Immunogenicity of liposome-associated and refined antigen oral cholera vaccines in Thai volunteers

Nanoparticles-based technologies for cholera detection and therapy

Cholera is a waterborne disease caused by Vibrio cholerae bacteria generally transmitted through contaminated food or water sources. Although it has been eradicated in most Western countries, cholera continues to be a highly transmitted and lethal disease in several African and Southeast Asian countries. Unfortunately, current diagnostic methods for cholera have challenges including high cost or delayed diagnoses that can lead to increased disease transmission during pandemics, while current treatments such as therapeutic drugs and vaccines have limited efficacy against drug-resistant serogroups of Vibrio cholerae. As such, new solutions that can treat cholera in an efficient manner that avoids Vibrio cholerae's adaptive immunity are needed. Nanoparticles (NPs) are a suitable platform for enhancing current theranostic tools because of their biocompatibility and ability to improve drug circulation and targeting. Nanoparticle surfaces can also be modified with various protein receptors targeting cholera toxins produced by Vibrio cholerae. This review will address recent developments in diagnostics, therapeutics, and prevention against cholera particularly focusing on the use of metal-based nanoparticles and organic nanoparticles. We will then discuss future directions regarding nanoparticle research for cholera.

Oral vaccines for preventing cholera

EDITORIAL NOTE

This review is superseded by the published Cochrane Review, Saif‐Ur‐Rahman 2024 [https://doi.org/10.1002/14651858.CD014573], which considers only the oral killed vaccines because the live oral vaccines do not have World Health Organization (WHO) prequalification. Saif‐Ur‐Rahman 2024 also considered only currently available WHO pre‐qualified oral killed cholera vaccines (Dukoral, Shanchol, and Euvichol/Euvichol‐Plus).

BACKGROUND

Cholera is a cause of acute watery diarrhoea which can cause dehydration and death if not adequately treated. It usually occurs in epidemics, and is associated with poverty and poor sanitation. Effective, cheap, and easy to administer vaccines could help prevent epidemics.

OBJECTIVES

To assess the effectiveness and safety of oral cholera vaccines in preventing cases of cholera and deaths from cholera.

SEARCH STRATEGY

In October 2010, we searched the Cochrane Infectious Disease Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; the metaRegister of Controlled Trials (mRCT), and the WHO International Clinical Trials Registry Platform (ICTRP) for relevant published and ongoing trials.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of oral cholera vaccines in healthy adults and children.

DATA COLLECTION AND ANALYSIS

Each trial was assessed for eligibility and risk of bias by two authors working independently. Data was extracted by two independent reviewers and analysed using the Review Manager 5 software. Outcomes are reported as vaccine protective efficacy (VE) with 95% confidence intervals (CIs).

MAIN RESULTS

Seven large efficacy trials, four small artificial challenge studies, and twenty-nine safety trials contributed data to this review.Five variations of a killed whole cell vaccine have been evaluated in large scale efficacy trials (four trials, 249935 participants). The overall vaccine efficacy during the first year was 52% (95% CI 35% to 65%), and during the second year was 62% (95% CI 51% to 62%). Protective efficacy was lower in children aged less than 5 years; 38% (95% CI 20% to 53%) compared to older children and adults; 66% (95% CI 57% to 73%).One trial of a killed whole cell vaccine amongst military recruits demonstrated 86% protective efficacy (95% CI 37% to 97%) in a small epidemic occurring within 4 weeks of the 2-dose schedule (one trial, 1426 participants). Efficacy data is not available beyond two years for the currently available vaccine formulations, but based on data from older trials is unlikely to last beyond three years.The safety data available on killed whole cell vaccines have not demonstrated any clinically significant increase in adverse events compared to placebo.Only one live attenuated vaccine has reached Phase III clinical evaluation and was not effective (one trial, 67508 participants). Two new candidate live attenuated vaccines have demonstrated clinical effectiveness in small artificial challenge studies, but are still in development.

AUTHORS' CONCLUSIONS

The currently available oral killed whole cell vaccines can prevent 50 to 60% of cholera episodes during the first two years after the primary vaccination schedule. The impact and cost-effectiveness of adopting oral cholera vaccines into the routine vaccination schedule of endemic countries will depend on the prevalence of cholera, the frequency of epidemics, and access to basic services providing rapid rehydration therapy.

Topical and mucosal liposomes for vaccine delivery

Mucosal (and in minor extent transcutanous) stimulation can induce local or distant mucosa secretory IgA. Liposomes and other vesicles as mucosal and transcutaneous adjuvants are attractive alternatives to parenteral vaccination. Liposomes can be massively produced under good manufacturing practices and stored for long periods, at high antigen/vesicle mass ratios. However, their uptake by antigen-presenting cells (APC) at the inductive sites remains as a major challenge. As neurotoxicity is a major concern in intranasal delivery, complexes between archaeosomes and calcium as well as cationic liposomes complexed with plasmids encoding for antigenic proteins could safely elicit secretory and systemic antigen-specific immune responses. Oral bilosomes generate intense immune responses that remain to be tested against challenge, but the admixing with toxins or derivatives is mandatory to reduce the amount of antigen. Most of the current experimental designs, however, underestimate the mucus blanket 100- to 1000-fold thicker than a 100-nm diameter liposome, which has first to be penetrated to access the underlying M cells. Overall, designing mucoadhesive chemoenzymatic resistant liposomes, or selectively targeted to M cells, has produced less relevant results than tailoring the liposomes to make them mucus penetrating. Opposing, the nearly 10 µm thickness stratum corneum interposed between liposomes and underlying APC can be surpassed by ultradeformable liposomes (UDL), with lipid matrices that penetrate up to the limit with the viable epidermis. UDL made of phospholipids and detergents, proved to be better transfection agents than conventional liposomes and niosomes, without the toxicity of ethosomes, in the absence of classical immunomodulators.

Orally delivered malaria vaccines: not too hard to swallow

Vaccines offer efficient and cost-effective protection against a wide range of infectious diseases. Unfortunately, no effective vaccine is yet available against malaria, and this infection remains one of the most important causes of human morbidity and mortality in the developing world. Over the past two decades a number of candidate proteins for inclusion in a subunit vaccine have been identified. Malariologists believe that an effective malaria vaccine will need to include multiple proteins that induce protective immune responses against different stages of the Plasmodium life cycle. The construction of such multivalent vaccines is beset by considerable logistical difficulties, not least of which is how to deliver them to a population living in endemic areas. Compared with other routes of vaccine administration, oral delivery has several advantages that make it an attractive strategy for vaccine development. This review summarises the progress towards an oral vaccine delivery system for malaria and discusses the feasibility of this approach.

Immunization with the recombinant PorB outer membrane protein induces a bactericidal immune response against Neisseria meningitidis

Infections with Neisseria meningitidis are characterized by life-threatening meningitis and septicemia. The meningococcal porin proteins from serogroup B meningococci have been identified as candidates for inclusion in vaccines to prevent such infections. In this study, we investigated the vaccine potential of the PorB porin protein free of other meningococcal components. The porB gene from a strain of Neisseria meningitidis expressing the class 3 outer membrane porin protein (PorB3) was cloned into the pRSETB vector, and the protein was expressed at high levels in a heterologous host Escherichia coli. The recombinant protein was purified to homogeneity by affinity chromatography and used for immunization after incorporation into liposomes and into micelles composed either of zwitterionic detergent or nondetergent sulfobetaine. The immunogenicity of these preparations was compared to recombinant PorB protein adsorbed to Al(OH)(3) adjuvant as a control. Although sera raised against the protein adsorbed to Al(OH)(3) reacted with the purified recombinant protein, sera raised against liposomes and micelles showed greater activity with native protein, as measured by enzyme immunoassay with outer membranes and by whole-cell immunofluorescence. Reactivity with native protein was considerably enhanced by incorporation of the adjuvant monophosphoryl lipid A into the liposome or micelle preparations. Recognition of the native protein was in a serotype-specific manner and was associated with the ability of the antisera to promote high levels of serotype-specific complement-mediated killing of meningococci. These results demonstrate that the PorB protein should be considered as a component of a vaccine designed to prevent serogroup B meningococcal infection.

The development and use of vaccine adjuvants

Interest in vaccine adjuvants is intense and growing, because many of the new subunit vaccine candidates lack sufficient immunogenicity to be clinically useful. In this review, I have emphasized modern vaccine adjuvants injected parenterally, or administered orally, intranasally, or transcutaneously with licensed or experimental vaccines in humans. Every adjuvant has a complex and often multi-factorial immunological mechanism, usually poorly understood in vivo. Many determinants of adjuvanticity exist, and each adjuvanted vaccine is unique. Adjuvant safety is critical and can enhance, retard, or stop development of an adjuvanted vaccine. The choice of an adjuvant often depends upon expensive experimental trial and error, upon cost, and upon commercial availability. Extensive regulatory and administrative support is required to conduct clinical trials of adjuvanted vaccines. Finally, comparative adjuvant trials where one antigen is formulated with different adjuvants and administered by a common protocol to animals and humans can accelerate vaccine development.

Development of hyperfimbriated strains of Vibrio cholerae O1

The Vibrio cholerae O1 and O139 fimbrillin genes (fimA or mshA) were amplified by polymerase chain reaction and cloned into an Escherichia coli pCR vector. These clones were sequenced. The fimA sequences were found to be identical between V cholerae O1 and O139. One of the plasmids was digested with EcoR I and inserted into the EcoR I site of pGEX-3X. The plasmid pVPP thus obtained was transferred into strains of wild-type V cholerae O1 Bgd17 (classical in biotype) and its fimbriated strain by electroporation. The recombinant plasmid pVPP overexpressed mature fimbriae following induction of the tac promoter with isopropyl-beta-D-thiogalactopyranoside. The cloned gene product was purified to homogeneity by sucrose-linear gradient centrifugation (7.8 mg of fimbriae/L-culture). All the properties of the recombinant fimbriae (e.g., subunit structure, hydrophobicity, hemagglutinating activity sensitive to D-mannose and D-glucose and immunogenicity) were identical to those of the wild-type fimbriae. This overexpression system will be extremely useful for rapid, inexpensive preparation of large amounts of fimbriae for vaccine design and development.

Vaccines for preventing cholera

BACKGROUND

Oral cholera vaccines (either killed whole cell or live recombinant vaccines) are newer alternatives to the parenteral vaccines which have been thought to confer only moderate and short-term immunity.

OBJECTIVES

The objective of this review was to assess the effect of cholera vaccines in preventing cases of cholera and preventing deaths.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group trials register, Medline, Embase and reference lists of articles. We handsearched the journal Vaccine, contacted researchers in the field and manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing cholera vaccines (killed or live) with placebo, control vaccines or no intervention, or comparing types, doses or schedules of cholera vaccine. We included adults and children irrespective of immune status or special risk category.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of trial quality was done independently by two reviewers.

MAIN RESULTS

Thirty-two trials were included. Seventeen efficacy trials of relatively good quality, testing parenteral and oral killed whole cell vaccines and involving over 2. 6 million adults, children and infants were included. Nineteen safety trials have been conducted for both types of killed whole cell vaccines and for live vaccines and have involved 11,459 people. For all types of vaccines compared to placebo, the relative risk of contracting cholera at 12 months was 0.49, 95% confidence interval 0. 41 to 0.59 (random effects model). This translates to an efficacy of 51%, 95% confidence interval 41% to 59%. Both parenteral and oral administration were relatively efficacious, but significant protection extended into the third year for oral killed whole cell vaccines. Children under 5 were only protected for up to a year, while older children or adults were protected for up to three years. Parenteral killed whole cell vaccines were associated with increased systemic and local adverse effects compared to placebo. Oral killed whole cell vaccines or oral live vaccines were not.

REVIEWER'S CONCLUSIONS

Cholera killed whole cell vaccines appear to be relatively effective and safe. Live oral recombinant vaccines appear to be safe, but efficacy data are not available. Protection against cholera appears to persist for up to two years following a single dose of vaccine, and for three to four years with an annual booster.