Physical disruption of skin during poxvirus immunization is critical for the generation of highly protective T cell-mediated immunity

Variola major infection (Smallpox) claimed hundreds of millions lives before it was eradicated by a simple vaccination strategy: epicutaneous application of the related orthopoxvirus Vaccinia virus (VACV) to superficially injured skin (skin scarification, s.s.)1. However, the remarkable success of this strategy was attributed to the immunogenicity of VACV rather than the unique vaccine delivery mode. We now demonstrate that VACV immunization via s.s., but not conventional injection routes, is essential to the generation of superior T cell-mediated immune responses that provide complete protection against subsequent challenges, independent of neutralizing antibodies. Skin-resident effector memory T cells (T(EM)) provide complete protection against cutaneous challenge, while protection against lethal respiratory challenge requires both respiratory mucosal T(EM) and central memory T cells (T(CM)). Vaccination with recombinant VACV (rVACV) expressing a tumor antigen was protective against tumor challenge only if delivered via s.s. route, but not by hypodermic injection. Finally, the clinically safer non-replicative Modified Vaccinia Ankara (MVA) also generated far superior protective immunity when delivered via s.s route compared to intramuscular injection used in MVA clinical trials. Thus, delivering rVACV -based vaccines, including MVA vaccines, through physically disrupted epidermis represents a uniquely powerful strategy with clear-cut advantages over conventional vaccination via hypodermic injection.