with both seroconversion and CD4+ T cell response in multivariable logistic regression.Interpretation: Our results suggest that the pH1N1 component switch in LAIV may have overcome problems in prior formulations. LAIV effectiveness against pH1N1 should therefore improve in upcoming influenza seasons. Our data also highlight the importance of evaluating replicative fitness, in addition to antigenicity, when selecting annual LAIV components and design of potentially more effective vaccines.
Funding:The Wellcome Trust.The study was approved by the Gambia Government/MRC Joint Ethics Committee and the Medicines Control Agency of The Gambia, and conducted according to ICH-GCP standards. A parent provided written or thumb-printed informed consent for their children to participate. Where parents were not English literate, an impartial witness was present throughout the informed consent discussion undertaken in a local language and signed to confirm completeness of the consent provided.
ProceduresChildren received one dose of intranasal trivalent Russian-backbone LAIV (Nasovac-S, Serum Institute of India Pvt Ltd) northern hemisphere (NH) formulation in either 2017 (2016-17 NH formulation) or 2018 (2017-18 NH formulation). In the 2017-18 LAIV, HA and NA from pH1N1 Cal09 were replaced with those from NY15, while identical H3N2 and B/Victoria lineage (B/Vic) strains were used. Vaccine titres per dose (50% Egg Infectious Doses (EID50)/ml) were 1x10 8.0 for pH1N1, 1x10 7.5 for H3N2, 1x10 7.2 for B/Vic in the 2016-17 LAIV and 1x10 7.7 for pH1N1, 1x10 7.6 for H3N2, 1x10 7.3 for B/Vic in the 2017-18 LAIV.Nasopharyngeal swabs (NPS) were taken pre-vaccination (day 0, D0), at day 2 (D2) and day 7 (D7) using flocked swabs (Copan Flo...