1
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Niu L, Wang H, Luo G, Zhou J, Hu Z, Yan B. Advances in understanding immune homeostasis in latent tuberculosis infection. WIREs Mech Dis 2024; 16:e1643. [PMID: 38351551 DOI: 10.1002/wsbm.1643] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 07/13/2024]
Abstract
Nearly one-fourth of the global population is infected by Mycobacterium tuberculosis (Mtb), and approximately 90%-95% remain asymptomatic as latent tuberculosis infection (LTBI), an estimated 5%-10% of those with latent infections will eventually progress to active tuberculosis (ATB). Although it is widely accepted that LTBI transitioning to ATB results from a disruption of host immune balance and a weakening of protective immune responses, the exact underlying immunological mechanisms that promote this conversion are not well characterized. Thus, it is difficult to accurately predict tuberculosis (TB) progression in advance, leaving the LTBI population as a significant threat to TB prevention and control. This article systematically explores three aspects related to the immunoregulatory mechanisms and translational research about LTBI: (1) the distinct immunocytological characteristics of LTBI and ATB, (2) LTBI diagnostic markers discovery related to host anti-TB immunity and metabolic pathways, and (3) vaccine development focus on LTBI. This article is categorized under: Infectious Diseases > Molecular and Cellular Physiology Infectious Diseases > Genetics/Genomics/Epigenetics Immune System Diseases > Genetics/Genomics/Epigenetics.
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Affiliation(s)
- Liangfei Niu
- Center for Tuberculosis Research, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People's Republic of China
| | - Hao Wang
- Center for Tuberculosis Research, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People's Republic of China
- School of Life Science and Technology, Wuhan Polytechnic University, Wuhan, China
| | - Geyang Luo
- Center for Tuberculosis Research, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People's Republic of China
| | - Jing Zhou
- Department of Pathology, Center for Tuberculosis Research, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People's Republic of China
| | - Zhidong Hu
- Center for Tuberculosis Research, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People's Republic of China
| | - Bo Yan
- Center for Tuberculosis Research, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People's Republic of China
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2
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Zhou F, Zhang D. Recent advance in the development of tuberculosis vaccines in clinical trials and virus-like particle-based vaccine candidates. Front Immunol 2023; 14:1238649. [PMID: 38022657 PMCID: PMC10652786 DOI: 10.3389/fimmu.2023.1238649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Tuberculosis (TB) remains a serious public health threat around the world. An effective vaccine is urgently required for cost-effective, long-term control of TB. However, the only licensed vaccine Bacillus Calmette-Guerin (BCG) is limited to prevent TB for its highly variable efficacy. Substantial progress has been made in research and development (R&D) of TB vaccines in the past decades, and a dozen vaccine candidates, including live attenuated mycobacterial vaccines, killed mycobacterial vaccines, adjuvanted subunit vaccines, viral vector vaccines, and messenger RNA (mRNA) vaccines were developed in clinical trials to date. Nevertheless, many challenges to the successful authorization for the use and deployment of an effective tuberculosis vaccine remain. Therefore, it is still necessary and urgent to continue exploring new vaccine construction approaches. Virus-like particles (VLPs) present excellent prospects in the field of vaccine development because of their helpful immunological features such as being safe templates without containing viral nucleic acid, repetitive surface geometry, conformational epitopes similar to natural viruses, and enhancing both innate and adaptive immune responses. The marketization process of VLP vaccines has never stopped despite VLP vaccines face several shortcomings such as their complex and slow development process and high production cost, and several VLP-based vaccines, including vaccines against Human papillomavirus (HPV), Hepatitis B Virus (HBV) and malaria, are successfully licensed for use at the market. In this review, we provide an update on the current progress regarding the development of TB vaccines in clinical trials and seek to give an overview of VLP-based TB vaccine candidates.
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Affiliation(s)
- Fangbin Zhou
- Department of Tropical Diseases, Naval Medical University, Shanghai, China
| | - Dongmei Zhang
- Department of Tropical Diseases, Naval Medical University, Shanghai, China
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3
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Ahmed A, Tripathi H, van Meijgaarden KE, Kumar NC, Adiga V, Rakshit S, Parthiban C, Eveline J S, D’Souza G, Dias M, Ottenhoff TH, Netea MG, Joosten SA, Vyakarnam A. BCG revaccination in adults enhances pro-inflammatory markers of trained immunity along with anti-inflammatory pathways. iScience 2023; 26:107889. [PMID: 37817935 PMCID: PMC10561055 DOI: 10.1016/j.isci.2023.107889] [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: 03/21/2023] [Revised: 06/22/2023] [Accepted: 09/07/2023] [Indexed: 10/12/2023] Open
Abstract
This study characterized mechanisms of Bacille Calmette-Guérin (BCG) revaccination-induced trained immunity (TI) in India. Adults, BCG vaccinated at birth, were sampled longitudinally before and after a second BCG dose. BCG revaccination significantly elevated tumor necrosis factor alpha (TNF-α), interleukin (IL)-1β, and IL-6 in HLA-DR+CD16-CD14hi monocytes, demonstrating induction of TI. Mycobacteria-specific CD4+ T cell interferon (IFN) γ, IL-2, and TNF-α were significantly higher in re-vaccinees and correlated positively with HLA-DR+CD16-CD14hi TI responses. This, however, did not translate into increased mycobacterial growth control, measured by mycobacterial growth inhibition assay (MGIA). Post revaccination, elevated secreted TNF-α, IL-1β, and IL-6 to "heterologous" fungal, bacterial, and enhanced CXCL-10 and IFNα to viral stimuli were also observed concomitant with increased anti-inflammatory cytokine, IL-1RA. RNA sequencing after revaccination highlighted a BCG and LPS induced signature which included upregulated IL17 and TNF pathway genes and downregulated key inflammatory genes: CXCL11, CCL24, HLADRA, CTSS, CTSC. Our data highlight a balanced immune response comprising pro- and anti-inflammatory mediators to be a feature of BCG revaccination-induced immunity.
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Affiliation(s)
- Asma Ahmed
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Himanshu Tripathi
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | | | - Nirutha Chetan Kumar
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Vasista Adiga
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
- Department of Biotechnology, PES University, Bangalore, India
| | - Srabanti Rakshit
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Chaitra Parthiban
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Sharon Eveline J
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - George D’Souza
- Department of Pulmonary Medicine, St. John’s Medical College, Bangalore, India
| | - Mary Dias
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Tom H.M. Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Mihai G. Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Immunology and Metabolism, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Simone A. Joosten
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Annapurna Vyakarnam
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
- Department of Immunobiology, School of Immunology & Microbial Sciences, Faculty of Life Science & Medicine, King’s College, London, UK
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4
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Perera DJ, Domenech P, Babuadze GG, Naghibosadat M, Alvarez F, Koger-Pease C, Labrie L, Stuible M, Durocher Y, Piccirillo CA, Lametti A, Fiset PO, Elahi SM, Kobinger GP, Gilbert R, Olivier M, Kozak R, Reed MB, Ndao M. BCG administration promotes the long-term protection afforded by a single-dose intranasal adenovirus-based SARS-CoV-2 vaccine. iScience 2023; 26:107612. [PMID: 37670783 PMCID: PMC10475483 DOI: 10.1016/j.isci.2023.107612] [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: 06/03/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 09/07/2023] Open
Abstract
Recent publications have explored intranasal (i.n.) adenovirus-based (Ad) vaccines as an effective strategy for SARS-CoV-2 in pre-clinical models. However, the effects of prior immunizations and infections have yet to be considered. Here, we investigate the immunomodulatory effects of Mycobacterium bovis BCG pre-immunization followed by vaccination with an S-protein-expressing i.n. Ad, termed Ad(Spike). While i.n. Ad(Spike) retains some protective effect after 6 months, a single administration of BCG-Danish prior to Ad(Spike) potentiates its ability to control viral replication of the B.1.351 SARS-CoV-2 variant within the respiratory tract. Though BCG-Danish did not affect Ad(Spike)-generated humoral immunity, it promoted the generation of cytotoxic/Th1 responses over suppressive FoxP3+ TREG cells in the lungs of infected mice. Thus, this vaccination strategy may prove useful in limiting future pandemics by potentiating the long-term efficacy of mucosal vaccines within the context of the widely distributed BCG vaccine.
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Affiliation(s)
- Dilhan J. Perera
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Pilar Domenech
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- McGill International TB Centre, McGill University, Montréal, QC, Canada
| | - George Giorgi Babuadze
- Department of Biological Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
- Department of Microbiology & Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Maedeh Naghibosadat
- Department of Biological Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Fernando Alvarez
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Department of Microbiology and Immunology, McGill University, Montréal, QC, Canada
| | - Cal Koger-Pease
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Lydia Labrie
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Department of Microbiology and Immunology, McGill University, Montréal, QC, Canada
| | - Matthew Stuible
- Department of Production Platforms & Analytics, Human Health Therapeutics Research Center, National Research Council Canada, Montréal, QC, Canada
| | - Yves Durocher
- Department of Production Platforms & Analytics, Human Health Therapeutics Research Center, National Research Council Canada, Montréal, QC, Canada
| | - Ciriaco A. Piccirillo
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Department of Microbiology and Immunology, McGill University, Montréal, QC, Canada
| | - André Lametti
- Department of Pathology, McGill University, Montréal, QC, Canada
| | | | - Seyyed Mehdy Elahi
- Department of Production Platforms & Analytics, Human Health Therapeutics Research Center, National Research Council Canada, Montréal, QC, Canada
| | - Gary P. Kobinger
- Département de Microbiologie-Infectiologie et Immunologie, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Rénald Gilbert
- Department of Production Platforms & Analytics, Human Health Therapeutics Research Center, National Research Council Canada, Montréal, QC, Canada
| | - Martin Olivier
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Department of Microbiology and Immunology, McGill University, Montréal, QC, Canada
| | - Robert Kozak
- Department of Biological Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine and Molecular Diagnostics, Division of Microbiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Michael B. Reed
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- McGill International TB Centre, McGill University, Montréal, QC, Canada
| | - Momar Ndao
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Department of Microbiology and Immunology, McGill University, Montréal, QC, Canada
- National Reference Centre for Parasitology, McGill University Health Centre, Montréal, QC, Canada
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5
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Rakshit S, Babji S, Parthiban C, Madhavan R, Adiga V, J SE, Chetan Kumar N, Ahmed A, Shivalingaiah S, Shashikumar N, V M, Johnson AR, Ramesh N, B RG, Asokan M, Mayor S, Kang G, D'souza G, Dias M, Vyakarnam A. Polyfunctional CD4 T-cells correlating with neutralising antibody is a hallmark of COVISHIELD TM and COVAXIN ® induced immunity in COVID-19 exposed Indians. NPJ Vaccines 2023; 8:134. [PMID: 37709772 PMCID: PMC10502007 DOI: 10.1038/s41541-023-00731-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
Detailed characterisation of immune responses induced by COVID-19 vaccines rolled out in India: COVISHIELDTM (CS) and COVAXIN® (CO) in a pre-exposed population is only recently being discovered. We addressed this issue in subjects who received their primary series of vaccination between November 2021 and January 2022. Both vaccines are capable of strongly boosting Wuhan Spike-specific neutralising antibody, polyfunctional Th1 cytokine producing CD4+ T-cells and single IFN-γ + CD8+ T-cells. Consistent with inherent differences in vaccine platform, the vector-based CS vaccine-induced immunity was of greater magnitude, breadth, targeting Delta and Omicron variants compared to the whole-virion inactivated vaccine CO, with CS vaccinees showing persistent CD8+ T-cells responses until 3 months post primary vaccination. This study provides detailed evidence on the magnitude and quality of CS and CO vaccine induced responses in subjects with pre-existing SARS-CoV-2 immunity in India, thereby mitigating vaccine hesitancy arguments in such a population, which remains a global health challenge.
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Affiliation(s)
- Srabanti Rakshit
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
| | - Sudhir Babji
- The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Chaitra Parthiban
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
| | - Ramya Madhavan
- The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vasista Adiga
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
- Department of Biotechnology, PES University, Bangalore, Karnataka, India
| | - Sharon Eveline J
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
| | - Nirutha Chetan Kumar
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
| | - Asma Ahmed
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
| | | | - Nandini Shashikumar
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
| | - Mamatha V
- St. John's Medical College, Bangalore, Karnataka, India
| | | | - Naveen Ramesh
- St. John's Medical College, Bangalore, Karnataka, India
| | | | | | - Satyajit Mayor
- National Centre for Biological Sciences, Bengaluru, Karnataka, India
| | - Gagandeep Kang
- The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - George D'souza
- Department of Pulmonary Medicine, St. John's Medical College, Bangalore, Karnataka, India
| | - Mary Dias
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India
- St. John's Medical College, Bangalore, Karnataka, India
| | - Annapurna Vyakarnam
- Division of Infectious Diseases, St. John's Research Institute, Bangalore, Karnataka, India.
- Department of Immunobiology, School of Immunology & Microbial Sciences, Faculty of Life Science & Medicine, King's College, London, UK.
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6
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Jalbert E, Liu C, Mave V, Lang N, Kagal A, Valvi C, Paradkar M, Gupte N, Lokhande R, Bharadwaj R, Kulkarni V, Gupta A, Weinberg A. Comparative immune responses to Mycobacterium tuberculosis in people with latent infection or sterilizing protection. iScience 2023; 26:107425. [PMID: 37564701 PMCID: PMC10410524 DOI: 10.1016/j.isci.2023.107425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 03/22/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023] Open
Abstract
There is great need for vaccines against tuberculosis (TB) more efficacious than the licensed BCG. Our goal was to identify new vaccine benchmarks by identifying immune responses that distinguish individuals able to eradicate the infection (TB-resisters) from individuals with latent infection (LTBI-participants). TB-resisters had higher frequencies of circulating CD8+ glucose monomycolate (GMM)+ Granzyme-B+ T cells than LTBI-participants and higher proportions of polyfunctional conventional and nonconventional T cells expressing Granzyme-B and/or PD-1 after ex vivo M. tuberculosis stimulation of blood mononuclear cells. LTBI-participants had higher expression of activation markers and cytokines, including IL10, and IFNγ. An exploratory analysis of BCG-recipients with minimal exposure to TB showed absence of CD8+GMM+Granzyme-B+ T cells, lower or equal proportions of Granzyme-B+PD-1+ polyfunctional T cells than TB-resisters and higher or equal than LTBI-participants. In conclusion, high Granzyme-B+PD-1+ T cell responses to M. tuberculosis and, possibly, of CD8+GMM+Granzyme-B+ T cells may be desirable for new TB vaccines.
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Affiliation(s)
- Emilie Jalbert
- Department of Pediatrics, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Cuining Liu
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site (BJGMC-JHU CRS), Pune, Maharashtra, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, Maharashtra, India
- School of Medicine, Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA
| | - Nancy Lang
- Department of Pediatrics, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Anju Kagal
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Chhaya Valvi
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site (BJGMC-JHU CRS), Pune, Maharashtra, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, Maharashtra, India
- School of Medicine, Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site (BJGMC-JHU CRS), Pune, Maharashtra, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, Maharashtra, India
- School of Medicine, Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA
| | - Rahul Lokhande
- Department of Pulmonary Medicine, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Renu Bharadwaj
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site (BJGMC-JHU CRS), Pune, Maharashtra, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, Maharashtra, India
- School of Medicine, Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA
| | - Amita Gupta
- Johns Hopkins Center for Infectious Diseases in India, Pune, Maharashtra, India
- School of Medicine, Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA
| | - Adriana Weinberg
- Departments of Pediatrics, Medicine and Pathology, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
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7
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Kim H, Choi HG, Shin SJ. Bridging the gaps to overcome major hurdles in the development of next-generation tuberculosis vaccines. Front Immunol 2023; 14:1193058. [PMID: 37638056 PMCID: PMC10451085 DOI: 10.3389/fimmu.2023.1193058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Although tuberculosis (TB) remains one of the leading causes of death from an infectious disease worldwide, the development of vaccines more effective than bacille Calmette-Guérin (BCG), the only licensed TB vaccine, has progressed slowly even in the context of the tremendous global impact of TB. Most vaccine candidates have been developed to strongly induce interferon-γ (IFN-γ)-producing T-helper type 1 (Th1) cell responses; however, accumulating evidence has suggested that other immune factors are required for optimal protection against Mycobacterium tuberculosis (Mtb) infection. In this review, we briefly describe the five hurdles that must be overcome to develop more effective TB vaccines, including those with various purposes and tested in recent promising clinical trials. In addition, we discuss the current knowledge gaps between preclinical experiments and clinical studies regarding peripheral versus tissue-specific immune responses, different underlying conditions of individuals, and newly emerging immune correlates of protection. Moreover, we propose how recently discovered TB risk or susceptibility factors can be better utilized as novel biomarkers for the evaluation of vaccine-induced protection to suggest more practical ways to develop advanced TB vaccines. Vaccines are the most effective tools for reducing mortality and morbidity from infectious diseases, and more advanced technologies and a greater understanding of host-pathogen interactions will provide feasibility and rationale for novel vaccine design and development.
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Affiliation(s)
- Hongmin Kim
- Department of Microbiology, Institute for Immunology and Immunological Diseases, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Han-Gyu Choi
- Department of Microbiology and Medical Science, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Sung Jae Shin
- Department of Microbiology, Institute for Immunology and Immunological Diseases, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
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8
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Banurekha VV, Padmapriyadarsini C, Bhargava S, Sachdeva K. NATCON 2022 Panel discussion: "TB vaccination - Going Forward". Indian J Tuberc 2023; 70:366-369. [PMID: 37562914 DOI: 10.1016/j.ijtb.2023.03.022] [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: 03/25/2023] [Accepted: 03/31/2023] [Indexed: 08/12/2023]
Abstract
Vaccination is important tuberculosis (TB) preventive strategy that is essential to achieve the goals of the End TB strategy. The BCG vaccination at birth offers protection against TB in young children but not in adolescents and adults. New TB vaccines are the need of the hour. The TB vaccine development pipeline in the past years is encouraging with newer TB vaccines in clinical trials in humans. The focus of the newer TB vaccine is the prevention of infection, disease, and recurrence of TB disease. Therapeutic vaccines focus on better treatment outcomes and prevention of TB recurrence. BCG revaccination is of current interest. Novel, safe, and efficient TB vaccines that prevent TB infection and disease if introduced in 2025 could drastically reduce the rate of TB incidence. However, the development of an effective vaccine for TB is challenging. Engagement of stakeholders, mobilizing funding, and advocacy could accelerate the newer TB vaccine development process.
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Affiliation(s)
- V V Banurekha
- ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - K Sachdeva
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
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9
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Singh S, Diwakar A, Singh RK. BCG vaccination policy, natural boosting and pediatric brain and CNS tumor incidences. Front Immunol 2023; 14:1174006. [PMID: 37383238 PMCID: PMC10295148 DOI: 10.3389/fimmu.2023.1174006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023] Open
Abstract
Bacille Calmette-Guérin (BCG) vaccination supposedly imparts and augments "trained immunity" that cross-protects against multiple unrelated pathogens and enhances general immune surveillance. Gradual reductions in tuberculosis burden over the last 3-5 decades have resulted in the withdrawal of BCG vaccination mandates from developed industrialized countries while reducing to a single neonatal shot in the rest. Concurrently, a steady increase in early childhood Brain and CNS (BCNS) tumors has occurred. Though immunological causes of pediatric BCNS cancer are suspected, the identification of a causal protective variable with intervention potential has remained elusive. An examination of the countries with contrasting vaccination policies indicates significantly lower BCNS cancer incidence in 0-4-year-olds (per hundredthousand) of countries following neonatal BCG inoculations (n=146) vs. non-BCG countries (n=33) [Mean: 1.26 vs. 2.64; Median: 0.985 vs. 2.8; IQR: 0.31-2.0 vs. 2.4-3.2; P=<0.0001 (two-tailed)]. Remarkably, natural Mycobacterium spp. reexposure likelihood is negatively correlated with BCNS cancer incidence in 0-4-year-olds of all affected countries [r(154): -0.6085, P=<0.0001]. Seemingly, neonatal BCG vaccination and natural "boosting" are associated with a 15-20-fold lower BCNS cancer incidence. In this opinion article, we attempt to synthesize existing evidence implying the immunological basis of early childhood BCNS cancer incidence and briefly indicate possible causes that could have precluded objective analysis of the existing data in the past. We draw the attention of the stakeholders to consider the comprehensive evaluation of immune training as a potential protective variable through well-designed controlled clinical trials or registry-based studies as feasible for its potential applications in reducing childhood BCNS cancer incidence.
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Affiliation(s)
- Samer Singh
- Centre of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Amita Diwakar
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rakesh K. Singh
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi, India
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10
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Puri M, Miranda-Hernandez S, Subbian S, Kupz A. Repurposing mucosal delivery devices for live attenuated tuberculosis vaccines. Front Immunol 2023; 14:1159084. [PMID: 37063870 PMCID: PMC10098179 DOI: 10.3389/fimmu.2023.1159084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023] Open
Abstract
Tuberculosis (TB) remains one of the most lethal infectious diseases globally. The only TB vaccine approved by the World Health Organization, Bacille Calmette-Guérin (BCG), protects children against severe and disseminated TB but provides limited protection against pulmonary TB in adults. Although several vaccine candidates have been developed to prevent TB and are undergoing preclinical and clinical testing, BCG remains the gold standard. Currently, BCG is administered as an intradermal injection, particularly in TB endemic countries. However, mounting evidence from experimental animal and human studies indicates that delivering BCG directly into the lungs provides enhanced immune responses and greater protection against TB. Inhalation therapy using handheld delivery devices is used for some diseases and allows the delivery of drugs or vaccines directly into the human respiratory tract. Whether this mode of delivery could also be applicable for live attenuated bacterial vaccines such as BCG or other TB vaccine candidates remains unknown. Here we discuss how two existing inhalation devices, the mucosal atomization device (MAD) syringe, used for influenza vaccines, and the Respimat® Soft Mist™ inhaler, used for chronic obstructive pulmonary disease (COPD) therapy, could be repurposed for mucosal delivery of live attenuated TB vaccines. We also outline the challenges and outstanding research questions that will require further investigations to ensure usefulness of respiratory delivery devices that are cost-effective and accessible to lower- and middle-income TB endemic countries.
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Affiliation(s)
- Munish Puri
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
| | - Socorro Miranda-Hernandez
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
| | - Selvakumar Subbian
- Public Health Research Institute (PHRI), New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Andreas Kupz
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
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11
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Goudouris E, Aranda CS, Solé D. Implications of the non-specific effect induced by Bacillus Calmette-Guerin (BCG) vaccine on vaccine recommendations. J Pediatr (Rio J) 2023; 99 Suppl 1:S22-S27. [PMID: 36309066 PMCID: PMC10066422 DOI: 10.1016/j.jped.2022.09.002] [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: 09/14/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Since the beginning of its use for the prevention of tuberculosis (TB) in 1921, other uses of BCG (Bacillus Calmette-Guérin) have been proposed, particularly in the treatment of malignant solid tumors, multiple sclerosis, and other autoimmune diseases. Its beneficial impact on other infections, by nontuberculous mycobacteria, and by viruses, has been more often studied in recent years, especially after the introduction of the concept of trained immunity. The present study's objective was to review the possible indications of BCG and the immunological rationale for these indications. DATA SOURCE Non-systematic review carried out in the PubMed, SciELO and Google Scholar databases, using the following search terms: "BCG" and "history", "efficacy", "use", "cancer", "trained immunity", "other infections", "autoimmune diseases". DATA SYNTHESIS There is epidemiological evidence that BCG can reduce overall child morbidity/mortality beyond what would be expected from TB control. BCG is able to promote cross-immunity with nontuberculous mycobacteria and other bacteria. BCG promotes in vitro changes that increase innate immune response to other infections, mainly viral ones, through mechanisms known as trained immunity. Effects on cancer, except bladder cancer, and on autoimmune and allergic diseases are debatable. CONCLUSIONS Despite evidence obtained from in vitro studies, and some epidemiological and clinical evidence, more robust evidence of in vivo efficacy is still needed to justify the use of BCG in clinical practice, in addition to what is recommended by the National Immunization Program for TB prevention and bladder cancer treatment.
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Affiliation(s)
- Ekaterini Goudouris
- Universidade Federal do Rio de Janeiro (UFRJ), Faculdade de Medicina, Departamento de Pediatria, Rio de Janeiro, RJ, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Serviço de Alergia e Imunologia, Rio de Janeiro, RJ, Brazil.
| | - Carolina Sanchez Aranda
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia, São Paulo, SP, Brazil
| | - Dirceu Solé
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia, São Paulo, SP, Brazil
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12
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Arinaminpathy N, Rade K, Kumar R, Joshi RP, Rao R. The potential impact of vaccination on tuberculosis burden in India: A modelling analysis. Indian J Med Res 2023; 157:119-126. [PMID: 37202930 PMCID: PMC10319376 DOI: 10.4103/ijmr.ijmr_328_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Indexed: 05/20/2023] Open
Abstract
Background & objectives Vaccination will play an important role in meeting the end tuberculosis (TB) goals. While certain vaccine candidates in advanced stages of clinical trials raise hope for the future availability of new tools, in the immediate term, there is also increasing interest in Bacille Calmette-Guérin revaccination among adults and adolescents as a potential strategy. Here, we sought to estimate the potential epidemiological impact of TB vaccination in India. Methods We developed a deterministic, age-structured, compartmental model of TB in India. Data from the recent national prevalence survey was used to inform epidemiological burden while also incorporating a vulnerable population who may be prioritized for vaccination, the latter consistent with the burden of undernutrition. Using this framework, the potential impact on incidence and mortality of a vaccine with 50 per cent efficacy was estimated, if rolled out in 2023 to cover 50 per cent of the unvaccinated each year. Simulated impacts were compared for disease- vs. infection-preventing vaccines, as well as when prioritizing vulnerable groups (those with undernutrition) rather than the general population. A sensitivity analyses were also conducted with respect to the duration, and efficacy, of vaccine immunity. Results When rolled out in the general population, an infection-preventing vaccine would avert 12 per cent (95% Bayesian credible intervals (Crl): 4.3-28%) of cumulative TB incidence between 2023 and 2030, while a disease-preventing vaccine would avert 29 per cent (95% Crl: 24-34%). Although the vulnerable population accounts for only around 16 per cent of India's population, prioritizing this group for vaccination would achieve almost half the impact of rollout in the general population, in the example of an infection-preventing vaccine. Sensitivity analysis also highlights the importance of the duration and efficacy of vaccine-induced immunity. Interpretation & conclusions These results highlight how even a vaccine with moderate effectiveness (50%) could achieve substantial reductions in TB burden in India, especially when prioritized for the most vulnerable.
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Affiliation(s)
- Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Kirankumar Rade
- WHO India Country Office, Ministry of Health & Family Welfare, New Delhi, India
| | - Ravinder Kumar
- Central TB Division, Ministry of Health & Family Welfare, New Delhi, India
| | - Rajendra P. Joshi
- Central TB Division, Ministry of Health & Family Welfare, New Delhi, India
| | - Raghuram Rao
- Central TB Division, Ministry of Health & Family Welfare, New Delhi, India
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13
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Du J, Su Y, Wang R, Dong E, Cao Y, Zhao W, Gong W. Research progress on specific and non-specific immune effects of BCG and the possibility of BCG protection against COVID-19. Front Immunol 2023; 14:1118378. [PMID: 36798128 PMCID: PMC9927227 DOI: 10.3389/fimmu.2023.1118378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023] Open
Abstract
Bacille Calmette-Guérin (BCG) is the only approved vaccine for tuberculosis (TB) prevention worldwide. BCG has an excellent protective effect on miliary tuberculosis and tuberculous meningitis in children or infants. Interestingly, a growing number of studies have shown that BCG vaccination can induce nonspecific and specific immunity to fight against other respiratory disease pathogens, including SARS-CoV-2. The continuous emergence of variants of SARS-CoV-2 makes the protective efficiency of COVID-19-specific vaccines an unprecedented challenge. Therefore, it has been hypothesized that BCG-induced trained immunity might protect against COVID-19 infection. This study comprehensively described BCG-induced nonspecific and specific immunity and the mechanism of trained immunity. In addition, this study also reviewed the research on BCG revaccination to prevent TB, the impact of BCG on other non-tuberculous diseases, and the clinical trials of BCG to prevent COVID-19 infection. These data will provide new evidence to confirm the hypotheses mentioned above.
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Affiliation(s)
- Jingli Du
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Yue Su
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Ruilan Wang
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Enjun Dong
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Yan Cao
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Wenjuan Zhao
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Wenping Gong
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
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14
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Rakshit S, Adiga V, Ahmed A, Parthiban C, Chetan Kumar N, Dwarkanath P, Shivalingaiah S, Rao S, D’Souza G, Dias M, Maguire TJA, Doores KJ, Zoodsma M, Geckin B, Dasgupta P, Babji S, van Meijgaarden KE, Joosten SA, Ottenhoff THM, Li Y, Netea MG, Stuart KD, De Rosa SC, McElrath MJ, Vyakarnam A. Evidence for the heterologous benefits of prior BCG vaccination on COVISHIELD™ vaccine-induced immune responses in SARS-CoV-2 seronegative young Indian adults. Front Immunol 2022; 13:985938. [PMID: 36268023 PMCID: PMC9577398 DOI: 10.3389/fimmu.2022.985938] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/26/2022] [Indexed: 11/15/2022] Open
Abstract
This proof-of-concept study tested if prior BCG revaccination can qualitatively and quantitively enhance antibody and T-cell responses induced by Oxford/AstraZeneca ChAdOx1nCoV-19 or COVISHIELD™, an efficacious and the most widely distributed vaccine in India. We compared COVISHIELD™ induced longitudinal immune responses in 21 BCG re-vaccinees (BCG-RV) and 13 BCG-non-revaccinees (BCG-NRV), all of whom were BCG vaccinated at birth; latent tuberculosis negative and SARS-CoV-2 seronegative prior to COVISHIELD™ vaccination. Compared to BCG-NRV, BCG-RV displayed significantly higher and persistent spike-specific neutralizing (n) Ab titers and polyfunctional CD4+ and CD8+ T-cells for eight months post COVISHIELD™ booster, including distinct CD4+IFN-γ+ and CD4+IFN-γ- effector memory (EM) subsets co-expressing IL-2, TNF-α and activation induced markers (AIM) CD154/CD137 as well as CD8+IFN-γ+ EM,TEMRA (T cell EM expressing RA) subset combinations co-expressing TNF-α and AIM CD137/CD69. Additionally, elevated nAb and T-cell responses to the Delta mutant in BCG-RV highlighted greater immune response breadth. Mechanistically, these BCG adjuvant effects were associated with elevated markers of trained immunity, including higher IL-1β and TNF-α expression in CD14+HLA-DR+monocytes and changes in chromatin accessibility highlighting BCG-induced epigenetic changes. This study provides first in-depth analysis of both antibody and memory T-cell responses induced by COVISHIELD™ in SARS-CoV-2 seronegative young adults in India with strong evidence of a BCG-induced booster effect and therefore a rational basis to validate BCG, a low-cost and globally available vaccine, as an adjuvant to enhance heterologous adaptive immune responses to current and emerging COVID-19 vaccines.
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Affiliation(s)
- Srabanti Rakshit
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Vasista Adiga
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
- Department of Biotechnology, PES University, Bangalore, India
| | - Asma Ahmed
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Chaitra Parthiban
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Nirutha Chetan Kumar
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | | | | | - Srishti Rao
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - George D’Souza
- Division of Nutrition, St. John’s Research Institute, Bangalore, India
| | - Mary Dias
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | | | - Katie J. Doores
- Department of Pulmonary Medicine, St. John’s Medical College, Bangalore, India
| | - Martijn Zoodsma
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
- Department of Computational Biology for Individualized Infection Medicine, Centre for Individualized Infection Medicine (CiiM), a joint venture between the Helmholtz Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Busranur Geckin
- TWINCORE, a joint venture between the Helmholtz Centre for Infection Research, (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Prokar Dasgupta
- Department of Internal Medicine and Radboud Center for infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sudhir Babji
- Peter Gorer Department of Immunobiology, Liver Renal Urology Transplant Gastro/Gastrointestinal Surgery, Inflammation Biology, King’s College London, London, United Kingdom
| | | | - Simone A. Joosten
- The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, India
| | - Tom H. M. Ottenhoff
- The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, India
| | - Yang Li
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
- Department of Computational Biology for Individualized Infection Medicine, Centre for Individualized Infection Medicine (CiiM), a joint venture between the Helmholtz Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Mihai G. Netea
- TWINCORE, a joint venture between the Helmholtz Centre for Infection Research, (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Kenneth D. Stuart
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Stephen C. De Rosa
- Centre for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, WA, United States
| | - M. Juliana McElrath
- Centre for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Centre, Seattle, WA, United States
| | - Annapurna Vyakarnam
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
- *Correspondence: Annapurna Vyakarnam, ;
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15
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Gong W, Liang Y, Mi J, Xue Y, Wang J, Wang L, Zhou Y, Sun S, Wu X. A peptide-based vaccine ACP derived from antigens of Mycobacterium tuberculosis induced Th1 response but failed to enhance the protective efficacy of BCG in mice. Indian J Tuberc 2022; 69:482-495. [PMID: 36460380 DOI: 10.1016/j.ijtb.2021.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/31/2021] [Accepted: 08/10/2021] [Indexed: 06/17/2023]
Abstract
BACKGROUND Tuberculosis (TB) is a global infectious disease, but there is no ideal vaccine against TB except the Bacille Calmette-Guérin (BCG) vaccine. METHODS Herein, 25 candidate peptides were predicted from four antigens of Mycobacterium tuberculosis based on their high-affinity binding capacity for the human leukocyte antigen (HLA) DRB1∗0101. Three T-helper 1 (Th1) immunodominant peptides (Ag85B12-26, CFP2112-26, and PPE18149-163) were identified by ELISPOT assays in the humanized C57BL/6 mice. They resulted in a novel Th1 peptide-based vaccine ACP named by the first letter of the three peptides. In addition, the protective efficacy was evaluated in humanized or wild-type C57BL/6 mice and the humoral and cellular immune responses were confirmed in vitro. RESULTS Compared with the PBS group, the ACP vaccinated mice showed slight decreases in colony-forming units (CFUs) and pathological lesions. However, when using it as a booster, the ACP vaccine did not significantly enhance the protective efficacy of BCG in humanized or wild-type mice. Interestingly, we found that ACP vaccination significantly increased the number of interferon-γ positive (IFN-γ+) T lymphocytes and the levels of IFN-γ cytokines as well as antibodies. Furthermore, the IL-2 level was significantly higher in humanized mice prime-boosted with BCG and ACP. CONCLUSIONS Our results suggested that ACP vaccination could stimulate higher levels of cytokines and antibodies but failed to improve the protective efficacy of BCG in mice, indicating that the secretion level of IFN-γ may not be positively correlated with the protection efficiency of the vaccine. These findings provided important information on the feasibility of a peptide vaccine as a booster for enhancing the protective efficacy of BCG.
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Affiliation(s)
- Wenping Gong
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, 100091, China
| | - Yan Liang
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, 100091, China
| | - Jie Mi
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, 100091, China
| | - Yong Xue
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, 100091, China
| | - Jie Wang
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, 100091, China
| | - Lan Wang
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, 100091, China
| | - Yusen Zhou
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, 100071, China
| | - Shihui Sun
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, 100071, China
| | - Xueqiong Wu
- Tuberculosis Prevention and Control Key Laboratory/Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, 100091, China.
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16
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Singh S, Saavedra-Avila NA, Tiwari S, Porcelli SA. A century of BCG vaccination: Immune mechanisms, animal models, non-traditional routes and implications for COVID-19. Front Immunol 2022; 13:959656. [PMID: 36091032 PMCID: PMC9459386 DOI: 10.3389/fimmu.2022.959656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/01/2022] [Indexed: 11/21/2022] Open
Abstract
Bacillus Calmette-Guerin (BCG) has been used as a vaccine against tuberculosis since 1921 and remains the only currently approved vaccine for this infection. The recent discovery that BCG protects against initial infection, and not just against progression from latent to active disease, has significant implications for ongoing research into the immune mechanisms that are relevant to generate a solid host defense against Mycobacterium tuberculosis (Mtb). In this review, we first explore the different components of immunity that are augmented after BCG vaccination. Next, we summarize current efforts to improve the efficacy of BCG through the development of recombinant strains, heterologous prime-boost approaches and the deployment of non-traditional routes. These efforts have included the development of new recombinant BCG strains, and various strategies for expression of important antigens such as those deleted during the M. bovis attenuation process or antigens that are present only in Mtb. BCG is typically administered via the intradermal route, raising questions about whether this could account for its apparent failure to generate long-lasting immunological memory in the lungs and the inconsistent level of protection against pulmonary tuberculosis in adults. Recent years have seen a resurgence of interest in the mucosal and intravenous delivery routes as they have been shown to induce a better immune response both in the systemic and mucosal compartments. Finally, we discuss the potential benefits of the ability of BCG to confer trained immunity in a non-specific manner by broadly stimulating a host immunity resulting in a generalized survival benefit in neonates and the elderly, while potentially offering benefits for the control of new and emerging infectious diseases such as COVID-19. Given that BCG will likely continue to be widely used well into the future, it remains of critical importance to better understand the immune responses driven by it and how to leverage these for the design of improved vaccination strategies against tuberculosis.
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Affiliation(s)
- Shivani Singh
- Department of Medicine, New York University School of Medicine, New York, NY, United States
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, New York, NY, United States
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
- *Correspondence: Shivani Singh,
| | | | - Sangeeta Tiwari
- Department of Biological Sciences and Border Biomedical Research Center, University of Texas at El Paso, Texas, United States
| | - Steven A. Porcelli
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, New York, NY, United States
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
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17
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James CA, Yu KKQ, Mayer-Blackwell K, Fiore-Gartland A, Smith MT, Layton ED, Johnson JL, Hanekom WA, Scriba TJ, Seshadri C. Durable Expansion of TCR-δ Meta-Clonotypes After BCG Revaccination in Humans. Front Immunol 2022; 13:834757. [PMID: 35432299 PMCID: PMC9005636 DOI: 10.3389/fimmu.2022.834757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Mycobacterium bovis bacille Calmette-Guérin (BCG) has been used for 100 years and prevents disseminated tuberculosis and death in young children. However, it shows only partial efficacy against pulmonary tuberculosis (TB) in adults, so new vaccines are urgently needed. The protective efficacy of BCG depends on T cells, which are typically activated by pathogen-derived protein antigens that bind to highly polymorphic major histocompatibility complex (MHC) molecules. Some T cells recognize non-protein antigens via antigen presenting systems that are independent of genetic background, leading to their designation as donor-unrestricted T (DURT) cells. Whether live whole cell vaccines, like BCG, can induce durable expansions of DURT cells in humans is not known. We used combinatorial tetramer staining, multi-parameter flow cytometry, and immunosequencing to comprehensively characterize the effect of BCG on activation and expansion of DURT cell subsets. We examined peripheral blood mononuclear cells (PBMC) derived from a Phase I study of South African adults in which samples were archived at baseline, 3 weeks, and 52 weeks post-BCG revaccination. We did not observe a change in the frequency of total mucosal-associated invariant T (MAIT) cells, invariant natural killer T (iNKT) cells, germline encoded mycolyl-reactive (GEM) T cells, or γδ T cells at 52 weeks post-BCG. However, immunosequencing revealed a set of TCR-δ clonotypes that were expanded at 52 weeks post-BCG revaccination. These expanded clones expressed the Vδ2 gene segment and could be further defined on the basis of biochemical similarity into several 'meta-clonotypes' that likely recognize similar epitopes. Our data reveal that BCG vaccination leads to durable expansion of DURT cell clonotypes despite a limited effect on total circulating frequencies in the blood and have implications for defining the immunogenicity of candidate whole cell TB vaccines.
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Affiliation(s)
- Charlotte A. James
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Krystle K. Q. Yu
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Koshlan Mayer-Blackwell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Andrew Fiore-Gartland
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Malisa T. Smith
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Erik D. Layton
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - John L. Johnson
- Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Willem A. Hanekom
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Thomas J. Scriba
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Chetan Seshadri
- Department of Medicine, University of Washington, Seattle, WA, United States
- Tuberculosis Research and Training Center, University of Washington, Seattle, WA, United States
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18
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Larsen SE, Williams BD, Rais M, Coler RN, Baldwin SL. It Takes a Village: The Multifaceted Immune Response to Mycobacterium tuberculosis Infection and Vaccine-Induced Immunity. Front Immunol 2022; 13:840225. [PMID: 35359957 PMCID: PMC8960931 DOI: 10.3389/fimmu.2022.840225] [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: 12/20/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
Despite co-evolving with humans for centuries and being intensely studied for decades, the immune correlates of protection against Mycobacterium tuberculosis (Mtb) have yet to be fully defined. This lapse in understanding is a major lag in the pipeline for evaluating and advancing efficacious vaccine candidates. While CD4+ T helper 1 (TH1) pro-inflammatory responses have a significant role in controlling Mtb infection, the historically narrow focus on this cell population may have eclipsed the characterization of other requisite arms of the immune system. Over the last decade, the tuberculosis (TB) research community has intentionally and intensely increased the breadth of investigation of other immune players. Here, we review mechanistic preclinical studies as well as clinical anecdotes that suggest the degree to which different cell types, such as NK cells, CD8+ T cells, γ δ T cells, and B cells, influence infection or disease prevention. Additionally, we categorically outline the observed role each major cell type plays in vaccine-induced immunity, including Mycobacterium bovis bacillus Calmette-Guérin (BCG). Novel vaccine candidates advancing through either the preclinical or clinical pipeline leverage different platforms (e.g., protein + adjuvant, vector-based, nucleic acid-based) to purposefully elicit complex immune responses, and we review those design rationales and results to date. The better we as a community understand the essential composition, magnitude, timing, and trafficking of immune responses against Mtb, the closer we are to reducing the severe disease burden and toll on human health inflicted by TB globally.
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Affiliation(s)
- Sasha E. Larsen
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, United States
| | - Brittany D. Williams
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, United States,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Maham Rais
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, United States
| | - Rhea N. Coler
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, United States,Department of Global Health, University of Washington, Seattle, WA, United States,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Susan L. Baldwin
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, United States,*Correspondence: Susan L. Baldwin,
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19
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Rakshit S, Adiga V, Ahmed A, Parthiban C, Kumar NC, Dwarkanath P, Shivalingaiah S, Rao S, D’Souza G, Dias M, Maguire TJ, Doores K, Dasgupta P, Babji S, Ottenhoff TH, Stuart KD, De Rosa S, McElrath MJ, Vyakarnam A. BCG revaccination qualitatively and quantitatively enhances SARS-CoV-2 spike-specific neutralizing antibody and T cell responses induced by the COVISHIELD ™ vaccine in SARS-CoV-2 seronegative young Indian adults. RESEARCH SQUARE 2022:rs.3.rs-1395683. [PMID: 35262071 PMCID: PMC8902867 DOI: 10.21203/rs.3.rs-1395683/v1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study tested if prior BCG revaccination can further boost immune responses subsequently induced by a widely distributed and otherwise efficacious Oxford/AstraZeneca ChAdOx1nCoV-19 vaccine, referred to as COVISHIELD™, in India. We compared COVISHIELD™ induced longitudinal immune responses in 21 BCG re-vaccinees (BCG-RV) and 13 BCG-non-revaccinees (BCG-NRV), all of whom were BCG vaccinated at birth and latent tuberculosis negative, after COVISHIELD™ prime and boost with baseline samples that were collected pre-pandemic and pre-BCG revaccination. Compared to BCG-NRV, BCG-RV displayed significantly higher magnitude of spike-specific Ab and T cell responses, including a greater proportion of high responders; better quality polyfunctional CD4 and CD8 T cells that persisted and a more robust Ab and T cell response to the Delta mutant of SARS-CoV-2 highlighting greater breadth. Mechanistically, BCG adjuvant effects on COVISHIELD™ induced adaptive responses was associated with more robust innate responses to pathogen-associated-molecular-patterns through TNF-α and IL-1β secretion. This study provides first in-depth analysis of immune responses induced by COVISHIELD™ in India and highlights the potential of using a cheap and globally available vaccine, BCG, as an adjuvant to enhance heterologous adaptive immune responses induced by COVIDSHIELD™ and other emerging vaccines.
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Affiliation(s)
- Srabanti Rakshit
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Vasista Adiga
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Asma Ahmed
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Chaitra Parthiban
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Nirutha Chetan Kumar
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | | | | | - Srishti Rao
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - George D’Souza
- Department of Pulmonary Medicine, St. John’s Medical College, Bangalore, India
| | - Mary Dias
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
| | - Thomas J.A. Maguire
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King’s College London
| | - Katie Doores
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King’s College London
| | - Prokar Dasgupta
- Peter Gorer Department of Immunobiology, Liver Renal Urology Transplant Gastro/Gastrointestinal Surgery, Inflammation Biology, King’s College, London
| | - Sudhir Babji
- The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, India
| | - Tom H.M Ottenhoff
- Dept. Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Stephen De Rosa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Centre, Seattle, Washington, USA
| | - M. Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Centre, Seattle, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Annapurna Vyakarnam
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
- Infectious Disease Unit, St. John’s Research Institute, Bangalore, India
- Department of Immunobiology, School of Immunology & Microbial Sciences, Faculty of Life Science & Medicine, King’s College, London
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20
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Erawati M, Andriany M. Determinants of latent tuberculosis infection among nurses at public health centers in Indonesia. BELITUNG NURSING JOURNAL 2022; 8:28-34. [PMID: 37521074 PMCID: PMC10386802 DOI: 10.33546/bnj.1846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/11/2021] [Accepted: 11/18/2021] [Indexed: 08/01/2023] Open
Abstract
Background The incidence of latent tuberculosis among healthcare workers, especially nurses, at public health centers in Indonesia has been increased. Therefore, factors related to the tuberculosis incidence need to be further investigated. Objective This study aimed to identify the determinants of latent tuberculosis infection among nurses at public health centers in Indonesia. Methods This non-experimental, cross-sectional study included 98 nurses. Data on the determinants of latent tuberculosis infection were collected using validated questionnaires, and the infection status was confirmed by Interferon Gamma Release Assay or IGRA test. Logistic regression was used for statistical analysis, with a significance level of p < 0.05. Results Health facilities for tuberculosis transmission prevention were available in all public health centers (100%). Protocols for preventing tuberculosis transmission including occupational health and safety training (OR = 13.24, 95% CI [2.29-58.55]; p = 0.001), handwashing after contact with patients or specimens (OR = 20.55, 95% CI [4.23-99.93]; p = 0.000), and wearing of medical masks (OR = 9.56, 95% CI [1.99-45.69]; p = 0.005) were found to be significant determinants of latent tuberculosis infection among nurses. Conclusion The availability of protective equipment and implementation of health protocols among nurses at public health centers are the main determinants of latent tuberculosis infection. Hence, they should be maintained by all nurses to prevent the spread of tuberculosis.
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Affiliation(s)
- Meira Erawati
- Department of Nursing, Faculty of Medicine, Universitas Diponegoro, Indonesia
| | - Megah Andriany
- Department of Nursing, Faculty of Medicine, Universitas Diponegoro, Indonesia
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21
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Corsenac P, Parent MÉ, Wolfson C, Arbour N, Duquette P, Benedetti A, Richard H, Stäger S, Rousseau MC. Bacillus Calmette-Guerin vaccination and multiple sclerosis: a population-based birth cohort study in Quebec, Canada. Eur J Neurol 2022; 29:1791-1804. [PMID: 35165983 DOI: 10.1111/ene.15290] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/15/2021] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Bacillus Calmette-Guerin (BCG) vaccine could reduce the incidence of multiple sclerosis (MS) through immunomodulation. Previous studies, presenting some limitations, reported no association. We re-examined this association in a large cohort focusing on relapsing-remitting MS (RRMS). METHODS The cohort included 400,563 individuals, and was linked with the Quebec provincial BCG vaccination registry and administrative health data. Individuals were followed-up from 1983 to 2014 and then within period 1 (1983-1996) and period 2 (1997-2014), for the occurrence of MS. Incident MS cases were defined as those with ≥3 hospital or physician claims for MS. Subjects with ≥1 drug reimbursement for MS disease-modifying therapies were classified as RRMS. Cox proportional hazards regression was used to estimate hazard ratios (HR) over the follow-ups, adjusting for potential confounders. Possible effect modification due to sex was assessed. RESULTS A total of 178,335 (46%) individuals were BCG vaccinated. There were 274 (0.06%) incident MS cases identified in 1983-1996, and 1,433 (0.4%) in 1997-2014. No association was found with RRMS, either in period 1 (adjusted HRs= 0.96, 95% confidence interval: 0.63-1.45; 96 cases) or in period 2 (HRadj= 1.02, 0.85-1.23; 480 cases). The remaining MS cases, for whom the phenotype was unknown, were positively associated with BCG over the entire follow-up (HRadj= 1.25, 1.10-1.41; 1,131 cases) and in period 2 (HRadj=1.33, 1.17-1.52; 953 cases). No interaction with sex was found. CONCLUSION Findings suggest that BCG vaccination does not decrease the risk of RRMS, and that future studies should consider phenotypes of MS.
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Affiliation(s)
- P Corsenac
- Epidemiology and Biostatistics Unit, Centre Armand-Frappier Santé Biotechnologie, Institut National de la Recherche Scientifique (INRS), Laval, Canada
| | - M É Parent
- Epidemiology and Biostatistics Unit, Centre Armand-Frappier Santé Biotechnologie, Institut National de la Recherche Scientifique (INRS), Laval, Canada
| | - Christina Wolfson
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, QC, Canada
| | - Nathalie Arbour
- Centre de recherche du CHUM, Department of Neurosciences, Université de Montréal, Montreal, QC, Canada
| | - Pierre Duquette
- Centre de recherche du CHUM, Department of Neurosciences, Université de Montréal, Montreal, QC, Canada
| | - A Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - H Richard
- Epidemiology and Biostatistics Unit, Centre Armand-Frappier Santé Biotechnologie, Institut National de la Recherche Scientifique (INRS), Laval, Canada
| | - S Stäger
- Centre Armand-Frappier Santé Biotechnologie, Institut National de la Recherche Scientifique (INRS), Laval, Canada
| | - M C Rousseau
- Epidemiology and Biostatistics Unit, Centre Armand-Frappier Santé Biotechnologie, Institut National de la Recherche Scientifique (INRS), Laval, Canada
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22
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Soma S, Lewinsohn DA, Lewinsohn DM. Donor Unrestricted T Cells: Linking innate and adaptive immunity. Vaccine 2021; 39:7295-7299. [PMID: 34740474 DOI: 10.1016/j.vaccine.2021.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/06/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022]
Abstract
Donor Unrestricted T Cells (DURTs) are characterized by their use of antigen presentation molecules that are often invariant. As these cells recognize diverse mycobacterial antigens, often found in BCG, these cells have the potential to either serve as targets for vaccination, or as a means to enable the induction of traditional T and B cell immunity. Here, we will review specific DURT family members, and their relationship to BCG.
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Affiliation(s)
- Shogo Soma
- Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR 97239, United States
| | - Deborah A Lewinsohn
- Division of Pediatric Infectious Disease, Department of Pediatrics, Oregon Health & Science University, Portland, OR. 97239, United States
| | - David M Lewinsohn
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Portland VA Medical Center, Oregon Health & Science University, United States.
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23
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Qu M, Zhou X, Li H. BCG vaccination strategies against tuberculosis: updates and perspectives. Hum Vaccin Immunother 2021; 17:5284-5295. [PMID: 34856853 DOI: 10.1080/21645515.2021.2007711] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Bacillus Calmette-Guérin (BCG) is the only licensed vaccine against tuberculosis (TB). However, BCG has variable efficacy and cannot completely prevent TB infection and transmission. Therefore, the worldwide prevalence of TB calls for urgent development of a more effective TB vaccine. In the absence of other approved vaccines, it is also necessary to improve the efficacy of BCG itself. Intravenous (IV) BCG administration and BCG revaccination strategies have recently shown promising results for clinical usage. Therefore, it is necessary for us to revisit the BCG vaccination strategies and summarize the current research updates related to BCG vaccination. This literature review provides an updated overview and perspectives of the immunization strategies against TB using BCG, which may inspire the following research on TB vaccine development.
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Affiliation(s)
- Mengjin Qu
- College of Veterinary Medicine, China Agricultural University, Beijing, China.,Key Laboratory of Animal Epidemiology and Zoonosis, Ministry of Agriculture, National Animal Transmissible Spongiform Encephalopathy Laboratory, China Agricultural University, Beijing, China
| | - Xiangmei Zhou
- College of Veterinary Medicine, China Agricultural University, Beijing, China.,Key Laboratory of Animal Epidemiology and Zoonosis, Ministry of Agriculture, National Animal Transmissible Spongiform Encephalopathy Laboratory, China Agricultural University, Beijing, China
| | - Hao Li
- College of Veterinary Medicine, China Agricultural University, Beijing, China.,Center for Infectious Disease Research, School of Medicine, Tsinghua University, Beijing, China
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24
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Singhania A, Dubelko P, Kuan R, Chronister WD, Muskat K, Das J, Phillips EJ, Mallal SA, Seumois G, Vijayanand P, Sette A, Lerm M, Peters B, Lindestam Arlehamn C. CD4+CCR6+ T cells dominate the BCG-induced transcriptional signature. EBioMedicine 2021; 74:103746. [PMID: 34902786 PMCID: PMC8671872 DOI: 10.1016/j.ebiom.2021.103746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/26/2021] [Accepted: 11/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The century-old Mycobacterium bovis Bacillus Calmette-Guerin (BCG) remains the only licensed vaccine against tuberculosis (TB). Despite this, there is still a lot to learn about the immune response induced by BCG, both in terms of phenotype and specificity. METHODS We investigated immune responses in adult individuals pre and 8 months post BCG vaccination. We specifically determined changes in gene expression, cell subset composition, DNA methylome, and the TCR repertoire induced in PBMCs and CD4 memory T cells associated with antigen stimulation by either BCG or a Mycobacterium tuberculosis (Mtb)-derived peptide pool. FINDINGS Following BCG vaccination, we observed increased frequencies of CCR6+ CD4 T cells, which includes both Th1* (CXCR3+CCR6+) and Th17 subsets, and mucosal associated invariant T cells (MAITs). A large number of immune response genes and pathways were upregulated post BCG vaccination with similar patterns observed in both PBMCs and memory CD4 T cells, thus suggesting a substantial role for CD4 T cells in the cellular response to BCG. These upregulated genes and associated pathways were also reflected in the DNA methylome. We described both qualitative and quantitative changes in the BCG-specific TCR repertoire post vaccination, and importantly found evidence for similar TCR repertoires across different subjects. INTERPRETATION The immune signatures defined herein can be used to track and further characterize immune responses induced by BCG, and can serve as reference for benchmarking novel vaccination strategies.
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Affiliation(s)
- Akul Singhania
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA
| | - Paige Dubelko
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA
| | - Rebecca Kuan
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA
| | - William D Chronister
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA
| | - Kaylin Muskat
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA
| | - Jyotirmoy Das
- Division of Infection and Inflammation, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, WA 6150, Australia; Vanderbilt University School of Medicine, Nashville, TN 37235, USA
| | - Simon A Mallal
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, WA 6150, Australia; Vanderbilt University School of Medicine, Nashville, TN 37235, USA
| | - Grégory Seumois
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA
| | - Pandurangan Vijayanand
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA
| | - Alessandro Sette
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA; Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Maria Lerm
- Division of Infection and Inflammation, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Bjoern Peters
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA; Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Cecilia Lindestam Arlehamn
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, La Jolla, CA 92037, USA.
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25
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Kumar NP, Padmapriyadarsini C, Rajamanickam A, Bhavani PK, Nancy A, Jayadeepa B, Selvaraj N, Asokan D, Renji RM, Venkataramani V, Tripathy S, Babu S. BCG vaccination induces enhanced frequencies of memory T cells and altered plasma levels of common γc cytokines in elderly individuals. PLoS One 2021; 16:e0258743. [PMID: 34758029 PMCID: PMC8580239 DOI: 10.1371/journal.pone.0258743] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/26/2021] [Indexed: 12/03/2022] Open
Abstract
BCG vaccination is known to induce innate immune memory, which confers protection against heterologous infections. However, the effect of BCG vaccination on the conventional adaptive immune cells subsets is not well characterized. We investigated the impact of BCG vaccination on the frequencies of T cell subsets and common gamma c (γc) cytokines in a group of healthy elderly individuals (age 60–80 years) at one month post vaccination as part of our clinical study to examine the effect of BCG on COVID-19. Our results demonstrate that BCG vaccination induced enhanced frequencies of central (p<0.0001) and effector memory (p<0.0001) CD4+ T cells and diminished frequencies of naïve (p<0.0001), transitional memory (p<0.0001), stem cell memory (p = 0.0001) CD4+ T cells and regulatory T cells. In addition, BCG vaccination induced enhanced frequencies of central (p = 0.0008), effector (p<0.0001) and terminal effector memory (p<0.0001) CD8+ T cells and diminished frequencies of naïve (p<0.0001), transitional memory (p<0.0001) and stem cell memory (p = 0.0034) CD8+T cells. BCG vaccination also induced enhanced plasma levels of IL-7 (p<0.0001) and IL-15 (p = 0.0020) but diminished levels of IL-2 (p = 0.0033) and IL-21 (p = 0.0020). Thus, BCG vaccination was associated with enhanced memory T cell subsets as well as memory enhancing γc cytokines in elderly individuals, suggesting its ability to induce non-specific adaptive immune responses.
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Affiliation(s)
- Nathella Pavan Kumar
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
- * E-mail: (NPK); (SB)
| | | | | | - Perumal Kannabiran Bhavani
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - Arul Nancy
- ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Bharathi Jayadeepa
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - Nandhini Selvaraj
- ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Dinesh Asokan
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | | | | | - Srikanth Tripathy
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
- Dr D Y Patil Medical College, Hospital and Research Centre, Pune, India
| | - Subash Babu
- ICMR-National Institute for Research in Tuberculosis, Chennai, India
- * E-mail: (NPK); (SB)
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26
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Glynn JR, Fielding K, Mzembe T, Sichali L, Banda L, McLean E, Kanjala C, Crampin AC, Ponnighaus JM, Warndorff DK, Fine PEM. BCG re-vaccination in Malawi: 30-year follow-up of a large, randomised, double-blind, placebo-controlled trial. Lancet Glob Health 2021; 9:e1451-e1459. [PMID: 34534489 PMCID: PMC8459381 DOI: 10.1016/s2214-109x(21)00309-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/31/2021] [Accepted: 06/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND A large, double-blind, randomised, placebo-controlled trial of repeat BCG found 49% efficacy against leprosy but no protection against tuberculosis after 6-9 years' follow-up in 1995. We report here additional follow-up, which resulted in greatly increased tuberculosis case numbers, and allowed subgroup analysis. METHODS Nearly 47 000 individuals of all ages living in northern Malawi with a BCG vaccine scar were randomly assigned (1:1) between 1986 and 1989 to receive a second BCG or placebo. The investigators and project staff remained masked to all interventions. Enhanced passive surveillance ensured ascertainment of tuberculosis and leprosy to the end of 2018. Tuberculosis case definitions included rigorous microbiological or histological confirmation. Prespecified subgroup analyses were by tuberculosis type, age at vaccination, time since vaccination, previous tuberculin reactivity, HIV status and Mycobacterium tuberculosis lineage. The original trial is registered with ISRCTN registry, ISRCTN11311670. FINDINGS In follow-up until Dec 31, 2018, 824 participants had developed tuberculosis, including 786 with pulmonary disease, of whom 383 (63%) of 607 with known HIV status were HIV positive. There was no effect of a second BCG overall (odds ratio [OR] 0·92; 95% CI 0·80-1·05), or for pulmonary (0·93; 0·81-1·07), or lymph node tuberculosis (0·60; 0·31-1·17). The OR was lower for those with known HIV-negative tuberculosis (0·77; 0·59-1·00), for those vaccinated as children (aged <5 years, 0·74; 0·41-1·35; aged 5-14 years, 0·77; 0·60-0·99), and for cases arising at least 20 years after vaccination (0·79; 0·63-1·01). There were no differences by tuberculin status at vaccination, or lineage. There was no evidence of protection against leprosy beyond 10 years after vaccination (although there have been only nine diagnostically certain cases since 1995). INTERPRETATION There was no evidence that repeat BCG vaccination provides appreciable protection against overall tuberculosis in this rural African population with a high prevalence of HIV. Subgroup effects should not be overinterpreted given the multiple analyses done. However, the evidence for modest protection against HIV-negative tuberculosis, and for a delayed benefit in those vaccinated as children, is consistent with other observations in the literature. FUNDING LEPRA, Wellcome Trust, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Judith R Glynn
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Katherine Fielding
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Themba Mzembe
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Lifted Sichali
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Louis Banda
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Estelle McLean
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK; Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Chifundo Kanjala
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK; Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Amelia C Crampin
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK; Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | | | | | - Paul E M Fine
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK.
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Chatterjee R, Mehta P, Agarwal V, Gupta L. High burden of infections in Indian patients with Idiopathic Inflammatory Myopathy: validation of observations from the MyoCite dataset. Rheumatology (Oxford) 2021; 60:4315-4326. [PMID: 33493341 DOI: 10.1093/rheumatology/keab015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/07/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine the prevalence, profile and predictors of infections in an Indian cohort with idiopathic inflammatory myopathies (IIM). METHODS We reviewed the records of a retrospective cohort with IIM enrolled from consecutive patients being followed up in the clinic, and these constituted the observation cohort. A newly diagnosed inception cohort with IIM were followed prospectively as the validation cohort for confirmation of observations and comparison with the observation cohort. RESULTS Among the 68 patients in the observation cohort (average age 33.4 years, female:male 4.2:1), 37 (54.4%) experienced 54 infections between them; of these 54 infections, 21 (38.8%) were major and recurrent infections and they occurred in 11 patients (16.17%) over 3.08 years. Tuberculosis was the most common infection (12, 22.2%), with a predominance of extrapulmonary forms. Serum protein [odds ratio (OR) 0.44], platelets (0.44) at disease onset and daily steroid dose (1.04) predicted major infections on multivariate analysis. A higher daily dose of steroids at first infection correlated with number of recurrent infections. The infection-free 1-year survival was 73.8%.Of the 70 patients in the validation cohort (average age 35.7 years, female:male 3.7:1), 3 had myositis attributed to an infection. A similar proportion of the cohort experienced infections (22, 33.3%) with similar number of major (10, 45.4%) and recurrent (4, 18%) infections being recorded. The most common infection was community-acquired pneumonia, followed by tuberculosis, with serum albumin (OR 0.25) at disease onset being the only predictor. The one-year infection-free survival rate was 64.7%. Those who had a major infection had increased mortality at 1 year, with a survival rate of 60%, compared with 89.09% in those without.In both cohorts, a daily prednisone dose >6.25 mg predisposed to major infections. CONCLUSION Major and recurrent infections are common in Indian IIM patients and confer higher risk for future infections and lower survival. Respiratory and atypical bacterial infections such as tuberculosis occur throughout the disease course.
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Affiliation(s)
- Rudrarpan Chatterjee
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Pankti Mehta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Ahmed A, Rakshit S, Adiga V, Dias M, Dwarkanath P, D'Souza G, Vyakarnam A. A century of BCG: Impact on tuberculosis control and beyond. Immunol Rev 2021; 301:98-121. [PMID: 33955564 DOI: 10.1111/imr.12968] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/13/2021] [Accepted: 03/13/2021] [Indexed: 12/14/2022]
Abstract
BCG turns 100 this year and while it might not be the perfect vaccine, it has certainly contributed significantly towards eradication and prevention of spread of tuberculosis (TB). The search for newer and better vaccines for TB is an ongoing endeavor and latest results from trials of candidate TB vaccines such as M72AS01 look promising. However, recent encouraging data from BCG revaccination trials in adults combined with studies on mucosal and intravenous routes of BCG vaccination in non-human primate models have renewed interest in BCG for TB prevention. In addition, several well-demonstrated non-specific effects of BCG, for example, prevention of viral and respiratory infections, give BCG an added advantage. Also, BCG vaccination is currently being widely tested in human clinical trials to determine whether it protects against SARS-CoV-2 infection and/or death with detailed analyses and outcomes from several ongoing trials across the world awaited. Through this review, we attempt to bring together information on various aspects of the BCG-induced immune response, its efficacy in TB control, comparison with other candidate TB vaccines and strategies to improve its efficiency including revaccination and alternate routes of administration. Finally, we discuss the future relevance of BCG use especially in light of its several heterologous benefits.
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Affiliation(s)
- Asma Ahmed
- Laboratory of Immunology of HIV-TB co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Srabanti Rakshit
- Laboratory of Immunology of HIV-TB co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Vasista Adiga
- Laboratory of Immunology of HIV-TB co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Mary Dias
- Division of Infectious Diseases, St John's Research Institute, Bangalore, India
| | | | - George D'Souza
- Division of Infectious Diseases, St John's Research Institute, Bangalore, India.,Department of Pulmonary Medicine, St John's Medical College, Bangalore, India
| | - Annapurna Vyakarnam
- Laboratory of Immunology of HIV-TB co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, Guy's Hospital, King's College London, London, UK
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29
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The safety of BCG revaccination: A systematic review. Vaccine 2021; 39:2736-2745. [PMID: 33810902 DOI: 10.1016/j.vaccine.2020.08.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/27/2020] [Accepted: 08/06/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Revaccination with Bacillus Calmette-Guérin (BCG) vaccine is not generally recommended due to a lack of proven efficacy of repeat doses for protection against tuberculosis. However, there is a growing interest in the use of BCG vaccine for its 'off-target' effects which might involve revaccination. We did a systematic review of the safety of BCG revaccination. METHODS MEDLINE (1946 to March 2020) and the BCG World Atlas (updated 2017) were searched, limiting to studies of BCG administration by the intradermal or percutaneous route. Adverse events as well as patient and vaccine characteristics were reviewed. RESULTS The search identified 388 articles, of which 24 met the inclusion criteria. These reported 22 studies comprising eight randomised trials, four case-control studies, four observational studies and six case series or reports. Overall, there was evidence for a small increase in the rate of mild local and systemic reactions. No serious adverse events were reported in immunocompetent individuals. CONCLUSIONS Evidence to date suggests that revaccination with BCG vaccine carries minimal risk. Future studies of BCG vaccine for novel applications should report adverse event data stratified by prior BCG vaccination status.
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Morgan J, Muskat K, Tippalagama R, Sette A, Burel J, Lindestam Arlehamn CS. Classical CD4 T cells as the cornerstone of antimycobacterial immunity. Immunol Rev 2021; 301:10-29. [PMID: 33751597 PMCID: PMC8252593 DOI: 10.1111/imr.12963] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 12/13/2022]
Abstract
Tuberculosis is a significant health problem without an effective vaccine to combat it. A thorough understanding of the immune response and correlates of protection is needed to develop a more efficient vaccine. The immune response against Mycobacterium tuberculosis (Mtb) is complex and involves all aspects of the immune system, however, the optimal protective, non‐pathogenic T cell response against Mtb is still elusive. This review will focus on discussing CD4 T cell immunity against mycobacteria and its importance in Mtb infection with a primary focus on human studies. We will in particular discuss the large heterogeneity of immune cell subsets that have been revealed by recent immunological investigations at an unprecedented level of detail. These studies have identified specific classical CD4 T cell subsets important for immune responses against Mtb in various states of infection. We further discuss the functional attributes that have been linked to the various subsets such as upregulation of activation markers and cytokine production. Another important topic to be considered is the antigenic targets of Mtb‐specific immune responses, and how antigen reactivity is influenced by both disease state and environmental exposure(s). These are key points for both vaccines and immune diagnostics development. Ultimately, these factors are holistically considered in the definition and investigations of what are the correlates on protection and resolution of disease.
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Affiliation(s)
- Jeffrey Morgan
- Center for Infectious Disease, La Jolla Institute for Immunology, La Jolla, CA, USA
| | - Kaylin Muskat
- Center for Infectious Disease, La Jolla Institute for Immunology, La Jolla, CA, USA
| | - Rashmi Tippalagama
- Center for Infectious Disease, La Jolla Institute for Immunology, La Jolla, CA, USA
| | - Alessandro Sette
- Center for Infectious Disease, La Jolla Institute for Immunology, La Jolla, CA, USA
| | - Julie Burel
- Center for Infectious Disease, La Jolla Institute for Immunology, La Jolla, CA, USA
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31
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Garzon-Chavez D, Rivas-Condo J, Echeverria A, Mozo J, Quentin E, Reyes J, Teran E. COVID-19 Infection and Previous BCG Vaccination Coverage in the Ecuadorian Population. Vaccines (Basel) 2021; 9:91. [PMID: 33513693 PMCID: PMC7912416 DOI: 10.3390/vaccines9020091] [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: 12/20/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 02/06/2023] Open
Abstract
The Bacillus Calmette-Guérin (BCG) is a well-known vaccine with almost a century of use, with the apparent capability to improve cytokine production and epigenetics changes that could develop a better response to pathogens. It has been postulated that BCG protection against SARS-CoV-2 has a potential role in the pandemic, through the presence of homologous amino acid sequences. To identify a possible link between BCG vaccination coverage and COVID-19 cases, we used official epidemic data and Ecuadorian Ministry of Health and Pan American Health Organization vaccination information. BCG information before 1979 was available only at a national level. Therefore, projections based on the last 20 years were performed, to compare by specific geographic units. We used a Mann-Kendall test to identify BCG coverage variations, and mapping was conducted with a free geographic information system (QGIS). Nine provinces where BCG vaccine coverage was lower than 74.25% show a significant statistical association (χ2 Pearson's = 4.800, df = 1, p = 0.028), with a higher prevalence of cases for people aged 50 to 64 years than in younger people aged 20 to 49 years. Despite the availability of BCG vaccination data and the mathematical models needed to compare these data with COVID-19 cases, our results show that, in geographic areas where BCG coverage was low, 50% presented a high prevalence of COVID-19 cases that were young; thus, low-coverage years were more affected.
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Affiliation(s)
- Daniel Garzon-Chavez
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito CP 170901, Ecuador;
| | - Jackson Rivas-Condo
- Ministerio de Salud Publica del Ecuador, Quito CP 170146, Ecuador; (J.R.-C.); (A.E.); (J.M.)
| | - Adriana Echeverria
- Ministerio de Salud Publica del Ecuador, Quito CP 170146, Ecuador; (J.R.-C.); (A.E.); (J.M.)
| | - Jhoanna Mozo
- Ministerio de Salud Publica del Ecuador, Quito CP 170146, Ecuador; (J.R.-C.); (A.E.); (J.M.)
| | - Emmanuelle Quentin
- Centro de Investigación en Salud Pública y Epidemiología Clínica, Universidad Tecnológica Equinoccial, Quito CP 170527, Ecuador;
| | - Jorge Reyes
- Servicio de Laboratorio, Hospital IESS Quito Sur, Quito CP 170111, Ecuador;
- Facultad de Ciencias Químicas, Universidad Central del Ecuador, Quito CP 170403, Ecuador
| | - Enrique Teran
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito CP 170901, Ecuador;
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Rakshit S, Hingankar N, Alampalli SV, Adiga V, Sundararaj BK, Sahoo PN, Finak G, Uday Kumar J AJ, Dhar C, D'Souza G, Virkar RG, Ghate M, Thakar MR, Paranjape RS, De Rosa SC, Ottenhoff THM, Vyakarnam A. HIV Skews a Balanced Mtb-Specific Th17 Response in Latent Tuberculosis Subjects to a Pro-inflammatory Profile Independent of Viral Load. Cell Rep 2020; 33:108451. [PMID: 33264614 DOI: 10.1016/j.celrep.2020.108451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 09/15/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023] Open
Abstract
HIV infection predisposes latent tuberculosis-infected (LTBI) subjects to active TB. This study is designed to determine whether HIV infection of LTBI subjects compromises the balanced Mycobacterium tuberculosis (Mtb)-specific T helper 17 (Th17) response of recognized importance in anti-TB immunity. Comparative analysis of Mtb- and cytomegalovirus (CMV)-specific CD4+ T cell responses demonstrates a marked dampening of the Mtb-specific CD4+ T cell effectors and polyfunctional cells while preserving CMV-specific response. Additionally, HIV skews the Mtb-specific Th17 response in chronic HIV-infected LTBI progressors, but not long-term non-progressors (LTNPs), with preservation of pro-inflammatory interferon (IFN)-γ+/interleukin-17+ (IL-17+) and significant loss of anti-inflammatory IL-10+/IL-17+ effectors that is restored by anti-retroviral therapy (ART). HIV-driven impairment of Mtb-specific response cannot be attributed to preferential infection as cell-associated HIV DNA and HIV RNA reveal equivalent viral burden in CD4+ T cells from different antigen specificities. We therefore propose that beyond HIV-induced loss of Mtb-specific CD4+ T cells, the associated dysregulation of Mtb-specific T cell homeostasis can potentially enhance the onset of TB in LTBI subjects.
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Affiliation(s)
- Srabanti Rakshit
- Laboratory of Immunology of HIV-TB Co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Nitin Hingankar
- Laboratory of Immunology of HIV-TB Co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Shuba Varshini Alampalli
- Laboratory of Immunology of HIV-TB Co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Vasista Adiga
- Laboratory of Immunology of HIV-TB Co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Bharath K Sundararaj
- Laboratory of Immunology of HIV-TB Co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Pravat Nalini Sahoo
- Laboratory of Immunology of HIV-TB Co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Greg Finak
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Anto Jesuraj Uday Kumar J
- Departments of Infectious Diseases & Pulmonary Medicine, St. John's Research Institute, Bangalore, India
| | - Chirag Dhar
- Departments of Infectious Diseases & Pulmonary Medicine, St. John's Research Institute, Bangalore, India
| | - George D'Souza
- Departments of Infectious Diseases & Pulmonary Medicine, St. John's Research Institute, Bangalore, India
| | | | - Manisha Ghate
- National Aids Research Institute, Bhosari, Pune, Maharashtra, India
| | - Madhuri R Thakar
- National Aids Research Institute, Bhosari, Pune, Maharashtra, India
| | | | - Stephen C De Rosa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Annapurna Vyakarnam
- Laboratory of Immunology of HIV-TB Co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences & Medicine, Guy's Hospital, King's College London, London SE1 9RT, UK.
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33
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Kuan R, Muskat K, Peters B, Lindestam Arlehamn CS. Is mapping the BCG vaccine-induced immune responses the key to improving the efficacy against tuberculosis? J Intern Med 2020; 288:651-660. [PMID: 33210407 PMCID: PMC9432460 DOI: 10.1111/joim.13191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022]
Abstract
In recent years, the century-old Mycobacterium bovis Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis (TB) has been re-evaluated for its capacity to stem the global tide of TB. There is increasing evidence that the efficacy of BCG can be improved by the modified administration methods and schedules. Here, we first discuss recent approaches of vaccine administration, revaccination or boosting that have been used to try to improve the efficacy of BCG against TB. We then dive deeper into studies investigating the immune correlates of protection and describe studies that have investigated BCG-specific T-cell responses and the influence of environmental exposures. These studies all highlight that there is still a lot to learn about the immune response induced by BCG, both in terms of phenotype and specificity, which has been surprisingly understudied. We argue that several critical gaps in knowledge exist and must be addressed by future research to rationally improve the efficacy of BCG, including comprehensive, proteome-wide understanding of the epitopes derived from BCG recognized by BCG-vaccinated individuals, the phenotype of responding antigen-specific T cells and how previous exposure to environmental mycobacteria affect these parameters and thus influence vaccine efficacy. The development of modern techniques allows us to answer some of these questions to better understand how BCG works in terms of both protection against TB and the immune response that it triggers.
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Affiliation(s)
- R Kuan
- From the, La Jolla Institute for Immunology, La Jolla, CA, USA
| | - K Muskat
- From the, La Jolla Institute for Immunology, La Jolla, CA, USA
| | - B Peters
- From the, La Jolla Institute for Immunology, La Jolla, CA, USA.,Department of Medicine, University of California San Diego, USA
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34
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Weinberg A, Tugizov S, Pandiyan P, Jin G, Rakshit S, Vyakarnam A, Naglik JR. Innate immune mechanisms to oral pathogens in oral mucosa of HIV-infected individuals. Oral Dis 2020; 26 Suppl 1:69-79. [PMID: 32862519 PMCID: PMC7570967 DOI: 10.1111/odi.13470] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A crucial aspect of mucosal HIV transmission is the interaction between HIV, the local environmental milieu and immune cells. The oral mucosa comprises many host cell types including epithelial cells, CD4 + T cells, dendritic cells and monocytes/macrophages, as well as a diverse microbiome predominantly comprising bacterial species. While the oral epithelium is one of the first sites exposed to HIV through oral-genital contact and nursing infants, it is largely thought to be resistant to HIV transmission via mechanisms that are still unclear. HIV-1 infection is also associated with predisposition to secondary infections, such as tuberculosis, and other diseases including cancer. This review addresses the following questions that were discussed at the 8th World Workshop on Oral Health and Disease in AIDS held in Bali, Indonesia, 13 September –15 September 2019: (a) How does HIV infection affect epithelial cell signalling? (b) How does HIV infection affect the production of cytokines and other innate antimicrobial factors, (c) How is the mucosal distribution and function of immune cells altered in HIV infection? (d) How do T cells affect HIV (oral) pathogenesis and cancer? (e) How does HIV infection lead to susceptibility to TB infections?
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Affiliation(s)
- Aaron Weinberg
- Department of Biological Sciences, School of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Sharof Tugizov
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Pushpa Pandiyan
- Department of Biological Sciences, School of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ge Jin
- Department of Biological Sciences, School of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Srabanti Rakshit
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Annapurna Vyakarnam
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Laboratory of Immunology of HIV-TB co-infection, Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Julian R Naglik
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
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35
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Rozot V, Nemes E, Geldenhuys H, Musvosvi M, Toefy A, Rantangee F, Makhethe L, Erasmus M, Bilek N, Mabwe S, Finak G, Fulp W, Ginsberg AM, Hokey DA, Shey M, Gurunathan S, DiazGranados C, Bekker LG, Hatherill M, Scriba TJ. Multidimensional analyses reveal modulation of adaptive and innate immune subsets by tuberculosis vaccines. Commun Biol 2020; 3:563. [PMID: 33037320 PMCID: PMC7547090 DOI: 10.1038/s42003-020-01288-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 09/11/2020] [Indexed: 12/13/2022] Open
Abstract
We characterize the breadth, function and phenotype of innate and adaptive cellular responses in a prevention of Mycobacterium tuberculosis infection trial. Responses are measured by whole blood intracellular cytokine staining at baseline and 70 days after vaccination with H4:IC31 (subunit vaccine containing Ag85B and TB10.4), Bacille Calmette-Guerin (BCG, a live attenuated vaccine) or placebo (n = ~30 per group). H4:IC31 vaccination induces Ag85B and TB10.4-specific CD4 T cells, and an unexpected NKTlike subset, that expresses IFN-γ, TNF and/or IL-2. BCG revaccination increases frequencies of CD4 T cell subsets that either express Th1 cytokines or IL-22, and modestly increases IFNγ-producing NK cells. In vitro BCG re-stimulation also triggers responses by donor-unrestricted T cells, which may contribute to host responses against mycobacteria. BCG, which demonstrated efficacy against sustained Mycobacterium tuberculosis infection, modulates multiple immune cell subsets, in particular conventional Th1 and Th22 cells, which should be investigated in discovery studies of correlates of protection.
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Affiliation(s)
- Virginie Rozot
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa.
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Hennie Geldenhuys
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Munyaradzi Musvosvi
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Asma Toefy
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Frances Rantangee
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Lebohang Makhethe
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Mzwandile Erasmus
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Nicole Bilek
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Simbarashe Mabwe
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Greg Finak
- Fred Hutchinson Cancer Research Center (FHCRC), Seattle, WA, USA
| | - William Fulp
- Fred Hutchinson Cancer Research Center (FHCRC), Seattle, WA, USA
| | | | | | - Muki Shey
- Aeras South Africa Endpoint Assay Laboratory, Cape Town, South Africa
| | | | | | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa.
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Singh S, Maurya RP, Singh RK. "Trained immunity" from Mycobacterium spp. exposure or BCG vaccination and COVID-19 outcomes. PLoS Pathog 2020; 16:e1008969. [PMID: 33119725 PMCID: PMC7595322 DOI: 10.1371/journal.ppat.1008969] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/08/2020] [Indexed: 12/15/2022] Open
Abstract
Protective variables for Coronavirus Disease 2019 (COVID-19) are unknown. "Trained immunity" of the populace as a result of Bacille Calmette-Guérin (BCG) vaccination policy implementation and coverage had been suggested to be one of the factors responsible for the differential impact of COVID-19 on different countries. Several trials are underway to evaluate the potential protective role of BCG vaccination in COVID-19. However, the lack of clarity on the use of appropriate controls concerning the measures of "trained immunity" or the heterologous cell-mediated immunity conferred by BCG vaccination has been a cause of concern leading to more confusion as exemplified by a recently concluded trial in Israel that failed to find any protective correlation with regard to BCG vaccination. Whereas, when we analyze the COVID-19 epidemiological data of European countries without any regard for BCG vaccination policy but with similar age distribution, comparable confounding variables, and the stage of the pandemic, the prevalence of tuberculin immunoreactivity-a measure of cell-mediated immunity persistence as a result of Mycobacterium spp. (including BCG vaccine) exposure of the populations-is found consistently negatively correlated with COVID-19 infections and mortality. We seek to draw attention toward the inclusion of controls for underlying "trained immunity" and heterologous cell-mediated immunity prevalence that may be preexisting or resulting from the intervention (e.g., BCG vaccine) in such trials to arrive at more dependable conclusions concerning potential benefit from them.
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Affiliation(s)
- Samer Singh
- Centre of Experimental Medicine and Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Department of Microbial Biotechnology, Panjab University, Chandigarh, India
| | - Rajendra Prakash Maurya
- Regional Institute of Ophthalmology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rakesh K. Singh
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi, India
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Expanding the role of bacterial vaccines into life-course vaccination strategies and prevention of antimicrobial-resistant infections. NPJ Vaccines 2020; 5:84. [PMID: 32963814 PMCID: PMC7486369 DOI: 10.1038/s41541-020-00232-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/19/2020] [Indexed: 12/28/2022] Open
Abstract
A crisis in bacterial infections looms as ageing populations, increasing rates of bacteraemia and healthcare-associated infections converge with increasing antimicrobial resistance and a paucity of new antimicrobial classes. New initiatives are needed to develop bacterial vaccines for older adults in whom immune senescence plays a critical role. Novel vaccines require an expanded repertoire to prevent mucosal diseases such as pneumonia, skin and soft tissue infections and urinary tract infections that are major causes of morbidity and mortality in the elderly, and key drivers of antimicrobial resistance. This review considers the challenges inherent to the prevention of bacterial diseases, particularly mucosal infections caused by major priority bacterial pathogens against which current vaccines are sub-optimal. It has become clear that prevention of many lung, urinary tract and skin infections requires more than circulating antibodies. Induction of Th1/Th17 cellular responses with tissue-resident memory (Trm) cells homing to mucosal tissues may be a pre-requisite for success.
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Dhamne C, Prakash G, Narula G, Banavali S, Bajpai J. 100-Year-Old Vaccine for a Novel Virus: Killing Two Birds with One Stone! Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_161_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Chetan Dhamne
- Department of Medical Oncology, TMC, Mumbai, Maharashtra, India
| | - Gagan Prakash
- Department of Surgical Oncology, TMC, Mumbai, Maharashtra, India
| | - Gaurav Narula
- Department of Medical Oncology, TMC, Mumbai, Maharashtra, India
| | | | - Jyoti Bajpai
- Department of Medical Oncology, TMC, Mumbai, Maharashtra, India
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