Vibriocidal Antibody Research Articles

Susceptibility to Vibrio cholerae Infection in a Cohort of Household Contacts of Patients with Cholera in Bangladesh

BackgroundDespite recent progress in understanding the molecular basis of Vibrio cholerae pathogenesis, there is relatively little knowledge of the factors that determine the variability in human susceptibility to V. cholerae infection.Methods and FindingsWe performed an observational study of a cohort of household contacts of cholera patients in Bangladesh, and compared the baseline characteristics of household members who went on to develop culture-positive V. cholerae infection with individuals who did not develop infection. Although the vibriocidal antibody is the only previously described immunologic marker associated with protection from V. cholerae infection, we found that levels of serum IgA specific to three V. cholerae antigens—the B subunit of cholera toxin, lipopolysaccharide, and TcpA, the major component of the toxin–co-regulated pilus—also predicted protection in household contacts of patients infected with V. cholerae O1, the current predominant cause of cholera. Circulating IgA antibodies to TcpA were also associated with protection from V. cholerae O139 infection. In contrast, there was no association between serum IgG antibodies specific to these three antigens and protection from infection with either serogroup. We also found evidence that host genetic characteristics and serum retinol levels modify susceptibility to V. cholerae infection.ConclusionsOur observation that levels of serum IgA (but not serum IgG) directed at certain V. cholerae antigens are associated with protection from infection underscores the need to better understand anti–V. cholerae immunity at the mucosal surface. Furthermore, our data suggest that susceptibility to V. cholerae infection is determined by a combination of immunologic, nutritional, and genetic characteristics; additional factors that influence susceptibility to cholera remain unidentified.

Significância de anticorpos vibriocidas circulantes em área pós-epidêmica de diarréia, São Bento do Una, Estado de Pernambuco

The levels of vibriocidal antibodies were investigated among 41 adults without any past or present history of diarrhea due to Vibrio cholerae O1 who were living in the municipality of São Bento do Una, Pernambuco. A diarrhea outbreak occurred in this locality at the beginning of 2004, involving multiple bacterial agents, including Vibrio cholerae. The microtitration test was used to investigate the presence of anti-Ogawa and anti-Inaba vibriocidal serum antibodies. Vibriocidal titers e" 1:640 were considered indicative of infection by Vibrio cholerae O1. The frequency of the reagents was 36 (87.8%) for the Ogawa serovar, which showed that Vibrio cholerae O1 was possibly circulating during and/or after the diarrhea epidemic.

A semi-automated vibriocidal assay for improved measurement of cholera vaccine-induced immune responses

Vibriocidal antibody assay has been a surrogate standard assay in the evaluation of cholera vaccine efficacy because it has a good correlation with protection. Although the optical density-based vibriocidal assay in a 96-well microtiter-plate format is widely used in clinical trials, it has limitations as vibriocidal titers are altered by incubation time and samples with the same end-point titers could have potentially different vibriocidal kinetics. In the present study, we developed an improved agar-plate assay coupled with an automated colony counting system. Through testing 30 pairs of human sera from vaccinees administered with a cholera vaccine or placebo, these two assays showed good correlations for the vibriocidal titers and fold increases in titers between pre- and post-vaccinated sera as determined by the Pearson correlation coefficient and the Regression coefficient. Notably, the newly-developed semi-automated assay demonstrated that serum samples with the same end-point titers turned out to have distinct vibriocidal kinetics that were not distinguishable by the microtiter-plate assay. The semi-automated assay responded specifically to Vibrio cholerae but not to irrelevant bacteria such as Salmonella typhi and Escherichia coli. These results demonstrate that the semi-automated assay provides better sensitivity, accuracy, and stability of the assay results with minimized efforts than conventional microtiter-plate assay and could provide a useful tool as an in vitro surrogate assay for the evaluation of cholera vaccine efficacy.

A Vibrio cholerae serogroup O1 vaccine candidate against CTX ETΦ infection

Cholera is a severe diarrheal disease that may spread rapidly. Vaccination is considered a valid measure against it. We developed a new vaccine candidate, IEM109, against Vibrio cholerae. To generate this candidate, a chromosomal fragment containing the TLC element, attB of the CTXΦ integration site, and RTX cluster responsible for the cytotoxic activity for mammalian cells was deleted through homologous recombination from the previously described El Tor biotype, IEM101. The protective genes ctxB and rstR, which establish resistance to CTXΦ infections, were inserted into that same location on the chromosome of IEM109 to enhance the safety and genetic stability of the vaccine candidate and to prevent horizontal gene transfer. In in vivo tests, cell cultures showed that the cytotoxic effect of IEM109 on Hep-2 was negative. Furthermore, the infection rate of El Tor biotype CTXΦ to that of IEM109 in the rabbit intestine is 3000-fold lower than that of IEM101. Intraintestinal vaccination of rabbits with a single dose of IEM109 elicits high titers of anti-CTB IgG and vibriocidal antibodies. When challenged with 0.5–2 μg CT and 10 5 to 10 8 CFU of four wild toxigenic strains of different biotypes and serogroups, IEM109 conferred full protection. Thus, IEM109 is a stable vaccine candidate that evokes not only antitoxic and vibriocidal immunities, but also resistance to the El Tor biotype CTXΦ infection.

Breast Milk Reduces the Risk of Illness in Children of Mothers With Cholera

A protective effect of breastfeeding against cholera has been demonstrated in areas endemic of cholera. To assess the protection offered by breast milk from mothers living in an area that had been free from cholera for 7 years, we investigated mothers with cholera and their children during an epidemic with Vibrio cholerae El Tor in the capital of Guinea-Bissau. Eighty mothers with clinical cholera and their children were identified, and interviewed. Blood samples for vibriocidal and antitoxin antibodies were collected from mother-and-child pairs. Breast milk samples were collected from lactating mothers. Cholera was defined as acute watery diarrhea during the epidemic and a vibriocidal reciprocal titer of 20 or above. Three (7%) of 42 breastfed children had cholera as defined above compared with 9 (24%) of 38 nonbreastfed children (RR for breastfed children, 0.19; 95% CI, 0.04-0.91, adjusted for age). The 3 breastfed children who developed cholera received milk containing lower concentrations of anticholera toxin IgA/total IgA (median, 2.0 units/mL) than 14 children who had serologic signs of colonization but did not develop the disease (median, 17.4 units/mL). The protective effect of breast milk against cholera is not confined to endemic areas. Lactating mothers with cholera should receive supportive care to continue breastfeeding.

B‐Cell Responses to Lipopolysaccharide Epitopes: Who Sees What First – Does It Matter?

Cholera is the paradigm for waterborne bacterial diseases. For over a 100 years, scientists have tried to develop a universally effective vaccine for cholera. We are hampered in our efforts because we do not know the details of the basic immune response to Vibrio cholerae antigens. What are the most proactive antigens? What special needs for immunization are engendered by previous exposure to cholera or the age of the individual? How long does immunity last, and is this immunity a classic immunologic memory or re-exposure and continual boosting? Immunization with synthetic derivatives of the carbohydrate moieties of V. cholerae lipopolysaccharide (LPS) coupled to different carrier proteins (neoglycoconjugates, NGC) has allowed dissection of the response to the disaccharide array of perosamine that represent either the Inaba or the Ogawa serotype. Studying serum anti-LPS endpoint titers and the serum vibriocidal response to NGC provides insight into the importance of LPS serotype-specific B-cell epitopes and how antibody response are influenced by the form of the LPS immunogen. We found that murine serum antibody responses to V. cholerae LPS are dynamic. The magnitude of serum anti-LPS antibody titers and the capacity to induced vibriocidal antibodies (immunoglobulin M) are influenced by the initial immunizing serotype of LPS, the structure of the LPS immunogen (native LPS versus NGC), and the order of serotype immunization in a prime boost immunization strategy. The dynamic of the immune response to LPS immunogens is typified by the fact that the host species can affect the immunization response. We found mice do not make vibriocidal antibody to Inaba NGC but rabbits do. This is in contrast to the Ogawa NGC that induced vibriocidal antibody in mice. The results suggest that the host's B-cell repertoire can influence the immunization efficacy; therefore, the development of the new generation of NGC V. cholerae vaccines should focus on human volunteers and their ability to mount protective responses.

Peru-15, a live attenuated oral cholera vaccine, is safe and immunogenic in Bangladeshi toddlers and infants

A live oral Vibrio cholerae O1 El Tor vaccine, Peru-15 was tested in a double-blind, randomized placebo controlled study for safety and immunogenicity in Phase I and Phase II studies in 240 Bangladeshi children aged 9 months–5 years of age. Two different doses (2 × 10 7 and 2 × 10 8 cfu) were tested. Vaccination did not elicit adverse events and the strain was genetically stable. Vibriocidal antibody responses developed in 42/50 (84%) toddlers (2–5 years) and 35/50 (70%) of younger children (9–23 months) and overall 77/100 (77%) who received the high dose. LPS-IgA-antibody responses were seen in 60% of toddlers and 34% of infants; 40% responded with IgA antibodies to cholera toxin. The responses to the reduced dose was lower. These studies demonstrate that Peru-15 at a dose of 2 × 10 8 cfu is safe and immunogenic in children in Bangladesh.

Immunological properties of complex conjugates based on Vibrio cholerae O1 Ogawa lipopolysaccharide antigen

Host protection by humoral immunity against Vibrio cholerae O1 confers lipopolysaccharide (LPS)-specific vibriocidal antibodies. Levels of relevant specific antibodies are closely related to complement-mediated inactivation of the vibrios inoculum, especially on the mucosal surface of intestine. We have tested complex V. cholerae O1 Ogawa-detoxified lipopolysaccharide (dLPS) conjugates. The first conjugate contained glucan both as the immunomodulator and the matrix; the second conjugate contained immunologically inert amylose as matrix. Both d-LPS conjugates contain multiply attached dLPS antigen. These conjugates elicited a statistically significant increase of antigen-specific IgG levels in mice (P<0.001 and P<0.05, respectively). The specific anti-conjugate IgG and IgA response after the second (booster) dose were significantly higher compared to pre-immune and whole-cell response. The most effective vibriocidal activity was observed in the case of conjugate, with glucan as the matrix. The highest correlation was found between vibriocidal activity and specific IgG2b (r=0.765) and IgA (r=0.887) sera levels. The determination of specific IgG subclasses and IgG2a + 2b/IgG1 ratio revealed a dominant T(H)1 cell response crucial for effective vaccine candidate.

Length of the linker and the interval between immunizations influences the efficacy ofVibrio choleraeO1, Ogawa hexasaccharide neoglycoconjugates

Ogawa hexasaccharide neoglycoconjugates induce protective antibodies in mice. Similar Ogawa conjugates but with a longer linker that connects the carrier to shorter saccharides are immunogenic, but generally ineffective at inducing vibriocidal or protective antibodies. The efficacy of Ogawa hexasaccharide neoglycoconjugates of different linker lengths were tested. The majority of mice given immunizations separated by a 14-day gap did not produce vibriocidal or protective antibodies. Mice immunized 28 days apart with immunogens containing the shortest or medium length linker, but not the longest, produced vibriocidal and protective antibodies. A nonprotective, priming dose of purified Ogawa LPS followed 5 days later with a booster of the Ogawa neoglycoconjugates (di-, tetra-, or hexasaccharide) resulted in vibriocidal antibodies at day 10.

Blood Group, Immunity, and Risk of Infection with Vibrio cholerae in an Area of Endemicity

Individuals with blood group O are more susceptible than other individuals to severe cholera, although the mechanism underlying this association is unknown. To assess the respective roles of both intrinsic host factors and adaptive immune responses that might influence susceptibility to infection with Vibrio cholerae, we prospectively followed a cohort of household contacts of patients with cholera in Bangladesh. In this study, we made the novel observation that persons with blood group O were less likely than those with other blood groups to become infected with V. cholerae O1 (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.53 to 0.85; P = 0.008). Consistent with prior studies, however, household contacts with blood group O were more likely to develop severe illness if infected with V. cholerae O1 (OR, 2.3; 95% CI, 0.98 to 5.59; P = 0.05). While blood group O protected significantly against infection with V. cholerae O1, there was no evidence of protection against V. cholerae O139. A multivariate analysis demonstrated that the association between blood group O and protection from infection with V. cholerae O1 was independent of age, gender, and baseline anti-cholera toxin and vibriocidal antibody titers. Based on this epidemiologic evidence, we propose a hypothesis for understanding the association between blood group O and the risk of infection with V. cholerae O1 and O139 as well as the risk of developing severe symptoms once infected.

Vibrio cholerae O139 Bengal—10 years on

A second aetiological agent of cholera, Vibrio cholerae O139 Bengal was identified in late 1992 when it caused large outbreaks of diarrhoea in India and Bangladesh. The new strain probably arose as a result of lateral transfer of genes encoding a novel somatic antigen and a capsule from an unknown bacterium to an O1 El Tor strain with the subsequent loss of genes encoding O1 somatic antigen. O139 produces a semi-rough type colony with a truncated lipopolysaccharide which contains a unique sugar, colitose. Otherwise, O139 and O1 are strikingly similar. The diseases produced by the two serogroups are indistinguishable. There is a moderate inflammatory response in cholera, and in spite of the possession of a capsule by O139, it is no more inflammatory than O1. A number of diagnostic tests have been developed for O139 that are modelled after tests for O1 including rapid tests for field use. O139 has spread to countries of south and south-east Asia, China and Russia. Currently, cholera is caused by both these serogroups in these countries with the O1 serogroup predominant. O139 continues to cause occasional local outbreaks in India and Bangladesh. Genotyping of isolates has shown circulation of multiple clones and their derivation from multiple progenitors. Although there have been changes in antibiogram with the resistance genes being carried on a constin, the strains remain susceptible to tetracycline, a preferred antibiotic for treatment. O139 carries a number of filamentous lysogenic and lytic phages and the latter have been utilized to develop a phage typing scheme. A number of environmental variables have been linked to the occurrence of cholera and lytic phages may determine the course of epidemics. Although the capsule confers serum resistance, vibriocidal antibody assay has been developed for O139. However, unlike in O1 cholera, serum vibriocidal antibody does not seem to correlate with protection against O139 infection. Promising O139 vaccines have been developed or are in the pipeline. It is too early to predict whether O139 will become the causative agent of 'the eighth pandemic of cholera'; it will require many years of monitoring and reporting from regions prone to cholera to find the answer.

Construction and evaluation of a O139 Vibrio cholerae vaccine candidate based on a hemA gene mutation

In this paper, we describe the development of VCUSM2, a live metabolic auxotroph of Vibrio cholerae O139. Auxotrophy was achieved by mutating a house keeping gene, hemA, that encodes for glutamyl-tRNA reductase, an important enzyme in the C5 pathway for δ-aminolevulenic acid (ALA) biosynthesis, which renders this strain dependent on exogenous ALA for survival. Experiments using the infant mouse and adult rabbit models show that VCUSM2 is a good colonizer of the small intestine and elicits greater than a four-fold rise in vibriocidal antibodies in vaccinated rabbits. Rabbits vaccinated with VCUSM2 were fully protected against subsequent challenge with 1 × 10 11 CFU of the virulent wild type (WT) strain. Experiments using ligated ileal loops of rabbits show that VCUSM2 is 2.5-fold less toxic at the dose of 1 × 10 6 CFU compared to the WT strain. Shedding of VCUSM2 in rabbits were found to occur for no longer than 4 days and its maximum survival rate in environmental waters is 8 days compared to the greater than 20 days for the WT strain. VCUSM2 is thus a potential vaccine candidate against infection by V. cholerae O139.

Randomized, Controlled Study of the Safety and Immunogenicity of Peru‐15, a Live Attenuated Oral Vaccine Candidate for Cholera, in Adult Volunteers in Bangladesh

A live oral Vibrio cholerae O1 El Tor vaccine candidate, Peru-15, was studied for safety, immunogenicity, and excretion in phase 1 (inpatient) and phase 2 (outpatient) studies of Bangladeshi adults.METHODs. The study was conducted among adults, by use of a double-blind, randomized, placebo-controlled design. A single dose of Peru-15 (approximately 2 x 108 cfu) or placebo (buffer only) was given in standard bicarbonate and ascorbic acid buffer.RESULTS. Study treatment did not elicit any major adverse events in the volunteers, during either the inpatient or the outpatient phases, and there were no reports of diarrhea. V. cholerae was isolated from the stool of only 1 volunteer and was found to be genetically identical to the vaccine strain. Vibriocidal antibody responses were seen in 30 (75%) of 40 vaccine recipients and in 3 (10%) of 30 placebo recipients. Peripheral blood immunoglobulin (Ig) A and IgM antibody-secreting cell responses to lipopolysaccharide were seen in the majority of vaccine recipients (response rate, 78%--88%). Seroconversion for lipopolysaccharide-specific IgA antibodies was seen in 88% of vaccine recipients. The response in vaccine recipients was significantly higher than that in placebo recipients, in all of the immunological assays (P=.036 to <.001). A lower immunological response against cholera toxin B subunit was detected.CONCLUSIONS. The safety and immunogenicity of this Peru-15 vaccine candidate indicates the usefulness of future studies in Bangladesh, where cholera is endemic.

The Vaccine Candidate Vibrio cholerae 638 Is Protective against Cholera in Healthy Volunteers

Vibrio cholerae 638 is a living candidate cholera vaccine strain attenuated by deletion of the CTXPhi prophage from C7258 (O1, El Tor Ogawa) and by insertion of the Clostridium thermocellum endoglucanase A gene into the hemagglutinin/protease coding sequence. This vaccine candidate was previously found to be well tolerated and immunogenic in volunteers. This article reports a randomized, double-blind, placebo-controlled trial conducted to test short-term protection conferred by 638 against subsequent V. cholerae infection and disease in volunteers in Cuba. A total of 45 subjects were enrolled and assigned to receive vaccine or placebo. The vaccine contained 10(9) CFU of freshly harvested 638 buffered with 1.3% NaHCO(3), while the placebo was buffer alone. After vaccine but not after placebo intake, 96% of volunteers had at least a fourfold increase in vibriocidal antibody titers, and 50% showed a doubling of at least the lipopolysaccharide-specific immunoglobulin A titers in serum. At 1 month after vaccination, five volunteers from the vaccine group and five from the placebo group underwent an exploratory challenge study with 10(9) CFU of DeltaCTXPhi attenuated mutant strain V. cholerae 81. Only two volunteers from the vaccine group shed strain 81 in their feces, but none of them experienced diarrhea; in the placebo group, all volunteers excreted the challenge strain, and three had reactogenic diarrhea. An additional 12 vaccinees and 9 placebo recipients underwent challenge with 7 x 10(5) CFU of virulent strain V. cholerae 3008 freshly harvested from a brain heart infusion agar plate and buffered with 1.3% NaHCO(3). Three volunteers (25%) from the vaccine group and all from the placebo group shed the challenge agent in their feces. None of the 12 vaccinees but 7 volunteers from the placebo group had diarrhea, and 2 of the latter exhibited severe cholera (>5,000 g of diarrheal stool). These results indicate that at 1 month after ingestion of a single oral dose (10(9) CFU) of strain 638, volunteers remained protected against cholera infection and disease provoked by the wild-type challenge agent V. cholerae 3008. We recommend that additional vaccine lots of 638 be prepared under good manufacturing practices for further evaluation.

Preparation and evaluation of Vibrio cholerae O1 EL Tor Ogawa lipopolysaccharide–tetanus toxoid conjugates

The lipopolysaccharide (LPS) of Vibrio cholerae is considered one of the most important antigens from the point of view of immunogenicity in these bacteria. We have undertaken detoxification of this LPS by basic hydrolysis and the resultant amine groups were used for their conjugation to tetanus toxoid as carrier protein using carbodiimide-mediated coupling. The resulting conjugates were inoculated in Balb/c mice for immunogenicity studies. The anti-LPS IgG and vibriocidal antibodies were measured in serum. The antigenicity of this conjugated was evaluated by ELISA, with serums of humans vaccinated with a strain genetically modified. The conjugated elicited: high titers of IgG anti-LPS, high titers of vibriocidal antibodies and there was recognition of LPS by antibodies from cholerae immunised human serum. These results show that the conjugated LPS obtained by us, could be evaluated like a potential vaccine for human use.

Th1-type immune response to a Coccidioides immitis antigen delivered by an attenuated strain of the non-invasive enteropathogen Vibrio cholerae

The antigen-2 or proline rich antigen (Ag2/PRA) from Coccidioides immitis, known to protect mice against experimental Coccidioidomycosis, was expressed in the genetically attenuated cholera vaccine candidate Vibrio cholerae 638 and its thymine auxotrophic derivative 638T. Intranasal immunization of mice with strains producing Ag2/PRA induced serum vibriocidal antibody and Ag2/PRA-specific total IgG responses in outbred Swiss Webster and inbred BALB/c mice. Analysis of IgG subclasses showed a predominance of IgG2a subclass antibodies. Lymphocytes from immunized mice stimulated with pure Ag2/PRA showed a significant proliferative response with production of interferon-γ. Positive selection for plasmid maintenance in vivo did not enhance immune response to Ag2/PRA. These results demonstrate that genetically attenuated strains of the non-invasive pathogen V. cholerae can be used to express and deliver foreign antigens to stimulate a Th1 type of immune response.

The major subunit of the toxin-coregulated pilus TcpA induces mucosal and systemic immunoglobulin A immune responses in patients with cholera caused by Vibrio cholerae O1 and O139.

Diarrhea caused by Vibrio cholerae is known to give long-lasting protection against subsequent life-threatening illness. The serum vibriocidal antibody response has been well studied and has been shown to correlate with protection. However, this systemic antibody response may be a surrogate marker for mucosal immune responses to key colonization factors of this organism, such as the toxin-coregulated pilus (TCP) and other factors. Information regarding immune responses to TCP, particularly mucosal immune responses, is lacking, particularly for patients infected with the El Tor biotype of V. cholerae O1 or V. cholerae O139 since highly purified TcpA from these strains has not been available previously for use in immune assays. We studied the immune responses to El Tor TcpA in cholera patients in Bangladesh. Patients had substantial and significant increases in TcpA-specific antibody-secreting cells in the circulation on day 7 after the onset of illness, as well as similar mucosal responses as determined by an alternate technique, the assay for antibody in lymphocyte supernatant. Significant increases in antibodies to TcpA were also seen in sera and feces of patients on days 7 and 21 after the onset of infection. Overall, 93% of the patients showed a TcpA-specific response in at least one of the specimens compared with the results obtained on day 2 and with healthy controls. These results demonstrate that TcpA is immunogenic following natural V. cholerae infection and suggest that immune responses to this antigen should be evaluated for potential protection against subsequent life-threatening illness.

Incomplete correlation of serum vibriocidal antibody titer with protection from Vibrio cholerae infection in urban Bangladesh.

The serum vibriocidal antibody is the only recognized predictor of protection from cholera, but no seroepidemiological data have been gathered since the emergence of Vibrio cholerae O139. We assessed the association between the vibriocidal antibody titer and protection from cholera in an endemic setting. Although a higher baseline vibriocidal titer correlated with protection from V. cholerae O1, infection still developed in some contacts with very high titers. No association between baseline vibriocidal titer and protection from V. cholerae O139 infection was found. Our findings suggest that the vibriocidal antibody is an incomplete predictor of protection from V. cholerae infection.

A simple and convenient microtiter plate assay for the detection of bactericidal antibodies to Vibrio cholerae O1 and Vibrio cholerae O139

It is believed that the correlate of protection for cholera can be determined by the serum vibriocidal assay. The currently available vibriocidal assays, based on the conventional agar plating technique, are labor intensive. We developed a simple and convenient microtiter plate assay for the detection of vibriocidal antibodies that is equally as efficient for Vibrio cholerae O1 and for V. cholerae O139. The addition of succinate and neotetrazolium made it possible to measure the growth of surviving bacterial target cells by monitoring a color change. We evaluated assay parameters (target strains, growth of target cells, complement source and concentration) that may affect the reproducibility of the method for V. cholerae O139. The results obtained with the microtiter plate assay were uniformly similar to those obtained with the conventional agar plating assay, when testing both the Inaba and Ogawa serotypes of V. cholerae O1. The microtiter plate assay was also convenient for measuring the activity of animal sera and mouse monoclonal antibodies.

Construction and evaluation of a safe, live, oral Vibrio cholerae vaccine candidate, IEM108.

IEM101, a Vibrio cholerae O1 El Tor Ogawa strain naturally deficient in CTXPhi, was previously selected as a live cholera vaccine candidate. To make a better and safer vaccine that can induce protective immunity against both the bacteria and cholera toxin (CT), a new vaccine candidate, IEM108, was constructed by introducing a ctxB gene and an El Tor-derived rstR gene into IEM101. The ctxB gene codes for the protective antigen CTB subunit, and the rstR gene mediates phage immunity. The stable expression of the two genes was managed by a chromosome-plasmid lethal balanced system based on the housekeeping gene thyA. Immunization studies indicate that IEM108 generates good immune responses against both the bacteria and CT. After a single-dose intraintestinal vaccination with 10(9) CFU of IEM108, both anti-CTB immunoglobulin G and vibriocidal antibodies were detected in the immunized-rabbit sera. However, only vibriocidal antibodies are detected in rabbits immunized with IEM101. In addition, IEM108 but not IEM101 conferred full protection against the challenges of four wild-type toxigenic strains of V. cholerae O1 and 4 micro g of CT protein in a rabbit model. By introducing the rstR gene, the frequency of conjugative transfer of a recombinant El Tor-derived RS2 suicidal plasmid to IEM108 was decreased 100-fold compared to that for IEM101. This indicated that the El Tor-derived rstR cloned in IEM108 was fully functional and could effectively inhibit the El Tor-derived CTXPhi from infecting IEM108. Our results demonstrate that IEM108 is an efficient and safe live oral cholera vaccine candidate that induces antibacterial and antitoxic immunity and CTXPhi phage immunity.