Evolution of immunologic responsiveness of persons living in an area of endemic bancroftian filariasis: a 17-year follow-up

Pre-clinical development of a vaccine for human lymphatic filariasis

This study was conducted to optimize a fusion protein vaccine for translational development as a vaccine against the human tropical parasitic infection, lymphatic filariasis (LF). The vaccine candidate, His-tagged rBmHAXT was developed previously in our laboratory and was tested in various animal models including mouse, gerbils and Rhesus macaque where it exhibited significant levels of vaccine-induced protection. However, for commercial manufacturing and for regulatory approval for human use, there was a need to modify the vaccine antigen and its production and analytical release methods. Therefore, the major focus of this study was to develop a process for manufacturing an affinity tag-free rBmHAXT and evaluate its immunogenicity, potency and protective efficacy in both inbred and outbred mouse models, as well as in outbred gerbil models. Our results demonstrate that the tag-free rBmHAXT vaccine produced with a process suitable for cGMP production had protective properties equivalent to the original His-tagged rBmHAXT.

Advances in Vaccine Development for Human Lymphatic Filariasis

According to the World Health Organization, over 880 million people are currently at risk of acquiring lymphatic filariasis (LF) in over 52 countries worldwide. Current approaches to control LF by 2020 are short of the anticipated goal. Several studies suggest the existence of protective immunity against LF in humans. Thus, it is possible to develop a prophylactic vaccine against LF in humans. Several potential vaccine candidates were identified and tested for their potential against LF. To date, preclinical studies suggest that it is possible to develop a prophylactic vaccine against LF. Much work needs to be done, but it is clear that a prophylactic vaccine, combined with targeted chemotherapy, is critically required for eliminating LF worldwide.

Altered levels of memory T cell subsets and common γc cytokines in Strongyloides stercoralis infection and partial reversal following anthelmintic treatment

BACKGROUND

CD4+ and CD8+ T cells are central players in immunity to helminth infections. However, the role of T cell subsets in human helminth infections is not well understood. In addition, the common γc cytokines, IL-2, IL-4, IL-7, IL-9 and IL-15 play an important role in the maintenance of these CD4+ and CD8+ T cell subsets.

METHODS

To examine the major T cell subsets and their association with the common γc cytokines, the absolute numbers of CD4+ and CD8+ naïve, central memory, effector memory and effector cells and the plasma levels of IL-2, IL-4, IL-7, IL-9 and IL-15 were measured in Strongyloides stercoralis (Ss) infected (INF, n = 60), helminth-uninfected (UN, n = 58) and in post treatment INF individuals.

RESULTS

Ss infection is characterized by significantly increased absolute numbers of naïve and decreased absolute numbers of central and effector memory CD4+ T cells in comparison to UN individuals. No significant difference in the numbers of CD8+ T cell subsets was observed between the groups. The numbers of naïve cells and central memory CD4+ T cells were significantly reversed after anthelmintic treatment. Circulating levels of IL-2, IL-7 and IL-15 were significantly diminished, whereas the levels of IL-4 and IL-9 were significantly increased in INF compared to UN individuals. Following anthelminthic treatment, IL-2, IL-7 and IL-15 levels were significantly increased, while IL-4 and IL-9 levels were significantly decreased. Our data also showed a significant positive correlation between the levels of IL-7 and the numbers of central and effector memory CD4+ T cells.

CONCLUSION

Ss infection is characterized by alterations in the absolute numbers of CD4+ T cell subsets and altered levels of common γc cytokines IL-2, IL-4, IL-7, IL-9 and IL-15; alterations which are partially reversed after anthelmintic treatment.

Scope of detectability of circulating antigens of human lymphatic filarial parasite Wuchereria bancrofti with smaller amount of serum by Og4C3 assay: its application in lymphatic filariasis elimination programme

Filarial antigen detection is an appropriate epidemiological indicator for mapping lymphatic filariasis and impact evaluation of filariasis elimination programme in view of low sensitivity of parasite detection. Monoclonal antibody-based Og4C3 immunological test requires 100 µl serum, which is difficult to collect by finger prick method during community based surveys. Hence, we tested lesser volume of serum compared to standard volume of 100 µl to compare its sensitivity and specificity in detecting the circulating filarial antigens. Blood samples were collected from individuals who tested positive [with titer groups 4 (border line positives), 6 (medium positives), and 8 (high positives)] and negative (titre group 3) for Og4C3 assay. Different volumes of serum samples were used to make-up required volume (100 µl) with appropriate dilutions and subjected to Og4C3 assay. The results showed that known negative samples tested negative at all the serum volumes tested. All positives (titer groups 6 and 8) showed positivity at all reduced volumes of serum sample. However one of the medium positive sample showed negative reaction in 5 µl volume of serum and two of the border line positives showed negative at all the serum volume tested. The results thus showed as less as 15 µl serum is adequate for use in Og4C3 assay. So the test can be performed without losing its sensitivity even with 5 µl serum samples at high titre of antigen (titre group 8) and 15 µl for other groups and this method has scope in programme evaluation.

Antibody to the filarial antigen Wb123 reflects reduced transmission and decreased exposure in children born following single mass drug administration (MDA)

Background

Antibody (Ab) to the Wuchereria bancrofti (Wb) infective larval (L3) antigen Wb123, using a Luciferase Immunoprecipitation System (LIPS) assay, has been shown to be a species-specific, early marker of infection developed for potential use as a surveillance tool following transmission interruption post mass drug administration. To examine its usefulness in a single filarial-endemic island assessed at two time points with markedly different levels of transmission, Ab to Wb123 was measured in sera collected from subjects from Mauke, Cook Islands in 1975 (no previous treatment) and 1992 (5 years after a one time island-wide treatment with diethylcarbamazine [DEC]).

Findings

Between 1975 and 1992, Wb transmission decreased dramatically as evidenced by reduced prevalences of microfilariae (31% vs. 5%) and circulating Ag (CAg, 49% vs. 16%). Age specific prevalence analysis showed a dramatic reduction in Wb123 Ab positivity from 54% (25/46) in 1975 to 8% (3/38) in 1992 in children 1–5 years (p<0.0001), reflecting the effects of single-dose treatment five years earlier. By 1992, Wb123 Ab prevalence in children 6–10 years had fallen from 75% (42/56) in 1975 to 42% (33/79) consistent with a lower cumulative transmission potential. In the whole population, Wb123 seropositivity decreased from 86% to 60% between 1975 and 1992. In CAg+ subjects the levels of Wb123 Ab were indistinguishable between the 2 time points but differed in those who were CAg− (p<0.0001). In paired sample analysis, individuals who were CAg+ in 1975 but became CAg− in 1992 had significantly lower Ab levels in 1992 (p<0.0001), with 9/40 (23%) becoming seronegative for Wb123.

Conclusions

The relationship between reduction in Wb123 Ab prevalence and the reduction of transmission, seen most clearly in young children, strongly advocates for the continuing assessment and rapid development of Wb123 as a surveillance tool to detect potential transmission of bancroftian filariasis in treated endemic areas.

Lymphatic filariasis (LF) causes an enormous disease burden throughout the tropics and subtropics. The Global Programme to Eliminate Lymphatic Filariasis was begun in 2000 following the advent of large donations from drug companies for treating LF and the development of a rapid antigen assay for detection of infection. As more countries undergo mass drug administration (MDA), the driving need is for development of a highly sensitive and specific antibody assay for detecting ongoing exposure to vector-borne filaria following MDA. The target group for such surveillance is children born during or following MDA. Current assays, while sensitive, are not specific enough where non-LF filaria species are co-endemic. Recently, we developed an antibody assay based upon the highly specific larval antigen Wb123 using the Luciferase Immunoprecipitation System (LIPS). In the current study, we determined that the Wb123 LIPS assay detects a reduction in LF transmission on an endemic island following a one-time island wide MDA with diethylcarbamazine, with the most pronounced reduction in prevalence of antibody to Wb123 occurring in young children born just prior to and following this MDA. We propose that Wb123 can be an extremely useful surveillance tool following MDA and should be developed into a rapid test format.

Impact of filarial infections on coincident intracellular pathogens: Mycobacterium tuberculosis and Plasmodium falciparum

PURPOSE OF REVIEW

To examine the consequences of the immune modulation seen in chronic filarial infection on responses to intracellular pathogens (and their antigens) that are often co-endemic with filarial infections, namely Plasmodium and Mycobacterium tuberculosis.

RECENT FINDINGS

Much of the recent data on filaria/mycobacteria or filaria/Plasmodium co-infection has focused on the modulation of mycobacteria-specific or malaria-specific responses by chronic filarial infection. As such, filarial infections very clearly alter the magnitude and quality of the mycobacteria-specific or malaria-specific cytokine responses, responses that have been typically associated with control of these intracellular pathogens.

SUMMARY

Although phylogenetically distinct, mycobacteria and Plasmodium spp. often share the same geographical niche with filarial infections. The complex interplay between filarial parasites that are associated with immunomodulation and those microbial pathogens that require a proinflammatory or unmodulated response for their control is easily demonstrable ex vivo, but whether this interplay affects disease outcome in tuberculosis or malaria remains an open question.

Regulation of global gene expression in human Loa loa infection is a function of chronicity

Background

Human filarial infection is characterized by downregulated parasite-antigen specific T cell responses but distinct differences exist between patients with longstanding infection (endemics) and those who acquired infection through temporary residency or visits to filarial-endemic regions (expatriates).

Methods and Findings

To characterize mechanisms underlying differences in T cells, analysis of global gene expression using human spotted microarrays was conducted on CD4⁺ and CD8⁺ T cells from microfilaremic Loa loa-infected endemic and expatriate patients. Assessment of unstimulated cells showed overexpression of genes linked to inflammation and caspase-associated cell death, particularly in endemics, and enrichment of the Th1/Th2 canonical pathway in endemic CD4⁺ cells. However, pathways within CD8⁺ unstimulated cells were most significantly enriched in both patient groups. Antigen (Ag)-driven gene expression was assessed to microfilarial Ag (MfAg) and to the nonparasite Ag streptolysin O (SLO). For MfAg-driven cells, the number of genes differing significantly from unstimulated cells was greater in endemics compared to expatriates (p<0.0001). Functional analysis showed a differential increase in genes associated with NFkB (both groups) and caspase activation (endemics). While the expatriate response to MfAg was primarily a CD4⁺ pro-inflammatory one, the endemic response included CD4⁺ and CD8⁺ cells and was linked to insulin signaling, histone complexes, and ubiquitination. Unlike the enrichment of canonical pathways in CD8⁺ unstimulated cells, both groups showed pathway enrichment in CD4⁺ cells to MfAg. Contrasting with the divergent responses to MfAg seen between endemics and expatriates, the CD4⁺ response to SLO was similar; however, CD8⁺ cells differed strongly in the nature and numbers (156 [endemics] vs 36 [expatriates]) of genes with differential expression.

Conclusions

These data suggest several important pathways are responsible for the different outcomes seen among filarial-infected patients with varying levels of chronicity and imply an important role for CD8⁺ cells in some of the global changes seen with lifelong exposure.

Infection with the filarial parasite Loa loa causes a parasite-specific downregulation of T cell responses. However, differences exist (clinical and immunologic) between patients born and living in filarial endemic regions (endemics) and those who become infected during travel or short-term residency (expatriates). T cell responses are more depressed in endemics while expatriates have more clinical “allergic-type” symptoms. In this study, we showed that these differences reflect transcriptional differences within the T cell compartment. Using microarrays, we examined global gene expression in both CD4⁺ and CD8⁺ T cells of microfilaremic endemic and expatriate patients and found differences not only ex vivo, but also to parasite and, for CD8⁺ cells, to nonparasite antigens. Functional analysis showed that endemic patients expressed genes linked to inflammatory disease and caspase associated cell death at homeostasis while expatriates tended to have a more activation-induced gene profile at homeostasis and a CD4⁺ inflammatory response to parasite antigen. Patient groups were similar in their CD4⁺ response to nonparasite antigen but strongly differed in their CD8⁺ responses, demonstrating the potential global ramifications of chronic, longstanding infection. Our study describes potential transcriptional mechanisms for the variability seen in patients with different levels of exposure to and chronicity of filarial infection.

A 22 year follow-up study on lymphatic filariasis in Tanzania: analysis of immunological responsiveness in relation to long-term infection pattern

Seventy-one individuals who had been examined for Wuchereria bancrofti microfilaraemia in 1975, some of whom had been offered mass treatment with diethylcarbamazine (DEC) in subsequent years, were re-identified in 1996 and examined for microfilaraemia, circulating filarial antigenemia and cellular and humoral immunoresponsiveness to crude antigen homogenates prepared from Brugia pahangi parasite material. 85.9% of the study individuals had the same infection status in 1975 and 1996, suggesting strong predisposition to infection over extended periods of time. IL-4, IL-5 and IFNγ responses were associated with being infection negative in 1996 whereas IL-10 responses were associated with being infection positive. Similarly, specific IgG3 and IgE were strongly associated with being infection negative in 1996 whereas specific IgG4, and thus high IgG4/IgE ratios, were strongly associated with being infection positive. Intermediary levels of mainly IL-5, IFNγ and PBMC stimulation indices were observed for study individuals who changed from being infection positive in 1975 to infection negative in 1996, or vice versa, suggesting a transition in cellular immunoresponsiveness associated with changing infection status. The findings suggest that some people are more disposed to infection with bancroftian filariasis than others and that this is largely unaffected by treatment with DEC. The findings also suggest that specific cellular and antibody responses are more related to current than past infection status, and that IL-4, IL-5, IFNγ, specific IgG3 and IgE are associated with parasite clearance, whereas IL-10 and specific IgG4 are associated with parasite protection.

Sensitization with anti-inflammatory BmAFI of Brugia malayi allows L3 development in the hostile peritoneal cavity of Mastomys coucha

Filarial parasites survive by inducing tolerance in host but the antigens and mechanisms involved are not clear. Recently we found that BmAFI, a Sephadex G-200 eluted fraction of Brugia malayi adult worm extract, stimulates IL-10 release from THP-1 cells. In the present study, we determined the SDS-PAGE profile of BmAFI and infective 3rd stage larva (L3), investigated the effect of pre-sensitization of host with BmAFI on the survival and development of L3 in the non-permissive peritoneal cavity (p.c.) of the permissive host Mastomys coucha and in the p.c. of non-permissive Swiss mice, and studied immunological correlates for the observed effects. The parasite development and burden in p.c., was determined in sensitized infected M. coucha and Swiss mice and the release of TGF-β, IL-4, IL-10, IL-13, IFN-γ and NO, cellular proliferative response to Con A and BmAFI and levels of IgG subclasses and IgE were determined in sensitized infected M. coucha. Cellular proliferative response to Con A and BmAFI, mRNA expression of GATA-3, CTLA-4 and T-bet were determined in sensitized Swiss mice. In addition, the parasitological parameter was also studied in BmAFI-sensitized M. coucha exposed to the infection by standard subcutaneous (s.c.) route to assess whether sensitization enhances the intensity of infection. BmAFI-sensitization permitted survival of L3 and their development to adult stage by day 60 p.i. in the p.c. of M. coucha; in non-sensitized animals L3 could molt to L4 only and no parasite could be recovered beyond day 30 p.i. In M. coucha that received infection by s.c. route, pre-sensitization with BmAFI enhanced the microfilaraemia and adult worm recovery. In sensitized Swiss mice L3 could successfully molt to L4 in p.c. with improved recovery of parasite. BmAFI sensitization upregulated TGF-β and IL-10 release, IgG1 and IgG2b levels, GATA-3 and CTLA-4 mRNA expression, suppressed the cellular proliferative response and downregulated Con A stimulated response, IgE, IL-13, IFN-γ and NO responses. Immunoblot analysis showed that the BmAFI antiserum also strongly reacts with some L3 molecules. The results show, for the first time, that sensitization with the anti-inflammatory BmAFI which shares some of its molecules with those in L3, facilitates parasite survival in the non-permissive p.c. of the permissive host M. coucha, render a non-permissive Swiss mouse partially permissive to infection and enhances parasite load in M. coucha receiving the infection through permissive s.c. route by evoking a modified Th2 type of response and anti-inflammatory milieu. In conclusion, the findings suggest that the anti-inflammatory BmAFI fraction facilitates survival of B. malayi infection even in non-permissive environment.

Altered T cell memory and effector cell development in chronic lymphatic filarial infection that is independent of persistent parasite antigen

Chronic lymphatic filarial (LF) infection is associated with suppression of parasite-specific T cell responses that persist even following elimination of infection. While several mechanisms have been implicated in mediating this T cell specific downregulation, a role for alterations in the homeostasis of T effector and memory cell populations has not been explored. Using multiparameter flow cytometry, we investigated the role of persistent filarial infection on the maintenance of T cell memory in patients from the filarial-endemic Cook Islands. Compared to filarial-uninfected endemic normals (EN), microfilaria (mf) positive infected patients (Inf) had a reduced CD4 central memory (T_CM) compartment. In addition, Inf patients tended to have more effector memory cells (T_EM) and fewer effector cells (T_EFF) than did ENs giving significantly smaller T_EFF ∶ T_EM ratios. These contracted T_CM and T_EFF populations were still evident in patients previously mf+ who had cleared their infection (CLInf). Moreover, the density of IL-7Rα, necessary for T memory cell maintenance (but decreased in T effector cells), was significantly higher on memory cells of Inf and CLInf patients, although there was no evidence for decreased IL-7 or increased soluble IL7-Rα, both possible mechanisms for signaling defects in memory cells. However, effector cells that were present in Inf and CLInf patients had lower percentages of HLA-DR suggesting impaired function. These changes in T cell populations appear to reflect chronicity of infection, as filarial-infected children, despite the presence of active infection, did not show alterations in the frequencies of these T cell phenotypes. These data indicate that filarial-infected patients have contracted T_CM compartments and a defect in effector cell development, defects that persist even following clearance of infection. The fact that these global changes in memory and effector cell compartments do not yet occur in infected children makes early treatment of LF even more crucial.

A method for detecting microfilaraemia, filarial specific antigens and antibodies and typing of parasites for drug resistance and genotypes using finger prick blood sample

Monitoring and evaluation of programme to eliminate lymphatic filariasis (LF) depends on epidemiological assessment using appropriate indicators. Minimum efforts using reliable tests are necessary to guide the programme managers in decision-making. Impact of Mass Drug Administration (MDA) towards filariasis elimination can be assessed by the detection of microfilariae (mf) or parasite DNA (infective), filarial antigens (infected) and antibodies (exposure). It is also important to monitor drug resistance and variation in genetic structure of parasite populations using molecular markers. We developed a method to carry out parasitological, molecular, immunological and genetic analysis from a minimum volume of blood sample (about 150 microl) drawn from finger tip of an individual residing in LF endemic area. The method involves separation of sera for immunological assays and isolation of mf of Wuchereria bancrofti from the blood clots for counting, which were then used for W. bancrofti specific PCR, screening for albendazole sensitivity/resistance alleles by AS-PCR, RAPD profiling and ITS 2 PCR for genotyping. A protocol is also suggested for the separation of sera for assays to detect antigen and antibodies and isolation of mf from clots for genetic analysis. The protocol developed has shown potential application in monitoring several immunological, parasitological and molecular parameters from a limited amount of blood sample collected by finger prick, in large-scale operations.

Neonatal tolerance and patent filarial infection

Lymphatic filariasis occurs in endemic pockets. Patent infections with long-term, high-grade microfilaremia do not develop in nonendemic individuals. It is tempting to speculate that individuals with intact immune responses to filarial antigens are capable of dealing with filarial exposure without developing persistent infection. There are published data that support the idea that only those individuals who are impaired in their immune defense against these parasites owing to neonatal tolerization become productively infected with the filarial parasites. If the model is correct, there are profound implications for global eradication.

Aping Jane Goodall: insights into human lymphatic filariasis

The relationship between infection and disease has been a subject of intense debate in human filariasis. Most patients with chronic disease such as lymphedema or elephantiasis are free of demonstrable current infection. Based on cross-sectional data and a few assumptions and presumptions, two models of natural history of filariasis have been in vogue during the past two decades. The only (but arduous) way to understand the sequence of events is to follow up subjects with and without patent infections over a period of several years. This article offers critical comments and highlights the insights acquired from such studies.

CTLA-4 in filarial infections: implications for a role in diminished T cell reactivity

To determine the role that CTLA-4 might play in mediating the diminished parasite Ag-specific T cell responsiveness that is characteristically seen in filaria-infected patients, several study populations and methods were used. First, quantitative assessment of mRNA expression determined that PBMC from uninfected adolescents exposed in utero to microfilarial (Mf) Ag demonstrated a strong up-regulation of CTLA-4 to the Mf stage of the parasite in contrast to that observed in cells from children born of uninfected mothers (p = 0.005). Next, the frequency of CTLA-4 expression was examined using flow cytometry in cells from filaria-infected and -uninfected individuals ex vivo. Individuals born in filarial endemic regions of the world (with long-standing infections) had greater percentages of CD4(+)CTLA-4(+) cells than did expatriate infected or uninfected individuals (p = 0.005 and 0.05, respectively); in addition, Mf(+) patients demonstrated higher frequencies of CD4(+)CTLA-4(+) and CD8(+)CTLA-4(+) cells (p = 0.027 and 0.037, respectively) than did Mf(-) infected individuals. Of interest, the greatest intensity of CTLA-4 expression occurred in CD4(+)CD25(+) cells, a population purported to include suppressor cells. Finally, in vitro blocking of CTLA-4 expression in PBMC from filaria-infected individuals induced a mean increase of 44% in IL-5 production to Mf Ag, whereas there was a concurrent mean decrease of 42% in IFN-gamma production, suggesting that CTLA-4 also acts to alter the Th1/Th2 balance in filaria-infected individuals. Together, these data indicate a significant role for CTLA-4 in regulating the host response to filarial infections and that factors such as length of exposure and patency are important codeterminants.

Update on Lymphatic Filarial Infections

Filarial infections remain significant causes of disability in tropical areas worldwide. However, insights into the developmental and molecular biology of the parasite and the immunobiology of the host response to infection have advanced our understanding, even as progress is being made towards implementing eradication programs. This article summarizes some of the recent advances in the understanding of filarial biology and parasite immune evasion mechanisms, and reviews those newer aspects of diagnosis and treatment most relevant to clinicians.

Lymphatic filariasis: new insights and prospects for control

Although lymphatic filariasis remains among the major causes of disability among the tropical infectious diseases, dramatic advances have been made in the approach to its diagnosis, epidemiology and treatment, in our understanding of the molecular composition of the parasites that cause these infections, and in the factors underlying the pathology seen. Superimposing the tools of modern epidemiology, immunology, and molecular biology on field-based clinical trials has allowed the emergence of the concept of elimination of lymphatic filariasis. Much of the important new research emphasizes parasite development in the context of the host response, the importance of both the adult worm and other factors in the pathogenesis of lymphatic filarial disease, the role the Wolbachia endosymbiont holds as both a target for drug treatment and in inducing post-treatment reactions, and the various principles underlying the implementation of control programs.