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Zhang HZ, Xie W, Zhou WC, Chen J, Wang Y, Zhu YY, Wen TH, Cheng L. Oral immunotherapy with enteric-coated capsules for allergic rhinitis caused by house dust mites. FRONTIERS IN ALLERGY 2024; 5:1345929. [PMID: 38774588 PMCID: PMC11106396 DOI: 10.3389/falgy.2024.1345929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/23/2024] [Indexed: 05/24/2024] Open
Abstract
Background Oral immunotherapy (OIT) is a promising allergen-specific approach in the management of food allergy; however, studies on OIT for allergic rhinitis (AR) have rarely been reported. The purpose of this study is to evaluate the efficacy and safety of OIT using enteric-coated capsules for AR induced by house dust mites. Methods A total of 49 patients with AR were enrolled, including 25 who received subcutaneous immunotherapy (SCIT) and 24 who received OIT. The clinical efficacy and safety in both groups were evaluated. Results After 1 year of treatment, both SCIT and OIT demonstrated significant therapeutic effects. OIT was found to be more effective than SCIT in reducing the total AR symptom score and improving the results of nasal provocation tests. Local and systemic adverse reactions were observed in the SCIT group, while none were reported in the OIT group. Conclusion OIT is an effective and safe treatment for mite-induced AR.
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Affiliation(s)
- Han-Zhong Zhang
- Department of Otorhinolaryngology, Wuxi Hospital of Traditional Chinese Medicine, Wuxi, China
| | - Wei Xie
- Department of Otorhinolaryngology, Wuxi Hospital of Traditional Chinese Medicine, Wuxi, China
| | - Wen-Cheng Zhou
- Department of Otorhinolaryngology & Clinical Allergy Center, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Jian Chen
- Department of Otorhinolaryngology, Wuxi Hospital of Traditional Chinese Medicine, Wuxi, China
| | - Ying Wang
- Department of Otorhinolaryngology, Wuxi Hospital of Traditional Chinese Medicine, Wuxi, China
| | - Yuan-Yuan Zhu
- Department of Otorhinolaryngology, Wuxi Hospital of Traditional Chinese Medicine, Wuxi, China
| | - Ting-Huan Wen
- Mites Laboratory, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Lei Cheng
- Department of Otorhinolaryngology & Clinical Allergy Center, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
- International Centre for Allergy Research, Nanjing Medical University, Nanjing, China
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2
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Zemelka-Wiacek M, Agache I, Akdis CA, Akdis M, Casale TB, Dramburg S, Jahnz-Różyk K, Kosowska A, Matricardi PM, Pfaar O, Shamji MH, Jutel M. Hot topics in allergen immunotherapy, 2023: Current status and future perspective. Allergy 2024; 79:823-842. [PMID: 37984449 DOI: 10.1111/all.15945] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/10/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
The importance of allergen immunotherapy (AIT) is multifaceted, encompassing both clinical and quality-of-life improvements and cost-effectiveness in the long term. Key mechanisms of allergen tolerance induced by AIT include changes in memory type allergen-specific T- and B-cell responses towards a regulatory phenotype with decreased Type 2 responses, suppression of allergen-specific IgE and increased IgG1 and IgG4, decreased mast cell and eosinophil numbers in allergic tissues and increased activation thresholds. The potential of novel patient enrolment strategies for AIT is taking into account recent advances in biomarkers discoveries, molecular allergy diagnostics and mobile health applications contributing to a personalized approach enhancement that can increase AIT efficacy and compliance. Artificial intelligence can help manage and interpret complex and heterogeneous data, including big data from omics and non-omics research, potentially predict disease subtypes, identify biomarkers and monitor patient responses to AIT. Novel AIT preparations, such as synthetic compounds, innovative carrier systems and adjuvants, are also of great promise. Advances in clinical trial models, including adaptive, complex and hybrid designs as well as real-world evidence, allow more flexibility and cost reduction. The analyses of AIT cost-effectiveness show a clear long-term advantage compared to pharmacotherapy. Important research questions, such as defining clinical endpoints, biomarkers of patient selection and efficacy, mechanisms and the modulation of the placebo effect and alternatives to conventional field trials, including allergen exposure chamber studies are still to be elucidated. This review demonstrates that AIT is still in its growth phase and shows immense development prospects.
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Affiliation(s)
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Thomas B Casale
- Departments of Medicine and Pediatrics and Division of Allergy and Immunology, Joy McCann Culverhouse Clinical Research Center, University of South Florida, Tampa, Florida, USA
| | - Stephanie Dramburg
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karina Jahnz-Różyk
- Department of Internal Diseases, Pneumonology, Allergology and Clinical Immunology, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | - Anna Kosowska
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
| | - Paolo M Matricardi
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
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3
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Lin YJ, Zimmermann J, Schülke S. Novel adjuvants in allergen-specific immunotherapy: where do we stand? Front Immunol 2024; 15:1348305. [PMID: 38464539 PMCID: PMC10920236 DOI: 10.3389/fimmu.2024.1348305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/05/2024] [Indexed: 03/12/2024] Open
Abstract
Type I hypersensitivity, or so-called type I allergy, is caused by Th2-mediated immune responses directed against otherwise harmless environmental antigens. Currently, allergen-specific immunotherapy (AIT) is the only disease-modifying treatment with the potential to re-establish clinical tolerance towards the corresponding allergen(s). However, conventional AIT has certain drawbacks, including long treatment durations, the risk of inducing allergic side effects, and the fact that allergens by themselves have a rather low immunogenicity. To improve AIT, adjuvants can be a powerful tool not only to increase the immunogenicity of co-applied allergens but also to induce the desired immune activation, such as promoting allergen-specific Th1- or regulatory responses. This review summarizes the knowledge on adjuvants currently approved for use in human AIT: aluminum hydroxide, calcium phosphate, microcrystalline tyrosine, and MPLA, as well as novel adjuvants that have been studied in recent years: oil-in-water emulsions, virus-like particles, viral components, carbohydrate-based adjuvants (QS-21, glucans, and mannan) and TLR-ligands (flagellin and CpG-ODN). The investigated adjuvants show distinct properties, such as prolonging allergen release at the injection site, inducing allergen-specific IgG production while also reducing IgE levels, as well as promoting differentiation and activation of different immune cells. In the future, better understanding of the immunological mechanisms underlying the effects of these adjuvants in clinical settings may help us to improve AIT.
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Affiliation(s)
- Yen-Ju Lin
- Section Molecular Allergology, Paul-Ehrlich-Institut, Langen, Germany
| | | | - Stefan Schülke
- Section Molecular Allergology, Paul-Ehrlich-Institut, Langen, Germany
- Section Research Allergology (ALG 5), Division of Allergology, Paul-Ehrlich-Institut, Langen, Germany
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Rispens T, Huijbers MG. The unique properties of IgG4 and its roles in health and disease. Nat Rev Immunol 2023; 23:763-778. [PMID: 37095254 PMCID: PMC10123589 DOI: 10.1038/s41577-023-00871-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/26/2023]
Abstract
IgG4 is the least abundant subclass of IgG in human serum and has unique functional features. IgG4 is largely unable to activate antibody-dependent immune effector responses and, furthermore, undergoes Fab (fragment antigen binding)-arm exchange, rendering it bispecific for antigen binding and functionally monovalent. These properties of IgG4 have a blocking effect, either on the immune response or on the target protein of IgG4. In this Review, we discuss the unique structural characteristics of IgG4 and how these contribute to its roles in health and disease. We highlight how, depending on the setting, IgG4 responses can be beneficial (for example, in responses to allergens or parasites) or detrimental (for example, in autoimmune diseases, in antitumour responses and in anti-biologic responses). The development of novel models for studying IgG4 (patho)physiology and understanding how IgG4 responses are regulated could offer insights into novel treatment strategies for these IgG4-associated disease settings.
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Affiliation(s)
- Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Maartje G Huijbers
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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5
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Correa A, Miranda J, Oliveira L, Moreira P, Vieira F, Cunha-Junior J, Resende R, Taketomi E. Identification of carboxymethyl (CM)-binding proteins derived from Lolium multiflorum pollen extract and antibody reactivity in Brazilian allergic patients. Braz J Med Biol Res 2023; 56:e12957. [PMID: 37851792 PMCID: PMC10578120 DOI: 10.1590/1414-431x2023e12957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Lolium multiflorum grass is the major pollen allergen source in the southern region of Brazil, but most of its allergens remain poorly characterized. The aim of this study was to investigate antibody reactivity to L. multiflorum crude and carboxymethyl-ligand extracts in allergic patients and healthy individuals. Ion exchange carboxymethyl (CM) chromatography (CM-Sepharose) was used to isolate proteins (S2) from L. multiflorum crude extract (S1), which were assessed by SDS-PAGE. S1- and S2-specific IgE and IgG4 levels were measured by ELISA using sera from 55 atopic and 16 non-atopic subjects. Reactive polypeptide bands in S1 and S2 were detected by immunoblotting, and the most prominent bands in S2 were analyzed by mass spectrometry (MS-MS). Similar IgE and IgG4 levels were observed to both S1 (IgE median absorbance: 1.22; IgG4 median absorbance: 0.68) and S2 (IgE median absorbance: 1.26; IgG4 median absorbance: 0.85) in atopic subjects. S1 and S2 had positive correlations for IgE and IgG4 (IgE: r=0.9567; IgG4: r=0.9229; P<0.0001) levels. Homology between S1 and S2 was confirmed by IgE (84%) and IgG4 (83%) inhibition. Immunoblotting revealed that the 29-32 kDa band was recognized by 100% of atopic subjects in both S1 and S2. MS-MS analysis identified similarity profile to groups 1 and 5 grass allergens. This study revealed that carboxymethyl-ligand fraction played an important role for pollen allergy diagnosis by containing clinically relevant allergens and constituted a promising candidate for allergen-specific immunotherapy.
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Affiliation(s)
- A.S. Correa
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - J.S. Miranda
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - L.A.R. Oliveira
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - P.F.S. Moreira
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - F.A.M. Vieira
- Departamento de Medicina, Universidade de Caxias do Sul, Caxias do Sul, RS, Brasil
| | - J.P. Cunha-Junior
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - R.O. Resende
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
- Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro, RJ, Brasil
| | - E.A. Taketomi
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
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Dissection of Antibody Responses of Gam-COVID-Vac-Vaccinated Subjects Suggests Involvement of Epitopes Outside RBD in SARS-CoV-2 Neutralization. Int J Mol Sci 2023; 24:ijms24065104. [PMID: 36982183 PMCID: PMC10049224 DOI: 10.3390/ijms24065104] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/14/2023] Open
Abstract
Millions of people have been vaccinated with Gam-COVID-Vac but fine specificities of induced antibodies have not been fully studied. Plasma from 12 naïve and 10 coronavirus disease 2019 (COVID-19) convalescent subjects was obtained before and after two immunizations with Gam-COVID-Vac. Antibody reactivity in the plasma samples (n = 44) was studied on a panel of micro-arrayed recombinant folded and unfolded severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) proteins and 46 peptides spanning the spike protein (S) and by immunoglobulin G (IgG) subclass enzyme-linked immunosorbent assay (ELISA). The ability of Gam-COVID-Vac-induced antibodies to inhibit binding of the receptor-binding domain (RBD) to its receptor angiotensin converting enzyme 2 (ACE2) was investigated in a molecular interaction assay (MIA). The virus-neutralizing capacity of antibodies was studied by the pseudo-typed virus neutralization test (pVNT) for Wuhan-Hu-1 and Omicron. We found that Gam-COVID-Vac vaccination induced significant increases of IgG1 but not of other IgG subclasses against folded S, spike protein subunit 1 (S1), spike protein subunit 2 (S2), and RBD in a comparable manner in naïve and convalescent subjects. Virus neutralization was highly correlated with vaccination-induced antibodies specific for folded RBD and a novel peptide (i.e., peptide 12). Peptide 12 was located close to RBD in the N-terminal part of S1 and may potentially be involved in the transition of the pre- to post-fusion conformation of the spike protein. In summary, Gam-COVID-Vac vaccination induced S-specific IgG1 antibodies in naive and convalescent subjects in a comparable manner. Besides the antibodies specific for RBD, the antibodies induced against a peptide close to the N-terminus of RBD were also associated with virus-neutralization.
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7
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Ghosh N, Sircar G, Saha S. Computational Vaccine Design for Common Allergens. Methods Mol Biol 2023; 2673:505-513. [PMID: 37258935 DOI: 10.1007/978-1-0716-3239-0_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In this chapter, the steps of designing candidate vaccine molecules for allergen-specific immunotherapy (AIT) using immunoinformatics are described. The most modern approach of AIT deals with carrier-bound B cell epitope and multi-epitope vaccine molecules. The strategy for designing these molecules and the bioinformatics tools and servers used for that are discussed in detail here.
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Affiliation(s)
- Nandini Ghosh
- Department of Microbiology, Vidyasagar University, Midnapore, West Bengal, India
| | - Gaurab Sircar
- Institute of Health Sciences, Presidency University (Newtown Campus), Kolkata, West Bengal, India
| | - Sudipto Saha
- Division of Bioinformatics, Bose Institute, Unified Campus Salt Lake, College More, Kolkata, West Bengal, India.
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8
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Potapova E, Bordas-Le Floch V, Schlederer T, Vrtala S, Huang HJ, Canonica GW, Valenta R, Matricardi PM, Mascarell L. Molecular reactivity profiling upon immunotherapy with a 300 IR sublingual house dust mite tablet reveals marked humoral changes towards major allergens. Allergy 2022; 77:3084-3095. [PMID: 35474582 DOI: 10.1111/all.15327] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/21/2022] [Accepted: 03/30/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Molecular antibody reactivity profiles have not yet been studied in depth in patients treated by sublingual house dust mite (HDM) tablet immunotherapy. Humoral immune responses to a large panel of HDM mite allergens were studied using allergen microarray technology in a subset of clinically defined high and low responder patients from a double-blind placebo-controlled allergen-specific immunotherapy (AIT) trial using sublingual 300 IR HDM tablets. METHODS Serum levels of IgE, IgG and IgG4 to 13 Dermatophagoides pteronyssinus molecules were measured at baseline and after 1-year AIT, using allergen microarrays in 100 subjects exhibiting high or low clinical benefit. RESULTS Der p 1, Der p 2 and Der p 23 were the most frequently recognized allergens in the study population. Patients with HDM-related asthma had significantly higher allergen-specific IgE levels to Der p 1 and Der p 23. No significant difference in the distribution of allergen sensitization pattern was observed between high and low responders. An increase in serum allergen-specific IgG and IgG4 occurred upon AIT, in particular to allergens Der p 1, Der p 2 and Der p 23 (p < 0.0001). CONCLUSIONS We confirm for our study population that Der p 1- and Der p 23-specific IgE levels are associated with asthma. IgE reactivity profiles were not predicitive of sublingual AIT outcomes, with 300 IR tablets as efficacious in pauci- and multi-sensitized subjects. Our study is the first to demonstrate the induction of IgG and IgG4 specific for the HDM allergens Der p 1, Der p 2 and Der p 23 by sublingual AIT.
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Affiliation(s)
- Ekaterina Potapova
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Thomas Schlederer
- Department of Pathophysiology and Allergy Research, Division of Immunopathology, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna and Krems, Austria
| | - Susanne Vrtala
- Department of Pathophysiology and Allergy Research, Division of Immunopathology, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna and Krems, Austria
| | - Huey-Jy Huang
- Department of Pathophysiology and Allergy Research, Division of Immunopathology, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna and Krems, Austria
| | - Giorgio W Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | - Rudolf Valenta
- Department of Pathophysiology and Allergy Research, Division of Immunopathology, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna and Krems, Austria.,NRC Institute of Immunology, Federal Biomedical Agency of Russia, Moscow, Russia.,Department of Clinical Immunology and Allergy, Sechenov First State Medical University, Moscow, Russia.,Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Paolo M Matricardi
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Kratzer B, Schlax LC, Gattinger P, Waidhofer‐Söllner P, Trapin D, Tauber PA, Sehgal ANA, Körmöczi U, Rottal A, Feichter M, Oberhofer T, Grabmeier‐Pfistershammer K, Borochova K, Dorofeeva Y, Tulaeva I, Weber M, Mühl B, Kropfmüller A, Negrin B, Kundi M, Valenta R, Pickl WF. Combined assessment of S- and N-specific IL-2 and IL-13 secretion and CD69 neo-expression for discrimination of post-infection and post-vaccination cellular SARS-CoV-2-specific immune response. Allergy 2022; 77:3408-3425. [PMID: 35690994 PMCID: PMC9348018 DOI: 10.1111/all.15406] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Antibody-based tests are available for measuring SARS-CoV-2-specific immune responses but fast T-cell assays remain scarce. Robust T cell-based tests are needed to differentiate specific cellular immune responses after infection from those after vaccination. METHODS One hundred seventeen individuals (COVID-19 convalescent patients: n = 40; SARS-CoV-2 vaccinees: n = 41; healthy controls: n = 36) were evaluated for SARS-CoV-2-specific cellular immune responses (proliferation, Th1, Th2, Th17, and inflammatory cytokines, activation-induced marker [AIM] expression) by incubating purified peripheral blood mononuclear cells (PBMC) or whole blood (WB) with SARS-CoV-2 peptides (S, N, or M), vaccine antigens (tetanus toxoid, tick borne encephalitis virus) or polyclonal stimuli (Staphylococcal enterotoxin, phytohemagglutinin). RESULTS N-peptide mix stimulation of WB identified the combination of IL-2 and IL-13 secretion as superior to IFN-γ secretion to discriminate between COVID-19-convalescent patients and healthy controls (p < .0001). Comparable results were obtained with M- or S-peptides, the latter almost comparably recalled IL-2, IFN-γ, and IL-13 responses in WB of vaccinees. Analysis 10 months as opposed to 10 weeks after COVID-19, but not allergic disease status, positively correlated with IL-13 recall responses. WB cytokine responses correlated with cytokine and proliferation responses of PBMC. Antigen-induced neo-expression of the C-type lectin CD69 on CD4+ (p < .0001) and CD8+ (p = .0002) T cells informed best about the SARS-CoV-2 exposure status with additional benefit coming from CD25 upregulation. CONCLUSION Along with N- and S-peptide-induced IL-2 and CD69 neo-expression, we suggest to include the type 2 cytokine IL-13 as T-cellular recall marker for SARS-CoV-2 specific T-cellular immune responses after infection and vaccination.
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Affiliation(s)
- Bernhard Kratzer
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Larissa C. Schlax
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Pia Gattinger
- Medical University of ViennaCenter for Pathophysiology, Infectiology and ImmunologyDepartment of Pathophysiology and Allergy ResearchViennaAustria
| | - Petra Waidhofer‐Söllner
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Doris Trapin
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Peter A. Tauber
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Al Nasar Ahmed Sehgal
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Ulrike Körmöczi
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Arno Rottal
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Melanie Feichter
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | - Teresa Oberhofer
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria
| | | | - Kristina Borochova
- Medical University of ViennaCenter for Pathophysiology, Infectiology and ImmunologyDepartment of Pathophysiology and Allergy ResearchViennaAustria
| | - Yulia Dorofeeva
- Medical University of ViennaCenter for Pathophysiology, Infectiology and ImmunologyDepartment of Pathophysiology and Allergy ResearchViennaAustria
| | - Inna Tulaeva
- Medical University of ViennaCenter for Pathophysiology, Infectiology and ImmunologyDepartment of Pathophysiology and Allergy ResearchViennaAustria,I. M. Sechenov First Moscow State Medical University (Sechenov University)Department of Clinical Immunology and AllergologyLaboratory for ImmunopathologyMoscowRussia
| | - Milena Weber
- Medical University of ViennaCenter for Pathophysiology, Infectiology and ImmunologyDepartment of Pathophysiology and Allergy ResearchViennaAustria
| | | | | | - Bettina Negrin
- Österreichische Gesundheitskasse, Klinikum PeterhofBadenAustria
| | - Michael Kundi
- Medical University of ViennaCenter for Public HealthDepartment for Environmental HealthViennaAustria
| | - Rudolf Valenta
- Medical University of ViennaCenter for Pathophysiology, Infectiology and ImmunologyDepartment of Pathophysiology and Allergy ResearchViennaAustria,I. M. Sechenov First Moscow State Medical University (Sechenov University)Department of Clinical Immunology and AllergologyLaboratory for ImmunopathologyMoscowRussia,NRC Institute of Immunology FMBA of RussiaMoscowRussia,Karl Landsteiner University of Health SciencesKremsAustria
| | - Winfried F. Pickl
- Medical University of ViennaCenter for PathophysiologyInfectiology and ImmunologyInstitute of ImmunologyViennaAustria,Karl Landsteiner University of Health SciencesKremsAustria
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10
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Gattinger P, Kratzer B, Tulaeva I, Niespodziana K, Ohradanova‐Repic A, Gebetsberger L, Borochova K, Garner‐Spitzer E, Trapin D, Hofer G, Keller W, Baumgartner I, Tancevski I, Khaitov M, Karaulov A, Stockinger H, Wiedermann U, Pickl W, Valenta R. Vaccine based on folded RBD-PreS fusion protein with potential to induce sterilizing immunity to SARS-CoV-2 variants. Allergy 2022; 77:2431-2445. [PMID: 35357709 PMCID: PMC9111473 DOI: 10.1111/all.15305] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/28/2022] [Accepted: 03/07/2022] [Indexed: 12/28/2022]
Abstract
Background Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is responsible for the ongoing global COVID‐19 pandemic. One possibility to control the pandemic is to induce sterilizing immunity through the induction and maintenance of neutralizing antibodies preventing SARS‐CoV‐2 from entering human cells to replicate in. Methods We report the construction and in vitro and in vivo characterization of a SARS‐CoV‐2 subunit vaccine (PreS‐RBD) based on a structurally folded recombinant fusion protein consisting of two SARS‐CoV‐2 Spike protein receptor‐binding domains (RBD) fused to the N‐ and C‐terminus of hepatitis B virus (HBV) surface antigen PreS to enable the two unrelated proteins serving as immunologic carriers for each other. Results PreS‐RBD, but not RBD alone, induced a robust and uniform RBD‐specific IgG response in rabbits. Currently available genetic SARS‐CoV‐2 vaccines induce mainly transient IgG1 responses in vaccinated subjects whereas the PreS‐RBD vaccine induced RBD‐specific IgG antibodies consisting of an early IgG1 and sustained IgG4 antibody response in a SARS‐CoV‐2 naive subject. PreS‐RBD‐specific IgG antibodies were detected in serum and mucosal secretions, reacted with SARS‐CoV‐2 variants, including the omicron variant of concern and the HBV receptor‐binding sites on PreS of currently known HBV genotypes. PreS‐RBD‐specific antibodies of the immunized subject more potently inhibited the interaction of RBD with its human receptor ACE2 and their virus‐neutralizing titers (VNTs) were higher than median VNTs in a random sample of healthy subjects fully immunized with registered SARS‐CoV‐2 vaccines or in COVID‐19 convalescent subjects. Conclusion The PreS‐RBD vaccine has the potential to serve as a combination vaccine for inducing sterilizing immunity against SARS‐CoV‐2 and HBV by stopping viral replication through the inhibition of cellular virus entry.
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Affiliation(s)
- Pia Gattinger
- Department of Pathophysiology and Allergy Research Division of Immunopathology Center for Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
| | - Bernhard Kratzer
- Center for Pathophysiology, Infectiology and Immunology Institute of Immunology Medical University of Vienna Vienna Austria
| | - Inna Tulaeva
- Department of Pathophysiology and Allergy Research Division of Immunopathology Center for Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
- Laboratory for Immunopathology Department of Clinical Immunology and Allergology Sechenov First Moscow State Medical University Moscow Russia
| | - Katarzyna Niespodziana
- Department of Pathophysiology and Allergy Research Division of Immunopathology Center for Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
- Karl Landsteiner University of Health Sciences Krems Austria
| | - Anna Ohradanova‐Repic
- Center for Pathophysiology, Infectiology and Immunology Institute for Hygiene and Applied Immunology Medical University of Vienna Vienna Austria
| | - Laura Gebetsberger
- Center for Pathophysiology, Infectiology and Immunology Institute for Hygiene and Applied Immunology Medical University of Vienna Vienna Austria
| | - Kristina Borochova
- Department of Pathophysiology and Allergy Research Division of Immunopathology Center for Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
| | - Erika Garner‐Spitzer
- Institute of Specific Prophylaxis and Tropical Medicine Medical University of Vienna Vienna Austria
| | - Doris Trapin
- Center for Pathophysiology, Infectiology and Immunology Institute of Immunology Medical University of Vienna Vienna Austria
| | - Gerhard Hofer
- Department of Materials and Environmental Chemistry University of Stockholm Stockholm Sweden
| | - Walter Keller
- Institute of Molecular Biosciences, BioTechMed Graz University of Graz Graz Austria
| | | | - Ivan Tancevski
- Department of Internal Medicine II Medical University of Innsbruck Innsbruck Austria
| | - Musa Khaitov
- NRC Institute of Immunology FMBA of Russia Moscow Russia
- Pirogov Russian National Research Medical University Moscow Russia
| | - Alexander Karaulov
- Laboratory for Immunopathology Department of Clinical Immunology and Allergology Sechenov First Moscow State Medical University Moscow Russia
| | - Hannes Stockinger
- Center for Pathophysiology, Infectiology and Immunology Institute for Hygiene and Applied Immunology Medical University of Vienna Vienna Austria
| | - Ursula Wiedermann
- Institute of Specific Prophylaxis and Tropical Medicine Medical University of Vienna Vienna Austria
| | - Winfried F. Pickl
- Center for Pathophysiology, Infectiology and Immunology Institute of Immunology Medical University of Vienna Vienna Austria
- Karl Landsteiner University of Health Sciences Krems Austria
| | - Rudolf Valenta
- Department of Pathophysiology and Allergy Research Division of Immunopathology Center for Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
- Laboratory for Immunopathology Department of Clinical Immunology and Allergology Sechenov First Moscow State Medical University Moscow Russia
- Karl Landsteiner University of Health Sciences Krems Austria
- NRC Institute of Immunology FMBA of Russia Moscow Russia
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11
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Allergen Immunotherapy: Current and Future Trends. Cells 2022; 11:cells11020212. [PMID: 35053328 PMCID: PMC8774202 DOI: 10.3390/cells11020212] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 02/06/2023] Open
Abstract
Allergen immunotherapy (AIT) is the sole disease-modifying treatment for allergic rhinitis; it prevents rhinitis from progressing to asthma and lowers medication use. AIT against mites, insect venom, and certain kinds of pollen is effective. The mechanism of action of AIT is based on inducing immunological tolerance characterized by increased IL-10, TGF-β, and IgG4 levels and Treg cell counts. However, AIT requires prolonged schemes of administration and is sometimes associated with adverse reactions. Over the last decade, novel forms of AIT have been developed, focused on better allergen identification, structural modifications to preserve epitopes for B or T cells, post-traductional alteration through chemical processes, and the addition of adjuvants. These modified allergens induce clinical-immunological effects similar to those mentioned above, increasing the tolerance to other related allergens but with fewer side effects. Clinical studies have shown that molecular AIT is efficient in treating grass and birch allergies. This article reviews the possibility of a new AIT to improve the treatment of allergic illness.
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12
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Abstract
Food allergy is a hypersensitivity reaction to food products initiated by immunologic mechanisms, which represents one of the major concerns in food safety. New therapies for food allergies including oral and epicutaneous allergen-specific immunotherapy are required, and B cell epitope-based allergy vaccines are a good promise to improve this field. In this chapter, we describe a workflow for the design of food allergy vaccines using proteomic tools. The strategy is defined based on the characterization of B cell epitopes for a particular food allergen. For that, the workflow comprises five consecutive steps: (1) shotgun proteomics analysis of different protein isoforms for a particular food allergen, (2) downloading all protein sequences for the specific allergen included in UniProtKB database, (3) analysis by protein-based bioinformatics of B cell epitopes, (4) synthesizing of the selected B cell peptide epitopes, and (5) performing of immunoassays using sera from healthy and allergic patients. The results from this method provide a rationale repository of B cell epitopes for the design of new specific immunotherapies for a particular food allergen. The strategy was optimized for all the beta-parvalbumins (β-PRVBs), which are considered as the main fish allergens. Using this workflow, a total of 35 peptides were identified as B cell epitopes, among them the top 4 B cell peptide epitopes that may induce protective immune response were selected as potential peptide vaccine candidates for fish allergy.
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Affiliation(s)
- Mónica Carrera
- Department of Food Technology, Spanish National Research Council (CSIC), Institute of Marine Research (IIM), Pontevedra, Spain
| | - Susana Magadán
- Biomedical Research Center (CINBIO), Universidade de Vigo, Immunology, Pontevedra, Spain.
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13
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Xu Y, Guan K, Sha L, Zhang J, Niu Y, Yin J, Wang L. Sensitization Profiles of Timothy Grass Pollen in Northern China. J Asthma Allergy 2021; 14:1431-1439. [PMID: 34876820 PMCID: PMC8643203 DOI: 10.2147/jaa.s334183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Grass pollen is an important cause of IgE-mediated allergy in countries worldwide, especially within Europe. However, there has been no research on grass pollen allergy in northern China. We aimed to determine the status of grass pollen allergy and the sensitization patterns to Phleum pratense (P. pratense) in northern China. Patients and Methods Pollen data were collected for three geographic areas (Beijing, Shenmu, Shizuishan) in northern China. The study enrolled 101 patients (62 men; age range, 1–64 years; median age, 10 years) who had allergic rhinoconjunctivitis and/or asthma during the grass pollen season and positive skin prick test results positive to P. pratense. Serum-specific IgE (sIgE) against Phl p 1, Phl p 2, Phl p 5, Phl p 6, Phl p 7, Phl p 12 was measured by ImmunoCAP. Results The pollen season of P. pratense was from June to September in Beijing, May to September in Shenmu and July to August in Shizuishan. P. pratense pollen accounted for 2–3% of the annual pollen index of total pollen counts. Among 101 patients with positive skin prick test results to P. pratense, 72% had detectable sIgE to P. pratense. Phl p 12 was the most frequently recognized component (45%), followed by Phl p 1 (22%), Phl p 5 (14%), Phl p 6 (8%) and Phl p 7 (3%). No patients had sIgE to Phl p 2. Ten sensitization patterns to the six components were observed. High rate of sIgE to Phl p 12 was positively correlated with co-sensitization to weed or tree pollen. Conclusion Considering the pollen concentration, P. pratense was a minor pollen allergen in northern China and its pollen season overlapped with that of weed pollen. IgE sensitization to P. pratense was likely to be induced by cross-reactivity between grass pollen allergy and weed/tree pollen allergy.
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Affiliation(s)
- Yingyang Xu
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China.,Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Beijing, 100730, People's Republic of China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, People's Republic of China
| | - Kai Guan
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China.,Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Beijing, 100730, People's Republic of China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, People's Republic of China
| | - Li Sha
- Department of Allergy, Capital Institute of Pediatrics, Beijing, 100020, People's Republic of China
| | - Jinghong Zhang
- Department of Allergy, The No.1 People's Hospital of Shizuishan, Shizuishan, 753000, Ningxia Hui Autonomous Region, People's Republic of China
| | - Yongliang Niu
- Department of Respiratory and Critical Care Medicine, Shenmu Hospital, Shenmu, 719300, Shanxi, People's Republic of China
| | - Jia Yin
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China.,Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Beijing, 100730, People's Republic of China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, People's Republic of China
| | - Lianglu Wang
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China.,Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Beijing, 100730, People's Republic of China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, People's Republic of China
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14
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Fuhrmann V, Huang HJ, Akarsu A, Shilovskiy I, Elisyutina O, Khaitov M, van Hage M, Linhart B, Focke-Tejkl M, Valenta R, Sekerel BE. From Allergen Molecules to Molecular Immunotherapy of Nut Allergy: A Hard Nut to Crack. Front Immunol 2021; 12:742732. [PMID: 34630424 PMCID: PMC8496898 DOI: 10.3389/fimmu.2021.742732] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/23/2021] [Indexed: 12/02/2022] Open
Abstract
Peanuts and tree nuts are two of the most common elicitors of immunoglobulin E (IgE)-mediated food allergy. Nut allergy is frequently associated with systemic reactions and can lead to potentially life-threatening respiratory and circulatory symptoms. Furthermore, nut allergy usually persists throughout life. Whether sensitized patients exhibit severe and life-threatening reactions (e.g., anaphylaxis), mild and/or local reactions (e.g., pollen-food allergy syndrome) or no relevant symptoms depends much on IgE recognition of digestion-resistant class I food allergens, IgE cross-reactivity of class II food allergens with respiratory allergens and clinically not relevant plant-derived carbohydrate epitopes, respectively. Accordingly, molecular allergy diagnosis based on the measurement of allergen-specific IgE levels to allergen molecules provides important information in addition to provocation testing in the diagnosis of food allergy. Molecular allergy diagnosis helps identifying the genuinely sensitizing nuts, it determines IgE sensitization to class I and II food allergen molecules and hence provides a basis for personalized forms of treatment such as precise prescription of diet and allergen-specific immunotherapy (AIT). Currently available forms of nut-specific AIT are based only on allergen extracts, have been mainly developed for peanut but not for other nuts and, unlike AIT for respiratory allergies which utilize often subcutaneous administration, are given preferentially by the oral route. Here we review prevalence of allergy to peanut and tree nuts in different populations of the world, summarize knowledge regarding the involved nut allergen molecules and current AIT approaches for nut allergy. We argue that nut-specific AIT may benefit from molecular subcutaneous AIT (SCIT) approaches but identify also possible hurdles for such an approach and explain why molecular SCIT may be a hard nut to crack.
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Affiliation(s)
- Verena Fuhrmann
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Huey-Jy Huang
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Aysegul Akarsu
- Division of Allergy and Asthma, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Igor Shilovskiy
- Laboratory for Molecular Allergology, National Research Center (NRC) Institute of Immunology Federal Medical-Biological Agency (FMBA) of Russia, Moscow, Russia
| | - Olga Elisyutina
- Laboratory for Molecular Allergology, National Research Center (NRC) Institute of Immunology Federal Medical-Biological Agency (FMBA) of Russia, Moscow, Russia
| | - Musa Khaitov
- Laboratory for Molecular Allergology, National Research Center (NRC) Institute of Immunology Federal Medical-Biological Agency (FMBA) of Russia, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Marianne van Hage
- Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University, Hospital, Stockholm, Sweden
| | - Birgit Linhart
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Margarete Focke-Tejkl
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Rudolf Valenta
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
- Laboratory for Molecular Allergology, National Research Center (NRC) Institute of Immunology Federal Medical-Biological Agency (FMBA) of Russia, Moscow, Russia
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Bulent Enis Sekerel
- Division of Allergy and Asthma, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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15
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Petrova SY, Khlgatian SV, Svirshchevskaya EV, Vasilyeva AV, Berzhets VM. DNA vaccines and recombinant allergens with reduced allergenic activity treat allergies. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This review is intended to familiarize readers with major novel directions of developing allergy vaccines, their structure, as well as the mechanisms of forming a new immunological response in the course of the treating immunoglobulin E (IgE)-mediated allergic diseases. Currently, science offers a huge variety of new experimental forms of recombinant allergens with reduced allergenic activity and increased immunogenicity, or vice-versa, immune tolerance. Often, the mechanisms of their effect on the immune system are not fully understood. Scientific publications, including reviews covering this topic, allowed us identifying top priority areas in the development of allergy vaccines: recombinant hypoallergenic allergen derivatives, T cell epitope-based allergy vaccines, and B cell epitope-based allergy vaccines. In addition, the review discusses use of deoxyribonucleic acid (DNA) vaccines. Immunotherapy with DNA vaccines is the newest and least studied method of treating allergic diseases.
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Affiliation(s)
| | | | - Elena V. Svirshchevskaya
- M.M. Shemyakin – Yu.A. Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences
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16
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Jensen-Jarolim E, Roth-Walter F, Jordakieva G, Pali-Schöll I. Allergens and Adjuvants in Allergen Immunotherapy for Immune Activation, Tolerance, and Resilience. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1780-1789. [PMID: 33753052 DOI: 10.1016/j.jaip.2020.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 11/25/2022]
Abstract
Allergen immunotherapy (AIT) is the only setting in which a vaccine is applied in patients allergic exactly to the active principle in the vaccine. Therefore, AIT products need to be not only effective but also safe. In Europe, for subcutaneous AIT, this has been achieved by the allergoid strategy in which IgE epitopes are destroyed or masked. In addition, adjuvants physically precipitate the allergen at the injection site to prevent too rapid systemic distribution. The choice of adjuvant critically shapes the efficacy and type of immune response to the injected allergen. In contrast to TH2-promoting adjuvants, others clearly counteract allergy. Marketed products in Europe are formulated with aluminum hydroxide (alum) (66.7%), microcrystalline tyrosine (16.7%), calcium phosphate (11.1%), or the TH1 adjuvant monophosphoryl lipid A (5.6%). In contrast to the European practice, in the United States mostly nonadjuvanted extracts and no allergoids are used for subcutaneous AIT, highlighting not only a regulatory but maybe a "historic preference." Sublingual AIT in the form of drops or tablets is currently applied worldwide without adjuvants, usually with higher safety but lower patient adherence than subcutaneous AIT. This article will discuss how AIT and adjuvants modulate the immune response in the treated patient toward immune activation, modulation, or-with new developments in the pipeline-immune resilience.
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Affiliation(s)
- Erika Jensen-Jarolim
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University Vienna, Vienna, Austria; The Interuniversity Messerli Research Institute, University of Veterinary Medicine Vienna, Medical University of Vienna, University Vienna, Vienna, Austria.
| | - Franziska Roth-Walter
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University Vienna, Vienna, Austria; The Interuniversity Messerli Research Institute, University of Veterinary Medicine Vienna, Medical University of Vienna, University Vienna, Vienna, Austria
| | - Galateja Jordakieva
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Isabella Pali-Schöll
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University Vienna, Vienna, Austria; The Interuniversity Messerli Research Institute, University of Veterinary Medicine Vienna, Medical University of Vienna, University Vienna, Vienna, Austria
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17
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Huang HJ, Campana R, Akinfenwa O, Curin M, Sarzsinszky E, Karsonova A, Riabova K, Karaulov A, Niespodziana K, Elisyutina O, Fedenko E, Litovkina A, Smolnikov E, Khaitov M, Vrtala S, Schlederer T, Valenta R. Microarray-Based Allergy Diagnosis: Quo Vadis? Front Immunol 2021; 11:594978. [PMID: 33679689 PMCID: PMC7928321 DOI: 10.3389/fimmu.2020.594978] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/08/2020] [Indexed: 12/24/2022] Open
Abstract
More than 30% of the world population suffers from allergy. Allergic individuals are characterized by the production of immunoglobulin E (IgE) antibodies against innocuous environmental allergens. Upon allergen recognition IgE mediates allergen-specific immediate and late-phase allergic inflammation in different organs. The identification of the disease-causing allergens by demonstrating the presence of allergen-specific IgE is the key to precision medicine in allergy because it allows tailoring different forms of prevention and treatment according to the sensitization profiles of individual allergic patients. More than 30 years ago molecular cloning started to accelerate the identification of the disease-causing allergen molecules and enabled their production as recombinant molecules. Based on recombinant allergen molecules, molecular allergy diagnosis was introduced into clinical practice and allowed dissecting the molecular sensitization profiles of allergic patients. In 2002 it was demonstrated that microarray technology allows assembling large numbers of allergen molecules on chips for the rapid serological testing of IgE sensitizations with small volumes of serum. Since then microarrayed allergens have revolutionized research and diagnosis in allergy, but several unmet needs remain. Here we show that detection of IgE- and IgG-reactivity to a panel of respiratory allergens microarrayed onto silicon elements is more sensitive than glass-based chips. We discuss the advantages of silicon-based allergen microarrays and how this technology will allow addressing hitherto unmet needs in microarray-based allergy diagnosis. Importantly, it described how the assembly of silicon microarray elements may create different microarray formats for suiting different diagnostic applications such as quick testing of single patients, medium scale testing and fully automated large scale testing.
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Affiliation(s)
- Huey-Jy Huang
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Raffaela Campana
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Oluwatoyin Akinfenwa
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Mirela Curin
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Eszter Sarzsinszky
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Antonina Karsonova
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ksenja Riabova
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexander Karaulov
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Katarzyna Niespodziana
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Olga Elisyutina
- Department of Allergology and Clinical Immunology, NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Elena Fedenko
- Department of Allergology and Clinical Immunology, NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Alla Litovkina
- Department of Allergology and Clinical Immunology, NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Evgenii Smolnikov
- Department of Allergology and Clinical Immunology, NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Musa Khaitov
- Department of Allergology and Clinical Immunology, NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Susanne Vrtala
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlederer
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Rudolf Valenta
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.,Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Allergology and Clinical Immunology, NRC Institute of Immunology FMBA of Russia, Moscow, Russia.,Karl Landsteiner University of Health Sciences, Krems, Austria
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18
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Akinfenwa O, Rodríguez-Domínguez A, Vrtala S, Valenta R, Campana R. Novel vaccines for allergen-specific immunotherapy. Curr Opin Allergy Clin Immunol 2021; 21:86-99. [PMID: 33369572 PMCID: PMC7810419 DOI: 10.1097/aci.0000000000000706] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Allergen-specific immunotherapy (AIT) is a highly economic, effective and disease-modifying form of allergy treatment but requires accurate prescription and monitoring. New molecular approaches are currently under development to improve AIT by reducing treatment-related side effects, cumbersome protocols and patients' compliance. We review the current advances regarding refined diagnosis for prescription and monitoring of AIT and the development of novel molecular vaccines for AIT. Finally, we discuss prophylactic application of AIT. RECENT FINDINGS There is evidence that molecular allergy diagnosis not only assists in the prescription and monitoring of AIT but also allows a refined selection of patients to increase the likelihood of treatment success. New data regarding the effects of AIT treatment with traditional allergen extracts by alternative routes have become available. Experimental approaches for AIT, such as virus-like particles and cell-based treatments have been described. New results from clinical trials performed with recombinant hypoallergens and passive immunization with allergen-specific antibodies highlight the importance of allergen-specific IgG antibodies for the effect of AIT and indicate opportunities for preventive allergen-specific vaccination. SUMMARY Molecular allergy diagnosis is useful for the prescription and monitoring of AIT and may improve the success of AIT. Results with molecular allergy vaccines and by passive immunization with allergen-specific IgG antibodies indicate the importance of allergen-specific IgG capable of blocking allergen recognition by IgE and IgE-mediated allergic inflammation as important mechanism for the success of AIT. New molecular vaccines may pave the road towards prophylactic allergen-specific vaccination.
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Affiliation(s)
- Oluwatoyin Akinfenwa
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Azahara Rodríguez-Domínguez
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Susanne Vrtala
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Rudolf Valenta
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
- NRC Institute of Immunology FMBA of Russia
- Laboratory for Immunopathology, Department of Clinical Immunology and Allergy, Sechenov First Moscow State Medical University, Moscow, Russia
- Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Raffaela Campana
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
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19
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Dorofeeva Y, Shilovskiy I, Tulaeva I, Focke‐Tejkl M, Flicker S, Kudlay D, Khaitov M, Karsonova A, Riabova K, Karaulov A, Khanferyan R, Pickl WF, Wekerle T, Valenta R. Past, present, and future of allergen immunotherapy vaccines. Allergy 2021; 76:131-149. [PMID: 32249442 PMCID: PMC7818275 DOI: 10.1111/all.14300] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/25/2020] [Accepted: 03/15/2020] [Indexed: 12/21/2022]
Abstract
Allergen-specific immunotherapy (AIT) is an allergen-specific form of treatment for patients suffering from immunoglobulin E (IgE)-associated allergy; the most common and important immunologically mediated hypersensitivity disease. AIT is based on the administration of the disease-causing allergen with the goal to induce a protective immunity consisting of allergen-specific blocking IgG antibodies and alterations of the cellular immune response so that the patient can tolerate allergen contact. Major advantages of AIT over all other existing treatments for allergy are that AIT induces a long-lasting protection and prevents the progression of disease to severe manifestations. AIT is cost effective because it uses the patient´s own immune system for protection and potentially can be used as a preventive treatment. However, broad application of AIT is limited by mainly technical issues such as the quality of allergen preparations and the risk of inducing side effects which results in extremely cumbersome treatment schedules reducing patient´s compliance. In this article we review progress in AIT made from its beginning and provide an overview of the state of the art, the needs for further development, and possible technical solutions available through molecular allergology. Finally, we consider visions for AIT development towards prophylactic application.
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Affiliation(s)
- Yulia Dorofeeva
- Division of ImmunopathologyDepartment of Pathophysiology and Allergy ResearchCenter for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
| | - Igor Shilovskiy
- National Research Center, Institute of immunology, FMBA of RussiaMoscowRussian Federation
| | - Inna Tulaeva
- Division of ImmunopathologyDepartment of Pathophysiology and Allergy ResearchCenter for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
- Department of Clinical Immunology and AllergyLaboratory of ImmunopathologySechenov First Moscow State Medical UniversityMoscowRussian Federation
| | - Margarete Focke‐Tejkl
- Division of ImmunopathologyDepartment of Pathophysiology and Allergy ResearchCenter for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
| | - Sabine Flicker
- Division of ImmunopathologyDepartment of Pathophysiology and Allergy ResearchCenter for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
| | - Dmitriy Kudlay
- National Research Center, Institute of immunology, FMBA of RussiaMoscowRussian Federation
| | - Musa Khaitov
- National Research Center, Institute of immunology, FMBA of RussiaMoscowRussian Federation
| | - Antonina Karsonova
- Department of Clinical Immunology and AllergyLaboratory of ImmunopathologySechenov First Moscow State Medical UniversityMoscowRussian Federation
| | - Ksenja Riabova
- Department of Clinical Immunology and AllergyLaboratory of ImmunopathologySechenov First Moscow State Medical UniversityMoscowRussian Federation
| | - Alexander Karaulov
- Department of Clinical Immunology and AllergyLaboratory of ImmunopathologySechenov First Moscow State Medical UniversityMoscowRussian Federation
| | - Roman Khanferyan
- Department of Immunology and AllergyRussian People’s Friendship UniversityMoscowRussian Federation
| | - Winfried F. Pickl
- Institute of ImmunologyCenter for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
| | - Thomas Wekerle
- Section of Transplantation ImmunologyDepartment of SurgeryMedical University of ViennaViennaAustria
| | - Rudolf Valenta
- Division of ImmunopathologyDepartment of Pathophysiology and Allergy ResearchCenter for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
- National Research Center, Institute of immunology, FMBA of RussiaMoscowRussian Federation
- Department of Clinical Immunology and AllergyLaboratory of ImmunopathologySechenov First Moscow State Medical UniversityMoscowRussian Federation
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20
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Tulaeva I, Cornelius C, Zieglmayer P, Zieglmayer R, Schmutz R, Lemell P, Weber M, Focke-Tejkl M, Karaulov A, Henning R, Valenta R. Quantification, epitope mapping and genotype cross-reactivity of hepatitis B preS-specific antibodies in subjects vaccinated with different dosage regimens of BM32. EBioMedicine 2020; 59:102953. [PMID: 32855110 PMCID: PMC7502672 DOI: 10.1016/j.ebiom.2020.102953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background Chronic hepatitis B virus (HBV) infections are a global health problem. There is a need for therapeutic strategies blocking continuous infection of liver cells. The grass pollen allergy vaccine BM32 containing the preS domain of the large HBV surface protein (LHBs) as immunogenic carrier induced IgG antibodies in human subjects inhibiting HBV infection in vitro. Aim of this study was the quantification, epitope mapping and investigation of HBV genotype cross-reactivity of preS-specific antibodies in subjects treated with different dosage regimens of BM32 Methods Hundred twenty eight grass pollen allergic patients received in a double-blind, placebo-controlled trial five monthly injections of placebo (aluminum hydroxide, n= 34) or different courses of BM32 (2 placebo + 3 BM32, n= 33; 1 placebo + 4 BM32, n= 30; 5 BM32, n= 31). Recombinant Escherichia coli-expressed preS was purified. Overlapping peptides spanning preS and the receptor-binding sites from consensus sequences of genotypes A–H were synthesized and purified. Isotype (IgM, IgG, IgA, IgE) and IgG subclass (IgG1-IgG4) responses to preS and peptides were determined by ELISA at baseline, one and four months after the last injection. IgG1 and IgG4 subclass concentrations specific for preS and the receptor-binding site were measured by quantitative ELISA. Findings Five monthly injections induced the highest levels of preS-specific IgG consisting mainly of IgG1 and IgG4, with a sum of median preS-specific IgG1 and IgG4 concentrations of >135 μg/ml reaching up to 1.8 mg/ml. More than 20% of preS-specific IgG was directed against the receptor-binding site. BM32-induced IgG cross-reacted with the receptor-binding domains from all eight HBV genotypes A-H. Interpretation BM32 induces high levels of IgG1 and IgG4 antibodies against the receptor binding sites of all eight HBV genotypes and hence might be suitable for therapeutic HBV vaccination. Funding This study was supported by the PhD program IAI (KPW01212FW), by Viravaxx AG and by the Danube-ARC funded by the Government of Lower Austria. Rudolf Valenta is a recipient of a Megagrant of the Government of the Russian Federation, grant No 14.W03.31.0024.
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Affiliation(s)
- Inna Tulaeva
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, WähringerGürtel 18-20, 3Q, A-1090 Vienna, Austria; Department of Clinical Immunology and Allergology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Carolin Cornelius
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, WähringerGürtel 18-20, 3Q, A-1090 Vienna, Austria
| | | | | | | | | | - Milena Weber
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, WähringerGürtel 18-20, 3Q, A-1090 Vienna, Austria
| | - Margarete Focke-Tejkl
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, WähringerGürtel 18-20, 3Q, A-1090 Vienna, Austria
| | - Alexander Karaulov
- Department of Clinical Immunology and Allergology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | | | - Rudolf Valenta
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, WähringerGürtel 18-20, 3Q, A-1090 Vienna, Austria; Department of Clinical Immunology and Allergology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation; NRC Institute of Immunology FMBA of Russia, Moscow, Russian Federation; Karl Landsteiner University of Health Sciences, Krems, Austria.
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21
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Tulaeva I, Kratzer B, Campana R, Curin M, van Hage M, Karsonova A, Riabova K, Karaulov A, Khaitov M, Pickl WF, Valenta R. Preventive Allergen-Specific Vaccination Against Allergy: Mission Possible? Front Immunol 2020; 11:1368. [PMID: 32733455 PMCID: PMC7358538 DOI: 10.3389/fimmu.2020.01368] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/28/2020] [Indexed: 12/17/2022] Open
Abstract
Vaccines for infectious diseases have improved the life of the human species in a tremendous manner. The principle of vaccination is to establish de novo adaptive immune response consisting of antibody and T cell responses against pathogens which should defend the vaccinated person against future challenge with the culprit pathogen. The situation is completely different for immunoglobulin E (IgE)-associated allergy, an immunologically-mediated hypersensitivity which is already characterized by increased IgE antibody levels and T cell responses against per se innocuous antigens (i.e., allergens). Thus, allergic patients suffer from a deviated hyper-immunity against allergens leading to inflammation upon allergen contact. Paradoxically, vaccination with allergens, termed allergen-specific immunotherapy (AIT), induces a counter immune response based on the production of high levels of allergen-specific IgG antibodies and alterations of the adaptive cellular response, which reduce allergen-induced symptoms of allergic inflammation. AIT was even shown to prevent the progression of mild to severe forms of allergy. Consequently, AIT can be considered as a form of therapeutic vaccination. In this article we describe a strategy and possible road map for the use of an AIT approach for prophylactic vaccination against allergy which is based on new molecular allergy vaccines. This road map includes the use of AIT for secondary preventive vaccination to stop the progression of clinically silent allergic sensitization toward symptomatic allergy and ultimately the prevention of allergic sensitization by maternal vaccination and/or early primary preventive vaccination of children. Prophylactic allergy vaccination with molecular allergy vaccines may allow halting the allergy epidemics affecting almost 30% of the population as it has been achieved for vaccination against infectious diseases.
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Affiliation(s)
- Inna Tulaeva
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.,Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Bernhard Kratzer
- Center for Pathophysiology, Infectiology and Immunology, Institute of Immunology, Medical University of Vienna, Vienna, Austria
| | - Raffaela Campana
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Mirela Curin
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Marianne van Hage
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Antonina Karsonova
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ksenja Riabova
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexander Karaulov
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Musa Khaitov
- NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Winfried F Pickl
- Center for Pathophysiology, Infectiology and Immunology, Institute of Immunology, Medical University of Vienna, Vienna, Austria
| | - Rudolf Valenta
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.,Laboratory of Immunopathology, Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia.,NRC Institute of Immunology FMBA of Russia, Moscow, Russia.,Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
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