Vaccines

Principles of Vaccination
The Adaptive Immune System
Unlike the innate immune system, the adaptive immune system recognises specific antigens and
coordinates a specific response mediated by B and T lymphocytes.

Importantly, the adaptive immune system has a memory. When exposed to an antigen, some
lymphocytes remain as memory cells. These memory cells can quickly recognise the antigen upon
subsequent exposure and mobilise a specific response.

Immunisation
Vaccines are agents which cause immunisation.

Active Immunisation = the body is exposed to an antigen, thus allowing the adaptive immune
system to become familiar with it and create specific memory cells against it. This makes the body
much more prepared to produce antibodies against future invasions of pathogens expressing the
same antigens.

Passive Immunisation = rather than stimulating the immune system to produce its own antibodies,
the body is provided with exogenous antibodies collected from a different organism that has already
been exposed to the antigen. This provides temporary protection as long as the antibodies remain in
the system.

Impact of Vaccines
Vaccines are the greatest preventative measure against infective disease, and are responsible for
protecting billions of people from potentially harmful pathogens.

- Measles, HiB, Pertussis and Tetanus are just some of the major childhood diseases which are
preventable with vaccines.

- A suitable vaccine is yet to be found for AIDS, TB or Malaria. Millions of people continue to
die from these diseases while the search for vaccines continues.

Types of Vaccines

Living Vaccines
Living vaccines contain microbes that are still alive. In order to prevent a full-blown infection with
these microbes, their virulence is attenuated by either natural or artificial means.

These vaccines can occasionally result in infection if there is insufficient attenuation, or if mutations
cause the attenuated microbe to revert to its virulent form.
Another disadvantage of live-attenuated vaccines is that they must be stored in a refrigerated state
in order to keep the microbe alive.

Serial Passage
The target microbe is cultured for multiple generations until an attenuated strain can be identified,
collected and used for live vaccines.

- For example, the live-attenuated flu vaccine can only survive at temperatures lower than the
upper respiratory tract.
- The live polio vaccine contains mutated strains that have lost their virulence.
- The BCG vaccine contains a mutant form of M. Bovis without pathogenicity.
- ETEC vaccine lacks the OmpR regulator
- V. Cholerae has a deletion in the gene for toxin synthesis
- Salmonella vaccine is missing AroA or GalE genes.

Non-Living Vaccines
Non-living vaccines do not contain live microbes, and therefore do not present the same risk of
infection as living vaccines. The antigen is still presented on dead microbes, or as subunit
components (e.g. proteins, polysaccharides, toxins) of the original microbe.

Although non-living microbes cannot cause an infection, the antigens present in the vaccine can still
trigger an allergic immune response.

Subunit vaccines can be lyophilised (dried and reconstituted) so they are available for use at any
time.

Subunit Components
- Polysaccharide capsules for Pneumococci, HiB and Meningoccus
- Hepatitis B Surface Antigen (HBsAg)
- Influenza sub-unit vaccine

Glycoconjugate Vaccines
The antigenic components are conjugated to tetanus toxoid. They elicit a T Cell response, which
recruits more T cells to the source.

Formaldehyde is used to convert a toxin to a toxoid, preserving its antigenicity while eliminating its
pathogenic effect.

- The Meningitis C vaccine uses polysaccharide-conjugated components of Haemophilus, and

has excellent success rates in teenagers and toddlers.
- Killed B. Pertussis can be combined with tetanus toxoid

Clinical Application

Adjuvants
Adjuvants are chemicals which are co-administered with vaccines in order to enhance the immune
response to the vaccine.

Irish Immunisation Programme

 - 0-1 month = BCG (for TB)
- 2 months = 6-in-1 and PCV
- 4 months = 6-in-1 and MenC
- 6 months = 6-in-1, MenC and PCV
- 12 months = MMR and PCV
- 13 months = MenC and Hib

(6-in-1 = Diptheria, Tetanus, Pertussis, Polio, Hib, HepB)

Herd Immunity
- Epidemics are caused by the transmission of a pathogen between members of a population.
- ‘Ro’ refers to the number secondary cases caused by each primary case.
- If Ro is greater than 1, the number of infections increases.
- Vaccines reduce the ability of pathogens to be transmitted from person-to-person
- If ‘Ro’ drops below 1, the epidemic is no longer sustainable.
- Vaccines impair the ability of pathogens to spread, thus providing ‘herd immunity’ even to
those that are not vaccinated.

Sterilisation & Disinfection

Microbes exist everywhere in our surroundings – on our skin, floors, furniture, surfaces and even
medical equipment. Our interactions with objects around us can transfer microbes between us and
our environment. In a hospital setting, methods are used to remove microbes from our hands and
equipment, so that bacteria are not transmitted from doctor to patient or vice-versa.

Hospital Acquired Infections

Ranking
1) Urinary Tract Infections are the most common, probably due to contaminated catheters.
(E. Coli > Candida > Enterococci)

2) Surgical Infections are due to entry of pathogens via open surgical wounds.
(Staphylococci > Enterococci > E. Coli > Pseudomonas)

3) Respiratory Tract Infections can be easily transmitted via airborne vectors.

(Staph. Aureus > Pseudomonas Aeruginosa)

4) Bacteraemia is the least common infection, and is a serious consequence of bacteria

escaping into the bloodstream.
(Staph. Aureus = E. Coli > Enterococci > Candida > Klebsiella)

Prevention
- Removing microbes from their surfaces
- Interruption of transmission (e.g. filtering airborne pathogens + encouraging aseptic
behaviour)
 - Enhancing host resistance

Stubborn Microbes
Pseudomonas Aeruginosa is an important commensal bacterium which inhabits most objects in the
hospital setting. It produces biofilm made out of alginate, which makes it very resistant to
antibacterial strategies.

P. Aeruginosa’s metabolic diversity and anti-bactericidal mechanisms further contribute to its

resistance.

Some bacteria can withstand even the harshest washing sessions by forming dormant endospores.

Sterilisation vs Disinfection

Sterilisation = a process to remove/destroy all microbial life, including endospores.

Disinfection = destruction of microbes by physical or chemical means, but may not include the
elimination of endospores.

Disinfectant = Chemical or physical means of killing bacteria on inaminate objects.

Antiseptics = applied on/in the living human body to prevent/arrest development of microorganisms
residing on us.

Grades of Disinfection
1) Low level
2) Intermediate level
3) High level
4) Sterilisation

Methods of Sterilisation
- Steam under pressure in an autoclave (121-132OC in 15 minutes)
- Filtration of air/water through 0.2 microns

Methods of Disinfection
- Clean hands and/or objects
- Moist heat (boiling between 65-80OC at sub-atmospheric pressure.
- Chemicals (e.g. Chlorine)

Gram-positive bacteria and enveloped viruses are most susceptible to chemical disinfection.

Disinfectants work by disrupting membranes and proteins of microbes.

 Antibacterial Agents
Antibiotic Principles
While disinfectants/sterilisers are very effective at removing bacteria from inanimate objects, they
can also be highly toxic to our own cells if consumed. In contrast, antibacterial agents (i.e.
antibiotics/antimicrobials) are chemicals that can combat infections within the body.

Selective Toxicity
Ideally, an antibiotic should be selectively toxic – it specifically targets pathogens, while leaving
native cells unharmed.

- Broad spectrum antibiotics are effective against a wide array of different pathogens
- Narrow spectrum antibiotics are more specific to a smaller number of pathogens

Route of Administration
- Oral agents must be able to survive exposure to the acidic conditions of the stomach
- Parenteral antibiotics can be directly administered intravenously.

Half-Lives
Like any other xenobiotic introduced to the body, antibiotics are subjected to metabolism and
elimination. The half-life of an antibiotic is an indicator of the agent’s duration of action.

Some agents can be co-administered to extend the half-life of an antibiotic. For example, Probenacid
increases the amount of time that Benzylpenicillin remains in the body.

Action
Antibiotics disrupt the normal function of microbes in a number of ways:

- Bactericidal agents cause the microbe to die (often by interfering with its structural or
metabolic integrity)

- Bacteriostatic agents do not kill the microbe, but prevent it from growing/multiplying. (This
is often achieved by interfering with the process of DNA replication, transcription or
translation)

Synergy & Antagonism

Antibiotics are often prescribed in combination.

- Some antibiotics work together to produce synergy (an enhanced effect)

- Some antibiotics interfere with each other’s efficacy (causing antagonism)

Resistance
Some genetic alterations can give bacteria resistance to antibiotics. This can be achieved by altering
the structure of the target site, preventing entry of the antibiotic or by expressing enzymes that
breakdown the antibiotic. These resistant strains have a survival advantage, and are naturally
selected for over non-resistant strains.
 Mechanisms of Action
Antibiotics can target various aspects of a microbe’s normal function:

Cell Wall Synthesis

- Cycloserine prevents D-Alanine from being incorporated into the terminal end of the
peptidoglycan.

- Bacitracin prevents dephosphorylation and dissociation of the peptidoglycan from its

phospholipid carrier.

- Glycopeptides prevent terminal D-Alanine residues from forming crosslinks with other
peptidoglycans in Gram negative bacteria.

- Beta-Lactams inhibit Transpeptidase enzymes which catalyse the formation of pentaglycine

bridges between peptidoglycans in Gram positive bacteria.

Beta-Lactams
Beta-lactams are a huge family of compounds which all possess a beta-lactam ring (3 carbons + 1
Nitrogen).

- Penicillins are attached to a 5-membered ring.

- Cephalosporins are attached to a 6-membered ring.

They prevent cell wall crosslinking by inhibiting Penicillin Binding Proteins. This activates the
bacterial autolysis system, leading to destruction of the bacterium.

- Penicillins were the first group of antibiotics to be discovered. Natural penicillin is effective
against Gram positive bacteria with thick peptidoglycan walls. However, semisynthetic forms
have been produced with increased efficacy against many Gram negative bacteria also.

- There are 5 generations of Cephalosporins, with the newer generations being increasingly
effective against Gram negative and antibiotic-resistant bacteria.

- Other groups of Beta-Lactams include Carbapenams and Monobactams

Beta-Lactamases
Many bacteria can resist these antibiotics by producing Beta-Lacatamase enzymes which attack the
Beta-Lactam ring.

- Class A enzymes are serine-based and highly effective against Amoxycillin.

- Class B enzymes are metallo-based. Chromosomal expression must be induced, whereas

plasmid genes are constitutively expressed.

- Class C enzymes are expressed on chromosomes of gram negative rods. Expression is usually
indiced, but AmpD enzyme is constitutively produced.

- Class D enzymes are mainly plasmid-mediated

Beta Lactamase Inhibitors

Inhibitors such as Augmentin have been developed to reduce bacterial resistance to Beta-Lactam
antibiotics.

Protein Synthesis
A number of antibiotics target protein synthesis at the bacteria’s 80S ribosome:

- Aminoglycosides bind to the 30S subunit to prevent the binding of fMet tRNA. This blocks
initiation of translation, producing misfolded proteins which trigger cell death mediated by
hydroxyl radicals.

- Tetracyclines bind to the 30S subunit to prevent Aminoacyl tRNA from entering the acceptor
site.

- Chloramphenicol binds to the 50S subunit to prevent the formation of peptide bonds
between amino acids in the chain.

- Macrolides bind to 23SRNA in the 50S subunit to prevent the release of tRNA following
peptide bond formation.

DNA Replication
Quinolones inhibit DNA Gyrase (GyrA + GyrB) and ParC/E. This prevents the normal “unzipping” of
DNA which is necessary to allow replication.

(Mutations in the QRDR of the bacterial genome provides resistance against Quinolones by reducing
their affinity for DNA Gyrases. Mutations in the Par gene are required for Fluoroquinolone
resistance)

Transcription
Rifampicin binds to the Beta subunit of RNA Polymerase, preventing it from transcribing bacterial
DNA to mRNA.

Nucleic Acid Precursor Synthesis

- Sulfonamides inhibit Dihydropteroate Synthase. This reduces the synthesis of Dihydropteroic

Acid, a precursor to dihydrofolate.

- Trimethoprim inhibits Dihydrofolate Reductase, impairing the conversion of dihydrofolate to

tetrahydrofolate.

Both of these reactions are essential for the production of purines and pyrimidines which are
required for nucleic acid synthesis.