1
|
Audran R, Karoui O, Donnet L, Soumas V, Fares F, Lovis A, Noirez L, Cavassini M, Fayet-Mello A, Satti I, McShane H, Spertini F. Randomised, double-blind, controlled phase 1 trial of the candidate tuberculosis vaccine ChAdOx1-85A delivered by aerosol versus intramuscular route. J Infect 2024; 89:106205. [PMID: 38897242 DOI: 10.1016/j.jinf.2024.106205] [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: 03/27/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND A BCG booster vaccination administered via the respiratory mucosa may establish protective immune responses at the primary site of Mycobacterium tuberculosis infection. The primary objective of this trial was to compare the safety and immunogenicity of inhaled versus intramuscular administered ChAdOx1-85A. METHODS We conducted a single-centre, randomised, double-blind, controlled phase 1 study (Swiss National Clinical Trials Portal number SNCTP000002920). After a dose-escalation vaccination in nine BCG-vaccinated healthy adults, a dose of 1 × 1010 vp of ChAdOx1-85A was administered to twenty BCG-vaccinated adults that were randomly allocated (1:1) into two groups: aerosol ChAdOx1-85A with intramuscular saline placebo or intramuscular ChAdOx1-85A with aerosol saline placebo, using block randomisation. A control group of ten BCG-naïve adults received aerosol ChAdOx1-85A at the same dose. Primary outcomes were solicited and unsolicited adverse events (AEs) up to day 16 post-vaccination and Serious AEs (SAEs) up to 24 weeks; secondary outcomes were cell-mediated and humoral immune responses in blood and bronchoalveolar lavage (BAL) samples. FINDINGS Both vaccination routes were well tolerated with no SAEs. Intramuscular ChAdOx1-85A was associated with more local AEs (mostly pain at the injection site) than aerosol ChAdOx1-85A. Systemic AEs occurred in all groups, mainly fatigue and headaches, without differences between groups. Respiratory AEs were not different between BCG-vaccinated groups. Aerosol ChAdOx1-85A vaccination induced Ag85A BAL and systemic cellular immune responses with compartmentalisation of the immune responses: aerosol ChAdOx1-85A induced stronger BAL cellular responses, particularly IFNγ/IL17+CD4+ T cells; intramuscular ChAdOx1-85A induced stronger systemic cellular and humoral responses. INTERPRETATION Inhaled ChAdOx1-85A was well-tolerated and induced lung mucosal and systemic Ag85A-specific T-cell responses. These data support further evaluation of aerosol ChAdOx1-85A and other viral vectors as a BCG-booster vaccination strategy.
Collapse
Affiliation(s)
- Régine Audran
- Department of Medicine, Division of Allergy and Immunology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Olfa Karoui
- Department of Medicine, Division of Allergy and Immunology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Laura Donnet
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Vassili Soumas
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Fady Fares
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Alban Lovis
- Department of Medicine, Division of Pneumology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Leslie Noirez
- Department of Medicine, Division of Pneumology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Matthias Cavassini
- Department of Medicine, Division of Infectious Disease, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Aurélie Fayet-Mello
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Iman Satti
- The Jenner Institute, University of Oxford, Oxford OX3 7DQ, UK
| | - Helen McShane
- The Jenner Institute, University of Oxford, Oxford OX3 7DQ, UK.
| | - François Spertini
- Department of Medicine, Division of Allergy and Immunology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| |
Collapse
|
2
|
Satti I, Marshall JL, Harris SA, Wittenberg R, Tanner R, Lopez Ramon R, Wilkie M, Ramos Lopez F, Riste M, Wright D, Peralta Alvarez MP, Williams N, Morrison H, Stylianou E, Folegatti P, Jenkin D, Vermaak S, Rask L, Cabrera Puig I, Powell Doherty R, Lawrie A, Moss P, Hinks T, Bettinson H, McShane H. Safety of a controlled human infection model of tuberculosis with aerosolised, live-attenuated Mycobacterium bovis BCG versus intradermal BCG in BCG-naive adults in the UK: a dose-escalation, randomised, controlled, phase 1 trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:909-921. [PMID: 38621405 DOI: 10.1016/s1473-3099(24)00143-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Mycobacterium tuberculosis is the main causative agent of tuberculosis. BCG, the only licensed vaccine, provides inadequate protection against pulmonary tuberculosis. Controlled human infection models are useful tools for vaccine development. We aimed to determine a safe dose of aerosol-inhaled live-attenuated Mycobacterium bovis BCG as a surrogate for M tuberculosis infection, then compare the safety and tolerability of infection models established using aerosol-inhaled and intradermally administered BCG. METHODS This phase 1 controlled human infection trial was conducted at two clinical research facilities in the UK. Healthy, immunocompetent adults aged 18-50 years, who were both M tuberculosis-naive and BCG-naive and had no history of asthma or other respiratory diseases, were eligible for the trial. Participants were initially enrolled into group 1 (receiving the BCG Danish strain); the trial was subsequently paused because of a worldwide shortage of BCG Danish and, after protocol amendment, was restarted using the BCG Bulgaria strain (group 2). After a dose-escalation study, during which participants were sequentially allocated to receive either 1 × 103, 1 × 104, 1 × 105, 1 × 106, or 1 × 107 colony-forming units (CFU) of aerosol BCG, the maximum tolerated dose was selected for the randomised controlled trial. Participants in this trial were randomly assigned (9:12), by variable block randomisation and using sequentially numbered sealed envelopes, to receive aerosol BCG (1 × 107 CFU) and intradermal saline or intradermal BCG (1 × 106 CFU) and aerosol saline. Participants were masked to treatment allocation until day 14. The primary outcome was to compare the safety of a controlled human infection model based on aerosol-inhaled BCG versus one based on intradermally administered BCG, and the secondary outcome was to evaluate BCG recovery in the airways of participants who received aerosol BCG or skin biopsies of participants who received intradermal BCG. BCG was detected by culture and by PCR. The trial is registered at ClinicalTrials.gov, NCT02709278, and is complete. FINDINGS Participants were assessed for eligibility between April 7, 2016, and Sept 29, 2018. For group 1, 15 participants were screened, of whom 13 were enrolled and ten completed the study; for group 2, 60 were screened and 33 enrolled, all of whom completed the study. Doses up to 1 × 107 CFU aerosol-inhaled BCG were sufficiently well tolerated. No significant difference was observed in the frequency of adverse events between aerosol and intradermal groups (median percentage of solicited adverse events per participant, post-aerosol vs post-intradermal BCG: systemic 7% [IQR 2-11] vs 4% [1-13], p=0·62; respiratory 7% [1-19] vs 4% [1-9], p=0·56). More severe systemic adverse events occurred in the 2 weeks after aerosol BCG (15 [12%] of 122 reported systemic adverse events) than after intradermal BCG (one [1%] of 94; difference 11% [95% CI 5-17]; p=0·0013), but no difference was observed in the severity of respiratory adverse events (two [1%] of 144 vs zero [0%] of 97; 1% [-1 to 3]; p=0·52). All adverse events after aerosol BCG resolved spontaneously. One serious adverse event was reported-a participant in group 2 was admitted to hospital to receive analgesia for a pre-existing ovarian cyst, which was deemed unrelated to BCG infection. On day 14, BCG was cultured from bronchoalveolar lavage samples after aerosol infection and from skin biopsy samples after intradermal infection. INTERPRETATION This first-in-human aerosol BCG controlled human infection model was sufficiently well tolerated. Further work will evaluate the utility of this model in assessing vaccine efficacy and identifying potential correlates of protection. FUNDING Bill & Melinda Gates Foundation, Wellcome Trust, National Institute for Health Research Oxford Biomedical Research Centre, Thames Valley Clinical Research Network, and TBVAC2020.
Collapse
Affiliation(s)
- Iman Satti
- The Jenner Institute, University of Oxford, Oxford, UK
| | | | | | | | - Rachel Tanner
- The Jenner Institute, University of Oxford, Oxford, UK
| | | | - Morven Wilkie
- The Jenner Institute, University of Oxford, Oxford, UK
| | | | - Michael Riste
- The Jenner Institute, University of Oxford, Oxford, UK
| | - Daniel Wright
- The Jenner Institute, University of Oxford, Oxford, UK
| | | | - Nicola Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | - Daniel Jenkin
- The Jenner Institute, University of Oxford, Oxford, UK
| | | | - Linnea Rask
- The Jenner Institute, University of Oxford, Oxford, UK
| | | | | | - Alison Lawrie
- The Jenner Institute, University of Oxford, Oxford, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Timothy Hinks
- Oxford Centre for Respiratory Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Henry Bettinson
- Oxford Centre for Respiratory Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Helen McShane
- The Jenner Institute, University of Oxford, Oxford, UK.
| |
Collapse
|
3
|
Sibley L, Sarfas C, Morrison AL, Williams J, Gkolfinos K, Mabbutt A, Eckworth W, Lawrence S, Dennis M, White A, Sharpe S. Immune cell population dynamics following neonatal BCG vaccination and aerosol BCG revaccination in rhesus macaques. Sci Rep 2024; 14:16993. [PMID: 39043848 PMCID: PMC11266652 DOI: 10.1038/s41598-024-67861-6] [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: 05/03/2023] [Accepted: 07/16/2024] [Indexed: 07/25/2024] Open
Abstract
The BCG vaccine is given to millions of children globally but efficacy wanes over time and differences in the immune systems between infants and adults can influence vaccine efficacy. To this end, 34 rhesus macaques were vaccinated with BCG within seven days of birth and blood samples were collected over 88 weeks for quantification of blood cell populations. Overall, the composition of cell populations did not change significantly between BCG vaccinated and unvaccinated groups, and that BCG vaccination did not perturb normal development. In comparison to adult macaques, higher numbers of CD4+ T-cells, Tregs and NK cells were measured in the infant age group, suggesting a potential bias towards immunosuppressive and innate immune populations. Antigen-specific IFNγ secreting cell frequencies in infant BCG vaccinated animals were detectable in peripheral blood samples for 36 weeks after vaccination but declined following this. To evaluate the long-term impact of infant BCG vaccination on subsequent revaccination with BCG, a pilot study of three adult macaques received an aerosol BCG revaccination approximately 3 years after their initial BCG vaccination as infants. This induced an increase in PPD-specific IFNγ secreting cells, and increased secretion of the cytokines IFNγ and IL-1β, following stimulation with other microorganisms, which are signals associated with trained innate immunity.
Collapse
Affiliation(s)
- Laura Sibley
- UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
| | | | | | | | | | - Adam Mabbutt
- UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
| | | | - Steve Lawrence
- UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
| | - Mike Dennis
- UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
| | - Andrew White
- UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK.
| | - Sally Sharpe
- UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Painter H, Harriss E, Fletcher HA, McShane H, Tanner R. Development and application of the direct mycobacterial growth inhibition assay: a systematic review. Front Immunol 2024; 15:1355983. [PMID: 38380319 PMCID: PMC10877019 DOI: 10.3389/fimmu.2024.1355983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction First described by Wallis et al. in 2001 for the assessment of TB drugs, the direct mycobacterial growth inhibition assay (MGIA) offers a tractable ex vivo tool measuring the combined influences of host immunity, strain virulence and intervention effects. Over the past 13 years, we have led efforts to adapt the direct MGIA for the assessment of TB vaccines including optimisation, harmonisation and validation of BCG vaccine-induced responses as a benchmark, as well as assay transfer to institutes worldwide. Methods We have performed a systematic review on the primary published literature describing the development and applications of the direct MGIA from 2001 to June 2023 in accordance with the PRISMA reporting guidelines. Results We describe 63 studies in which the direct MGIA has been applied across species for the evaluation of TB drugs and novel TB vaccine candidates, the study of clinical cohorts including those with comorbidities, and to further understanding of potential immune correlates of protection from TB. We provide a comprehensive update on progress of the assay since its conception and critically evaluate current findings and evidence supporting its utility, highlighting priorities for future directions. Discussion While further standardisation and validation work is required, significant advancements have been made in the past two decades. The direct MGIA provides a potentially valuable tool for the early evaluation of TB drug and vaccine candidates, clinical cohorts, and immune mechanisms of mycobacterial control. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023423491.
Collapse
Affiliation(s)
- Hannah Painter
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | - Helen A. Fletcher
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen McShane
- Nuffield Department of Medicine, Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Rachel Tanner
- Department of Biology, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
6
|
Morrison AL, Sarfas C, Sibley L, Williams J, Mabbutt A, Dennis MJ, Lawrence S, White AD, Bodman-Smith M, Sharpe SA. IV BCG Vaccination and Aerosol BCG Revaccination Induce Mycobacteria-Responsive γδ T Cells Associated with Protective Efficacy against M. tb Challenge. Vaccines (Basel) 2023; 11:1604. [PMID: 37897006 PMCID: PMC10611416 DOI: 10.3390/vaccines11101604] [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: 09/07/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Intravenously (IV) delivered BCG provides superior tuberculosis (TB) protection compared with the intradermal (ID) route in non-human primates (NHPs). We examined how γδ T cell responses changed in vivo after IV BCG vaccination of NHPs, and whether these correlated with protection against aerosol M. tuberculosis challenge. In the circulation, Vδ2 T cell populations expanded after IV BCG vaccination, from a median of 1.5% (range: 0.8-2.3) of the CD3+ population at baseline, to 5.3% (range: 1.4-29.5) 4 weeks after M. tb, and were associated with TB protection. This protection was related to effector and central memory profiles; homing markers; and production of IFN-γ, TNF-α and granulysin. In comparison, Vδ2 cells did not expand after ID BCG, but underwent phenotypic and functional changes. When Vδ2 responses in bronchoalveolar lavage (BAL) samples were compared between routes, IV BCG vaccination resulted in highly functional mucosal Vδ2 cells, whereas ID BCG did not. We sought to explore whether an aerosol BCG boost following ID BCG vaccination could induce a γδ profile comparable to that induced with IV BCG. We found evidence that the aerosol BCG boost induced significant changes in the Vδ2 phenotype and function in cells isolated from the BAL. These results indicate that Vδ2 population frequency, activation and function are characteristic features of responses induced with IV BCG, and the translation of responses from the circulation to the site of infection could be a limiting factor in the response induced following ID BCG. An aerosol boost was able to localise activated Vδ2 populations at the mucosal surfaces of the lung. This vaccine strategy warrants further investigation to boost the waning human ID BCG response.
Collapse
Affiliation(s)
- Alexandra L. Morrison
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Charlotte Sarfas
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Laura Sibley
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Jessica Williams
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Adam Mabbutt
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Mike J. Dennis
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Steve Lawrence
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Andrew D. White
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| | - Mark Bodman-Smith
- Infection and Immunity Research Institute, St. George’s University of London, London SW17 0BD, UK
| | - Sally A. Sharpe
- Vaccine Development and Evaluation Centre, UK Health Security Agency, Porton Down, Salisbury SP4 0JG, UK
| |
Collapse
|
7
|
White AD, Tran AC, Sibley L, Sarfas C, Morrison AL, Lawrence S, Dennis M, Clark S, Zadi S, Lanni F, Rayner E, Copland A, Hart P, Diogo GR, Paul MJ, Kim M, Gleeson F, Salguero FJ, Singh M, Stehr M, Cutting SM, Basile JI, Rottenberg ME, Williams A, Sharpe SA, Reljic R. Spore-FP1 tuberculosis mucosal vaccine candidate is highly protective in guinea pigs but fails to improve on BCG-conferred protection in non-human primates. Front Immunol 2023; 14:1246826. [PMID: 37881438 PMCID: PMC10594996 DOI: 10.3389/fimmu.2023.1246826] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/19/2023] [Indexed: 10/27/2023] Open
Abstract
Tuberculosis remains a major health threat globally and a more effective vaccine than the current Bacillus Calmette Guerin (BCG) is required, either to replace or boost it. The Spore-FP1 mucosal vaccine candidate is based on the fusion protein of Ag85B-Acr-HBHA/heparin-binding domain, adsorbed on the surface of inactivated Bacillus subtilis spores. The candidate conferred significant protection against Mycobacterium. tuberculosis challenge in naïve guinea pigs and markedly improved protection in the lungs and spleens of animals primed with BCG. We then immunized rhesus macaques with BCG intradermally, and subsequently boosted with one intradermal and one aerosol dose of Spore-FP1, prior to challenge with low dose aerosolized M. tuberculosis Erdman strain. Following vaccination, animals did not show any adverse reactions and displayed higher antigen specific cellular and antibody immune responses compared to BCG alone but this did not translate into significant improvement in disease pathology or bacterial burden in the organs.
Collapse
Affiliation(s)
- Andrew D. White
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Andy C. Tran
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Laura Sibley
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Charlotte Sarfas
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Alexandra L. Morrison
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Steve Lawrence
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Mike Dennis
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Simon Clark
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Sirine Zadi
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Faye Lanni
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Emma Rayner
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Alastair Copland
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Peter Hart
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Gil Reynolds Diogo
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Matthew J. Paul
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Miyoung Kim
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Fergus Gleeson
- Department of Oncology, The Churchill Hospital, Oxford, United Kingdom
| | - Francisco J. Salguero
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | | | | | - Simon M. Cutting
- School of Biological Sciences, Royal Holloway University of London, Surrey, United Kingdom
- Sporegen Ltd , London Bioscience Innovation Centre, London, United Kingdom
| | - Juan I. Basile
- Department of Microbiology, Tumour and Cell Biology and Centre for Tuberculosis Research, Karolinska Institute, Stockholm, Sweden
| | - Martin E. Rottenberg
- Department of Microbiology, Tumour and Cell Biology and Centre for Tuberculosis Research, Karolinska Institute, Stockholm, Sweden
| | - Ann Williams
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Sally A. Sharpe
- United Kingdom Health Security Agency (UKHSA), Porton Down, Salisbury, United Kingdom
| | - Rajko Reljic
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| |
Collapse
|
8
|
Zhang Y, Xu JC, Hu ZD, Fan XY. Advances in protein subunit vaccines against tuberculosis. Front Immunol 2023; 14:1238586. [PMID: 37654500 PMCID: PMC10465801 DOI: 10.3389/fimmu.2023.1238586] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/25/2023] [Indexed: 09/02/2023] Open
Abstract
Tuberculosis (TB), also known as the "White Plague", is caused by Mycobacterium tuberculosis (Mtb). Before the COVID-19 epidemic, TB had the highest mortality rate of any single infectious disease. Vaccination is considered one of the most effective strategies for controlling TB. Despite the limitations of the Bacille Calmette-Guérin (BCG) vaccine in terms of protection against TB among adults, it is currently the only licensed TB vaccine. Recently, with the evolution of bioinformatics and structural biology techniques to screen and optimize protective antigens of Mtb, the tremendous potential of protein subunit vaccines is being exploited. Multistage subunit vaccines obtained by fusing immunodominant antigens from different stages of TB infection are being used both to prevent and to treat TB. Additionally, the development of novel adjuvants is compensating for weaknesses of immunogenicity, which is conducive to the flourishing of subunit vaccines. With advances in the development of animal models, preclinical vaccine protection assessments are becoming increasingly accurate. This review summarizes progress in the research of protein subunit TB vaccines during the past decades to facilitate the further optimization of protein subunit vaccines that may eradicate TB.
Collapse
Affiliation(s)
- Ying Zhang
- Shanghai Public Health Clinical Center, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Jin-chuan Xu
- Shanghai Public Health Clinical Center, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Zhi-dong Hu
- Shanghai Public Health Clinical Center, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
- TB Center, Shanghai Emerging and Re-emerging Infectious Disease Institute, Fudan University, Shanghai, China
| | - Xiao-yong Fan
- Shanghai Public Health Clinical Center, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
- TB Center, Shanghai Emerging and Re-emerging Infectious Disease Institute, Fudan University, Shanghai, China
| |
Collapse
|
9
|
Corleis B, Bastian M, Hoffmann D, Beer M, Dorhoi A. Animal models for COVID-19 and tuberculosis. Front Immunol 2023; 14:1223260. [PMID: 37638020 PMCID: PMC10451089 DOI: 10.3389/fimmu.2023.1223260] [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: 05/15/2023] [Accepted: 07/21/2023] [Indexed: 08/29/2023] Open
Abstract
Respiratory infections cause tremendous morbidity and mortality worldwide. Amongst these diseases, tuberculosis (TB), a bacterial illness caused by Mycobacterium tuberculosis which often affects the lung, and coronavirus disease 2019 (COVID-19) caused by the Severe Acute Respiratory Syndrome Coronavirus type 2 (SARS-CoV-2), stand out as major drivers of epidemics of global concern. Despite their unrelated etiology and distinct pathology, these infections affect the same vital organ and share immunopathogenesis traits and an imperative demand to model the diseases at their various progression stages and localizations. Due to the clinical spectrum and heterogeneity of both diseases experimental infections were pursued in a variety of animal models. We summarize mammalian models employed in TB and COVID-19 experimental investigations, highlighting the diversity of rodent models and species peculiarities for each infection. We discuss the utility of non-human primates for translational research and emphasize on the benefits of non-conventional experimental models such as livestock. We epitomize advances facilitated by animal models with regard to understanding disease pathophysiology and immune responses. Finally, we highlight research areas necessitating optimized models and advocate that research of pulmonary infectious diseases could benefit from cross-fertilization between studies of apparently unrelated diseases, such as TB and COVID-19.
Collapse
Affiliation(s)
- Björn Corleis
- Institute of Immunology, Friedrich-Loeffler-Institut, Federal Research Institute for Animal Health, Greifswald-Insel Riems, Germany
| | - Max Bastian
- Friedrich-Loeffler-Institut, Federal Research Institute for Animal Health, Greifswald-Insel Riems, Germany
| | - Donata Hoffmann
- Institute of Diagnostic Virology, Friedrich-Loeffler-Institut, Federal Research Institute for Animal Health, Greifswald-Insel Riems, Germany
| | - Martin Beer
- Institute of Diagnostic Virology, Friedrich-Loeffler-Institut, Federal Research Institute for Animal Health, Greifswald-Insel Riems, Germany
| | - Anca Dorhoi
- Institute of Immunology, Friedrich-Loeffler-Institut, Federal Research Institute for Animal Health, Greifswald-Insel Riems, Germany
- Faculty of Mathematics and Natural Sciences, University of Greifswald, Greifswald, Germany
| |
Collapse
|
10
|
Tong R, Luo L, Zhao Y, Sun M, Li R, Zhong J, Chen Y, Hu L, Li Z, Shi J, Lyu Y, Hu L, Guo X, Liu Q, Shuang T, Zhang C, Yuan A, Sun L, Zhang Z, Qian K, Chen L, Lin W, Chen AF, Wang F, Pu J. Characterizing the cellular and molecular variabilities of peripheral immune cells in healthy recipients of BBIBP-CorV inactivated SARS-CoV-2 vaccine by single-cell RNA sequencing. Emerg Microbes Infect 2023; 12:e2187245. [PMID: 36987861 PMCID: PMC10171127 DOI: 10.1080/22221751.2023.2187245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
Over 3 billion doses of inactivated vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been administered globally. However, our understanding of the immune cell functional transcription and T cell receptor (TCR)/B cell receptor (BCR) repertoire dynamics following inactivated SARS-CoV-2 vaccination remains poorly understood. Here, we performed single-cell RNA and TCR/BCR sequencing on peripheral blood mononuclear cells at four time points after immunization with the inactivated SARS-CoV-2 vaccine BBIBP-CorV. Our analysis revealed an enrichment of monocytes, central memory CD4+ T cells, type 2 helper T cells and memory B cells following vaccination. Single-cell TCR-seq and RNA-seq comminating analysis identified a clonal expansion of CD4+ T cells (but not CD8+ T cells) following a booster vaccination that corresponded to a decrease in the TCR diversity of central memory CD4+ T cells and type 2 helper T cells. Importantly, these TCR repertoire changes and CD4+ T cell differentiation were correlated with the biased VJ gene usage of BCR and the antibody-producing function of B cells post-vaccination. Finally, we compared the functional transcription and repertoire dynamics in immune cells elicited by vaccination and SARS-CoV-2 infection to explore the immune responses under different stimuli. Our data provide novel molecular and cellular evidence for the CD4+ T cell-dependent antibody response induced by inactivated vaccine BBIBP-CorV. This information is urgently needed to develop new prevention and control strategies for SARS-CoV-2 infection. (ClinicalTrials.gov Identifier: NCT04871932).Trial registration: ClinicalTrials.gov identifier: NCT04871932..
Collapse
|
11
|
Surveillance of Daughter Micronodule Formation Is a Key Factor for Vaccine Evaluation Using Experimental Infection Models of Tuberculosis in Macaques. Pathogens 2023; 12:pathogens12020236. [PMID: 36839508 PMCID: PMC9961649 DOI: 10.3390/pathogens12020236] [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: 12/27/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Tuberculosis (TB) is still a major worldwide health problem and models using non-human primates (NHP) provide the most relevant approach for vaccine testing. In this study, we analysed CT images collected from cynomolgus and rhesus macaques following exposure to ultra-low dose Mycobacterium tuberculosis (Mtb) aerosols, and monitored them for 16 weeks to evaluate the impact of prior intradermal or inhaled BCG vaccination on the progression of lung disease. All lesions found (2553) were classified according to their size and we subclassified small micronodules (<4.4 mm) as 'isolated', or as 'daughter', when they were in contact with consolidation (described as lesions ≥ 4.5 mm). Our data link the higher capacity to contain Mtb infection in cynomolgus with the reduced incidence of daughter micronodules, thus avoiding the development of consolidated lesions and their consequent enlargement and evolution to cavitation. In the case of rhesus, intradermal vaccination has a higher capacity to reduce the formation of daughter micronodules. This study supports the 'Bubble Model' defined with the C3HBe/FeJ mice and proposes a new method to evaluate outcomes in experimental models of TB in NHP based on CT images, which would fit a future machine learning approach to evaluate new vaccines.
Collapse
|
12
|
Walker EM, Merino KM, Slisarenko N, Grasperge BF, Mehra S, Roy CJ, Kaushal D, Rout N. Impact of SIV infection on mycobacterial lipid-reactive T cell responses in Bacillus Calmette-Guérin (BCG) inoculated macaques. Front Immunol 2023; 13:1085786. [PMID: 36726992 PMCID: PMC9885173 DOI: 10.3389/fimmu.2022.1085786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
Background Although BCG vaccine protects infants from tuberculosis (TB), it has limited efficacy in adults against pulmonary TB. Further, HIV coinfection significantly increases the risk of developing active TB. In the lack of defined correlates of protection in TB disease, it is essential to explore immune responses beyond conventional CD4 T cells to gain a better understanding of the mechanisms of TB immunity. Methods Here, we evaluated unconventional lipid-reactive T cell responses in cynomolgus macaques following aerosol BCG inoculation and examined the impact of subsequent SIV infection on these responses. Immune responses to cellular lipids of M. bovis and M. tuberculosis were examined ex vivo in peripheral blood and bronchioalveolar lavage (BAL). Results Prior to BCG inoculation, innate-like IFN-γ responses to mycobacterial lipids were observed in T cells. Aerosol BCG exposure induced an early increase in frequencies of BAL γδT cells, a dominant subset of lipid-reactive T cells, along with enhanced IL-7R and CXCR3 expression. Further, BCG exposure stimulated greater IFN-γ responses to mycobacterial lipids in peripheral blood and BAL, suggesting the induction of systemic and local Th1-type response in lipid-reactive T cells. Subsequent SIV infection resulted in a significant loss of IL-7R expression on blood and BAL γδT cells. Additionally, IFN-γ responses of mycobacterial lipid-reactive T cells in BAL fluid were significantly lower in SIV-infected macaques, while perforin production was maintained through chronic SIV infection. Conclusions Overall, these data suggest that despite SIV-induced decline in IL-7R expression and IFN-γ production by mycobacterial lipid-reactive T cells, their cytolytic potential is maintained. A deeper understanding of anti-mycobacterial lipid-reactive T cell functions may inform novel approaches to enhance TB control in individuals with or without HIV infection.
Collapse
Affiliation(s)
- Edith M. Walker
- Division of Microbiology at Tulane National Primate Research Center, Covington, LA, United States
| | - Kristen M. Merino
- Division of Microbiology at Tulane National Primate Research Center, Covington, LA, United States
| | - Nadia Slisarenko
- Division of Microbiology at Tulane National Primate Research Center, Covington, LA, United States
| | - Brooke F. Grasperge
- Division of Microbiology at Tulane National Primate Research Center, Covington, LA, United States
| | - Smriti Mehra
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Chad J. Roy
- Division of Microbiology at Tulane National Primate Research Center, Covington, LA, United States
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, United States
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Namita Rout
- Division of Microbiology at Tulane National Primate Research Center, Covington, LA, United States
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, United States
- Tulane Center for Aging, Tulane University School of Medicine, New Orleans, LA, United States
| |
Collapse
|
13
|
Herrera MT, Guzmán-Beltrán S, Bobadilla K, Santos-Mendoza T, Flores-Valdez MA, Gutiérrez-González LH, González Y. Human Pulmonary Tuberculosis: Understanding the Immune Response in the Bronchoalveolar System. Biomolecules 2022; 12:biom12081148. [PMID: 36009042 PMCID: PMC9405639 DOI: 10.3390/biom12081148] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Mycobacterium tuberculosis, the causal agent of one of the most devastating infectious diseases worldwide, can evade or modulate the host immune response and remain dormant for many years. In this review, we focus on identifying the local immune response induced in vivo by M. tuberculosis in the lungs of patients with active tuberculosis by analyzing data from untouched cells from bronchoalveolar lavage fluid (BALF) or exhaled breath condensate (EBC) samples. The most abundant resident cells in patients with active tuberculosis are macrophages and lymphocytes, which facilitate the recruitment of neutrophils. The cellular response is characterized by an inflammatory state and oxidative stress produced mainly by macrophages and T lymphocytes. In the alveolar microenvironment, the levels of cytokines such as interleukins (IL), chemokines, and matrix metalloproteinases (MMP) are increased compared with healthy patients. The production of cytokines such as interferon (IFN)-γ and IL-17 and specific immunoglobulin (Ig) A and G against M. tuberculosis indicate that the adaptive immune response is induced despite the presence of a chronic infection. The role of epithelial cells, the processing and presentation of antigens by macrophages and dendritic cells, as well as the role of tissue-resident memory T cells (Trm) for in situ vaccination remains to be understood.
Collapse
Affiliation(s)
- María Teresa Herrera
- Department of Microbiology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Silvia Guzmán-Beltrán
- Department of Microbiology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Karen Bobadilla
- Laboratory of Transcriptomics and Molecular Immunology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Teresa Santos-Mendoza
- Laboratory of Transcriptomics and Molecular Immunology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Mario Alberto Flores-Valdez
- Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco, A.C., Guadalajara 44270, Mexico
| | - Luis Horacio Gutiérrez-González
- Laboratory of Transcriptomics and Molecular Immunology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
- Correspondence: (L.H.G.-G.); (Y.G.); Tel.: +52-55-5487-1700 (ext. 5117) (Y.G.)
| | - Yolanda González
- Department of Microbiology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
- Correspondence: (L.H.G.-G.); (Y.G.); Tel.: +52-55-5487-1700 (ext. 5117) (Y.G.)
| |
Collapse
|
14
|
White AD, Sibley L, Sarfas C, Morrison AL, Bewley K, Churchward C, Fotheringham S, Gkolfinos K, Gooch K, Handley A, Humphries HE, Hunter L, Kennard C, Longet S, Mabbutt A, Moffatt M, Rayner E, Tipton T, Watson R, Hall Y, Bodman-Smith M, Gleeson F, Dennis M, Salguero FJ, Carroll M, McShane H, Cookson W, Hopkin J, Sharpe S. Influence of Aerosol Delivered BCG Vaccination on Immunological and Disease Parameters Following SARS-CoV-2 Challenge in Rhesus Macaques. Front Immunol 2022; 12:801799. [PMID: 35222355 PMCID: PMC8863871 DOI: 10.3389/fimmu.2021.801799] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/24/2021] [Indexed: 12/19/2022] Open
Abstract
The tuberculosis vaccine, Bacille Calmette-Guerin (BCG), also affords protection against non-tuberculous diseases attributable to heterologous immune mechanisms such as trained innate immunity, activation of non-conventional T-cells, and cross-reactive adaptive immunity. Aerosol vaccine delivery can target immune responses toward the primary site of infection for a respiratory pathogen. Therefore, we hypothesised that aerosol delivery of BCG would enhance cross-protective action against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and be a deployable intervention against coronavirus disease 2019 (COVID-19). Immune parameters were monitored in vaccinated and unvaccinated rhesus macaques for 28 days following aerosol BCG vaccination. High-dose SARS-CoV-2 challenge was applied by intranasal and intrabronchial instillation and animals culled 6–8 days later for assessment of viral, disease, and immunological parameters. Mycobacteria-specific cell-mediated immune responses were detected following aerosol BCG vaccination, but SARS-CoV-2-specific cellular- and antibody-mediated immunity was only measured following challenge. Early secretion of cytokine and chemokine markers associated with the innate cellular and adaptive antiviral immune response was detected following SARS-CoV-2 challenge in vaccinated animals, at concentrations that exceeded titres measured in unvaccinated macaques. Classical CD14+ monocytes and Vδ2 γδ T-cells quantified by whole-blood immunophenotyping increased rapidly in vaccinated animals following SARS-CoV-2 challenge, indicating a priming of innate immune cells and non-conventional T-cell populations. However, viral RNA quantified in nasal and pharyngeal swabs, bronchoalveolar lavage (BAL), and tissue samples collected at necropsy was equivalent in vaccinated and unvaccinated animals, and in-life CT imaging and histopathology scoring applied to pulmonary tissue sections indicated that the disease induced by SARS-CoV-2 challenge was comparable between vaccinated and unvaccinated groups. Hence, aerosol BCG vaccination did not induce, or enhance the induction of, SARS-CoV-2 cross-reactive adaptive cellular or humoral immunity, although an influence of BCG vaccination on the subsequent immune response to SARS-CoV-2 challenge was apparent in immune signatures indicative of trained innate immune mechanisms and primed unconventional T-cell populations. Nevertheless, aerosol BCG vaccination did not enhance the initial clearance of virus, nor reduce the occurrence of early disease pathology after high dose SARS-CoV-2 challenge. However, the heterologous immune mechanisms primed by BCG vaccination could contribute to the moderation of COVID-19 disease severity in more susceptible species following natural infection.
Collapse
Affiliation(s)
- Andrew D White
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Laura Sibley
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Charlotte Sarfas
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Alexandra L Morrison
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Kevin Bewley
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Colin Churchward
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Susan Fotheringham
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Konstantinos Gkolfinos
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Karen Gooch
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Alastair Handley
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Holly E Humphries
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Laura Hunter
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Chelsea Kennard
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Stephanie Longet
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Adam Mabbutt
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Miriam Moffatt
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Emma Rayner
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Tom Tipton
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Robert Watson
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Yper Hall
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Mark Bodman-Smith
- Infection and Immunity Research Institute, St George's University of London, London, United Kingdom
| | - Fergus Gleeson
- Department of Oncology, Churchill Hospital, Oxford, United Kingdom
| | - Mike Dennis
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Francisco J Salguero
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Miles Carroll
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| | - Helen McShane
- The Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - William Cookson
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Julian Hopkin
- College of Medicine, Institute of Life Science, Swansea University, Swansea, United Kingdom
| | - Sally Sharpe
- Research and Evaluation, United Kingdom Health Security Agency, Salisbury, United Kingdom
| |
Collapse
|
15
|
Redmann RK, Kaushal D, Golden N, Threeton B, Killeen SZ, Kuehl PJ, Roy CJ. Particle Dynamics and Bioaerosol Viability of Aerosolized Bacillus Calmette-Guérin Vaccine Using Jet and Vibrating Mesh Clinical Nebulizers. J Aerosol Med Pulm Drug Deliv 2022; 35:50-56. [PMID: 34619040 PMCID: PMC8867098 DOI: 10.1089/jamp.2021.0030] [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] [Indexed: 02/03/2023] Open
Abstract
Background: Bacillus Calmette-Guérin (BCG) is a vaccine used to protect against tuberculosis primarily in infants to stop early infection in areas of the world where the disease is endemic. Normally administered as a percutaneous injection, BCG is a live significantly attenuated bacteria that is now being investigated for its potential within an inhalable vaccine formulation. This study investigates the feasibility and performance of two jet and two vibrating mesh nebulizers aerosolizing BCG and the resulting particle characteristics and residual viability of the bacteria postaerosolization. Methods: A jet nebulizer (Collison), outfitted either with a 3- or 6-jet head, was compared with two clinical nebulizers, the vibrating mesh Omron MicroAir and Aerogen Solo devices. Particle characteristics, including aerodynamic particle sizing, was performed on all devices within a common aerosol chamber configuration and comparable BCG innocula concentrations. Integrated aerosol samples were collected for each generator and assayed for bacterial viability using conventional microbiological technique. Results: A batch lot of BCG (Danish) was grown to titer and used in all generator assessments. Aerosol particles within the respirable range were generated from all nebulizers at four different concentrations of BCG. The jet nebulizers produced a uniformly smaller particle size than the vibrating mesh devices, although particle concentrations by mass were similar across all devices tested with the exception of the Aerogen Solo, which resulted in a low concentration of BCG aerosols. Conclusions: The resulting measured viable BCG aerosol concentration fraction produced by each device approximated one another; however, a measurable decrease of efficiency and overall viability reduction in the jet nebulizer was observed in higher BCG inoculum starting concentrations, whereas the vibrating mesh nebulizer returned a remarkably stable viable aerosol fraction irrespective of inoculum concentration.
Collapse
Affiliation(s)
- Rachel K. Redmann
- Infectious Disease Aerobiology, Division of Microbiology, Tulane National Primate Research Center, Covington, Louisiana, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Nadia Golden
- Infectious Disease Aerobiology, Division of Microbiology, Tulane National Primate Research Center, Covington, Louisiana, USA
| | - Breeanna Threeton
- Infectious Disease Aerobiology, Division of Microbiology, Tulane National Primate Research Center, Covington, Louisiana, USA
| | - Stephanie Z. Killeen
- Infectious Disease Aerobiology, Division of Microbiology, Tulane National Primate Research Center, Covington, Louisiana, USA
| | - Philip J. Kuehl
- Lovelace Biomedical Research Institute, Albuquerque, New Mexico, USA
| | - Chad J. Roy
- Infectious Disease Aerobiology, Division of Microbiology, Tulane National Primate Research Center, Covington, Louisiana, USA.,Department of Microbiology and Immunology, Tulane School of Medicine, New Orleans, Louisiana, USA.,Address correspondence to: Chad J. Roy, PhD, Infectious Disease Aerobiology, Division of Microbiology, Tulane National Primate Research Center, 18703 Three Rivers Road, Covington, LA 70433, USA
| |
Collapse
|
16
|
After 100 Years of BCG Immunization against Tuberculosis, What Is New and Still Outstanding for This Vaccine? Vaccines (Basel) 2021; 10:vaccines10010057. [PMID: 35062718 PMCID: PMC8778337 DOI: 10.3390/vaccines10010057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/17/2021] [Accepted: 12/29/2021] [Indexed: 12/14/2022] Open
Abstract
In 2021, most of the world was reasonably still concerned about the COVID-19 pandemic, how cases were up and down in different countries, how the vaccination campaigns were ongoing, and most people were familiar with the speed with which vaccines against SARS-Co-V2 were developed, analyzed, and started to be applied in an attempt to curb the pandemic. Because of this, it may have somehow passed relatively inadvertently for people outside of the field that the vaccine used to control tuberculosis (TB), Mycobacterium bovis Bacille Calmette-Guérin (BCG), was first applied to humans a century ago. Over these years, BCG has been the vaccine applied to most human beings in the world, despite its known lack of efficacy to fully prevent respiratory TB. Several strategies have been employed in the last 20 years to produce a novel vaccine that would replace, or boost, immunity and protection elicited by BCG. In this work, to avoid potential redundancies with recently published reviews, I only aim to present my current thoughts about some of the latest findings and outstanding questions that I consider worth investigating to help develop a replacement or modified BCG in order to successfully fight TB, based on BCG itself.
Collapse
|
17
|
Sarfas C, White AD, Sibley L, Morrison AL, Gullick J, Lawrence S, Dennis MJ, Marsh PD, Fletcher HA, Sharpe SA. Characterization of the Infant Immune System and the Influence and Immunogenicity of BCG Vaccination in Infant and Adult Rhesus Macaques. Front Immunol 2021; 12:754589. [PMID: 34707617 PMCID: PMC8542880 DOI: 10.3389/fimmu.2021.754589] [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: 08/06/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
In many countries where tuberculosis (TB) is endemic, the Bacillus Calmette–Guérin (BCG) vaccine is given as close to birth as possible to protect infants and children from severe forms of TB. However, BCG has variable efficacy and is not as effective against adult pulmonary TB. At present, most animal models used to study novel TB vaccine candidates rely on the use of adult animals. Human studies show that the infant immune system is different to that of an adult. Understanding how the phenotypic profile and functional ability of the immature host immune system compares to that of a mature adult, together with the subsequent BCG immune response, is critical to ensuring that new TB vaccines are tested in the most appropriate models. BCG-specific immune responses were detected in macaques vaccinated within a week of birth from six weeks after immunization indicating that neonatal macaques are able to generate a functional cellular response to the vaccine. However, the responses measured were significantly lower than those typically observed following BCG vaccination in adult rhesus macaques and infant profiles were skewed towards the activation and attraction of macrophages and monocytes and the synthesis in addition to release of pro-inflammatory cytokines such as IL-1, IL-6 and TNF-α. The frequency of specific immune cell populations changed significantly through the first three years of life as the infants developed into young adult macaques. Notably, the CD4:CD8 ratio significantly declined as the macaques aged due to a significant decrease in the proportion of CD4+ T-cells relative to a significant increase in CD8+ T-cells. Also, the frequency of both CD4+ and CD8+ T-cells expressing the memory marker CD95, and memory subset populations including effector memory, central memory and stem cell memory, increased significantly as animals matured. Infant macaques, vaccinated with BCG within a week of birth, possessed a significantly higher frequency of CD14+ classical monocytes and granulocytes which remained different throughout the first three years of life compared to unvaccinated age matched animals. These findings, along with the increase in monokines following vaccination in infants, may provide an insight into the mechanism by which vaccination with BCG is able to provide non-specific immunity against non-mycobacterial organisms.
Collapse
Affiliation(s)
- Charlotte Sarfas
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Andrew D White
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Laura Sibley
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Alexandra L Morrison
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Jennie Gullick
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Steve Lawrence
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Mike J Dennis
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Philip D Marsh
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| | - Helen A Fletcher
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sally A Sharpe
- National Infection Service, UK Health Security Agency, Salisbury, United Kingdom
| |
Collapse
|
18
|
White AD, Sibley L, Gullick J, Sarfas C, Clark S, Fagrouch Z, Verschoor E, Salguero FJ, Dennis M, Sharpe S. TB and SIV Coinfection; a Model for Evaluating Vaccine Strategies against TB Reactivation in Asian Origin Cynomolgus Macaques: A Pilot Study Using BCG Vaccination. Vaccines (Basel) 2021; 9:945. [PMID: 34579182 PMCID: PMC8473354 DOI: 10.3390/vaccines9090945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
This pilot study aimed to determine the utility of a cynomolgus macaque model of coinfection with simian immunodeficiency virus (SIV) for the assessment of vaccines designed to prevent reactivation of TB. Following infection caused by aerosol exposure to an ultralow dose of Mycobacterium tuberculosis (M. tb), data trends indicated that subsequent coinfection with SIVmac32H perturbed control of M. tb infection as evidenced by the increased occurrence of progressive disease in this group, higher levels of pathology and increased frequency of progressive tuberculous granulomas in the lung. BCG vaccination led to improved control of TB-induced disease and lower viral load in comparison to unvaccinated coinfected animals. The M. tb-specific IFNγ response after exposure to M. tb, previously shown to be associated with bacterial burden, was lower in the BCG-vaccinated group than in the unvaccinated groups. Levels of CD4+ and CD8+ T cells decreased in coinfected animals, with counts recovering more quickly in the BCG-vaccinated group. This pilot study provides proof of concept to support the use of the model for evaluation of interventions against reactivated/exacerbated TB caused by human immunodeficiency virus (HIV) infection.
Collapse
Affiliation(s)
- Andrew D. White
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Laura Sibley
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Jennie Gullick
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Charlotte Sarfas
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Simon Clark
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Zahra Fagrouch
- Department of Virology, Biomedical Primate Research Centre, Lange Kleiweg 161, 2288 GJ Rijswijk, The Netherlands; (Z.F.); (E.V.)
| | - Ernst Verschoor
- Department of Virology, Biomedical Primate Research Centre, Lange Kleiweg 161, 2288 GJ Rijswijk, The Netherlands; (Z.F.); (E.V.)
| | - Francisco J. Salguero
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Mike Dennis
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Sally Sharpe
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| |
Collapse
|
19
|
High-dose Mycobacterium tuberculosis aerosol challenge cannot overcome BCG-induced protection in Chinese origin cynomolgus macaques; implications of natural resistance for vaccine evaluation. Sci Rep 2021; 11:12274. [PMID: 34112845 PMCID: PMC8192909 DOI: 10.1038/s41598-021-90913-0] [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: 03/04/2021] [Accepted: 05/19/2021] [Indexed: 12/01/2022] Open
Abstract
This study describes the use of cynomolgus macaques of Chinese origin (CCM) to evaluate the efficacy and immunogenicity of the BCG vaccine against high dose aerosol Mycobacterium tuberculosis challenge. Progressive disease developed in three of the unvaccinated animals within 10 weeks of challenge, whereas all six vaccinated animals controlled disease for 26 weeks. Three unvaccinated animals limited disease progression, highlighting the intrinsic ability of this macaque species to control disease in comparison to macaques of other species and genotypes. Low levels of IFNγ were induced by BCG vaccination in CCM suggesting that IFNγ alone does not provide a sufficiently sensitive biomarker of vaccination in this model. An early response after challenge, together with the natural bias towards terminal effector memory T-cell populations and the contribution of monocytes appears to enhance the ability of CCM to naturally control infection. The high dose aerosol challenge model of CCM has value for examination of the host immune system to characterise control of infection which would influence future vaccine design. Although it may not be the preferred platform for the assessment of prophylactic vaccine candidates, the model could be well suited for testing post-exposure vaccination strategies and drug evaluation studies.
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Tarancón R, Mata E, Uranga S, Gómez AB, Marinova D, Otal I, Martín C, Aguiló N. Therapeutic efficacy of pulmonary live tuberculosis vaccines against established asthma by subverting local immune environment. EBioMedicine 2021; 64:103186. [PMID: 33478923 PMCID: PMC7910687 DOI: 10.1016/j.ebiom.2020.103186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Substantial recent advances in the comprehension of the molecular and cellular mechanisms behind asthma have evidenced the importance of the lung immune environment for disease outcome, making modulation of local immune responses an attractive therapeutic target against this pathology. Live attenuated mycobacteria, such as the tuberculosis vaccine BCG, have been classically linked with a type 1 response, and proposed as possible modulators of the type 2 response usually associated with asthma. Methods In this study we used different acute and chronic murine models of asthma to investigate the therapeutic efficacy of intranasal delivery of the live tuberculosis vaccines BCG and MTBVAC by regulating the lung immune environment associated with airway hyperresponsiveness (AHR). Findings Intranasal administration of BCG, or the novel tuberculosis vaccine candidate MTBVAC, abrogated AHR-associated hallmarks, including eosinophilia and lung remodeling. This correlated with the re-polarization of allergen-induced M2 macrophages towards an M1 phenotype, as well as with the induction of a strong allergen-specific Th1 response. Importantly, vaccine treatment was effective in a scenario of established chronic asthma where a strong eosinophil infiltration was already present prior to immunization. We finally compared the nebulization efficiency of clinical formulations of MTBVAC and BCG using a standard commercial nebulizer for potential aerosol application. Interpretation Our results demonstrate that pulmonary live tuberculosis vaccines efficiently revert established asthma in mice. These data support the further exploration of this approach as potential therapy against asthma. Funding Spanish Ministry of Science [grant numbers: BIO2014-5258P, RTI2018-097625-B-I00], Instituto de Salud Carlos III, Gobierno de Aragón/Fondo Social Europeo, University of Zaragoza [grant number: JIUZ-2018-BIO-01].
Collapse
Affiliation(s)
- Raquel Tarancón
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Elena Mata
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Santiago Uranga
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Ana Belén Gómez
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Dessislava Marinova
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Isabel Otal
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Carlos Martín
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain; Servicio de Microbiología, Hospital Universitario Miguel Servet, ISS Aragón, Paseo Isabel la Católica 1-3, Zaragoza 50009, Spain
| | - Nacho Aguiló
- Grupo de Genética de Micobacterias, Dpto. Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, ISS Aragón, C/ Domingo Miral s/n, Zaragoza 50009, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid 28029, Spain.
| |
Collapse
|