The dynamics of viral shedding and symptoms following influenza virus infection are key factors when considering epidemic control measures. The authors reviewed published studies describing the course of influenza virus infection in placebo-treated and untreated volunteers challenged with wild-type influenza virus. A total of 56 different studies with 1,280 healthy participants were considered. Viral shedding increased sharply between 0.5 and 1 day after challenge and consistently peaked on day 2. The duration of viral shedding averaged over 375 participants was 4.80 days (95% confidence interval: 4.31, 5.29). The frequency of symptomatic infection was 66.9% (95% confidence interval: 58.3, 74.5). Fever was observed in 37.0% of A/H1N1, 40.6% of A/H3N2 (p = 0.86), and 7.5% of B infections (p = 0.001). The total symptoms scores increased on day 1 and peaked on day 3. Systemic symptoms peaked on day 2. No such data exist for children or elderly subjects, but epidemiologic studies suggest that the natural history might differ. The present analysis confirms prior expert opinion on the duration of viral shedding or the frequency of asymptomatic influenza infection, extends prior knowledge on the dynamics of viral shedding and symptoms, and provides original results on the frequency of respiratory symptoms or fever.

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Time Lines of Infection and Disease in Human Influenza: A Review of Volunteer Challenge Studies

Background
Different types of influenza vaccines are currently produced worldwide. Healthy adults are presently targeted mainly in North America.

Objectives
Identify, retrieve and assess all studies evaluating the effects of vaccines against influenza in healthy adults.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 2), MEDLINE (January 1966 to June 2010) and EMBASE (1990 to June 2010).

Selection criteria
Randomised controlled trials (RCTs) or quasi-RCTs comparing influenza vaccines with placebo or no intervention in naturally-occurring influenza in healthy individuals aged 16 to 65 years. We also included comparative studies assessing serious and rare harms.

Data collection and analysis
Two review authors independently assessed trial quality and extracted data.

Main results
We included 50 reports. Forty (59 sub-studies) were clinical trials of over 70,000 people. Eight were comparative non-RCTs and assessed serious harms. Two were reports of harms which could not be introduced in the data analysis. In the relatively uncommon circumstance of vaccine matching the viral circulating strain and high circulation, 4% of unvaccinated people versus 1% of vaccinated people developed influenza symptoms (risk difference (RD) 3%, 95% confidence interval (CI) 2% to 5%). The corresponding figures for poor vaccine matching were 2% and 1% (RD 1, 95% CI 0% to 3%). These differences were not likely to be due to chance. Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates. Inactivated vaccines caused local harms and an estimated 1.6 additional cases of Guillain-Barre Syndrome per million vaccinations. The harms evidence base is limited.

Authors' conclusions
Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.

WARNING:
This review includes 15 out of 36 trials funded by industry (four had no funding declaration). An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favorable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in light of this finding.

Vaccines for preventing influenza in healthy adults

Viable bacteria were not cultured from the mesenteric lymph nodes, spleens, or livers of specific-pathogen-free (SPF) mice. Viable enteric bacteria, primarily indigenous Escherichia coli and lactobacilli, were present in the mesenteric lymph nodes of gnotobiotic mice inoculated intragastrically with the whole cecal microflora from SPF mice but not in the nodes of control SPF mice similarly inoculated. These indigenous E. coli also were cultured from the mesenteric lymph nodes of 96% of gnotobiotic mice monoassociated with E. coli but from none of the mesenteric lymph nodes of SPF mice inoculated with the E. coli. Furthermore, viable E. coli were detected in the mesenteric lymph nodes of these monoassociated gnotobiotes for as long as 112 days after inoculation. Indigenous Lactobacillus acidophilus also translocated to the mesenteric lymph nodes of gnotobiotic mice monoassociated with L. acidophilus. Apparently, there are mechanisms active in SPF mice inhibiting translocation of indigenous bacteria from the gastrointestinal tract to the mesenteric lymph nodes, spleens, and livers, whereas these mechanisms are either absent or reduced in gnotobiotic mice. Indigenous E. coli maintained higher population levels in the gastrointestinal tracts of the gnotobiotes compared with their population levels in SPF mice, suggesting that high bacterial population levels might promote translocation of certain bacteria from the gastrointestinal lumen to the mesenteric lymph nodes. Gnotobiotic and SPF mice, therefore, provide experimental models for determining the nature of the mechanisms operating to confine indigenous bacteria to the gastrointestinal tract in normal, healthy animals.

https://iai.asm.org/content/iai/23/2/403.full.pdf

Translocation of Certain Indigenous Bacteria from the Gastrointestinal Tract to the Mesenteric Lymph Nodes and Other Organs in a Gnotobiotic Mouse Model

The selective induction of antibodies in external secretions is desirable for the prevention of various systemic as well as predominantly mucosa-restricted infections. An enormous surface area of mucosal membranes is protected primarily by antibodies that belong, in many species, to the IgA isotype. Such antibodies are produced locally by large numbers of IgA-containing plasma cells distributed in subepithelial spaces of mucosal membranes and in the stroma of secretory glands. In humans and in some animal species, plasma-derived IgA antibodies do not enter external secretions in significant quantities and systemically administered preformed IgA antibodies would be of little use for passive immunization. Systemic administration of microbial antigens may boost an effective S-IgA immune response only in a situation whereby an immunized individual had previously encountered the same antigen by the mucosal route. Local injection of antigen in the vicinity of secretory glands is usually accompanied by an undesirable concomitant systemic response and frequently requires the addition of adjuvants that are unacceptable for administration in humans. Immunization routes that involve ingestion or possibly inhalation of antigens lead to the induction of not only local but also generalized immune responses manifested by the parallel appearance of S-Iga antibodies to ingested or inhaled antigens in secretions of glands distant from the site of immunization. Based on extensive studies in animal models as well as in humans, convincing evidence is available that antigen-sensitized and IgA-committed precursors of plasma cells from GALT are disseminated to the gut, other mucosa-associated tissues, and exocrine glands. However, due to the limited absorption of desired antigens from the gut lumen of orally immunized individuals, repeated large doses of antigens are required for an effective S-IgA response. Novel antigen delivery systems for the stimulation of such responses are currently being examined in several laboratories. Live attenuated or genetically manipulated bacteria expressing other microbial antigens have also been used for selective colonization of gut-associated lymphoid tissues. Unique antigen packaging and the use of adjuvants suitable for oral administration hold promise for an efficient antigen delivery to critical tissues in the intestine and deserve extensive exploration. The oral immunization route appears to have many advantages over systemic immunization.(ABSTRACT TRUNCATED AT 400 WORDS)

The common mucosal immune system and current strategies for induction of immune responses in external secretions

Influenza virus is a globally important respiratory pathogen which causes a high degree of morbidity and mortality annually. The virus is continuously undergoing antigenic change and thus bypasses the host's acquired immunity to influenza. Despite the improvement in antiviral therapy during the last decade, vaccination is still the most effective method of prophylaxis. Vaccination induces a good degree of protection (60-90% efficacy) and is well tolerated by the recipient. For those at risk of complications from influenza, annual vaccination is recommended due to the antigenic changes in circulating strains. However, there is still room for improvement in vaccine efficacy, long-lasting effect, ease of administration and compliance rates. The mucosal tissues of the respiratory tract are the main portal entry of influenza, and the mucosal immune system provides the first line of defence against infection. Secretory immunoglobulin A (SIgA) and IgM are the major neutralizing antibodies directed against mucosal pathogens. These antibodies work to prevent pathogen entry and can function intracellularly to inhibit replication of virus. This review describes influenza virus infection, epidemiology, clinical presentation and immune system response, particularly as it pertains to mucosal immunity and vaccine use. Specifically, this review provides an update of the current status on influenza vaccination and concentrates on the two main types of influenza vaccines currently in use, namely the cold-adapted vaccine (CAV) given intranasally/orally, and the inactivated vaccine (IV) delivered subcutanously or intramuscularly. The commercially available trivalent IV (TIV) elicits good serum antibody responses but induces poorly mucosal IgA antibody and cell-mediated immunity. In contrast, the CAV may elicit a long-lasting, broader immune (humoral and cellular) response, which more closely resembles natural immunity. The immune response induced by these two vaccines will be compared in this review.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.0300-9475.2004.01382.x

Influenza Virus: Immunity and Vaccination Strategies. Comparison of the Immune Response to Inactivated and Live, Attenuated Influenza Vaccines

The field of immunology developed as attempts were made to understand the observed phenomenon that, in many cases, individuals become immune (often permanently) to an infectious disease after having had that disease. As a natural corollary of this fact, attempts were made to induce this immune state without causing illness, or at least to reduce acceptably the severity of illness. During the past 200 years, the corollary aim has probably proven more successful than the attempts to understand the phenomenon, and the development of the several immunization practices now widely used has been the most successful aspect of the disciplines of immunology and infectious disease (with the possible exception of the role of the latter in the generally improved state of public hygiene). In addition, we feel that this contribution from the combined efforts of those in the fields of infectious diseases and immunology will continue to be great, e.g., in the development of vaccines against caries, herpesvirus, and streptococcal infections, the hepatitides, gonorrhea, and syphilis, and in improved vaccines against cholera and influenza.

https://www.jstor.org/stable/info/30106155

Immunity to Infections on Secretory Surfaces

The cell-mediated immune response on the secretory surface of the lower respiratory tract was investigated and compared to the systemic cell-mediated immune response and to the secretory and systemic antibody responses. Guinea pigs were immunized either parenterally or locally with dinitrophenylated human IgG. The effect of rendering animals tolerant on the local cell-mediated response and on the local antibody response was also studied. The antibody response in the bronchial washing fluids was predominantly of the IgA class. In the animals rendered tolerant by administering large doses of the antigen intravenously, the secretory antibody response was significantly reduced to about 40% of the levels in the animals which were not tolerant. Cellular immunity was assayed using the inhibition of macrophage migration. In animals which were immunized subcutaneously, splenic lymphocytes strongly inhibited the migration of normal guinea pig macrophages; however cells obtained from bronchial washings from the same animals exhibited little or no inhibition of macrophage migration in the presence of antigen. In the animals which were immunized by nose drops, splenic lymphocytes showed virtually no inhibition of macrophage migration; however, bronchial washing lymphocytes strongly inhibited the migration of normal macrophages. Thus, nose drop immunization gave rise to a significantly greater local cellular immune response than did parenteral immunization. In those animals which were immunized by nose drops after a tolerizing dose of antigen, there was virtually no inhibition of macrophage migration by either the cells from the spleens or bronchial washings. Studies were done which demonstrated that a substance similar to macrophage-inhibition factor was liberated by the bronchial washing cells on incubation with the antigen. Studies were also done which indicated that secretory antibody played no role in the inhibition of macrophage migration when bronchial washing lymphocytes were used. Lymphocytes were purified from bronchial washings and were found to inhibit normal macrophage migration in the presence of antigen to the same extent that the mixed population of lymphocytes and pulmonary macrophages did. Thus this study supports the concept that local cellular immunity can be initiated independently of systemic cellular immunity.

https://rupress.org/jem/article-pdf/134/2/482/1084341/482.pdf

Cell-mediated immunity and antibody responses in the respiratory tract after local and systemic immunization

Immunologic studies were performed on 5 patients with pigeon breeders' disease. Intradermal injection of pigeon serum produced an immediate wheal-and-flare reaction within 15 minutes and a secondary Arthus-type reaction within 4 to 8 hours. Immunofluorescent studies of the secondary reaction site showed IgG, C3, and C4 in 2 patients. Patients' sera produced multiple precipitin bands with pigeon serum when reacted by double diffusion in gel. IgG antibody isolated from each of the patients' serum formed precipitating immune complexes that fixed large amounts of complement (C4) when added to fresh human serum. Peripheral blood lymphocytes from 4 of the 5 patients produced macrophage migration inhibitory factor (MIF) when challenged with dilute pigeon serum. These studies are the first to show complement fixing antibodies and macrophage MIF production by lymphocytes from patients with hypersensitivity lung disease and suggest that both humoral and cellular immunity may be important in the pathogenesis of these disorders.

https://www.jacionline.org/article/0091-6749(73)90060-2/pdf

Immunologic mechanisms in hypersensitivity pneumonitis. I. Evidence for cell-mediated immunity and complement fixation in pigeon breeders' disease.

The Secretory Immunologic System

The effects of a live attenuated influenza vaccine and subsequent challenge with virulent influenza virus on the delayed hypersensitivity skin test, and the in vitro response of lymphocytes were evaluated. Volunteers were skin tested before and after administration of vaccine or placebo and challenge with PPD (a purified protein derivative of Mycobacterium tuberculosis), candida, mumps, and trichophytin, and their lymphocytes were tested for [3H]thymidine uptake in response to phytohemagglutin. Of eight volunteers who showed evidence of viral replication after administration of the attenuated vaccine, four had a significant diminution in their skin test response, whereas 8 of 13 volunteers infected with virulent influenza virus showed a diminution. Of the 21 volunteers who were infected with either attenuated or virulent influenza virus, 12 showed suppression of their phytohemagglutin response. None of the volunteers who were given placebo vaccine, or who showed no evidence for viral replication after immunization or challenge, had a suppression of their skin test or phytohemagglutin responses. Although most of the infected volunteers demonstrated suppression of their T-cell function, there was no evidence of a similar suppression of B-cell function.

Robert H. Waldman

Papers

Immunity to Infections on Secretory Surfaces

Cell-mediated immunity and antibody responses in the respiratory tract after local and systemic immunization

Immunologic mechanisms in hypersensitivity pneumonitis. I. Evidence for cell-mediated immunity and complement fixation in pigeon breeders' disease.

The Secretory Immunologic System

Immunosuppression during influenza virus infection.