Does Repeat Influenza Vaccination Constrain Influenza Immune Responses and Protection

The objectives of this study are to understand the long-term consequences of repeated annual influenza vaccination among healthcare workers (HCWs) and to use statistical and mathematical modelling to elucidate the immunological processes that underlie vaccination responses and their implications for vaccination effectiveness. These objectives will be achieved by pursuing three specific aims:

1. To study the immunogenicity and effectiveness of influenza vaccination by prior vaccination experience
2. To characterize immunological profiles associated with vaccination and infection
3. To evaluate the impact of immunity on vaccination effectiveness.

Under Aim 1, a cohort of hospital workers will be recruited and followed for up to 4 years to assess their pre- and post-vaccination and post-season antibody responses, and their risk of influenza infection. These outcomes will be compared by vaccination experience, classified as frequently vaccinated (received ≥3 vaccines in the past 5 years), infrequently vaccinated (\<3 vaccinations in past 5 years), vaccinated once, vaccine naïve and unvaccinated.

In Aim 2, intensive cellular and serological assessments will be conducted to dissect the influenza HA-reactive B cell and antibody response, and build antibody landscapes that typify the different vaccination groups.

In Aim 3, the data generated in Aims 1 and 2 will be used to develop a mathematical model that considers prior infection, vaccination history, antibody kinetics, and antigenic distance to understand the effects of repeated vaccination on vaccine effectiveness.

Completion of the proposed research will provide evidence to inform decisions about continued support for influenza vaccination programs among HCWs and general policies for annual influenza vaccination, as well as much needed clarity about the effects of repeated vaccination.

In March-April 2020 pursuant to the SARS-CoV-2 global pandemic an administrative supplement added a SARS-CoV-2 protocol addendum for follow-up of COVID-19 infections amongst our HCW participant cohort.

The following objectives were added:

1. To estimate risk factors and correlates of protection for SARS-CoV-2 infection amongst HCW
2. To characterize viral kinetics and within-host viral dynamics of SARS-CoV-2 infecting HCW
3. To characterize immunological profiles following infection by SARS-CoV-2
4. To characterize immunological profiles following vaccination for SARS-CoV-2.

Over 140 million Americans are among the more than 500 million people who receive influenza vaccines annually. An important subgroup are healthcare workers (HCWs) for whom vaccination is recommended, and sometimes mandated, to protect themselves and vulnerable patients from influenza infection. However, there have been no large, long term studies of HCWs to support the effectiveness of these policies. HCWs are now a highly vaccinated population, the effects of which are also poorly understood. Mounting evidence suggests antibody responses to vaccination can be attenuated with repeated vaccination, which is corroborated by reports of poor vaccine effectiveness among the repeatedly vaccinated. Thus, there is a compelling need to directly evaluate HCW vaccination programs. The long term goal is to improve the efficient and effective use of influenza vaccines.

The specific objectives of this study are to understand the long-term consequences of repeated annual influenza vaccination among HCWs and to use statistical and mathematical modeling to elucidate the immunological processes that underlie vaccination responses and their implications for vaccination effectiveness. These objectives will be achieved by pursuing three specific aims:

1. To study the immunogenicity and effectiveness of influenza vaccination by prior vaccination experience
2. To characterize immunological profiles associated with vaccination and infection
3. To evaluate the impact of immunity on vaccination effectiveness.

Under Aim 1, a cohort of hospital workers will be recruited and followed for up to 4 years to assess their pre- and post-vaccination and post-season antibody responses, and their risk of influenza infection. These outcomes will be compared by vaccination experience, classified as frequently vaccinated (received ≥3 vaccines in the past 5 years), infrequently vaccinated (\<3 vaccinations in past 5 years), vaccinated once, vaccine naïve and unvaccinated.

In Aim 2, intensive cellular and serological assessments will be conducted to dissect the influenza HA-reactive B cell and antibody response, and build antibody landscapes that typify the different vaccination groups.

In Aim 3, the data generated in Aims 1 and 2 will be used to develop a mathematical model that considers prior infection, vaccination history, antibody kinetics, and antigenic distance to understand the effects of repeated vaccination on vaccine effectiveness. This approach is innovative because it will provide insights into the effect of complex immunological dynamics on infection outcomes, thereby representing a novel departure from previous studies, which have ignored these difficult-to-measure processes. Completion of the proposed research will provide evidence to inform decisions about continued support for influenza vaccination programs among HCWs and general policies for annual influenza vaccination, as well as much needed clarity about the effects of repeated vaccination.

In March-April 2020 pursuant to the SARS-CoV-2 global pandemic an administrative supplement added a SARS-CoV-2 protocol addendum for follow-up of COVID-19 infections amongst our HCW participant cohort.

The following objectives were added under the supplement IRB application:

1. To estimate risk factors and correlates of protection for SARS-CoV-2 infection amongst HCW
2. To characterize viral kinetics and within-host viral dynamics of SARS-CoV-2 infecting HCW
3. To characterize immunological profiles following infection by SARS-CoV-2
4. To characterize immunological profiles following vaccination for SARS-CoV-2.

Eligibility Criteria:
Inclusion Criteria:

Eligible participants will be recruited from 1 of 6 participating hospitals and will meet the following criteria:

* Personnel (including staff, honorary staff, students and volunteers) located at a participating hospital or healthcare service at the time of recruitment who would be eligible for the hospital's free vaccination programme
* Be aged ≥18 years old and ≤60 years old;
* Have a mobile phone that can receive and send SMS messages;
* Willing and able to provide blood samples;
* Available for follow-up over the next 7 months;
* Able and willing to complete the informed consent process.

There are no restrictions on the type of healthcare worker (HCW) that can be recruited into the study in terms of their job role. HCWs can be any hospital staff, including clinical, research, administrative and support staff.

Exclusion Criteria:

* Immunosuppressive treatment (including systemic corticosteroids) within the past 6 months;
* Personnel for whom vaccination is contraindicated at the time of recruitment.