Efficacy Of Tuberculosis Vaccines Research Articles

Human biomarkers: can they help us to develop a new tuberculosis vaccine?

The most effective intervention for the control of infectious disease is vaccination. The BCG vaccine, the only licensed vaccine for the prevention of tuberculosis (TB) disease, is only partially effective and a new vaccine is urgently needed. Biomarkers can aid the development of new TB vaccines through discovery of immune mechanisms, early assessment of vaccine immunogenicity or vaccine take and identification of those at greatest risk of disease progression for recruitment into smaller, targeted efficacy trials. The ultimate goal, however, remains a biomarker of TB vaccine efficacy that can be used as a surrogate for a TB disease end point and there remains an urgent need for further research in this area.

Protection and Long-Lived Immunity Induced by the ID93/GLA-SE Vaccine Candidate against a Clinical Mycobacterium tuberculosis Isolate.

Mycobacterium tuberculosis HN878 represents a virulent clinical strain from the W-Beijing family, which has been tested in small animal models in order to study its virulence and its induction of host immune responses following infection. This isolate causes death and extensive lung pathology in infected C57BL/6 mice, whereas lab-adapted strains, such as M. tuberculosis H37Rv, do not. The use of this clinically relevant isolate of M. tuberculosis increases the possibilities of assessing the long-lived efficacy of tuberculosis vaccines in a relatively inexpensive small animal model. This model will also allow for the use of knockout mouse strains to critically examine key immunological factors responsible for long-lived, vaccine-induced immunity in addition to vaccine-mediated prevention of pulmonary immunopathology. In this study, we show that the ID93/glucopyranosyl lipid adjuvant (GLA)-stable emulsion (SE) tuberculosis vaccine candidate, currently in human clinical trials, is able to elicit protection against M. tuberculosis HN878 by reducing the bacterial burden in the lung and spleen and by preventing the extensive lung pathology induced by this pathogen in C57BL/6 mice.

Relevance of bovine tuberculosis research to the understanding of human disease: Historical perspectives, approaches, and immunologic mechanisms

Pioneer studies on infectious disease and immunology by Jenner, Pasteur, Koch, Von Behring, Nocard, Roux, and Ehrlich forged a path for the dual-purpose with dual benefit approach, demonstrating a profound relevance of veterinary studies for biomedical applications. Tuberculosis (TB), primarily due to Mycobacterium tuberculosis in humans and Mycobacterium bovis in cattle, is an exemplary model for the demonstration of this concept. Early studies with cattle were instrumental in the development of the use of Koch's tuberculin as an in vivo measure of cell-mediated immunity for diagnostic purposes. Calmette and Guerin demonstrated the efficacy of an attenuated M. bovis strain (BCG) in cattle prior to use of this vaccine in humans. The interferon-γ release assay, now widely used for TB diagnosis in humans, was developed circa 1990 for use in the Australian bovine TB eradication program. More recently, M. bovis infection and vaccine efficacy studies with cattle have demonstrated a correlation of vaccine-elicited T cell central memory (TCM) responses to vaccine efficacy, correlation of specific antibody to mycobacterial burden and lesion severity, and detection of antigen-specific IL-17 responses to vaccination and infection. Additionally, positive prognostic indicators of bovine TB vaccine efficacy (i.e., responses measured after infection) include: reduced antigen-specific IFN-γ, iNOS, IL-4, and MIP1-α responses; reduced antigen-specific expansion of CD4+ T cells; and a diminished activation profile on T cells within antigen stimulated cultures. Delayed type hypersensitivity and IFN-γ responses correlate with infection but do not necessarily correlate with lesion severity whereas antibody responses generally correlate with lesion severity. Recently, serologic tests have emerged for the detection of tuberculous animals, particularly elephants, captive cervids, and camelids. B cell aggregates are consistently detected within tuberculous lesions of humans, cattle, mice and various other species, suggesting a role for B cells in the immunopathogenesis of TB. Comparative immunology studies including partnerships of researchers with veterinary and medical perspectives will continue to provide mutual benefit to TB research in both man and animals.

Experimental aerosol Mycobacterium bovis model of infection in goats

The use of animal models is essential in testing the efficacy for novel therapies against tuberculosis (TB). Calves and non-human primates are examples of large animal models currently used to test TB vaccine efficacy but these animals are difficult and very expensive to house under high containment conditions. The goat may represent an effective but less expensive alternative for testing prototype vaccines against TB. Goats are susceptible to Mycobacterium bovis, Mycobacterium caprae and Mycobacterium tuberculosis infection. Aerosolized bacteria are the most common source of natural infection in humans and the primary site of natural infection is the respiratory tract. We developed a simple procedure for infecting goats with M.bovis by aerosol exposure. After 8 and 12 weeks of infection the goats were euthanized, post-mortem analysis was performed, and all exposed animals presented TB compatible lesions in the lung and associated lymph nodes. Selected lung lesions and respiratory lymph nodes were evaluated and cultured for bacteriological and histological analysis. The present work shows a reliable new animal model of aerosol infection to be used in the understanding of TB disease and development of new therapies.

Mycobacterial growth inhibition in murine splenocytes as a surrogate for protection against Mycobacterium tuberculosis (M. tb)

Development of an improved vaccine against tuberculosis (TB) is hindered by the lack of a surrogate ofprotection. Efficacy of new TB vaccines in humans can only be evaluated by expensive and time consuming efficacy trials within TB endemic areas. It is critical that vaccines with the greatest potential to protect are selected for these trials. Mycobacterial growth inhibition assays (MGIAs) have been developed with the hope that these in-vitro functional assays will correlate with protection, which could aid in the selection of the best vaccine candidates. The present study describes the use of the BACTEC system to perform MGIAs in mice. We demonstrate reproducible mycobacterial growth inhibition in splenocytes from BCG immunised mice compared with unimmunised mice (P<0.023), which corresponded with in-vivo efficacy against Mycobacterium tuberculosis (M.tb) challenge. Microarray data showed extensive differential gene expression in splenocyte responses to ex-vivo BCG stimulation between unimmunised and BCG-immunised mice. TH1 responses, including IFN-γ, nitric oxide synthase (NOS2) and Interleukin -17 (IL-17) expression were enhanced in BCG immunised mice, indicating a possible mechanism for mycobacterial growth inhibition. Further investigation into whether the BACTEC MGIA can be used as a surrogate of protection in humans and preclinical animal models is now warranted.

Screening for TB in high school adolescents in a high burden setting in South Africa

Screening for tuberculosis (TB) disease is important for TB control and TB vaccine efficacy trials but this has not been evaluated in adolescents. We conducted a study to determine the prevalence of active TB and performance of specific screening tests for TB in adolescents in a high burden setting. Adolescents aged 12-18 years were recruited from high schools in a rural town in South Africa. Participants were screened for active TB using symptoms, household TB contact, positive interferon gamma release assay (IGRA) and positive tuberculin skin test (TST). Of 6363 adolescents recruited, 21 were newly diagnosed with TB of whom 19 were culture positive. After exclusions, the derived prevalence of smear positive TB was 16/5682 = 3/1000 (95% confidence interval (CI) 1-4/1000). The sensitivity of TST and IGRA for active TB were 85% (95% CI 62-100%) and 94% (95% CI 79-100%) respectively. None of the methods alone or in combination had positive predictive values greater than 2%. The screening tools evaluated in this study may not be practical for routine use owing to low positive predictive values but may be useful in TB vaccine clinical trials.

Lessons learnt from the first efficacy trial of a new infant tuberculosis vaccine since BCG

SummaryBackgroundNew tuberculosis (TB) vaccines are being developed to combat the global epidemic. A phase IIb trial of a candidate vaccine, MVA85A, was conducted in a high burden setting in South Africa to evaluate proof-of-concept efficacy for prevention of TB in infants.ObjectiveTo describe the study design and implementation lessons from an infant TB vaccine efficacy trial.MethodsThis was a randomised, controlled, double-blind clinical trial comparing the safety and efficacy of MVA85A to Candin control administered to 4–6-month-old, BCG-vaccinated, HIV-negative infants at a rural site in South Africa. Infants were followed up for 15–39 months for incident TB disease based on pre-specified endpoints.Results2797 infants were enrolled over 22 months. Factors adversely affecting recruitment and the solutions that were implemented are discussed. Slow case accrual led to six months extension of trial follow up.ConclusionThe clinical, regulatory and research environment for modern efficacy trials of new TB vaccines are substantially different to that when BCG vaccine was first evaluated in infants. Future infant TB vaccine trials will need to allocate sufficient resources and optimise operational efficiency. A stringent TB case definition is necessary to maximize specificity, and TB case accrual must be monitored closely.

The immune response to tuberculosis infection in the setting ofHelicobacter pyloriand helminth infections

We screened 176 healthy, adult (aged 18-55 years) US refugees from tuberculosis (TB)-endemic countries to evaluate whether cytokine responses to latent TB infection (LTBI) are modified in the setting of concurrent H. pylori and helminth infection. As measured by the Quantiferon-TB GOLD interferon-γ release assay, a total 38 (22%) subjects had LTBI, of which 28 (74%) also were H. pylori seropositive and/or helminth infected. Relative to ten subjects with LTBI only, 16 subjects with concurrent H. pylori infection had significantly elevated levels of IFN-γ, and nine subjects with both H. pylori and helminth infection had significantly elevated levels of IFN-γ, IL-2, IL-13, and IL-5. H. pylori is associated with enhanced IFN-γ responses to TB, even in the setting of concurrent helminth infection. Efficacy of TB vaccines may vary with the co-existence of these three infections in the developing world.

Preclinical Development of an In Vivo BCG Challenge Model for Testing Candidate TB Vaccine Efficacy

There is an urgent need for an immunological correlate of protection against tuberculosis (TB) with which to evaluate candidate TB vaccines in clinical trials. Development of a human challenge model of Mycobacterium tuberculosis (M.tb) could facilitate the detection of such correlate(s). Here we propose a novel in vivo Bacille Calmette-Guérin (BCG) challenge model using BCG immunization as a surrogate for M.tb infection. Culture and quantitative PCR methods have been developed to quantify BCG in the skin, using the mouse ear as a surrogate for human skin. Candidate TB vaccines have been evaluated for their ability to protect against a BCG skin challenge, using this model, and the results indicate that protection against a BCG skin challenge is predictive of BCG vaccine efficacy against aerosol M.tb challenge. Translation of these findings to a human BCG challenge model could enable more rapid assessment and down selection of candidate TB vaccines and ultimately the identification of an immune correlate of protection.

Tuberculosis Immunity: Opportunities from Studies with Cattle

Mycobacterium tuberculosis and M. bovis share >99% genetic identity and induce similar host responses and disease profiles upon infection. There is a rich history of codiscovery in the development of control measures applicable to both human and bovine tuberculosis (TB) including skin-testing procedures, M. bovis BCG vaccination, and interferon-γ release assays. The calf TB infection model offers several opportunities to further our understanding of TB immunopathogenesis. Recent observations include correlation of central memory immune responses with TB vaccine efficacy, association of SIRPα + cells in ESAT-6:CFP10-elicited multinucleate giant cell formation, early γδ T cell responses to TB, antimycobacterial activity of memory CD4+ T cells via granulysin production, association of specific antibody with antigen burden, and suppression of innate immune gene expression in infected animals. Partnerships teaming researchers with veterinary and medical perspectives will continue to provide mutual benefit to TB research in man and animals.

Immunogenicity and Protective Efficacy of Prime-Boost Regimens with Recombinant Δ ureC hly + Mycobacterium bovis BCG and Modified Vaccinia Virus Ankara Expressing M. tuberculosis Antigen 85A against Murine Tuberculosis

In the light of the recent emergence of multidrug-resistant and extensively drug-resistant strains of Mycobacterium tuberculosis, the epidemic of tuberculosis (TB) in populations coinfected with human immunodeficiency virus, and the failure of Mycobacterium bovis bacillus Calmette-Guerin (BCG) to protect against disease, new vaccines against TB are urgently needed. Two promising new vaccine candidates are the recombinant DeltaureC hly(+) BCG (recBCG), which has been developed to replace the current BCG vaccine strain, and modified vaccinia virus Ankara (MVA) expressing M. tuberculosis antigen 85A (MVA85A), which is a leading candidate vaccine designed to boost the protective efficacy of BCG. In the present study, we examined the effect of MVA85A boosting on the protection afforded at 12 weeks postchallenge by BCG and recBCG by using bacterial CFU as an efficacy readout. recBCG-immunized mice were significantly better protected against aerosol challenge with M. tuberculosis than mice immunized with the parental strain of BCG. Intradermal boosting with MVA85A did not reduce the bacterial burden any further. In order to identify a marker for the development of a protective immune response against M. tuberculosis challenge, we analyzed splenocytes after priming or prime-boosting by using intracytoplasmic cytokine staining and assays for cytokine secretion. Boosting with MVA85A, but not priming with BCG or recBCG, greatly increased the antigen 85A-specific T-cell response, suggesting that the mechanism of protection may differ from that against BCG or recBCG. We show that the numbers of systemic multifunctional cytokine-producing cells did not correlate with protection against aerosol challenge in BALB/c mice. This emphasizes the need for new biomarkers for the evaluation of TB vaccine efficacy.

Chronic helminth infections may negatively influence immunity against tuberculosis and other diseases of public health importance

Tuberculosis (TB) has once again become a major public health threat owing to the combined effects of deteriorating socioeconomic situations and the emergence of the HIV/AIDS pandemic. The only vaccine available against TB, although effective in reducing the burden of childhood TB, shows enormous variability in its efficacy against pulmonary TB, which is the most common form of the disease in adults. Most areas of high TB incidence and poor TB vaccine efficacy have a high prevalence of intestinal helminth infections. Such infections have been shown to cause a range of immunomodulation characterized by enhanced T helper 2-type cytokine profile, high immunoglobulin E levels and upregulated regulatory T-cell activity, as well as chronic immune activation. An altered background immune profile could have adverse effects on the outcome of subsequent infections and vaccinations. In support of this hypothesis, studies conducted in animals and humans living in worm-endemic areas have shown that helminths impair resistance against a number of infections of major public health importance, including TB, malaria and HIV/AIDS. Understanding such interactions could assist in the design of vaccines against these diseases.

Nippostrongylus brasiliensis infection modulates Mycobacterium tuberculosis induced Th1 response (43.45)

Abstract Modulation of Th1 response generated against pathogens like M tuberculosis (Mtb) by helminths is an important, area of investigation, because of the prevalence of coinfections in TB endemic regions. In this study we have designed an approach to investigate how the Th1 response generated by Mtb is modulated by helminthic infection. We have used the ovalbumin – specific TCR transgenic adoptive transfer system, wherein the ability of Mtb-pulsed dendritic cells to initiate a Th1 response was studied on the background of a helminth infection. BALB/c mice were infected with N. brasiliensis, and groups of uninfected and infected mice were injected with CFSE labeled OVA-specific TCR transgenic T cells followed by intratracheal instillation of Mtb and ovalbumin peptide-pulsed bone marrow-derived dendritic cells. Analysis of the labeled transgenic T cells harvested from the draining lymph nodes indicated proliferation of T cells from both groups of mice. However, we observed significantly reduced level of IFNγ and a reciprocal increase in IL-4 in T cells derived form the helminth-infected mice. These findings indicate that helminth infection does not abrogate the priming ability of Mtb-pulsed DCs, but interferes with their ability to promote a Th1 response. The significance of the findings lies in the potential of helminth infections to modulate resistance to tuberculosis, and also to interfere with the efficacy of tuberculosis vaccines.

Revaccination of neonatal calves with Mycobacterium bovis BCG reduces the level of protection against bovine tuberculosis induced by a single vaccination.

Cattle may provide a suitable model for testing ways of improving tuberculosis vaccine efficacy in human infants. A vaccination and challenge study was undertaken in calves to determine the optimal time to vaccinate neonatal animals with Mycobacterium bovis bacillus Calmette-Guérin (BCG) for protection against tuberculosis and to determine whether revaccination with BCG was beneficial. Calves (10 per group) were vaccinated with BCG within 8 h of birth or at 6 weeks of age, when immune responses to antigens of environmental mycobacteria were detectable, or vaccinated at birth and revaccinated at 6 weeks. A control group was not vaccinated. BCG vaccination at birth induced strong antigen-specific gamma interferon (IFN-gamma) and interleukin-2 (IL-2) responses and antigen-specific activation in CD4(+), CD8(+), and WC1(+) gammadelta T-cell subsets from blood. The proportions of animals per group with macroscopic tuberculous lesions after challenge were 0/10 for BCG at birth, 1/9 for BCG at 6 weeks, 4/10 for the revaccinated group, and 10/10 for the nonvaccinated group. There was no significant difference in the levels of protection between groups vaccinated at birth or at 6 weeks, while animals vaccinated both at birth and at 6 weeks had significantly less protection than those vaccinated only at birth. The revaccinated calves that subsequently developed tuberculous lesions had significantly stronger IFN-gamma and IL-2 responses to bovine purified protein derivative after the BCG booster than those in the same group that did not develop lesions. The results indicated that BCG vaccination at birth induced a high level of immunity and that the sensitization of very young animals to antigens of environmental mycobacteria by 6 weeks of age did not affect the effectiveness of BCG. However, BCG revaccination of these young animals was contraindicated.

Vaccination of animals against Mycobacterium bovis.

Vaccination could potentially be used as a practical means of controlling bovine tuberculosis in countries in which a wildlife reservoir of the disease is present, and also in those countries which cannot afford conventional control strategies. An understanding of the processes involved in the protective immune response to tuberculosis is desirable for the rational development and testing of new vaccines for tuberculosis. The authors review current knowledge regarding the processes involved in protective immune responses to tuberculosis, much of which has been derived from studies in mice. This knowledge is discussed in relation to the problem of using vaccination to induce protective immunity in cattle, deer and wildlife. Challenge models have now been developed to test candidate vaccines in many domestic animals and wildlife species and these models are being used to evaluate tuberculosis vaccines. Most studies of the efficacy of tuberculosis vaccines in target animals have focused on the use of bacillus Calmette-Guérin (BCG), an attenuated strain of Mycobacterium bovis. Recent advances in immunology and the molecular biology of mycobacteria have greatly increased the options for candidate vaccines and future studies will test new types of vaccines including new attenuated strains of M. bovis, sub-unit protein vaccines and recombinant deoxyribonucleic acid vaccines. Several of these vaccines have shown promising results when tested in small animal models. Although progress has been made in the development of vaccine delivery systems for animals, the technical problems associated with vaccination of wildlife remain a challenge.

Optimal models to evaluate the protective efficacy of tuberculosis vaccines

BCG has been used widely as a vaccine to prevent tuberculosis (TB) for 80 years, yet there is still considerable controversy about its efficacy. Many experimental variables have obscured the true efficacy of BCG. The absence of appropriate animal models for the study of protective efficacy and the lack of in vitro correlates of protective immunity have impeded progress. Laboratory animal studies, which have contributed to understanding the pathogenesis, heritability of resistance and immunology of TB, have failed to identify the immunological pathways necessary for protective immunity. In recent years, cattle and deer, which are naturally susceptible to TB, have been used to study protective immunity in vaccinated animals, challenged with virulent bacteria. A deer TB infection model has been developed that can measure protection against TB infection or the development of disease. Data from this model show that, providing live BCG is administered in a short interval prime-boost protocol, significant protection against infection and disease can be obtained. Single dose vaccine provides suboptimal protection that attenuates pathology but does not prevent infection. Low dose BCG vaccine (104cfu), administered in a prime-boost protocol, sufficient to prevent infection, does not cause conversion to delayed type hypersensitivity or produce unacceptable side-effects. Immune memory for protection against infection persists at optimal levels for at least 12 months post vaccination. Used optimally, BCG produces good levels of protection against TB and improved protocols or its use should be explored, before attempts are made to replace it with new-generation vaccines. It is now possible to integrate the fundamental information obtained from laboratory animals with studies of functional immune protection in target host species. Justification for the use of TB vaccines for domestic livestock under field conditions, must be underpinned by scientific evidence that they provide acceptable levels of protection long term.

A large, simple trial of a tuberculosis vaccine.

Although there are no new tuberculosis vaccines currently available, it is possible to estimate the infrastructure needed for efficacy trials of such a vaccine. A randomized, placebo-controlled vaccine strategy for community-wide vaccination of adults is proposed: a large, simple trial with recipients stratified at enrollment by human immunodeficiency virus serologic status and purified protein derivative-skin test status. The outcome, tuberculous disease, would be assessed by community-wide surveillance. Such a trial could be carried out in populations in developed countries where the annual incidence of tuberculous disease is >100 cases per 100,000 persons and in developing countries where the incidence is >400 per 100,000 persons. In developed countries, enrollment of 14,600-80,000 persons would be needed, depending on the initial assumptions; in developing countries, enrollment would be 4400-27,000 persons. Readiness for tuberculosis vaccine efficacy trials will require epidemiological field studies to identify potential trial sites and investment in local diagnostic, surveillance, and data management capabilities.