Journal of Autoimmunity xxx (2014) 1e6

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Journal of Autoimmunity
journal homepage: www.elsevier.com/locate/jautimm

Epitope-based approaches to a universal influenza vaccine

Tanya Gottlieb, Tamar Ben-Yedidia*
BiondVax Pharmacuticals Ltd., Ness Ziona, Israel

a r t i c l e i n f o a b s t r a c t

Article history: The development of vaccines has been one of the most important contributions of immunology to public
Received 28 July 2014 health to date. Although several infectious diseases have all but vanished thanks to effective vaccines, the
Accepted 29 July 2014 most common infectious disease, influenza, still represents a major threat to public health. This is more
Available online xxx
concerning than ever before in light of potentially virulent avian pandemic strains which have emerged
in the last decade and infected human hosts, causing high morbidity and mortality. Despite considerable
Keywords:
efforts to improve production of influenza vaccines and vaccinate large portions of the population
Influenza
annually, the currently available influenza vaccines are strain-specific and not effective enough.
Multimeric-001
Pandemic
Considering the vulnerability of infants and elderly to seasonal influenza-related complications and the
Peptide ever present public health threat of a deadly influenza pandemic, there is urgent need for a new kind of
Seasonal influenza vaccine. Ideally, such a vaccine should provide enhanced long term, multi-strain protection
Vaccines without compromising safety and in this way, dramatically improve global protection against seasonal
and pandemic influenza viruses. This review highlights one approach to developing a universal influenza
vaccine, which is based on highly conserved viral sequences, ‘epitopes’, that specifically activate humoral
and/or cellular immune responses. This approach to vaccinology was pioneered by Prof Arnon, who
initiated development of an epitope-based universal vaccine called Multimeric-001 (M-001), which has
already been validated in clinical trials to induce broad immunity against A and B-Type, seasonal and
pandemic strains.
© 2014 Elsevier Ltd. All rights reserved.

1. Influenza disease and today's influenza vaccines
Pathogens that exist as multiple strains present a challenge for
vaccine design. Examples of such pathogens include Mycobacterium
tuberculosis, HPV, Streptococcus pneumoniae that cause meningitis,
and smallpox. To be effective, a vaccine must comprise virus anti-
gens similar to those expressed by the pathogen strains infecting
the population. Vaccines against diseases caused by polyvalent
pathogens typically comprise several antigenically related strains
belonging to the same bacterial species or viral family.
This approach is challenging in the case of influenza due to
frequent and unpredictable mutations in two influenza envelope
proteins, Hemagglutinin (HA) and Neuraminidase (NA), which
result in a constantly changing assortment of numerous circulating
viruses. ‘These mutations occur mainly in influenza Type A strains,
which represent around 80% of human influenza infections; influ-
enza B strains are less susceptible to mutation. The mutations are
introduced by viral RNA polymerases that lack a proof-reading
* Corresponding author. BiondVax Pharmaceuticals Ltd., 14 Einstein St., Ness
Ziona 7414002, Israel. Tel.: þ972 8 9302529; fax: þ972 8 9302531.
E-mail address: benyedidia@biondvax.com (T. Ben-Yedidia).
function, so the errors frequently appear as nucleotide sub-
stitutions, some of which result in the amino acid changes that
underlie most seasonal epidemics. Additionally, as the influenza
viral genome is comprised of discrete units, a ‘shift’ can occur
involving concomitant larger changes in multiple genes and this
level of mutation is associated with emergence of new potentially
pandemic strains [1e4].
Despite the complex mix of seasonal and potentially pandemic
influenza strains circulating globally at any given time, the general
approach to influenza vaccines has not changed for many decades
and involves picking the strains considered most likely to be
causing human disease. Most current flu vaccines are subunit
vaccines, based on the surface of the virus. The virus is grown and
inactivated, and ultimately, its surface proteins are used for im-
munization. The other common type of flu vaccine uses the live-
attenuated virus to confer immunity an example is FluMist (Med-
Immune, USA). Typically, these influenza vaccines are nasal sprays
or injections, and comprise the following A and B strains: one
H3N2, one H1N1 and one or two influenza B virus strain. Strain
selection for seasonal influenza vaccines is conducted annually by
the World Health Organization (WHO) and is primarily based on
surveillance of the strains circulating in the other hemisphere.

http://dx.doi.org/10.1016/j.jaut.2014.07.005
0896-8411/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Gottlieb T, Ben-Yedidia T, Epitope-based approaches to a universal influenza vaccine, Journal of Autoimmunity
(2014), http://dx.doi.org/10.1016/j.jaut.2014.07.005
2 T. Gottlieb, T. Ben-Yedidia / Journal of Autoimmunity xxx (2014) 1e6
These influenza vaccines rely predominantly on triggering humoral
immune responses to the variable regions in the influenza envelope
protein Hemagglutinin (HA) and consequently, are highly strain-
specific. Therefore, current influenza vaccines afford incomplete
protection as often there is low correlation between the vaccines'
immunogenic substance and the influenza viruses actually circu-
lating, a phenomenon termed ‘mismatch’. Moreover, high risk
populations such as the elderly typically respond poorly to these
strain-specific influenza vaccines, resulting in limited immunity
even to the strains contained within the vaccine. Indeed, vaccine
efficacy is typically only 60% among the general population during
seasons when most circulating flu viruses match those in the vac-
cine [5]. Further, among elderly persons and those persons with
chronic medical conditions, the influenza vaccine has been shown
to be between 30% and 70% effective in preventing hospitalization
for pneumonia and influenza [6e8].
Pandemic vaccines differ from seasonal vaccines in several
ways: first, the vaccines usually comprise an emerging influenza
virus, not detected in previous seasons and not included in the
seasonal vaccines. Pandemic influenza viruses are usually so
different that they are not easily recognized by most human
immune systems and quickly spread globally. Pandemic influenza
vaccines contain only a single strain of the pandemic virus (for
example, H1N1 virus) instead of the usual three (trivalent) or
four (quadrivalent) virus types used in a seasonal vaccine
mixture.
Today, the industry can produce ~500M doses of seasonal vac-
cine per year [9] or divide this production capacity between sea-
sonal and pandemic formulations. In recent years, great efforts and
resources have been devoted to shortening the influenza vaccine
production cycle, reducing it from around 8 to 4 months. The
influenza vaccine cycle includes production, testing for safety and
immunogenicity, approval by regulatory bodies, distribution, and
administration. Until 2013, all commercially available influenza
vaccines were made from viruses cultivated in chicken eggs, which
were then collected, purified, and formulated before being tested
for safety and efficacy, and once approved, distributed to care
providers. In 2013, Flublok (Protein Sciences Corp, US) was
approved for use; this is a trivalent vaccine produced in an egg-free
system using insect cells containing recombinant DNA that encodes
viral hemagglutinins (antigens). To date, the Improvements in the
influenza vaccine cycle include: 1) Modifying production such that
the live viruses are propagated in cell culture instead of in eggs:
[10]; 2) Modifying production such that recombinant HA proteins
are produced in cell culture; 3) Addition of extra virus subtypes into
the vaccine, as exemplified by the quadrivalent seasonal vaccines;
and 4) addition of adjuvants, which can somewhat broaden the
cross reactivity of the vaccine to non-constituent flu strains.
Adjuvant is added to the vaccine to increase the body's immune
response to the vaccine and often allows using smaller amounts of
the immunogen. Many commercial adjuvants are based on
aluminum salt that is added to the active component. Although
alum is able to induce a good antibody (Th2) response, it has little
capacity to stimulate cellular (Th1) immune responses that are so
important for protection against many pathogens. In addition, the
use of alum raises safety concerns as it has the potential to cause
severe local and systemic side-effects including sterile abscesses,
eosinophilia and myofascitis [11]. Indeed, seasonal influenza vac-
cines used in the United States do not contain adjuvants to avoid
yearly exposure to the adjuvants. During the recent 2009 swine flu
pandemic, the widespread administration of H1N1 vaccine that
contains AS03 adjuvant was associated with rare cases of narco-
lepsy, a chronic neurological disorder caused by the brain's inability
to regulate sleepewake cycles. The Centers for Disease Control
(CDC) is currently sponsoring an international study on the
Please cite this article in press as: Gottlieb T, Ben-Yedidia T, Epitope-based approaches to a universal influenza vaccine, Journal of Autoimmunity
(2014), http://dx.doi.org/10.1016/j.jaut.2014.07.005
associations between adjuvanted monovalent 2009 H1N1 influ-
enza vaccines and narcolepsy; the study is expected to be
completed in 2014.
Notably, the most challenging feature of today's influenza vac-
cines, namely strain-specificity, is hardly addressed by such im-
provements in the influenza vaccine cycle. The cumbersome and
sometimes inaccurate annual (or pandemic) strain prediction/se-
lection procedure is still inclined towards inadequate and inflexible
supply and, most worryingly, prolonged exposure of the public to
the circulating virulent virus in the event of pandemic [12].
The limitations inherent in today's set-up became acutely
apparent during the recent 2009 A/H1N1 swine flu pandemic that
spread globally in a few weeks. The inability of manufacturers to
produce enough of the relevant vaccine in time resulted in a low
impact of vaccination on the spread of the pandemic despite best
efforts to produce as much as fast as possible [13,14]. Further, as the
pandemic progressed, it became evident that an oversupply of
vaccines would occur [15]. Fortunately, this swine flu pandemic
was low in severity, but the next one may not be mild and so there
is an urgent need to develop a new generation of broad specificity
influenza vaccines that will prevent seasonal and pandemic influ-
enza disease.
2. The clinical and economic impact of influenza
The clinical impact of seasonal influenza infections is typically
considered to be marginal. Primarily at-risk populations are in
danger, namely the elderly, very young toddlers and people with
chronic illnesses and health authorities generally recommend that
these discrete population groups get vaccinated. However, health
authorities have been changing their approach in recent years in
view of the emerging pandemic strains, which appear either highly
pathogenic (avian strains) or highly infective (swine strain), and
have the potential to cause morbidity and mortality in healthy
segments of the population not previously considered susceptible
to influenza infection. Health authorities have recognized that
population-wide annual vaccination against seasonal influenza not
only ensures sustainability of vaccine manufacturers, which is
essential if they are to provide vaccines during a pandemic, but
expands immunity against influenza that could lower the burden of
pandemic disease. In the USA, for example, the recommendations
of the Advisory Committee on Immunization Practices (ACIP) for
2013e14 are routine annual influenza vaccination of all persons
aged 6 months and older [16]. Nevertheless, based on the influenza
vaccine industry infrastructure available today, it is estimated that a
deadly pandemic flu virus still has potential to cause 175e350
million deaths worldwide [17].
The economic impact of seasonal influenza was estimated in
2007 as $10.4B in direct medical costs, with a total economic
burden to society of $87.1B [18]. An estimate for the potential so-
cietal economic burden of a deadly influenza pandemic ranges to a
remarkable 8% of GDP [19]. This alarming statistic combined with
the obligation to better protect their population against pandemic
influenza has prompted governments worldwide to promote
development of next generation influenza vaccines.
3. The unique benefits of a universal influenza vaccine
A truly universal flu vaccine would immunize against all strains,
regardless of antigenic drift or shift, and thereby prevent disease
caused by both seasonal and pandemic viruses. This would mean an
immunized population was no longer vulnerable to emergence of
new influenza strains, a goal of governments and health authorities
worldwide. An additional benefit of such a vaccine is that it could
be produced and administered year-round and stockpiled,
 T. Gottlieb, T. Ben-Yedidia / Journal of Autoimmunity xxx (2014) 1e6
overcoming the availability and supply limitations of today's flu
vaccines. This ease of administration combined with the reduced
number of required administrations, every 3e5 years as opposed to
annually, would be expected to facilitate population-wide coverage
as well as compliance, enabling a much greater penetration.
Furthermore, given the new production methods (recombinant and
cell culture) of the universal vaccines currently in development,
such a vaccine would also eliminate the need for egg-based pro-
duction and the many problems associated with this production
process. Finally, it has been estimated that the annual cost savings
of the quadrivalent vaccine with a premium price of $5 versus the
trivalent vaccine are $28M and $310M in third payer costs and
societal costs, respectively [20]. Since a universal flu vaccine can be
expected to result in even greater cost savings, there is huge
financial incentive for health authorities and health insurance
payers to adopt such a vaccine should it become available.
4. Immune mechanisms mediating broad strain coverage of
an influenza vaccine
It has been known for decades that a mild influenza infection in
animals can provide protection against a subsequent, more severe
challenge with a virus bearing different HA and NA (a hetero-
subtypic challenge) [21,22]. Most mechanistic studies of cross
protective immunity have been performed in mice models. Most
studies focused on cross protection against influenza A strains as no
such finding was reported for distantly related type B influenza
viruses [23]. However, a later study performed by Schwemmle et al.
[24] described a highly conserved PA-binding domain of the poly-
merase subunit PB1 of influenza A and B and based on this region
created a binding peptide that blocked the viral polymerase activity
and growth of both virus types. Generally, cross protection was
demonstrated either by immunization with a live virus followed by
challenge with a divergent strain [25e27] or by immunization with
conserved peptides and subsequent immunity and protection
against different strains [28,29]. Studies employing gene knockout
mice indicated that cross protective immunity is mediated pri-
marily by T-cells and is dependent on the cytolytic effector mole-
cule perforin. Reduced inflammation following infection with a
heterotypic strain was associated with enhanced early recruitment
of both CD4(þ) and CD8(þ) T-cells, and with early influenza virus-
specific cytotoxic T-cell responses [30]. The T-cell response was
accompanied by secretion of cytokines such as interferon IFN-g [31]
and tumor necrosis factor TNF-a [27] .
One model for the role of CD4þ T-cells in cross protection is in
supporting and enhancing CTL responses and providing help for B-
cell responses via cytokine secretion. It is possible that CD4þ T-cells
specific for conserved viral antigens potentiate subsequent anti-
body responses to the HA of a different virus encountered subse-
quently. In accord with this model, prior immunity to internal
proteins has been shown to result in heightened or accelerated HA-
specific antibody responses to a different subtype virus [32,33]. The
evolving understanding of immunological mechanisms underlying
cross protection provided the groundwork for an epitope-based
approach to influenza vaccine development.
5. The epitope-based approach to vaccine development
During the last three decades, advances in biotechnology
methods and in the understanding of immunology have enabled
the emergence of new approaches towards rational design of vac-
cines. One approach is to employ epitopes corresponding to
immunogenic, conserved sequences of microbial proteins [34]. The
epitope-based approach focuses on the minimal component that
activates the lymphocyte: short peptides of 8e10 amino acids for
Please cite this article in press as: Gottlieb T, Ben-Yedidia T, Epitope-based approaches to a universal influenza vaccine, Journal of Autoimmunity
(2014), http://dx.doi.org/10.1016/j.jaut.2014.07.005
3
activating T-cells and longer regions of up to 20 amino acids for
activating B-cells [35]. Furthermore, improved understanding of
the molecular basis of antigen recognition and HLA (Human
Leukocyte Antigen) binding motifs has enabled selection of pep-
tides predicted to bind to human class I or class II major histo-
compatibility molecules.
The immunological efficacy of peptide-based vaccines against
infectious diseases has been demonstrated in animal models
[36e39], as well as in clinical studies. Responses to peptide vaccines
against various infectious diseases including malaria [40,41], Hepa-
titis B [42] and HIV [43,44] have been reported. However, there are
certain challenges associated with peptide vaccines, most notably
low immunogenicity relative to whole pathogen vaccines and the
need for reliable and simple assays to measure the T-cell responses.
On the other hand, a distinct and notable advantage of peptide-based
vaccines is the range of production options. For example, a mixture of
synthetic peptides can be chemically produced or a poly-epitope
product can be produced as a recombinant protein using various
expression systems, including microbial fermentation. Both methods
enables a flexible production according to demand.
6. Candidate influenza epitopes for a universal influenza
vaccine
The hemagglutinin (HA) glycoprotein is the primary target of
antibodies that confer protective immunity against influenza vi-
ruses. In many cases, such antibodies are capable of neutralizing
virus infection by preventing attachment or fusion between the
virus and host cells. The levels of such antibodies in serum, as
measured by neutralization assays and/or Hemagglutination inhi-
bition (HAI) assays, serve as biomarkers for the regulatory author-
ities when evaluating the efficacy of today's influenza vaccines.
However, for the most part, neutralizing antibodies are reactive to
variable regions of the HA protein and so do not indicate epitopes
that would be useful for a universal influenza vaccine.
Recently, rare monoclonal antibodies specific to non-variable HA
regions were found to confer cross protection and shown to block/
neutralize infection [45]. Some of these cross protective epitopes
reside in the stem region of HA. Marasco et al. [46] identified ten
neutralizing antibodies that were effective against all group 1
influenza viruses tested, including H5N1 avian flu strains and the
H1N1 'Spanish flu'. The crystal structure of one of these neutralizing
antibodies highlighted its mechanism of action: the antibody blocks
infection by inserting its heavy chain into a conserved pocket in the
stem region, thus preventing membrane fusion. Subsequently, Palese
et al., [47] identified a continuous HA region that may act as an
immunogen to elicit broadly protective immunity to H3 viruses. The
anti-H3 monoclonal antibodies were identified after immunization
of mice with the hemagglutinin of four different viruses (A/Hong
Kong/1/1968, A/Alabama/1/1981, A/Beijing/47/1992, A/Wyoming/3/
2003). Since these broadly protective antibodies were induced
in vivo, this study raises the possibility that a vaccine could be
designed to comprise non-variable HA epitopes that would induce
cross protection. However, it is important to note that certain cross
protective HA antibodies were found to enhance the severity of
disease in pigs [48], indicating that anti-stem antibodies may play
pro-as well as anti-infective roles in the pathogen-host interaction.
Until recently, there were several universal flu vaccine candi-
dates that focused on the highly conserved M2e protein. M2 is a
viral ion channel protein that mediates viral uncoating and is the
target protein for the therapeutic drug amantadine, and its methyl
derivative rimantadine [49]. M2e is composed of 24 amino acids
and induces antibodies that can inhibit a broad spectrum of influ-
enza A subtypes in vitro and in vivo. Although relatively conserved,
21 M2e variants have been identified among recently emerged
4 T. Gottlieb, T. Ben-Yedidia / Journal of Autoimmunity xxx (2014) 1e6
influenza A strains, with most of the mutations appearing in the
middle part of the M2e domain. The prevalence of M2e mutations
in this middle region cast doubt on its ability to serve as the basis
for a universal influenza vaccine and likely contributed to the
discontinuation of several programs testing M2e candidate vac-
cines. Furthermore, it was discovered that virus mutants with
antigenic changes in M2e emerged in 65% of virus-infected mice
treated with M2e-specific MAbs but not in control mice [50]. This
not with standing, a region near the beginning of M2e (amino acids
2e9), which is common to both M1 and M2 proteins, was shown to
represent a highly conserved epitope, SLLTEVET. Indeed, mono-
clonal antibodies (mAb) against this epitope potently inhibited the
replication of influenza A virus H1 and H3 subtypes in MDCK cells.
Two important amino acids in this conserved M2e epitope, Thre-
onine at position five and the Glutamic acid at position six, were
identified as associated with antibody-escaping variants [51]. This
particular region of M2e is still considered to represent a potential
epitope to be included in a broadly protective influenza vaccine.
Immunization with internal viral epitopes (as opposed to those
exposed outside the viral particle) has been demonstrated [52,53]
to broaden the immune response against influenza and induce
cross strain immunity. However, this cross protective immunity
usually does not prevent a host from becoming infected, but instead
reduces viral replication, accelerates viral clearance, and likely re-
duces the severity of disease. Internal viral epitopes have the po-
tential to contribute to the efficacy of a universal influenza vaccine.
7. Epitope-based universal influenza vaccines in clinical
development today
7.1. FP01
Immune Targeting Systems (UK) is developing the FP01 vaccine
candidate to combat both seasonal and pandemic influenza. FP01
consists of six long (35 amino acids) CD4þ and CD8þ conserved T-
cell epitopes administered as synthetic fluoropeptides, which form
stable nanoparticles. In a Phase IIa clinical trial this vaccine candi-
date exhibited good safety and an ability to induce cellular re-
sponses to a number of influenza antigens, without a negative
impact on the antibody response to conventional seasonal influ-
enza vaccine (TIV) in subjects who received both FP01 and TIV [54].
7.2. Flu-v
A prediction algorithm was employed to identify conserved
immunogenic regions in animal and human influenza strains
[55,56], which serve as the basis for a universal influenza vaccine
candidate being developed by SEEK (PeptCell). Six highly conserved
regions within multiple proteins (not including HA) that are
capable of triggering an immune response were identified. These
six peptides (called Flu-v) were then chemically synthesized and
used to immunize transgenic mice. Following immunization with
Flu-v, the mice launched a specific CD8þ response against the
peptides and were protected against heterotypic infection. In 2010,
a Phase 1b challenge trial was performed [57], whereby healthy
volunteers were exposed to an attenuated (mild) strain of flu.
Subjects immunized with Flu-v exhibited lower symptom scores
and viral titer levels as compared with non-immunized subjects. In
addition and most critically, blood cells from immunized subjects
showed cross reactive immunity to a range of influenza viruses.
7.3. M-001
Prof Arnon conceptualized an epitope-based vaccine comprising
both B- and T-cell epitopes from influenza [58]. This vaccine, now
Please cite this article in press as: Gottlieb T, Ben-Yedidia T, Epitope-based approaches to a universal influenza vaccine, Journal of Autoimmunity
(2014), http://dx.doi.org/10.1016/j.jaut.2014.07.005
called Mutlimeric-001 (M-001), has subsequently been further
developed by BiondVax Pharmaceuticals Ltd. M-001 comprises
nine conserved epitopes from the HA, NP and M proteins, derived
from influenza A and B strains (see Fig. 1). These nine epitopes are
combined in triplicate into a single recombinant protein expressed
in E. Coli. This multimeric design overcomes the relatively low
immunogenicity of single peptides and the high costs of
manufacturing synthetic peptides [59]. Of note, ‘supertype’ epi-
topes with broad HLA coverage were chosen, such that the pre-
dicted overall HLA coverage is greater than 90%. In pre-clinical
studies, immunization with M-001 protected mice against infection
with different influenza strains, including the highly pathogenic
H5N1 strain [60]. M-001 has been tested in two Phase 1/2 trials and
in two Phase 2 trials in a total of 443 adults and elderly. In these
trials the vaccine was found to be safe and to induce both humoral
and cellular influenza-specific immune responses [61]. In all four
trials, the immune responses elicited by M-001 alone were exam-
ined. M-001 alone was demonstrated to elicit influenza-specific cell
mediated immunity (CMI), as assessed by proliferation and/or IFN-
gamma secretion of peripheral blood mononuclear cells (PBMCs)
isolated from participants and exposed ex vivo to influenza anti-
gens. Since influenza specific CD4 cells correlate with protection in
human [62], FACS analysis of PBMCs was performed in the most
recent trial in elderly and indeed M-001 administration alone was
shown to result in an increased proportion of CD4þ lymphocytes
producing IFN-gamma upon ex vivo exposure to various influenza
antigens.
As mentioned earlier, the regulatory authorities evaluate today's
influenza vaccines based on HAI antibodies. The M-001 vaccine
does not induce these antibodies when administered alone since it
comprises only conserved epitopes. To demonstrate the efficacy of
the Multimeric-001 vaccine using the standard HAI parameter,
BiondVax has successfully performed pre-clinical and clinical trials
using the M-001 vaccine as a primer before boosting with seasonal
or pandemic strain specific vaccines. This prime-boost schedule
mimics the situation whereby M-001 is given as a universal flu
vaccine and then the individual is exposed to circulating influenza
virus and thus enables assessment of M-001's efficacy using the
well accepted HAI biomarker. Furthermore, the prime-boost
vaccination schedule offers an innovative approach to pandemic
preparedness (explained in more detail below). Notably, this
prime-boost vaccination schedule resulted in more people
demonstrating protective levels of HAI antibodies to viruses con-
tained in the strain-specific vaccines and also to other viruses. For
example, priming with M-001 three weeks before the 2011/12 TIV
resulted in 20% more elderly (aged 65þ) seroconverted towards the
constituent H1N1 pandemic swine influenza strain (A/California/7/
09), as compared to elderly persons administered the TIV alone
[63]. Such data support the broad strain immunity induced by M-
001 and indicate efficacy of M-001 both as a universal pandemic
primer and as a standalone universal flu vaccine. Regarding mo-
lecular mechanisms, based on our data we conclude that M-001's
mechanism of action involves a complex interaction of immuno-
logical responses triggered by the conserved and common epitopes
in the context of the M-001 protein. The overlap of antigenic ma-
terial in the M-001 and the circulating virus (or strain-specific
vaccine) results in amplification of influenza-specific cellular and
humoral (e.g., HAI) immune responses.
The remarkable capacity of M-001 to synergize with today's
influenza vaccines (i.e., enhance seroconversion) offers the op-
portunity to propose a novel approach to pandemic preparedness.
Namely, M-001 is administered as a universal pandemic primer
immediately upon pandemic outbreak and the pandemic strain-
specific vaccine administered subsequently as a boost (when it
becomes available, typically after 4e6 months) [59]. This prime-
 T. Gottlieb, T. Ben-Yedidia / Journal of Autoimmunity xxx (2014) 1e6
Fig. 1. M-001, a universal influenza vaccine candidate, comprises nine common regions from 3 Influenza proteins that are produced as a single recombinant protein.
boost pandemic vaccination schedule provides tremendous ben-
efits for the population and health authorities: 1) immediate ac-
tion for any pandemic, whatever the emerging strain; 2) more
people protected (seroconverted); 3) pandemic specific vaccine
sparing. Specifically, we propose that national governments
should proactively stockpile the universal vaccine during inter-
pandemic phases to enable preparedness AHEAD of pandemic
outbreak. This proposal is in line with a model proposed by Dr
Robin Robinson, Director of BARDA (Biomedical Advanced
Research and Development Authority), USA [64]. Notably, priming
with a universal influenza vaccine is the only approach that en-
ables cost effective and practicable pandemic preparedness ahead
of outbreak, whatever the emerging strain, without resorting to
adjuvant. Moreover, the augmentation of pandemic vaccine ac-
tivity provided by priming with BiondVax's universal influenza
vaccine is particularly relevant today, as any strain-specific vac-
cine against the ‘stealth’ avian H7N9 strain is predicted to be
poorly immunogenic.
In summary, three promising epitope-based universal influenza
vaccine candidates that are in clinical development today were
described in this review: FP01, Flu-v and M-001. FP01 and Flu-v are
designed to induce cellular immunity. M-001, which is the most
advanced in its clinical stage, induces both cellular and humoral
immunity to Influenza A and B strains and can serve as universal
pandemic primer.
8. Personal note from Dr. Ben-Yedidia
I have the privilege to work with Professor Ruth Arnon, initially
as her PhD student and then as an associate professor in her lab,
developing the game changing universal flu vaccine Multimeric-
001 that is described above. As a chemist, Prof. Arnon took the
innovative approach of looking for the small determinant that is the
common denominator for all flu viruses, the one that can confer
universal immunity. I learned from her a great deal about team
work and how collaborating enriches the accomplishments of a
single scientist. I still collaborate with Prof Arnon, who is the head
of BiondVax's scientific advisory board and continuously provides
invaluable advice and insights.
I have been inspired by Ruth's ability to be a caring mother at the
same time as managing an impressive scientific career, she serves
as a model to all women with her remarkable achievements. It is
appropos that this issue is part of a dedicated effort by the Journal
of Autoimmunity to recognize truly distinguished immunologists
who have excelled in research, teaching and public service; this has
included in the past Ian Mackay, Noel Rose, Pierre Youinou, Chella
Please cite this article in press as: Gottlieb T, Ben-Yedidia T, Epitope-based approaches to a universal influenza vaccine, Journal of Autoimmunity
(2014), http://dx.doi.org/10.1016/j.jaut.2014.07.005
5
David, Abul Abbas, and Harry Moutsopoulos amongst others
[65e67].
9. Conclusions
There is a clear and pressing need for the development of a
universal vaccine against influenza. This is true now, more than
ever before, in view of the deficiencies in global preparedness
highlighted by the swine H1N1 pandemic in 2009 and the ongoing
avian pandemic threats. Three epitope-based universal vaccine
candidates that are in clinical development today are described in
this review. Future studies will reveal if they can live up to their
‘universal’ title.
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