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Comparative analysis of the ex vivo IFN-gamma responses to CD8+ T cell epitopes within allelic forms of PfAMA1 in subjects with natural exposure to malaria. PLoS One 2021; 16:e0257219. [PMID: 34506564 PMCID: PMC8432784 DOI: 10.1371/journal.pone.0257219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/25/2021] [Indexed: 11/20/2022] Open
Abstract
Antigen polymorphisms in essential malarial antigens are a key challenge to the design and development of broadly effective malaria vaccines. The effect of polymorphisms on antibody responses is fairly well studied while much fewer studies have assessed this for T cell responses. This study investigated the effect of allelic polymorphisms in the malarial antigen apical membrane antigen 1 (AMA1) on ex vivo T cell-specific IFN-γ responses in subjects with lifelong exposure to malaria. Human leukocyte antigen (HLA) class I-restricted peptides from the 3D7 clone AMA1 were bioinformatically predicted and those with variant amino acid positions used to select corresponding allelic sequences from the 7G8, FVO, FC27 and tm284 parasite strains. A total of 91 AMA1 9-10mer peptides from the five parasite strains were identified, synthesized, grouped into 42 allele sets and used to stimulate PBMCs from seven HLA class 1-typed subjects in IFN-γ ELISpot assays. PBMCs from four of the seven subjects (57%) made positive responses to 18 peptides within 12 allele sets. Fifty percent of the 18 positive peptides were from the 3D7 parasite variant. Amino acid substitutions that were associated with IFN-γ response abrogation were more frequently found at positions 1 and 6 of the tested peptides, but substitutions did not show a clear pattern of association with response abrogation. Thus, while we show some evidence of polymorphisms affecting T cell response induction, other factors including TCR recognition of HLA-peptide complexes may also be at play.
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Ofori EA, Tetteh JKA, Frimpong A, Ganeshan H, Belmonte M, Peters B, Villasante E, Sedegah M, Ofori MF, Kusi KA. Comparison of the impact of allelic polymorphisms in PfAMA1 on the induction of T Cell responses in high and low malaria endemic communities in Ghana. Malar J 2021; 20:367. [PMID: 34507582 PMCID: PMC8431259 DOI: 10.1186/s12936-021-03900-1] [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: 06/08/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria eradication requires a combined effort involving all available control tools, and these efforts would be complemented by an effective vaccine. The antigen targets of immune responses may show polymorphisms that can undermine their recognition by immune effectors and hence render vaccines based on antigens from a single parasite variant ineffective against other variants. This study compared the influence of allelic polymorphisms in Plasmodium falciparum apical membrane antigen 1 (PfAMA1) peptide sequences from three strains of P. falciparum (3D7, 7G8 and FVO) on their function as immunodominant targets of T cell responses in high and low malaria transmission communities in Ghana. METHODS Peripheral blood mononuclear cells (PBMCs) from 10 subjects from a high transmission area (Obom) and 10 subjects from a low transmission area (Legon) were tested against 15 predicted CD8 + T cell minimal epitopes within the PfAMA1 antigen of multiple parasite strains using IFN-γ ELISpot assay. The peptides were also tested in similar assays against CD8 + enriched PBMC fractions from the same subjects in an effort to characterize the responding T cell subsets. RESULTS In assays using unfractionated PBMCs, two subjects from the high transmission area, Obom, responded positively to four (26.7%) of the 15 tested peptides. None of the Legon subject PBMCs yielded positive peptide responses using unfractionated PBMCs. In assays with CD8 + enriched PBMCs, three subjects from Obom made positive recall responses to six (40%) of the 15 tested peptides, while only one subject from Legon made a positive recall response to a single peptide. Overall, 5 of the 20 study subjects who had positive peptide-specific IFN-γ recall responses were from the high transmission area, Obom. Furthermore, while subjects from Obom responded to peptides in PfAMA1 from multiple parasite strains, one subject from Legon responded to a peptide from 3D7 strain only. CONCLUSIONS The current data demonstrate the possibility of a real effect of PfAMA1 polymorphisms on the induction of T cell responses in malaria exposed subjects, and this effect may be more pronounced in communities with higher parasite exposure.
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Affiliation(s)
- Ebenezer A Ofori
- West Africa Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, University of Ghana, Legon, Accra, Ghana.,Department of Immunology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - John K A Tetteh
- Department of Immunology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Augustina Frimpong
- Department of Immunology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Harini Ganeshan
- Malaria Department, Naval Medical Research Center, Silver Spring, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Maria Belmonte
- Malaria Department, Naval Medical Research Center, Silver Spring, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Bjoern Peters
- La Jolla Institute for Allergy and Immunology, La Jolla, CA, USA
| | - Eileen Villasante
- Malaria Department, Naval Medical Research Center, Silver Spring, USA
| | - Martha Sedegah
- Malaria Department, Naval Medical Research Center, Silver Spring, USA
| | - Michael F Ofori
- West Africa Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, University of Ghana, Legon, Accra, Ghana.,Department of Immunology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Kwadwo A Kusi
- West Africa Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, University of Ghana, Legon, Accra, Ghana. .,Department of Immunology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana.
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Lozano JM, Rodríguez Parra Z, Hernández-Martínez S, Yasnot-Acosta MF, Rojas AP, Marín-Waldo LS, Rincón JE. The Search of a Malaria Vaccine: The Time for Modified Immuno-Potentiating Probes. Vaccines (Basel) 2021; 9:vaccines9020115. [PMID: 33540947 PMCID: PMC7913233 DOI: 10.3390/vaccines9020115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/25/2022] Open
Abstract
Malaria is a deadly disease that takes the lives of more than 420,000 people a year and is responsible for more than 229 million clinical cases globally. In 2019, 95% of malaria morbidity occurred in African countries. The development of a highly protective vaccine is an urgent task that remains to be solved. Many vaccine candidates have been developed, from the use of the entire attenuated and irradiated pre-erythrocytic parasite forms (or recombinantly expressed antigens thereof) to synthetic candidates formulated in a variety of adjuvants and delivery systems, however these have unfortunately proven a limited efficacy. At present, some vaccine candidates are finishing safety and protective efficacy trials, such as the PfSPZ and the RTS,S/AS01 which are being introduced in Africa. We propose a strategy for introducing non-natural elements into target antigens representing key epitopes of Plasmodium spp. Accordingly, chemical strategies and knowledge of host immunity to Plasmodium spp. have served as the basis. Evidence is obtained after being tested in experimental rodent models for malaria infection and recognized for human sera from malaria-endemic regions. This encourages us to propose such an immune-potentiating strategy to be further considered in the search for new vaccine candidates.
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Affiliation(s)
- José Manuel Lozano
- Grupo de Investigación Mimetismo Molecular de los Agentes Infecciosos, Departamento de Farmacia, Universidad Nacional de Colombia—Sede Bogotá, 111321 Bogota, Colombia;
- Correspondence: ; Tel.: +57-3102-504-657
| | - Zully Rodríguez Parra
- Grupo de Investigación Mimetismo Molecular de los Agentes Infecciosos, Departamento de Farmacia, Universidad Nacional de Colombia—Sede Bogotá, 111321 Bogota, Colombia;
| | - Salvador Hernández-Martínez
- Dirección de Infección e Inmunidad, Centro de Investigaciones Sobre Enfermedades Infecciosas, Instituto Nacional de Salud Pública, 62508 Cuernavaca, Morelos, Mexico;
| | - Maria Fernanda Yasnot-Acosta
- Grupo de Investigaciones Microbiológicas y Biomédicas de Córdoba, Universidad de Córdoba, 230002 Monteria, Colombia;
| | - Angela Patricia Rojas
- Grupo de Investigación Biología Celular y Autoinmuniad, Departamento de Farmacia, Universidad Nacional de Colombia-Sede Bogotá, 111321 Bogota, Colombia;
| | | | - Juan Edilberto Rincón
- Departamento de Ingeniería y Mecatrónica, Universidad Nacional de Colombia-Sede Bogotá, 111321 Bogota, Colombia;
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Heide J, Vaughan KC, Sette A, Jacobs T, Schulze Zur Wiesch J. Comprehensive Review of Human Plasmodium falciparum-Specific CD8+ T Cell Epitopes. Front Immunol 2019; 10:397. [PMID: 30949162 PMCID: PMC6438266 DOI: 10.3389/fimmu.2019.00397] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/15/2019] [Indexed: 12/16/2022] Open
Abstract
Control of malaria is an important global health issue and there is still an urgent need for the development of an effective prophylactic vaccine. Multiple studies have provided strong evidence that Plasmodium falciparum-specific MHC class I-restricted CD8+ T cells are important for sterile protection against Plasmodium falciparum infection. Here, we present an interactive epitope map of all P. falciparum-specific CD8+ T cell epitopes published to date, based on a comprehensive data base (IEDB), and literature search. The majority of the described P. falciparum-specific CD8+ T cells were directed against the antigens CSP, TRAP, AMA1, and LSA1. Notably, most of the epitopes were discovered in vaccine trials conducted with malaria-naïve volunteers. Only few immunological studies of P. falciparum-specific CD8+ T cell epitopes detected in patients suffering from acute malaria or in people living in malaria endemic areas have been published. Further detailed immunological mappings of P. falciparum-specific epitopes of a broader range of P. falciparum proteins in different settings and with different disease status are needed to gain a more comprehensive understanding of the role of CD8+ T cell responses for protection, and to better guide vaccine design and to study their efficacy.
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Affiliation(s)
- Janna Heide
- Infectious Diseases Unit, I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Kerrie C Vaughan
- Division of Vaccine Discovery, La Jolla Institute for Immunology, La Jolla, CA, United States
| | - Alessandro Sette
- Division of Vaccine Discovery, La Jolla Institute for Immunology, La Jolla, CA, United States.,Department of Medicine, Division of Infectious Diseases, University of California, San Diego (UCSD), La Jolla, CA, United States
| | - Thomas Jacobs
- Protozoa Immunology, Bernhard-Nocht-Institute of Tropical Medicine, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- Infectious Diseases Unit, I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
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5
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McCall MBB, Kremsner PG, Mordmüller B. Correlating efficacy and immunogenicity in malaria vaccine trials. Semin Immunol 2018; 39:52-64. [PMID: 30219621 DOI: 10.1016/j.smim.2018.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/06/2018] [Indexed: 12/19/2022]
Abstract
The availability of an effective and appropriately implemented malaria vaccine would form a crucial cornerstone of public health efforts to fight this disease. Despite many decades of research, however, no malaria vaccine has yet shown satisfactory protective efficacy or been rolled-out. Validated immunological substitute endpoints have the potential to accelerate clinical vaccine development by reducing the required complexity, size, duration and cost of clinical trials. Besides facilitating clinical development of existing vaccine candidates, understanding immunological mechanisms of protection may drive the development of fundamentally new vaccination approaches. In this review we focus on correlates of protection in malaria vaccine development: Does immunogenicity predict malaria vaccine efficacy and why is this question particularly difficult? Have immunological correlates accelerated malaria vaccine development in the past and will they facilitate it in the future? Does Controlled Human Malaria Infection represent a valid model for identifying such immunological correlates, or a correlate of protection against naturally-acquired malaria in itself?
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Affiliation(s)
- Matthew B B McCall
- Institut für Tropenmedizin, Universität Tübingen and Deutsches Zentrum für Infektionsforschung, Germany; Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon.
| | - Peter G Kremsner
- Institut für Tropenmedizin, Universität Tübingen and Deutsches Zentrum für Infektionsforschung, Germany; Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon
| | - Benjamin Mordmüller
- Institut für Tropenmedizin, Universität Tübingen and Deutsches Zentrum für Infektionsforschung, Germany; Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon
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Nlinwe ON, Kusi KA, Adu B, Sedegah M. T-cell responses against Malaria: Effect of parasite antigen diversity and relevance for vaccine development. Vaccine 2018; 36:2237-2242. [PMID: 29573877 DOI: 10.1016/j.vaccine.2018.03.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 01/21/2018] [Accepted: 03/07/2018] [Indexed: 11/24/2022]
Abstract
The on-going agenda for global malaria elimination will require the development of additional disease control and prevention measures since currently available tools are showing signs of inadequacy. Malaria vaccines are seen as one such important addition to the control arsenal since vaccines have proven to be highly effective public health tools against important human diseases. Both cell-mediated and antibody responses are generally believed to be important for malaria parasite control, although the exact targets of T and B cell responses against malaria have not been clearly defined. However, our current understanding of the immune response to malaria suggests that T cell responses against multiple antigenic targets may potentially be key for the development of a highly efficacious malaria vaccine. This review takes a comprehensive look at the available literature on T cell-mediated immunity against all human stages of the malaria parasite and the effect of antigen diversity on these responses. The implications of these interrelationships for the development of an effective vaccine for malaria are also highlighted.
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Affiliation(s)
- Omarine Nfor Nlinwe
- Immunology Department, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P.O. Box LG 581, Legon, Accra, Ghana.
| | - Kwadwo Asamoah Kusi
- Immunology Department, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P.O. Box LG 581, Legon, Accra, Ghana.
| | - Bright Adu
- Immunology Department, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P.O. Box LG 581, Legon, Accra, Ghana.
| | - Martha Sedegah
- Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 209 l0-7500, USA.
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Abstract
Controlled human malaria infection (CHMI) entails deliberate infection with malaria parasites either by mosquito bite or by direct injection of sporozoites or parasitized erythrocytes. When required, the resulting blood-stage infection is curtailed by the administration of antimalarial drugs. Inducing a malaria infection via inoculation with infected blood was first used as a treatment (malariotherapy) for neurosyphilis in Europe and the United States in the early 1900s. More recently, CHMI has been applied to the fields of malaria vaccine and drug development, where it is used to evaluate products in well-controlled early-phase proof-of-concept clinical studies, thus facilitating progression of only the most promising candidates for further evaluation in areas where malaria is endemic. Controlled infections have also been used to immunize against malaria infection. Historically, CHMI studies have been restricted by the need for access to insectaries housing infected mosquitoes or suitable malaria-infected individuals. Evaluation of vaccine and drug candidates has been constrained in these studies by the availability of a limited number of Plasmodium falciparum isolates. Recent advances have included cryopreservation of sporozoites, the manufacture of well-characterized and genetically distinct cultured malaria cell banks for blood-stage infection, and the availability of Plasmodium vivax-specific reagents. These advances will help to accelerate malaria vaccine and drug development by making the reagents for CHMI more widely accessible and also enabling a more rigorous evaluation with multiple parasite strains and species. Here we discuss the different applications of CHMI, recent advances in the use of CHMI, and ongoing challenges for consideration.
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Singh SP, Srivastava D, Mishra BN. Genome-wide identification of novel vaccine candidates for Plasmodium falciparum malaria using integrative bioinformatics approaches. 3 Biotech 2017; 7:318. [PMID: 28955615 DOI: 10.1007/s13205-017-0947-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 09/05/2017] [Indexed: 12/12/2022] Open
Abstract
In spite of decades of malaria research and clinical trials, a fully effective and long-lasting preventive vaccine remains elusive. In the present study, 5370 proteins of Plasmodium falciparum genome were screened for the presence of signal peptide/anchor and GPI anchor motifs. Out of 45 screened surface-associated proteins, 22 were consensually predicted as antigens and had no orthologs in human and mouse except circumsporozoite protein (PF3D7_0304600). Among 22 proteins, 19 were identified as new antigens. In the next step, a total of 4944 peptides were predicted as CD8+ T cell epitopes from 22 probable antigens. Of these, the highest scoring 262 epitopes from each antigen were taken for optimization study in the malaria-endemic regions which covered a broad human population (~93.95%). The predicted epitope 13ILFYFFLWV21 of antigen 6-cysteine (PF3D7_1346800) was binding to the HLA-A*0201 allele with the highest fraction (26%) of immunogenicity in the target populations of North-East Asia, South-East Asia, and sub-Saharan Africa. Therefore, these epitopes are proposed to be favored in vaccine designs against malaria.
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Affiliation(s)
- Satarudra Prakash Singh
- Amity Institute of Biotechnology, Amity University Uttar Pradesh (Lucknow Campus), Lucknow, 226028 India
| | - Deeksha Srivastava
- Institute of Engineering and Technology, Dr. A.P.J. Abdul Kalam Technical University (Formerly Known as U.P. Technical University), Lucknow, 226021 India
| | - Bhartendu Nath Mishra
- Institute of Engineering and Technology, Dr. A.P.J. Abdul Kalam Technical University (Formerly Known as U.P. Technical University), Lucknow, 226021 India
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Lima-Junior JDC, Morgado FN, Conceição-Silva F. How Can Elispot Add Information to Improve Knowledge on Tropical Diseases? Cells 2017; 6:cells6040031. [PMID: 28961208 PMCID: PMC5755491 DOI: 10.3390/cells6040031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/12/2017] [Accepted: 09/14/2017] [Indexed: 01/04/2023] Open
Abstract
Elispot has been used as an important tool for detecting immune cells' products and functions and has facilitated the understanding of host-pathogen interaction. Despite the incredible diversity of possibilities, two main approaches have been developed: the immunopathogenesis and diagnosis/prognosis of infectious diseases as well as cancer research. Much has been described on the topics of allergy, autoimmune diseases, and HIV-Aids, however, Elispot can also be applied to other infectious diseases, mainly leishmaniasis, malaria, some viruses, helminths and mycosis usually classified as tropical diseases. The comprehension of the function, concentration and diversity of the immune response in the infectious disease is pointed out as crucial to the development of infection or disease in humans and animals. In this review we will describe the knowledge already obtained using Elispot as a method for accessing the profile of immune response as well as the recent advances in information about host-pathogen interaction in order to better understand the clinical outcome of a group of tropical and neglected diseases.
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Affiliation(s)
- Josué da Costa Lima-Junior
- Laboratório de Imunoparasitologia, Instituto Oswaldo Cruz/FIOCRUZ, Pavilhão 26-4° andar, sala 406-C, Av. Brasil 4365, Manguinhos, 21045-900 Rio de Janeiro, Brazil.
| | - Fernanda Nazaré Morgado
- Laboratório de Pesquisa em Leishmaniose, Instituto Oswaldo Cruz/FIOCRUZ, Pavilhão 26-5° andar, sala 509, Av. Brasil 4365, Manguinhos, 21045-900 Rio de Janeiro, Brazil.
| | - Fátima Conceição-Silva
- Laboratório de Imunoparasitologia, Instituto Oswaldo Cruz/FIOCRUZ, Pavilhão 26-4° andar, sala 406-C, Av. Brasil 4365, Manguinhos, 21045-900 Rio de Janeiro, Brazil.
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Chattopadhyay R, Pratt D. Role of controlled human malaria infection (CHMI) in malaria vaccine development: A U.S. food & drug administration (FDA) perspective. Vaccine 2017; 35:2767-2769. [PMID: 28431816 DOI: 10.1016/j.vaccine.2017.03.072] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/21/2017] [Accepted: 03/23/2017] [Indexed: 11/20/2022]
Affiliation(s)
- Rana Chattopadhyay
- Division of Vaccines & Related Product Applications, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Building 71, 10903 New Hampshire Avenue, Silver Spring, MD 20993-0002, USA.
| | - Douglas Pratt
- Division of Vaccines & Related Product Applications, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Building 71, 10903 New Hampshire Avenue, Silver Spring, MD 20993-0002, USA
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Sedegah M, Peters B, Hollingdale MR, Ganeshan HD, Huang J, Farooq F, Belmonte MN, Belmonte AD, Limbach KJ, Diggs C, Soisson L, Chuang I, Villasante ED. Correction: Vaccine Strain-Specificity of Protective HLA-Restricted Class 1 P. falciparum Epitopes. PLoS One 2016; 11:e0168952. [PMID: 27997615 PMCID: PMC5173278 DOI: 10.1371/journal.pone.0168952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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