Influenza Immunization in Adults Over Age 75
Influenza Immunization in Adults Over Age 75
The immune system is the part of the body that protects against infection. The immune system
 often doesn't work as effectively as people get older. This research is being done to find
 out how the immune systems in older people who are over age 75 respond to influenza vaccine
 (flu shot). We also want to find out if chronic cytomegalovirus (CMV) infection, a common
 virus infection in older persons affects the immune response in people older than 75 years of
 age who receive a flu shot. The Flu Shot is a vaccine approved for the prevention of
 influenza ("Flu") infections and is recommended every year for all persons 50 years and
 older. People who are older than 75 years of age are considered healthy or frail may join. A
 total of 525 persons will be participating in this study.

 In order to determine if you are qualified for the study, we would ask you to answer a few
 questions over the phone that will take approximately 5 minutes. If you qualify and agree to
 proceed, you will be asked to come to Johns Hopkins Bayview Medical Center or, if you are
 unable to come to Bayview, one of our staff can visit you at your home. During that visit we
 obtain consent, review your medical history, and measure your vital signs, walking speed and
 grip strength. We will also administer a few brief questionnaires and collect urine and blood
 samples. We will then give you the Flu shot for free. Three to four weeks after you receive
 the Flu shot, you will have another visit at Johns Hopkins Bayview or your home where we will
 repeat some of the questionnaires, vital signs, and collect a second blood sample. Throughout
 the study, we will call you once a week to ask about your general health and any Flu-like
 symptoms. These calls will be made throughout the Flu season which typically lasts through
 the end of May. If you begin to have any influenza like symptoms at any time during the
 study, we ask that you call our office to report these symptoms so that we may perform a
 nasal swab to confirm influenza, and a third blood draw to look at the immune response and
 protection of influenza vaccine.
Seasonal influenza causes significant morbidity and mortality and is the fourth leading cause
 of death for older Americans. Annual immunization with a trivalent inactivated influenza
 vaccine (TIV) is recommended for all adults 50 years and older. However, despite improved
 vaccination coverage in older adults over time, influenza-related mortality has actually
 increased. While many TIV studies indicate its benefit for older adults as a whole, these
 studies lacked representation of the older and frail subset of the elderly who suffer over
 three-quarters of influenza-related mortality. Our pilot study funded by a Beeson K23 award
 showed significant vaccine failures in both antibody response to TIV and clinical protection
 in the frail elderly. Our preliminary data also suggest that chronic cytomegalovirus (CMV)
 infection as defined by the presence of CMV viral DNA in peripheral monocytes using a highly
 sensitive and specific nested PCR-based assay developed in our laboratory, rather than
 anti-CMV IgG serology, is associated with poor antibody and T-cell responses to TIV
 immunization as well as poor clinical protection. This is likely because anti-CMV IgG
 serology, the conventional diagnostic measure for chronic CMV infection, is a crude measure
 that merely indicates prior exposure to CMV and does not distinguish chronic (persistent)
 from past (resolved) infections. Mechanistically, precipitous immune functional decline has
 been observed in those over 75 and chronic CMV infection may contribute significantly to
 age-related immune senescent remodeling, termed immunosenescence. In order to improve our
 assessment of the effectiveness of TIV immunization and understanding of risk factors and
 underlying immune mechanisms that determine vaccine failure in adults over age 75, the frail,
 oldest old adult subset, this study is designed to conduct prospective, 4-year TIV
 immunization and post-vaccination influenza surveillance in adults over 75 years. We will
 first assess chronic CMV infection defined by detectable CMV DNA in peripheral blood
 monocytes and frailty status of the study participants and administer the Fluzone High-Dose
 TIV vaccine. Influenza-like illness (ILI) cases will be identified through post-vaccination
 influenza surveillance as previously done in the Beeson project and respiratory specimens
 obtained from ILI cases will be tested using the cutting edge PCR-based IBIS assay which can
 accurately subtype influenza and other respiratory viruses in the laboratory of Dr. Charlotte
 Gaydos in Division of Infectious Disease, a co-investigator of this project. Strain-specific
 antibody responses to TIV immunization will be measured by the standard hemogglutination
 inhibition (HI) assay. We will also evaluate T-cell responses to influenza viruses at
 baseline and after TIV immunization. Taken together, these studies will provide more accurate
 assessment of the clinical effectiveness of TIV immunization in real world geriatric
 population over age 75 and its underlying humoral and cell-mediated immune mechanisms.
 Moreover, we investigate the role of chronic CMV infection as defined by the presence of CMV
 viral DNA in peripheral monocytes as a risk factor for vaccine failure in the elderly over
 age 75. Because this oldest old subset is growing most rapidly in numbers and is at greatest
 risk for influenza-related morbidity and mortality. The long-term goal of this research is to
 strengthen immune protection against influenza for vulnerable older Americans through more
 effective and targeted immunization strategies as well as possibly through prevention and
 mitigation of chronic CMV infection.
Inclusion Criteria:

 -  Adults over age 75 years

 Exclusion Criteria:

 -  Allergies to egg or vaccine

 -  Active malignancies

 -  On radiation or chemotherapy

 -  Active systemic inflammatory diseases including rheumatoid arthritis, Crohn's disease,
 and ulcerative colitis

 -  Acute exacerbation of chronic cardiopulmonary conditions including decompensated CHF
 or COPD

 -  Taking oral steroids (such as prednisone) or immune modulating drugs (such as
 methotrexate).

 -  Lacking the capacity to consent (individuals who do not understand what Flu shot is or
 need someone else to decide if s/he should get the Flu shot)