Effects of Chronic Viral Infection on Immune Response to Zoster Vaccination

Study Overview
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Brief Summary
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This study aims to identify the innate and adaptive immune response to zoster vaccination. Half of the participants will be individuals with chronic hepatitis C, while the other half with healthy volunteers.The innate immune signature elicited by Zoster vaccination will be characterized by RNA-seq analysis of pre- and post-vaccination RNA from whole blood. We will compare fold changes in gene expression profiles pre- versus post-vaccination in each individual, as well as between the two arms of the study. RNA-seq will be used to assess innate immune activation by evaluating the changes to the expression levels of interferon-stimulated genes pre- and post-vaccination. Adaptive immune response will be determined by the traditional correlates of protection used in previous Zoster clinical studies in addition to flow cytometry24. Correlates of protection include antibody response, interferon gamma production and the frequency of responder cells post- vaccination24. For antibody production, we will perform Zoster glycoprotein ELISA (gpELISA) targeting IgG/IgM. The number and frequency of responder cells will be characterized by flow cytometry.

Detailed Description
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Chronic HCV infection is associated with persistent innate immune activation and dampened cellular immune responses. Interferons (IFNs) are key mediators of the antiviral innate immune response, initiating the expression of interferon-stimulated genes (ISG) with numerous host protective effector functions. However, in chronic HCV, high pre-therapy expression of ISG and persistent activation of the innate immune system negatively predicts the response to IFN-based therapies and failure of viral clearance8. In addition, HCV persistence is also associated with HCV-specific-CD8+ T cell exhaustion. HCV-specific CD8+ T cell exhaustion is characterized by diminished ex vivo polyfunctionality, upregulation of negative costimulatory cell modulators and, decreased cellular proliferation and IFN production10,12. This phenotype is associated with the development of short-term effector CD8+ T cells rather than durable, long-term memory CD8+ T cells. Chronic bystander infections (e.g. chronic HCV), characterized by persistent inflammation have been linked to bystander (non-HCV specific) CD8+ T cell dysfunction. Bystander CD8+ T cell dysfunction significantly impairs the expansion of memory CD8+ T cells and could prevent the development of secondary immunological memory to new antigens and/or vaccines11,13. Clinically, chronic HCV has been associated with impaired immune response to Hepatitis B vaccination13,14,15. Only 40% to 60% of individuals with chronic HCV achieve seroprotective titers following HBV vaccination versus 90% to 95% in healthy subjects13,14. Specific immune defects responsible for HBV vaccine failure in HCV-infected patients are unknown at present. However, some studies have suggested that the blunting of the immune response to HBV vaccination is associated with lymphocyte dysfunction and upregulation of PD-1 expression on CD4+ T cells in HBV vaccine non-responders13,15. In the United States, 99.5% of adults over 40 years have been infected with the Varicella zoster virus (VZV) and are at risk of Zoster virus reactivation (shingles) and its complications. Unilateral, painful, blistering rashes along dermatomes characterize shingles. Complications associated with shingles include acute or chronic pain, osteonecrosis, zoster ophthalmicus with visual impairment, increased risk of blindness and a 4-fold risk of cerebral vasculitis-associated stroke)1,2. Overall, complications of shingles have a negative impact on the quality of life and activities of daily living21,22. Zoster vaccine live (Zostavax®, Merck) is recommended for the prevention of shingles. Zoster vaccine is a live, attenuated vaccine that is licensed by the FDA for individuals older than 50 years without an underlying immune deficiency (HIV, malignancies, immunosuppression and transplantation). In non-immunocompromised individuals, Zoster vaccine decreases shingles by 51% in individuals between ages 60 - 89 years and 70% in individuals between 50 - 59 years of age. Chronic infections such as TB, malaria and chronic Hepatitis C virus (HCV) have been associated with increased susceptibility to other pathogens and decreased vaccination efficacy3-6. Although chronic HCV infection is not considered a clinically immunocompromised state, it is associated with persistent immune activation and decreased vaccination response7. Zostavax is routinely administered to chronic HCV patients. However, at present, no other study has documented the immune responses elicited by Zoster vaccination in this population. This study aims to identify the innate and adaptive immune signatures elicited by zoster vaccination in chronic HCV and healthy volunteers. Unrecognized suboptimal vaccine response in individuals with chronic immune dysregulated states (chronic bystander viral infections (HBV, HCV and HIV with CD4 >200), diabetes, advancing age, cancers and transplantation) could be potentially devastating and costly.

Official Title
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Effects of Chronic Viral Infection on Immune Response to Zoster Vaccination

Conditions
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Hepatitis C

Intervention / Treatment
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* Drug: Zoster vaccine live


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Willing to receive the herpes zoster vaccine Volunteer chronically infected with HCV (as demonstrated by serology testing and have a viral load >1000 copies) without treatment Healthy volunteer without significant medical problems Exclusion Criteria: Received any vaccine within a month prior to study vaccine Previous Zoster infection as an adult, >18 years HIV or Hepatitis B virus infection in the HCV and healthy arms For HCV-negative, healthy volunteers: History of HCV infection or positive HCV antibody test Participation in another clinical study of an investigational product currently or within the past 90 days, or expected particpation during this study In the opinion of the investigator, the volunteer is unlikely to comply with the study protocol Any clinically significant abnormality or medical history or physical examination including history of immunodeficiency or autoimmune disease (in addition to HCV infection, for HCV group) Currently taking systemic steroids or other immunomodulatory medications including anticancer medications and antiviral medications Any clinically significant acute or chronic medical condition requiring care by a primary care provider (e.g., diabetes, coronary artery disease, rheumatologic illness, malignancy, substance abuse) that, in the opinion of the investigator, would preclude participation Male or female < 50 and > 70 years of age Is pregnant or lactating Clinical, laboratory, or biopsy evidence of cirrhosis Allergy to gelatin and/or neomycin ALT and/or AST > 3.5 times the ULN Immunosuppressed or immunodeficient individuals including those with a history of primary or acquired immunodeficiency states, leukemia, lymphoma or other malignant neoplasms affecting the bone marrow or lymphatic system and those on immunosuppressive therapy Individuals with active untreated tuberculosis Prior Varicella vaccination HCV volunteers who have a viral load of <1000 copies

Ages Eligible for Study
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Minimum Age: 50 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Hepatitis C infected volunteers<br>Zoster vaccine live (Zostavax), 0.65 ml dose, administered subcutaneously to Hepatitis C infected volunteers | Drug: Zoster vaccine live<br>* Single Zostavax vaccine, 0.65 ml dose, administered subcutaneously<br>* Other names: Zostavax;|
| Active Comparator: Healthy volunteers<br>Zoster vaccine live (Zostavax), 0.65 ml dose, administered subcutaneously to healthy volunteers | Drug: Zoster vaccine live<br>* Single Zostavax vaccine, 0.65 ml dose, administered subcutaneously<br>* Other names: Zostavax;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Serum Zoster Antibody Level | Serum zoster antibody level would be measured by gpELISA expressed in (units/mL) | 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Interferon Stimulated Gene (ISG) Expression | Interferon stimulated gene (ISG) expression in PBMC will be expressed as fold-change (FCH) above baseline | 18 months | 
| Serum Biomarkers of Immune Activation(Expressed in%) | Serum biomarkers of immune activation will be measured and expressed in percentage. | 18 months | 
| Responder Cell Frequency | Responder cell frequency: VZV specific CD4+ T cells post-vaccination (expressed in %) | 18 months | 
| Interferon-gamma Response | Interferon-gamma response: by ELIspot expressed as number of spot-forming cells per million PBMCs | 18 months |