{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T13:02:44Z","timestamp":1788958964314,"version":"build-2803163510"},"reference-count":41,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2020,10,30]],"date-time":"2020-10-30T00:00:00Z","timestamp":1604016000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>The onset of narcolepsy, an irreversible sleep disorder, has been associated with 2009 influenza pandemic (pH1N1) infections in China, and with ASO3-adjuvanted pH1N1 vaccinations using Pandemrix in Europe. Intriguingly, however, the increased incidence was only observed following vaccination with Pandemrix but not Arepanrix in Canada. In this study, the mutational burden of actual vaccine lots of Pandemrix (n = 6) and Arepanrix (n = 5) sourced from Canada, and Northern Europe were characterized by mass spectrometry. The four most abundant influenza proteins across both vaccines were nucleoprotein NP, hemagglutinin HA, matrix protein M1, with the exception that Pandemrix harbored a significantly increased proportion of neuraminidase NA (7.5%) as compared to Arepanrix (2.6%). Most significantly, 17 motifs in HA, NP, and M1 harbored mutations, which significantly differed in Pandemrix versus Arepanrix. Among these, a 6-fold higher deamidation of HA146 (p.Asn146Asp) in Arepanrix was found relative to Pandemrix, while NP257 (p.Thr257Ala) and NP424 (p.Thr424Ile) were increased in Pandemrix. DQ0602 binding and tetramer analysis with mutated epitopes were conducted in Pandemrix-vaccinated cases versus controls but were unremarkable. Pandemrix harbored lower mutational burden than Arepanrix, indicating higher similarity to wild-type 2009 pH1N1, which could explain differences in narcolepsy susceptibility amongst the vaccines.<\/jats:p>","DOI":"10.3390\/vaccines8040630","type":"journal-article","created":{"date-parts":[[2020,10,29]],"date-time":"2020-10-29T21:21:00Z","timestamp":1604006460000},"page":"630","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Mass Spectrometric Characterization of Narcolepsy-Associated Pandemic 2009 Influenza Vaccines"],"prefix":"10.3390","volume":"8","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8462-3552","authenticated-orcid":false,"given":"Aditya","family":"Ambati","sequence":"first","affiliation":[{"name":"Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, 3165 Porter Drive, Stanford, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guo","family":"Luo","sequence":"additional","affiliation":[{"name":"Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, 3165 Porter Drive, Stanford, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elora","family":"Pradhan","sequence":"additional","affiliation":[{"name":"Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, 3165 Porter Drive, Stanford, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1071-1239","authenticated-orcid":false,"given":"Jacob","family":"Louis","sequence":"additional","affiliation":[{"name":"Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, 3165 Porter Drive, Stanford, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ling","family":"Lin","sequence":"additional","affiliation":[{"name":"Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, 3165 Porter Drive, Stanford, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryan D.","family":"Leib","sequence":"additional","affiliation":[{"name":"Stanford Mass Spectrometry Core, 333 Campus Drive, Mudd 175, Stanford University, Stanford, CA 94305, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanna Maria","family":"Ollila","sequence":"additional","affiliation":[{"name":"Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, 3165 Porter Drive, Stanford, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1965-3522","authenticated-orcid":false,"given":"Thomas","family":"Poiret","sequence":"additional","affiliation":[{"name":"Department of Laboratory Medicine, Karolinska Institutet, 14152 Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Adams","sequence":"additional","affiliation":[{"name":"Stanford Mass Spectrometry Core, 333 Campus Drive, Mudd 175, Stanford University, Stanford, CA 94305, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emmanuel","family":"Mignot","sequence":"additional","affiliation":[{"name":"Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, 3165 Porter Drive, Stanford, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,10,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1038\/s41583-018-0097-x","article-title":"The neurobiological basis of narcolepsy","volume":"20","author":"Mahoney","year":"2019","journal-title":"Nat. Rev. Neurosci."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1016\/S0896-6273(00)00058-1","article-title":"Reduced number of hypocretin neurons in human narcolepsy","volume":"27","author":"Thannickal","year":"2000","journal-title":"Neuron"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"991","DOI":"10.1038\/79690","article-title":"A mutation in a case of early onset narcolepsy and a generalized absence of hypocretin peptides in human narcoleptic brains","volume":"6","author":"Peyron","year":"2000","journal-title":"Nat. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"10911","DOI":"10.1073\/pnas.96.19.10911","article-title":"Orexin A activates locus coeruleus cell firing and increases arousal in the rat","volume":"96","author":"Hagan","year":"1999","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"726","DOI":"10.1046\/j.1460-9568.2000.00919.x","article-title":"The novel brain neuropeptide, orexin-A, modulates the sleep\u2013wake cycle of rats","volume":"12","author":"Piper","year":"2000","journal-title":"Eur. J. Neurosci."},{"key":"ref_6","first-page":"1012","article-title":"HLA DQB1*0602 is associated with cataplexy in 509 narcoleptic patients","volume":"20","author":"Mignot","year":"1997","journal-title":"Sleep"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1086\/318799","article-title":"Complex HLA-DR and -DQ interactions confer risk of narcolepsy-cataplexy in three ethnic groups","volume":"68","author":"Mignot","year":"2001","journal-title":"Am. J. Hum. Genet."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1393","DOI":"10.1016\/j.sleep.2013.06.017","article-title":"Association analysis of the major histocompatibility complex, class II, DQ beta1 gene, HLA-DQB1, with narcolepsy in Han Chinese patients from Taiwan","volume":"14","author":"Chen","year":"2013","journal-title":"Sleep Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1016\/j.ajhg.2014.12.010","article-title":"HLA-DPB1 and HLA class I confer risk of and protection from narcolepsy","volume":"96","author":"Ollila","year":"2015","journal-title":"Am. J. Hum. Genet."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Han, F., Faraco, J., Dong, X.S., Ollila, H.M., Lin, L., Li, J., An, P., Wang, S., Jiang, K.W., and Gao, Z.C. (2013). Genome wide analysis of narcolepsy in China implicates novel immune loci and reveals changes in association prior to versus after the 2009 H1N1 influenza pandemic. PLoS Genet., 9.","DOI":"10.1371\/journal.pgen.1003880"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"708","DOI":"10.1038\/ng.372","article-title":"Narcolepsy is strongly associated with the T-cell receptor alpha locus","volume":"41","author":"Hallmayer","year":"2009","journal-title":"Nat. Genet."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Faraco, J., Lin, L., Kornum, B.R., Kenny, E.E., Trynka, G., Einen, M., Rico, T.J., Lichtner, P., Dauvilliers, Y., and Arnulf, I. (2013). ImmunoChip study implicates antigen presentation to T cells in narcolepsy. PLoS Genet., 9.","DOI":"10.1371\/journal.pgen.1003270"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"979","DOI":"10.1093\/sleep\/32.8.979","article-title":"Elevated anti-streptococcal antibodies in patients with recent narcolepsy onset","volume":"32","author":"Aran","year":"2009","journal-title":"Sleep"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1111\/joim.12355","article-title":"Increased beta-haemolytic group A streptococcal M6 serotype and streptodornase B-specific cellular immune responses in Swedish narcolepsy cases","volume":"278","author":"Ambati","year":"2015","journal-title":"J. Intern. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.sleep.2020.03.019","article-title":"Anti-streptococcal antibodies in Chinese patients with type -1 narcolepsy","volume":"72","author":"Ding","year":"2020","journal-title":"Sleep Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1016\/j.sleep.2008.05.009","article-title":"Prevalence of narcolepsy in King County, Washington, USA","volume":"10","author":"Longstreth","year":"2009","journal-title":"Sleep Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1007\/s11910-018-0851-5","article-title":"Narcolepsy Associated with Pandemrix Vaccine","volume":"18","author":"Sarkanen","year":"2018","journal-title":"Curr. Neurol. Neurosci. Rep."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2486","DOI":"10.1093\/brain\/awt187","article-title":"Increased risk of narcolepsy in children and adults after pandemic H1N1 vaccination in France","volume":"136","author":"Dauvilliers","year":"2013","journal-title":"Brain"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Nohynek, H., Jokinen, J., Partinen, M., Vaarala, O., Kirjavainen, T., Sundman, J., Himanen, S.L., Hublin, C., Julkunen, I., and Olsen, P. (2012). AS03 adjuvanted AH1N1 vaccine associated with an abrupt increase in the incidence of childhood narcolepsy in Finland. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0033536"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Partinen, M., Saarenp\u00e4\u00e4-Heikkil\u00e4, O., Ilveskoski, I., Hublin, C., Linna, M., Ols\u00e9n, P., Nokelainen, P., Al\u00e9n, R., Wallden, T., and Espo, M. (2012). Increased incidence and clinical picture of childhood narcolepsy following the 2009 H1N1 pandemic vaccination campaign in Finland. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0033723"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"f794","DOI":"10.1136\/bmj.f794","article-title":"Risk of narcolepsy in children and young people receiving AS03 adjuvanted pandemic A\/H1N1 2009 influenza vaccine: Retrospective analysis","volume":"346","author":"Miller","year":"2013","journal-title":"BMJ Br. Med. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"867","DOI":"10.1016\/j.sleep.2013.03.020","article-title":"Incidence of narcolepsy in Norwegian children and adolescents after vaccination against H1N1 influenza A","volume":"14","author":"Heier","year":"2013","journal-title":"Sleep Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1111\/joim.12150","article-title":"Risks of neurological and immune-related diseases, including narcolepsy, after vaccination with Pandemrix: A population- and registry-based cohort study with over 2 years of follow-up","volume":"275","author":"Persson","year":"2014","journal-title":"J. Intern. Med."},{"key":"ref_24","first-page":"20789","article-title":"Investigation of an association between onset of narcolepsy and vaccination with pandemic influenza vaccine, Ireland April 2009-December 2010","volume":"19","author":"Barret","year":"2014","journal-title":"Eurosurveillance"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Montplaisir, J., Petit, D., Quinn, M.-J., Ouakki, M., Deceuninck, G., Desautels, A., Mignot, E., and De Wals, P. (2014). Risk of narcolepsy associated with inactivated adjuvanted (AS03) A\/H1N1 (2009) pandemic influenza vaccine in Quebec. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0108489"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1836","DOI":"10.1016\/j.vaccine.2010.12.044","article-title":"The development of vaccine viruses against pandemic A(H1N1) influenza","volume":"29","author":"Robertson","year":"2011","journal-title":"Vaccine"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"668","DOI":"10.1086\/655830","article-title":"AS03(A)-Adjuvanted influenza A (H1N1) 2009 vaccine for adults up to 85 years of age","volume":"51","author":"Roman","year":"2010","journal-title":"Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1016\/S0140-6736(07)61297-5","article-title":"Antigen sparing and cross-reactive immunity with an adjuvanted rH5N1 prototype pandemic influenza vaccine: A randomised controlled trial","volume":"370","author":"Borkowski","year":"2007","journal-title":"Lancet"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/S1473-3099(13)70238-X","article-title":"Pandemic influenza A H1N1 vaccines and narcolepsy: Vaccine safety surveillance in action","volume":"14","author":"Barker","year":"2014","journal-title":"Lancet. Infect. Dis."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1016\/j.bbi.2014.11.004","article-title":"Comparison of Pandemrix and Arepanrix, two pH1N1 AS03-adjuvanted vaccines differentially associated with narcolepsy development","volume":"47","author":"Jacob","year":"2015","journal-title":"Brain Behav. Immun."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1038\/s41586-018-0540-1","article-title":"T cells in patients with narcolepsy target self-antigens of hypocretin neurons","volume":"562","author":"Latorre","year":"2018","journal-title":"Nature"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"E12323","DOI":"10.1073\/pnas.1818150116","article-title":"Autoimmunity to hypocretin and molecular mimicry to flu in type 1 narcolepsy","volume":"115","author":"Luo","year":"2018","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Vaarala, O., Vuorela, A., Partinen, M., Baumann, M., Freitag, T.L., Meri, S., Saavalainen, P., Jauhiainen, M., Soliymani, R., and Kirjavainen, T. (2014). Antigenic Differences between AS03 Adjuvanted Influenza A (H1N1) Pandemic Vaccines: Implications for Pandemrix-Associated Narcolepsy Risk. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0114361"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"294ra105","DOI":"10.1126\/scitranslmed.aab2354","article-title":"Antibodies to influenza nucleoprotein cross-react with human hypocretin receptor 2","volume":"7","author":"Ahmed","year":"2015","journal-title":"Sci. Transl. Med."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Luo, G., Lin, L., Jacob, L., Bonvalet, M., Ambati, A., Plazzi, G., Pizza, F., Leib, R., Adams, C.M., and Partinen, M. (2017). Absence of anti-hypocretin receptor 2 autoantibodies in post pandemrix narcolepsy cases. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0187305"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"641","DOI":"10.1007\/s00251-015-0873-y","article-title":"Accurate pan-specific prediction of peptide-MHC class II binding affinity with improved binding core identification","volume":"67","author":"Andreatta","year":"2015","journal-title":"Immunogenetics"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Skowronski, D.M., Janjua, N.Z., De Serres, G., Sabaiduc, S., Eshaghi, A., Dickinson, J.A., Fonseca, K., Winter, A.-L., Gubbay, J.B., and Krajden, M. (2014). Low 2012\u201313 Influenza Vaccine Effectiveness Associated with Mutation in the Egg-Adapted H3N2 Vaccine Strain Not Antigenic Drift in Circulating Viruses. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0092153"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2370","DOI":"10.1126\/science.291.5512.2370","article-title":"Glycosylation and the immune system","volume":"291","author":"Rudd","year":"2001","journal-title":"Science"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"522","DOI":"10.1097\/MCP.0000000000000426","article-title":"Autoimmunity in narcolepsy","volume":"23","author":"Bonvalet","year":"2017","journal-title":"Curr. Opin. Pulm. Med."},{"key":"ref_40","first-page":"216ra176","article-title":"CD4+ T cell autoimmunity to hypocretin\/orexin and cross-reactivity to a 2009 H1N1 influenza A epitope in narcolepsy","volume":"5","author":"Kornum","year":"2013","journal-title":"Sci. Transl. Med."},{"key":"ref_41","first-page":"247rt1","article-title":"Retraction of the research article: \u201cCD4(+) T cell autoimmunity to hypocretin\/orexin and cross-reactivity to a 2009 H1N1 influenza A epitope in narcolepsy\u201d","volume":"6","author":"Kornum","year":"2014","journal-title":"Sci. Transl. Med."}],"container-title":["Vaccines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-393X\/8\/4\/630\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:26:44Z","timestamp":1760178404000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-393X\/8\/4\/630"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,10,30]]},"references-count":41,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2020,12]]}},"alternative-id":["vaccines8040630"],"URL":"https:\/\/doi.org\/10.3390\/vaccines8040630","relation":{"has-preprint":[{"id-type":"doi","id":"10.1101\/2020.08.21.256180","asserted-by":"object"}]},"ISSN":["2076-393X"],"issn-type":[{"value":"2076-393X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,10,30]]}}}