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Taggart M, Langworthy K, Hui S, Boyder C, Fulurija A, Morici M, Raby E, Manning L. Serological Responses to Streptococcus pyogenes Vaccine Candidate Antigens Suggests That Streptococcus dysgalactiae Is the Predominant Cause of Lower Limb Cellulitis. Open Forum Infect Dis 2024; 11:ofae272. [PMID: 38872850 PMCID: PMC11171425 DOI: 10.1093/ofid/ofae272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/23/2024] [Indexed: 06/15/2024] Open
Abstract
Background A future Streptococcus pyogenes (Strep A) vaccine will ideally prevent a significant burden of lower limb cellulitis; however, natural immune responses to proposed vaccine antigens following an episode of cellulitis remain uncharacterized. Methods We enrolled 63 patients with cellulitis and 26 with invasive beta hemolytic streptococci infection, using a multiplexed assay to measure immunoglobulin G against Strep A vaccine candidate antigens, including: streptolysin O (SLO), deoxyribonuclease B (DNB), group A carbohydrate (GAC), C5a peptidase (ScpA), cell envelope proteinase (SpyCEP), and adhesion and division protein (SpyAD). Responses in the invasive cohort were used to predict the infecting etiology in the cellulitis cohort. Results Of 41 patients with cellulitis and paired serological samples, 68.3% had evidence of beta hemolytic streptococci infection by conventional anti-SLO and/or anti-DNB criteria. A positive serological response to at least 1 of the tested antigens was seen in 78.0% of the cellulitis cohort. Individually, anti-SLO (58.5%), anti-SpyAD (46.3%), and anti-ScpA (39.0%) were the most common. Based on principal component analysis, increases in these 3 antibodies, without responses to DNB, GAC, and SpyCEP characterized Streptococcus dysgalactiae subspecies equisimilis (SDSE) infection. Conclusions SDSE appears to be the predominant cause of lower limb cellulitis. Effective Strep A vaccines incorporating antigens that provide additional cross protection against SDSE may prevent a significant burden of lower limb cellulitis.
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Affiliation(s)
- Michael Taggart
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
| | - Kristyn Langworthy
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
| | - Siong Hui
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
| | - Conchita Boyder
- Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Alma Fulurija
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Michael Morici
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Edward Raby
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
- Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Fremantle Hospitals Group, Murdoch Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
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Nakakana U, Serry-Bangura A, Edem BE, Tessitore P, Di Cesare L, Moriel DG, Podda A, De Ryck IS, Arora AK. Application of Transthoracic Echocardiography for Cardiac Safety Evaluation in the Clinical Development Process of Vaccines Against Streptococcus pyogenes. Drugs R D 2024; 24:1-12. [PMID: 38494581 PMCID: PMC11035538 DOI: 10.1007/s40268-024-00452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 03/19/2024] Open
Abstract
Superficial infections with Streptococcus pyogenes (Strep A), pharyngitis and impetigo can induce acute rheumatic fever, an autoimmune sequela manifesting mostly with arthritis and rheumatic carditis. Valvular heart damage can persist or advance following repeated episodes of acute rheumatic fever, causing rheumatic heart disease. Acute rheumatic fever and rheumatic heart disease disproportionately affect children and young adults in developing countries and disadvantaged communities in developed countries. People living with rheumatic heart disease are at risk of experiencing potentially fatal complications such as heart failure, bacterial endocarditis or stroke. Transthoracic echocardiography plays a central role in diagnosing both rheumatic carditis and rheumatic heart disease. Despite the obvious medical need, no licensed Strep A vaccines are currently available, as their clinical development process faces several challenges, including concerns for cardiac safety. However, the development of Strep A vaccines has been recently relaunched by many vaccine developers. In this context, a reliable and consistent safety evaluation of Strep A vaccine candidates, including the use of transthoracic echocardiography for detecting cardiac adverse events, could greatly contribute to developing a safe and efficacious product in the near future. Here, we propose a framework for the consistent use of transthoracic echocardiography to proactively detect cardiac safety events in clinical trials of Strep A vaccine candidates.
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Affiliation(s)
- Usman Nakakana
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy.
| | | | - Bassey Effiom Edem
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
- Janssen Biologics BV, Leiden, the Netherlands
| | | | - Leonardo Di Cesare
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
| | - Danilo Gomes Moriel
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
| | - Audino Podda
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
- Independent consultant, Siena, Italy
| | | | - Ashwani Kumar Arora
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
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3
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Frost H, Excler JL, Sriskandan S, Fulurija A. Correlates of immunity to Group A Streptococcus: a pathway to vaccine development. NPJ Vaccines 2023; 8:1. [PMID: 36650164 PMCID: PMC9844947 DOI: 10.1038/s41541-022-00593-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/06/2022] [Indexed: 01/19/2023] Open
Abstract
Understanding immunity in humans to Group A Streptococcus (Strep A) is critical for the development of successful vaccines to prevent the morbidity and mortality attributed to Strep A infections. Despite decades of effort, no licensed vaccine against Strep A exists and immune correlates of protection are lacking; a major impediment to vaccine development. In the absence of a vaccine, we can take cues from the development of natural immunity to Strep A in humans to identify immune correlates of protection. The age stratification of incidence of acute Strep A infections, peaking in young children and waning in early adulthood, coincides with the development of specific immune responses. Therefore, understanding the immune mechanisms involved in natural protection from acute Strep A infection is critical to identifying immune correlates to inform vaccine development. This perspective summarises the findings from natural infection studies, existing assays of immunity to Strep A, and highlights the gaps in knowledge to guide the development of Strep A vaccines and associated correlates of protection.
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Affiliation(s)
- Hannah Frost
- grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Melbourne, VIC Australia
| | - Jean-Louis Excler
- grid.30311.300000 0000 9629 885XInternational Vaccine Institute, Seoul, Republic of Korea
| | - Shiranee Sriskandan
- grid.7445.20000 0001 2113 8111Department of Infectious Disease, Imperial College London, London, UK ,grid.7445.20000 0001 2113 8111MRC Centre for Molecular Bacteriology & Infection, Imperial College London, London, UK
| | - Alma Fulurija
- grid.414659.b0000 0000 8828 1230Telethon Kid’s Institute, Perth, WA Australia ,grid.1012.20000 0004 1936 7910The University of Western Australia, Perth, WA Australia
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4
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Gorczyca D, Iwańczyk P, Staś K, Postępski J. Knee pain as a reason for referral to a paediatric rheumatologist: A retrospective study. J Paediatr Child Health 2023; 59:439-444. [PMID: 36627832 DOI: 10.1111/jpc.16309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/17/2022] [Accepted: 12/02/2022] [Indexed: 01/12/2023]
Abstract
AIM Knee pain is the most frequently reported type of lower extremity pain among children and adolescents. The objective of this study was to establish the features distinguishing inflammatory knee pain from non-inflammatory knee pain and to determine the specific variables to consider in suspected juvenile idiopathic arthritis (JIA). METHODS A retrospective chart review was performed among children with knee pain evaluated through paediatric rheumatology consultations at a single centre between 2012 and 2019. RESULTS Among the 262 children, 32 patients (12.2%) were diagnosed with JIA, 46 patients (17.6%) presented with inflammatory knee pain (IP) of an origin different than JIA, and 57 patients (21.7%) with non-inflammatory knee pain (NIP). In 127 cases (48.5%), no musculoskeletal disorder was diagnosed (NDD). The presence of limping, joint swelling, decreased passive range of motion and decreased active range of motion of the knee joint were registered more frequently in the JIA group compared to the other three groups. Multivariate analysis showed that a family history of autoimmune diseases and pain in other joints were associated with inflammatory pain. Increased pain after physical activity, pain only in the knee joint and absence of limping were predictors of NIP. The risk factors of JIA were limping and an erythrocyte sedimentation range of ≥10 mm after an hour. In the NDD group, the risk factors included no increase in pain after physical activity, serum C-reactive protein level < 5 mg/L and normal musculoskeletal ultrasound image. CONCLUSIONS The majority of children with knee pain referred to a paediatric rheumatologist do not have arthritis. Knee pain alone, as a chief complaint, rarely leads to a final JIA diagnosis. Further studies are necessary in order to design the appropriate diagnostic and therapeutic algorithms.
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Affiliation(s)
- Daiva Gorczyca
- Center for Chronically Sick Children Berlin, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Patrycja Iwańczyk
- Neonatology Department, The Institute of Mother and Child, Warsaw, Poland
| | - Karolina Staś
- Paediatric Department, Public Autonomous Health Care Hospital, Sulechów, Poland
| | - Jacek Postępski
- Department of Paediatric Pulmonology and Rheumatology, Medical University of Lublin, Lublin, Poland
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Development and Characterisation of a Four-Plex Assay to Measure Streptococcus pyogenes Antigen-Specific IgG in Human Sera. Methods Protoc 2022; 5:mps5040055. [PMID: 35893581 PMCID: PMC9326740 DOI: 10.3390/mps5040055] [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: 05/29/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/17/2022] Open
Abstract
The measurement of antibodies to vaccine antigens is crucial for research towards a safe and effective vaccine for Streptococcus pyogenes (Strep A). We describe the establishment and detailed characterisation of a four-plex assay to measure IgG to the Strep A vaccine antigens SpyCEP, Slo, SpyAD and GAC using the Luminex multiplex platform. A standard curve was established and characterized to allow the quantification of antigen-specific IgG. Assay specificity, precision, linearity, reproducibility and repeatability were determined via the measurement of antigen-specific IgG from pooled human serum. The assay is highly specific, reproducible and performs well across a large range of antibody concentrations against all four antigens. It is, therefore, suitable for future clinical trials in humans with a four-component vaccine, as well as for seroepidemiological studies to gain insights into naturally occurring immunity.
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6
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Whitcombe AL, McGregor R, Bennett J, Gurney JK, Williamson DA, Baker MG, Moreland NJ. OUP accepted manuscript. J Infect Dis 2022; 226:167-176. [PMID: 35134931 PMCID: PMC9373162 DOI: 10.1093/infdis/jiac043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background Group A Streptococcus (GAS) causes superficial pharyngitis and skin infections as well as serious autoimmune sequelae such as acute rheumatic fever (ARF) and subsequent rheumatic heart disease. ARF pathogenesis remains poorly understood. Immune priming by repeated GAS infections is thought to trigger ARF, and there is growing evidence for the role of skin infections in this process. Methods We utilized our recently developed 8-plex immunoassay, comprising antigens used in clinical serology for diagnosis of ARF (SLO, DNase B, SpnA), and 5 conserved putative GAS vaccine antigens (Spy0843, SCPA, SpyCEP, SpyAD, Group A carbohydrate), to characterize antibody responses in sera from New Zealand children with a range of clinically diagnosed GAS disease: ARF (n = 79), GAS-positive pharyngitis (n = 94), GAS-positive skin infection (n = 51), and matched healthy controls (n = 90). Results The magnitude and breadth of antibodies in ARF was very high, giving rise to a distinct serological profile. An average of 6.5 antigen-specific reactivities per individual was observed in ARF, compared to 4.2 in skin infections and 3.3 in pharyngitis. Conclusions ARF patients have a unique serological profile, which may be the result of repeated precursor pharyngitis and skin infections that progressively boost antibody breadth and magnitude.
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Affiliation(s)
- Alana L Whitcombe
- School of Medical Sciences and Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Reuben McGregor
- School of Medical Sciences and Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jason K Gurney
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Deborah A Williamson
- University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nicole J Moreland
- Correspondence: Nicole J. Moreland, BSc, PhD, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand ()
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Whitcombe AL, Han F, McAlister SM, Kirkham LAS, Young PG, Ritchie SR, Atatoa Carr P, Proft T, Moreland NJ. An eight-plex immunoassay for Group A streptococcus serology and vaccine development. J Immunol Methods 2021; 500:113194. [PMID: 34801540 DOI: 10.1016/j.jim.2021.113194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022]
Abstract
Group A Streptococcus (GAS) is a major human pathogen responsible for superficial infections through to life-threatening invasive disease and the autoimmune sequelae acute rheumatic fever (ARF). Despite a significant global economic and health burden, there is no licensed vaccine available to prevent GAS disease. Several pre-clinical vaccines that target conserved GAS antigens are in development. Assays that measure antigen-specific antibodies are essential for vaccine research. The aim of this study was to develop a multiplex beadbased immunoassay that can detect and quantify antibody responses to multiple GAS antigen targets in small volume blood samples. This builds on our existing triplex assay comprised of antigens used in clinical serology for the diagnosis of ARF (SLO, DNase B and SpnA). Five additional conserved putative GAS vaccine antigens (Spy0843, SCPA, SpyCEP, SpyAD and the Group A carbohydrate), were coupled to spectrally unique beads to form an 8-plex antigen panel. After optimisation of the assay protocol, standard curves were generated, and assessments of assay specificity, precision and reproducibility were conducted. A broad range of antibody (IgG) titres were able to be quickly and accurately quantified from a single serum dilution. Assay utility was assessed using a panel of 62 clinical samples including serum from adults with GAS bacteraemia and children with ARF. Circulating IgG to all eight antigens was elevated in patients with GAS disease (n = 23) compared to age-matched controls (n = 39) (P < 0.05). The feasibility of using dried blood samples to quantify antigen-specific IgG was also demonstrated. In summary, a robust and reproducible 8-plex assay has been developed that simultaneously quantifies IgG antibodies to GAS vaccine and diagnostic antigens.
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Affiliation(s)
- Alana L Whitcombe
- School of Medical Sciences, The University of Auckland, New Zealand; Maurice Wilkins Centre for Biodiscovery, The University of Auckland, New Zealand
| | - Franklin Han
- School of Medical Sciences, The University of Auckland, New Zealand
| | - Sonia M McAlister
- Wesfarmers Centre of Vaccines & Infectious Disease, Telethon Kids Institute, Perth, Western Australia, Australia; Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Lea-Ann S Kirkham
- Wesfarmers Centre of Vaccines & Infectious Disease, Telethon Kids Institute, Perth, Western Australia, Australia; Centre for Child Health Research, University of Western Australia, Perth, Australia
| | - Paul G Young
- School of Biological Sciences, The University of Auckland, New Zealand
| | | | | | - Thomas Proft
- School of Medical Sciences, The University of Auckland, New Zealand; Maurice Wilkins Centre for Biodiscovery, The University of Auckland, New Zealand
| | - Nicole J Moreland
- School of Medical Sciences, The University of Auckland, New Zealand; Maurice Wilkins Centre for Biodiscovery, The University of Auckland, New Zealand.
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8
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Bennett J, Moreland NJ, Williamson DA, Carapetis J, Crane J, Whitcombe AL, Jack S, Harwood M, Baker MG. Comparison of group A streptococcal titres in healthy children and those with pharyngitis and skin infections. J Infect 2021; 84:24-30. [PMID: 34710392 DOI: 10.1016/j.jinf.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/04/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Rates of acute rheumatic fever, a sequelae of group A Streptococcal (GAS) infection, remain unacceptably high in Indigenous Māori and Pacific children in New Zealand. This prospective study aimed to describe GAS antibody titres in healthy children (5-14 years) by ethnicity, and to determine how paired titres vary with GAS culture positive and negative pharyngitis, and GAS skin infections. METHODS Analysis included 887 children (32% Māori, 36% Pacific, 33% European/Other) from Auckland, New Zealand. Cases comprise 772 children who had a sore throat or skin infection, which resulted in a swab taken for culture. Healthy controls were asymptomatic (N = 154) and matched by age, ethnicity and region. All participants had a serum sample, with a second sample collected from cases only. Sera were analysed for anti-streptolysin O (ASO) and anti-DNase-B (ADB) antibodies. RESULTS Healthy Māori and Pacific children had higher GAS antibody titres than healthy European/Other children. Children with GAS-positive sore throat had the highest mean ASO titres and children with GAS-positive skin infection had the highest mean ADB titres. When a two-fold increase or an upper limit of normal cut-off (ASO 450 IU/ml, ADB 400 U/ml) was applied to titres from children with GAS-positive sore throat, 62.1% were classified as having serologically confirmed GAS pharyngitis and 37.9% had GAS detected without serological response. CONCLUSIONS Elevated ASO titres were associated with GAS pharyngitis and elevated ADB titres were associated with GAS skin infections in New Zealand children. Higher ASO/ADB titres in healthy Māori and Pacific children could indicate a greater prior exposure to GAS infections.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand.
| | - Nicole J Moreland
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Deborah A Williamson
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Victoria, Australia
| | - Jonathan Carapetis
- Telethon Kids Institute and Perth Children's Hospital, University of Western Australia, Perth 6009, Australia
| | - Julian Crane
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Alana L Whitcombe
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Susan Jack
- Public Health South, Southern District Health Board, Dunedin, New Zealand
| | - Matire Harwood
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
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9
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Bennett J, Rentta NN, Leung W, Atkinson J, Wilson N, Webb R, Baker MG. Early diagnosis of acute rheumatic fever and rheumatic heart disease as part of a secondary prevention strategy: Narrative review. J Paediatr Child Health 2021; 57:1385-1390. [PMID: 34296804 DOI: 10.1111/jpc.15664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 01/07/2023]
Abstract
Acute rheumatic fever (ARF) and its sequela rheumatic heart disease (RHD) remain significant causes of morbidity and mortality. In New Zealand, ARF almost exclusively affects Indigenous Māori and Pacific children. This narrative review aims to present secondary interventions to improve early and accurate diagnosis of ARF and RHD, in order to minimise disease progression in New Zealand. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 56 publications from 1980 onwards. Diagnosing ARF and RHD as early as possible is central to reducing disease progression. Recent identification of specific ARF biomarkers offer the opportunity to aid initial diagnosis and portable echocardiography has the potential to detect undiagnosed RHD in high-risk areas. However, further research into the benefits and risks to children with subclinical RHD is necessary, as well as an economic evaluation.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Neilenuo N Rentta
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - William Leung
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - June Atkinson
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Rachel Webb
- Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand.,KidzFirst Children's Hospital, Counties Manukau District Health Board, Auckland, New Zealand.,Department of Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
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10
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Osowicki J, Azzopardi KI, Fabri L, Frost HR, Rivera-Hernandez T, Neeland MR, Whitcombe AL, Grobler A, Gutman SJ, Baker C, Wong JMF, Lickliter JD, Waddington CS, Pandey M, Schuster T, Cheng AC, Pollard AJ, McCarthy JS, Good MF, Dale JB, Batzloff M, Moreland NJ, Walker MJ, Carapetis JR, Smeesters PR, Steer AC. A controlled human infection model of Streptococcus pyogenes pharyngitis (CHIVAS-M75): an observational, dose-finding study. THE LANCET MICROBE 2021; 2:e291-e299. [PMID: 35544165 DOI: 10.1016/s2666-5247(20)30240-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/17/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Streptococcus pyogenes is a leading cause of infection-related morbidity and mortality. A reinvigorated vaccine development effort calls for new clinically relevant human S pyogenes experimental infection models to support proof of concept evaluation of candidate vaccines. We describe the initial Controlled Human Infection for Vaccination Against S pyogenes (CHIVAS-M75) study, in which we aimed to identify a dose of emm75 S pyogenes that causes acute pharyngitis in at least 60% of volunteers when applied to the pharynx by swab. METHODS This observational, dose-finding study was done in a clinical trials facility in Melbourne (VIC, Australia). Groups of healthy volunteers aged 18-40 years, at low risk of complicated S pyogenes disease, and without high type-specific anti-emm75 IgG antibodies against the challenge strain were challenged and closely monitored as inpatients for up to 6 days, and then as outpatients for 6 months. Antibiotics were started upon diagnosis (clinical signs and symptoms of pharyngitis and a positive rapid molecular test) or after 5 days in those without pharyngitis. Rapid test results were confirmed by standard bacterial culture. After a sentinel participant, cohorts of five and then ten participants were challenged, with protocol-directed dose-escalation or de-escalation for subsequent cohorts. The primary outcome was the proportion of participants at each dose level with pharyngitis by day 5 after challenge. The study is registered with ClinicalTrials.gov, NCT03361163. FINDINGS Between July 10, 2018, and Sept 23, 2019, 25 healthy adults were challenged with emm75 S pyogenes and included in analyses. Pharyngitis was diagnosed in 17 (85%; 95% CI 62-97) of 20 participants at the starting dose level (1-3 × 105 colony-forming units [CFU]/mL). This high proportion prompted dose de-escalation. At the lower dose level (1-3 × 104 CFU/mL), pharyngitis was diagnosed in one of five participants. Immunological, biochemical, and microbiological results supported the clinical picture, with acute symptomatic pharyngitis characterised by pharyngeal colonisation by S pyogenes accompanied by significantly elevated C-reactive protein and inflammatory cytokines (eg, interferon-γ and interleukin-6), and modest serological responses to streptolysin O and deoxyribonuclease B. There were no severe (grade 3) or serious adverse events related to challenge. INTERPRETATION We have established a reliable pharyngitis human infection model with reassuring early safety findings to accelerate development of vaccines and other interventions to control disease due to S pyogenes. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia.
| | - Kristy I Azzopardi
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Loraine Fabri
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Hannah R Frost
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tania Rivera-Hernandez
- Unidad de Investigación Médica en Inmunoquímica, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico; School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Melanie R Neeland
- Epigenetics Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Alana L Whitcombe
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Anneke Grobler
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Sarah J Gutman
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia; Imaging Research, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Ciara Baker
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | | | | | - Claire S Waddington
- Department of Medicine, University of Cambridge, Cambridge, UK; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Manisha Pandey
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - James S McCarthy
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia; QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Michael F Good
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - James B Dale
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Michael Batzloff
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Nicole J Moreland
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia; Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Pierre R Smeesters
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium; Molecular Bacteriology Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew C Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
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McMillan DJ, Rafeek RAM, Norton RE, Good MF, Sriprakash KS, Ketheesan N. In Search of the Holy Grail: A Specific Diagnostic Test for Rheumatic Fever. Front Cardiovasc Med 2021; 8:674805. [PMID: 34055941 PMCID: PMC8160110 DOI: 10.3389/fcvm.2021.674805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/22/2021] [Indexed: 12/13/2022] Open
Abstract
Current diagnosis of Acute Rheumatic Fever and Rheumatic Heart Disease (ARF/RHD) relies on a battery of clinical observations aided by technologically advanced diagnostic tools and non-specific laboratory tests. The laboratory-based assays fall into two categories: those that (1) detect "evidence of preceding streptococcal infections" (ASOT, anti-DNAse B, isolation of the Group A Streptococcus from a throat swab) and (2) those that detect an ongoing inflammatory process (ESR and CRP). These laboratory tests are positive during any streptococcal infection and are non-specific for the diagnosis of ARF/RHD. Over the last few decades, we have accumulated considerable knowledge about streptococcal biology and the immunopathological mechanisms that contribute to the development, progression and exacerbation of ARF/RHD. Although our knowledge is incomplete and many more years will be devoted to understanding the exact molecular and cellular mechanisms involved in the spectrum of clinical manifestations of ARF/RHD, in this commentary we contend that there is sufficient understanding of the disease process that using currently available technologies it is possible to identify pathogen associated peptides and develop a specific test for ARF/RHD. It is our view that with collaboration and sharing of well-characterised serial blood samples from patients with ARF/RHD from different regions, antibody array technology and/or T-cell tetramers could be used to identify streptococcal peptides specific to ARF/RHD. The availability of an appropriate animal model for this uniquely human disease can further facilitate the determination as to whether these peptides are pathognomonic. Identification of such peptides will also facilitate testing of potential anti-streptococcal vaccines for safety and avoid potential candidates that may pre-dispose potential vaccine recipients to adverse outcomes. Such peptides can also be readily incorporated into a universally affordable point of care device for both primary and tertiary care.
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Affiliation(s)
- David J. McMillan
- School of Science and Technology, Engineering and Genecology Research Centre, University of the Sunshine Coast, Maroochydore, QLD, Australia
- School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Rukshan A. M. Rafeek
- School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Robert E. Norton
- School of Science and Technology, University of New England, Armidale, NSW, Australia
- Pathology Queensland, Townsville University Hospital, Douglas, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Michael F. Good
- Laboratory of Vaccines for the Developing World, Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Kadaba S. Sriprakash
- School of Science and Technology, University of New England, Armidale, NSW, Australia
- Queensland Institute of Medical Research Berghofer (QIMR) Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Natkunam Ketheesan
- School of Science and Technology, University of New England, Armidale, NSW, Australia
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