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Barten LJC, Zuurveld M, Faber J, Garssen J, Klok T. Oral immunotherapy as a curative treatment for food-allergic preschool children: Current evidence and potential underlying mechanisms. Pediatr Allergy Immunol 2023; 34:e14043. [PMID: 38010006 DOI: 10.1111/pai.14043] [Citation(s) in RCA: 3] [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: 07/13/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
The worldwide rising prevalence of food allergy is a major public health concern. Standard care consists of allergen avoidance and rescue medication upon accidental exposure. Oral immunotherapy (OIT) is increasingly being studied as a treatment option. Although desensitization (an increased reaction threshold) is often achieved during OIT, sustained unresponsiveness (SU; clinical nonreactivity after finishing OIT) is not achieved in most patients. A few studies have investigated the effectiveness of OIT in children younger than 4 years of age (early = e-OIT) and have shown a much more favorable outcome in terms of SU development. Together with food allergy prevention studies, which have demonstrated high efficacy of early oral allergen exposure, the outcomes of e-OIT studies indicate an early-life window of opportunity to achieve SU, allowing unrestricted dietary intake. However, the underlying mechanism of the high effectiveness of e-OIT is not understood yet. Both cohort and OIT studies indicate early-life immune plasticity. An immature food-allergic response in the first years of life seems to be a major driver of this immune plasticity, along with a higher tolerogenic immunological state. Allergy maturation can likely be disrupted effectively by early intervention, preventing the development of persistent food allergy. Upcoming studies will provide important additional data on the safety, feasibility, and effectiveness of e-OIT. Combined with immune mechanistic studies, this should inform the implementation of e-OIT.
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Affiliation(s)
- Lieke J C Barten
- Pediatric Allergy Treatment Center, Deventer Hospital, Deventer, The Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Marit Zuurveld
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Joyce Faber
- Pediatric Allergy Treatment Center, Deventer Hospital, Deventer, The Netherlands
| | - Johan Garssen
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Ted Klok
- Pediatric Allergy Treatment Center, Deventer Hospital, Deventer, The Netherlands
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2
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Malloy AMW, Lu Z, Kehl M, Pena DaMata J, Lau-Kilby AW, Turfkruyer M. Increased innate immune activation induces protective RSV-specific lung-resident memory T cells in neonatal mice. Mucosal Immunol 2023; 16:593-605. [PMID: 37392972 DOI: 10.1016/j.mucimm.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/24/2023] [Indexed: 07/03/2023]
Abstract
Young infants frequently experience respiratory tract infections, yet vaccines designed to provide mucosal protection are lacking. Localizing pathogen-specific cellular and humoral immune responses to the lung could provide improved immune protection. We used a well-characterized murine model of respiratory syncytial virus (RSV) to study the development of lung-resident memory T cells (TRM) in neonatal compared to adult mice. We demonstrated that priming with RSV during the neonatal period failed to retain RSV-specific clusters of differentiation (CD8) TRM 6 weeks post infection, in contrast to priming during adulthood. The reduced development of RSV-specific TRM was associated with poor acquisition of two key markers of tissue residence: CD69 and CD103. However, by augmenting both innate immune activation and antigen exposure, neonatal RSV-specific CD8 T cells increased expression of tissue-residence markers and were maintained in the lung at memory time points. Establishment of TRM correlated with more rapid control of the virus in the lungs upon reinfection. This is the first strategy to effectively establish RSV-specific TRM in neonates providing new insight into neonatal memory T cell development and vaccine strategies.
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Affiliation(s)
- Allison M W Malloy
- Laboratory of Infectious Diseases and Host Defense, Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA.
| | - Zhongyan Lu
- Laboratory of Infectious Diseases and Host Defense, Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, USA
| | - Margaret Kehl
- Laboratory of Infectious Diseases and Host Defense, Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, USA
| | - Jarina Pena DaMata
- Laboratory of Infectious Diseases and Host Defense, Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, USA
| | - Annie W Lau-Kilby
- Laboratory of Infectious Diseases and Host Defense, Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, USA
| | - Mathilde Turfkruyer
- Laboratory of Infectious Diseases and Host Defense, Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, USA
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3
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St Clair LA, Chaulagain S, Klein SL, Benn CS, Flanagan KL. Sex-Differential and Non-specific Effects of Vaccines Over the Life Course. Curr Top Microbiol Immunol 2023; 441:225-251. [PMID: 37695431 PMCID: PMC10917449 DOI: 10.1007/978-3-031-35139-6_9] [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] [Indexed: 09/12/2023]
Abstract
Biological sex and age have profound effects on immune responses throughout the lifespan and impact vaccine acceptance, responses, and outcomes. Mounting evidence from epidemiological, clinical, and animal model studies show that males and females respond differentially to vaccination throughout the lifespan. Within age groups, females tend to produce greater vaccine-induced immune responses than males, with sex differences apparent across all age groups, but are most pronounced among reproductive aged individuals. Females report more adverse effects following vaccination than males. Females, especially among children under 5 years of age, also experience more non-specific effects of vaccination. Despite these known sex- and age-specific differences in vaccine-induced immune responses and outcomes, sex and age are often ignored in vaccine research. Herein, we review the known sex differences in the immunogenicity, effectiveness, reactogenicity, and non-specific effects of vaccination over the lifespan. Ways in which these data can be leveraged to improve vaccine research are described.
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Affiliation(s)
- Laura A St Clair
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sabal Chaulagain
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christine Stabell Benn
- Institute of Clinical Research and Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Katie L Flanagan
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, TAS, Australia.
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4
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TLR agonists induce sustained IgG to hemagglutinin stem and modulate T cells following newborn vaccination. NPJ Vaccines 2022; 7:102. [PMID: 36038596 PMCID: PMC9424286 DOI: 10.1038/s41541-022-00523-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 08/05/2022] [Indexed: 11/08/2022] Open
Abstract
The newborn immune system is characterized by diminished immune responses that leave infants vulnerable to virus-mediated disease and make vaccination more challenging. Optimal vaccination strategies for influenza A virus (IAV) in newborns should result in robust levels of protective antibodies, including those with broad reactivity to combat the variability in IAV strains across seasons. The stem region of the hemagglutinin (HA) molecule is a target of such antibodies. Using a nonhuman primate model, we investigate the capacity of newborns to generate and maintain antibodies to the conserved stem region following vaccination. We find adjuvanting an inactivated vaccine with the TLR7/8 agonist R848 is effective in promoting sustained HA stem-specific IgG. Unexpectedly, HA stem-specific antibodies were generated with a distinct kinetic pattern compared to the overall response. Administration of R848 was associated with increased influenza-specific T follicular helper cells as well as Tregs with a less suppressive phenotype, suggesting adjuvant impacts multiple cell types that have the potential to contribute to the HA-stem response.
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5
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Cord-Blood-Derived Professional Antigen-Presenting Cells: Functions and Applications in Current and Prospective Cell Therapies. Int J Mol Sci 2021; 22:ijms22115923. [PMID: 34072923 PMCID: PMC8199409 DOI: 10.3390/ijms22115923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 11/21/2022] Open
Abstract
Human umbilical cord blood (UCB) represents a valuable source of hematopoietic stem cells, particularly for patients lacking a matching donor. UCB provides practical advantages, including a lower risk of graft-versus-host-disease and permissive human leukocyte antigen mismatching. These advantageous properties have so far been applied for stem cell, mesenchymal stromal cell, and chimeric antigen receptor T cell therapies. However, UCB-derived professional antigen-presenting cells are increasingly being utilized in the context of immune tolerance and regenerative therapy. Here, we review the cell-specific characteristics as well as recent advancements in UCB-based cell therapies focusing on dendritic cells, monocytes, B lymphocytes, innate lymphoid cells, and macrophages.
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6
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Lauro R, Irrera N, Eid AH, Bitto A. Could Antigen Presenting Cells Represent a Protective Element during SARS-CoV-2 Infection in Children? Pathogens 2021; 10:476. [PMID: 33920011 PMCID: PMC8071032 DOI: 10.3390/pathogens10040476] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/06/2021] [Accepted: 04/10/2021] [Indexed: 12/12/2022] Open
Abstract
Antigen Presenting Cells (APC) are immune cells that recognize, process, and present antigens to lymphocytes. APCs are among the earliest immune responders against an antigen. Thus, in patients with COVID-19, a disease caused by the newly reported SARS-CoV-2 virus, the role of APCs becomes increasingly important. In this paper, we dissect the role of these cells in the fight against SARS-CoV-2. Interestingly, this virus appears to cause a higher mortality among adults than children. This may suggest that the immune system, particularly APCs, of children may be different from that of adults, which may then explain differences in immune responses between these two populations, evident as different pathological outcome. However, the underlying molecular mechanisms that differentiate juvenile from other APCs are not well understood. Whether juvenile APCs are one reason why children are less susceptible to SARS-CoV-2 requires much attention. The goal of this review is to examine the role of APCs, both in adults and children. The molecular mechanisms governing APCs, especially against SARS-CoV-2, may explain the differential immune responsiveness in the two populations.
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Affiliation(s)
- Rita Lauro
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (R.L.); (N.I.)
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (R.L.); (N.I.)
| | - Ali H. Eid
- Department of Basic Medical Sciences, College of Medicine, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Alessandra Bitto
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (R.L.); (N.I.)
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Yokanovich LT, Newberry RD, Knoop KA. Regulation of oral antigen delivery early in life: Implications for oral tolerance and food allergy. Clin Exp Allergy 2021; 51:518-526. [PMID: 33403739 PMCID: PMC8743004 DOI: 10.1111/cea.13823] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/19/2020] [Accepted: 12/30/2020] [Indexed: 12/11/2022]
Abstract
The increasing incidence of food allergy remains a significant public health concern. Food allergy is partially due to a lack, or loss of tolerance to food allergens. Clinical outcomes surrounding early life practices, such as breastfeeding, antibiotic use and food allergen exposure, indicate the first year of life in children represents a unique time for shaping the immune system to reduce allergic outcomes. Animal models have identified distinctive aspects of when and where dietary antigens are delivered within the intestinal tract to promote oral tolerance prior to weaning. Additionally, animal models have identified contributions from maternal proteins from breast milk and bacterial products from the gut microbiota in regulating dietary antigen exposure and promoting oral tolerance, thus connecting decades of clinical observations on the benefits of breastfeeding, early food allergen introduction and antibiotic avoidance in the first year of life in reducing allergic outcomes. Here, we discuss how exposure to gut luminal antigens, including food allergens, is regulated in early life to generate protective tolerance and the implications of this process for preventing and treating food allergies.
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Affiliation(s)
| | - Rodney D. Newberry
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn A. Knoop
- Department of Immunology, Mayo Clinic, Rochester MN, USA
- Department of Pediatrics, Mayo Clinic, Rochester MN, USA
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8
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Environmental signals rather than layered ontogeny imprint the function of type 2 conventional dendritic cells in young and adult mice. Nat Commun 2021; 12:464. [PMID: 33469015 PMCID: PMC7815729 DOI: 10.1038/s41467-020-20659-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 12/13/2020] [Indexed: 01/29/2023] Open
Abstract
Conventional dendritic cells (cDC) are key activators of naive T cells, and can be targeted in adults to induce adaptive immunity, but in early life are considered under-developed or functionally immature. Here we show that, in early life, when the immune system develops, cDC2 exhibit a dual hematopoietic origin and, like other myeloid and lymphoid cells, develop in waves. Developmentally distinct cDC2 in early life, despite being distinguishable by fate mapping, are transcriptionally and functionally similar. cDC2 in early and adult life, however, are exposed to distinct cytokine environments that shape their transcriptional profile and alter their ability to sense pathogens, secrete cytokines and polarize T cells. We further show that cDC2 in early life, despite being distinct from cDC2 in adult life, are functionally competent and can induce T cell responses. Our results thus highlight the potential of harnessing cDC2 for boosting immunity in early life.
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von Mutius E, Smits HH. Primary prevention of asthma: from risk and protective factors to targeted strategies for prevention. Lancet 2020; 396:854-866. [PMID: 32910907 DOI: 10.1016/s0140-6736(20)31861-4] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/03/2020] [Accepted: 07/10/2020] [Indexed: 12/15/2022]
Abstract
Asthma is a complex disease that often starts in childhood. Genomic and environmental factors as well as aberrant immune maturation early in life can contribute to the onset of disease, with great disparity over time and geographical regions. Epidemiological studies have scrutinised environmental exposures and attempted to translate these exposures into prevention strategies. Some approaches for patients with asthma have been successful (eg, smoking ban, the Finnish Asthma Programme), and primary prevention of wheeze in pre-school children (age 0-5 years) by the supplementation of vitamin D or fish oil, or both, to pregnant women seems promising. Several recent prevention initiatives are based on strong asthma-protective environmental microbial exposures associated with traditional rural lifestyles. Preclinical studies with various bacterial lysates, bacterial and dietary metabolites, or helminthic compounds have yielded promising results that await translation into clinical practice. Given the immense societal and individual burden of asthma, there is an urgent need to further develop novel strategies to eradicate the disease.
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Affiliation(s)
- Erika von Mutius
- Department of Pediatrics, Dr von Hauner Children's Hospital, Ludwig Maximilians University, Munich, Germany; Helmholtz Zentrum Muenchen-German Research Center for Environmental Health, Institute for Asthma and Allergy Prevention, Neuherberg, Germany; Comprehensive Pneumology Center Munich, German Center for Lung Research, Neuherberg, Germany.
| | - Hermelijn H Smits
- Department of Parasitology, Center of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
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10
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Tsafaras GP, Ntontsi P, Xanthou G. Advantages and Limitations of the Neonatal Immune System. Front Pediatr 2020; 8:5. [PMID: 32047730 PMCID: PMC6997472 DOI: 10.3389/fped.2020.00005] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/07/2020] [Indexed: 12/30/2022] Open
Abstract
During early post-natal life, neonates must adjust to the transition from the sheltered intra-uterine environment to the microbe-laden external world, wherein they encounter a constellation of antigens and the colonization by the microbiome. At this vulnerable stage, neonatal immune responses are considered immature and present significant differences to those of adults. Pertinent to innate immunity, functional and quantitative deficiencies in antigen-presenting cells and phagocytes are often documented. Exposure to environmental antigens and microbial colonization is associated with epigenetic immune cell reprogramming and activation of effector and regulatory mechanisms that ensure age-depended immune system maturation and prevention of tissue damage. Moreover, neonatal innate immune memory has emerged as a critical mechanism providing protection against infectious agents. Still, in neonates, inexperience to antigenic exposure, along with enhancement of tissue-protective immunosuppressive mechanisms are often associated with severe immunopathological conditions, including sepsis and neurodevelopmental disorders. Despite significant advances in the field, adequate vaccination in newborns is still in its infancy due to elemental restrictions associated also with defective immune responses. In this review, we provide an overview of neonatal innate immune cells, highlighting phenotypic and functional disparities with their adult counterparts. We also discuss the effects of epigenetic modifications and microbial colonization on the regulation of neonatal immunity. A recent update on mechanisms underlying dysregulated neonatal innate immunity and linked infectious and neurodevelopmental diseases is provided. Understanding of the mechanisms that augment innate immune responsiveness in neonates may facilitate the development of improved vaccination protocols that can protect against pathogens and organ damage.
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Affiliation(s)
- George P Tsafaras
- Cellular Immunology Lab, Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Polyxeni Ntontsi
- Second Respiratory Medicine Department, 'Attikon' University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Georgina Xanthou
- Cellular Immunology Lab, Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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11
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Misra RS, Nayak JL. The Importance of Vaccinating Children and Pregnant Women against Influenza Virus Infection. Pathogens 2019; 8:pathogens8040265. [PMID: 31779153 PMCID: PMC6963306 DOI: 10.3390/pathogens8040265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 12/21/2022] Open
Abstract
Influenza virus infection is responsible for significant morbidity and mortality in the pediatric and pregnant women populations, with deaths frequently caused by severe influenza-associated lower respiratory tract infection and acute respiratory distress syndrome (ARDS). An appropriate immune response requires controlling the viral infection through activation of antiviral defenses, which involves cells of the lung and immune system. High levels of viral infection or high levels of inflammation in the lower airways can contribute to ARDS. Pregnant women and young children, especially those born prematurely, may develop serious complications if infected with influenza virus. Vaccination against influenza will lead to lower infection rates and fewer complications, even if the vaccine is poorly matched to circulating viral strains, with maternal vaccination offering infants protection via antibody transmission through the placenta and breast milk. Despite the health benefits of the influenza vaccine, vaccination rates around the world remain well below targets. Trust in the use of vaccines among the public must be restored in order to increase vaccination rates and decrease the public health burden of influenza.
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Affiliation(s)
- Ravi S Misra
- Department of Pediatrics Division of Neonatology, The University of Rochester Medical Center, Rochester, NY 14623, USA
- Correspondence:
| | - Jennifer L Nayak
- Department of Pediatrics Division of Pediatric Infectious Diseases, The University of Rochester Medical Center, Rochester, NY 14623, USA;
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12
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Fike AJ, Kumova OK, Carey AJ. Dissecting the defects in the neonatal CD8 + T-cell response. J Leukoc Biol 2019; 106:1051-1061. [PMID: 31260598 DOI: 10.1002/jlb.5ru0319-105r] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/24/2019] [Accepted: 06/10/2019] [Indexed: 12/26/2022] Open
Abstract
The neonatal period presents a complex scenario where the threshold of reactivity toward colonizing microbiota, maternal antigens, autoantigens, and pathogens must be carefully moderated and balanced. CD8+ T cells are critical for the response against intracellular bacteria and viruses, but this immune compartment maintains altered function relative to adult counterparts because of the unique challenges which infants face. Here, we review our current understanding of the factors which may promote the attenuation and altered function of the neonatal CD8+ T-cell response and potential avenues for future study. Specifically, we have focused on the neonatal CD8+ T-cell ontogeny, memory formation, TCR structure and repertoire, TCR inhibitory receptors, and the clinical implications of altered neonatal CD8+ T-cell function. Special emphasis has been placed on examining the response of preterm neonates relative to term neonates and adults.
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Affiliation(s)
- Adam J Fike
- Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Ogan K Kumova
- Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Alison J Carey
- Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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