[Development and present status of a leptospiral vaccine and the technology of vaccine production in China]

Historical Review of Leptospirosis in the Korea (1945 - 2015)

Leptospirosis is a widespread worldwide zoonosis. Human leptospirosis was first identified in the Korea in 1984 as the cause of “epidemic pulmonary hemorrhagic fever of unknown etiology” that occurred sporadically or in outbreaks. The major outbreaks, leading to some deaths, mainly involved rice field farmers who worked in wet and muddy rice paddies following floods or heavy rainfalls. Leptospirosis was designated a nationally notifiable disease in 1987. The Korean government introduced a supplementary immunization program to control the disease from 1988 to 1997, which provided people at risk in endemic areas with the inactivated vaccine prepared from a local strain Leptospira interrogans serovar Lai. In addition, the continuous promotion of education and awareness in the media played a role in improving personal hygiene management. Since then, the reported incidence of leptospirosis has been low. Leptospirosis is currently considered in the differential diagnosis of acute febrile illnesses occurring in fall. This study historically reviews clinical and epidemiological publications, scientific reports, and public health policies for recognition, identification, and infection control of human leptospirosis in the Korea.

Discovery of 6,7-dihydro-3H-pyrano[4,3-c]isoxazol-3-ones as a new class of pathogen specific anti-leptospiral agents

A simple and efficient method for the synthesis of a series of 6,7-dihydro-3H-pyrano[4,3-c]isoxazol-3-one derivatives starting from 5-carboalkoxy-2,3-dihydropyranone (5-CDHPs) has been developed. Pyranoisoxazolones 10a-j, dihydronaphthopyran-4-one (DHNPs) class of natural product 12b and 12c and its analogues 12a and 13a-c were preliminarily screened against pathogenic leptospiral serovar Autumnalis strain N2 at various concentrations. Six pyranoisoxazolones, 10b, 10d, 10f, 10g, 10i and 10j which displayed very good anti-leptospiral activity was taken for secondary screening against twelve strains of pathogenic and one non-pathogenic leptospiral serovars. While all the compounds displayed significant anti-leptospiral activity against the pathogenic serovars at MIC of 62.5-500 μg/mL. Compounds 10d, 10g and 10j did not show any significant effect on non-pathogenic serovar. Inhibition of leptospires at a significant level by pyranoisoxazolone 10g was confirmed using RT-qPCR assay. In vivo treatment of BALB/c mice with compound 10g revealed that, it has 95% survivability against the pathogenic strain Canicola and also showed inhibition of renal colonization of leptospires. Compound 10g was found to show cytotoxicity against THP-1 cells only at higher concentration (≥75 μg/mL). Effective binding of compound 10g with leptospiral outer membrane protein LipL32 observed via in silico molecular docking provided a suitable explanation for pathogen specificity of compound 10g. Antibiotics acting against leptospirosis in human are very few. The results obtained from in vitro, in vivo and in silico study reveals that 6,7-dihydro-3H-pyrano[4,3-c]isoxazol-3-ones class of compounds are lead molecules for further development as pathogen specific anti-leptospiral agents.

Using discrete choice modeling to evaluate the preferences and willingness to pay for leptospirosis vaccine

Leptospirosis is highly endemic in the Philippines and a serious concern to public health. Local research on candidate vaccine is moving through the development pipeline. The availability of vaccines alone does not guarantee acceptance because individuals' vaccination choice decision is influenced by several factors. This study assessed how vaccine attributes and socio-demographic factors affect the acceptability of leptospirosis vaccine; and estimated individuals' willingness to pay for leptospirosis vaccine. A discrete choice experiment was conducted among leptospirosis and non-leptospirosis case respondents (n = 342) living in Metro Manila. Random Parameters Logit model was used to estimate the relative importance of vaccine attributes and socio-demographic variables on respondents' leptospirosis vaccination choice decision. The estimated model coefficients were used to derive implicit prices and willingness to pay for leptospirosis vaccine. Both case respondents preferred leptospirosis vaccine with 70-100% efficacy, mild to moderate risk of side-effects, given in a single shot, and at a lower price. Non-leptospirosis case respondents preferred a vaccine with 7 to 10 y of protection, while leptospirosis case respondents preferred a vaccine with 10 y protection. The probability of leptospirosis vaccination acceptance was affected by respondents' age, education, family size and income, proximity of home to rivers and sewers, and leptospirosis awareness level. Respondents' willingness to pay for leptospirosis vaccine (US$ 31.14-US$ 65.89) was higher than the Japanese retail price (US$ 21.60-US$ 24.00). Our findings indicated significant potential for introducing leptospirosis vaccine in the Philippine vaccine market. Delivery strategies to ensure equitable access to future leptospirosis vaccine are recommended.

Leptospirosis in humans

Leptospirosis is a widespread and potentially fatal zoonosis that is endemic in many tropical regions and causes large epidemics after heavy rainfall and flooding. Infection results from direct or indirect exposure to infected reservoir host animals that carry the pathogen in their renal tubules and shed pathogenic leptospires in their urine. Although many wild and domestic animals can serve as reservoir hosts, the brown rat (Rattus norvegicus) is the most important source of human infections. Individuals living in urban slum environments characterized by inadequate sanitation and poor housing are at high risk of rat exposure and leptospirosis. The global burden of leptospirosis is expected to rise with demographic shifts that favor increases in the number of urban poor in tropical regions subject to worsening storms and urban flooding due to climate change. Data emerging from prospective surveillance studies suggest that most human leptospiral infections in endemic areas are mild or asymptomatic. Development of more severe outcomes likely depends on three factors: epidemiological conditions, host susceptibility, and pathogen virulence (Fig. 1). Mortality increases with age, particularly in patients older than 60 years of age. High levels of bacteremia are associated with poor clinical outcomes and, based on animal model and in vitro studies, are related in part to poor recognition of leptospiral LPS by human TLR4. Patients with severe leptospirosis experience a cytokine storm characterized by high levels of IL-6, TNF-alpha, and IL-10. Patients with the HLA DQ6 allele are at higher risk of disease, suggesting a role for lymphocyte stimulation by a leptospiral superantigen. Leptospirosis typically presents as a nonspecific, acute febrile illness characterized by fever, myalgia, and headache and may be confused with other entities such as influenza and dengue fever. Newer diagnostic methods facilitate early diagnosis and antibiotic treatment. Patients progressing to multisystem organ failure have widespread hematogenous dissemination of pathogens. Nonoliguric (high output) renal dysfunction should be supported with fluids and electrolytes. When oliguric renal failure occurs, prompt initiation of dialysis can be life saving. Elevated bilirubin levels are due to hepatocellular damage and disruption of intercellular junctions between hepatocytes, resulting in leaking of bilirubin out of bile caniliculi. Hemorrhagic complications are common and are associated with coagulation abnormalities. Severe pulmonary hemorrhage syndrome due to extensive alveolar hemorrhage has a fatality rate of >50 %. Readers are referred to earlier, excellent summaries related to this subject (Adler and de la Peña-Moctezuma 2010; Bharti et al. 2003; Hartskeerl et al. 2011; Ko et al. 2009; Levett 2001; McBride et al. 2005).

Whole-cell inactivated leptospirosis vaccine: future prospects

Leptospirosis is an infectious disease of worldwide distribution that is caused by pathogenic spirochete bacteria of the genus Leptospira. It is transmitted by the urine of an infected animal and contagious in a moist environment. Epidemiological studies indicate that infection is commonly associated with certain occupational workers such as farmers, sewage workers, veterinarians, and animal handlers. The annual incidence is estimated at 0.1-1 per 100,000 in temperate climates to 10-100 per 100,000 in the humid tropics. A disease incidence of more than 100 per 100,000 is encountered during outbreaks and in high-exposure risk groups. The 11 countries in South-East Asia (SEA) together have a population of more than 1.7 billion and a work force of about 770 million with more than 450 million people engaged in agriculture. Because of the large number of serovars and infection sources and the wide differences in conditions of transmission, the control of leptospirosis is complicated and will depend on local conditions. The available leptospirosis vaccines are mono- or polyvalent cellular suspensions. These cells are inactivated by chemical agents like formaldehyde and phenol, or by physical agents like heat. The vaccine confers protection for not longer than about one year, while there are cases that need revaccination six months later during epidemic periods.

Emergence, control and re-emerging leptospirosis: dynamics of infection in the changing world

Globally, leptospirosis poses an increasing public health problem, as evidenced by markedly increasing incidence rates and multiple outbreaks in all continents. Yet, the disease is severely neglected and hence, its global burden is largely unknown. The estimated incidence of about half a million severe human cases annually is probably an underestimation while the burden for animal health is unknown. It is anticipated that current international initiatives will assess the global burden of leptospirosis, while mathematical modelling of transmission dynamics will allow the identification and testing of appropriate intervention and outbreak response measures within the coming years.

Leptospira and leptospirosis

Leptospirosis is the most wide spread zoonosis worldwide; it is present in all continents except Antarctica and evidence for the carriage of Leptospira has been found in virtually all mammalian species examined. Humans most commonly become infected through occupational, recreational, or domestic contact with the urine of carrier animals, either directly or via contaminated water or soil. Leptospires are thin, helical bacteria classified into at least 12 pathogenic and 4 saprophytic species, with more than 250 pathogenic serovars. Immunity following infection is generally, but not exclusively, mediated by antibody against leptospiral LPS and restricted to antigenically related serovars. Vaccines currently available consist of killed whole cell bacterins which are used widely in animals, but less so in humans. Current work with recombinant protein antigens shows promise for the development of vaccines based on defined protective antigens. The cellular and molecular basis for virulence remains poorly understood, but comparative genomics of pathogenic and saprophytic species suggests that Leptospira expresses unique virulence determinants. However, the recent development of defined mutagenesis systems for Leptospira heralds the potential for gaining a much improved understanding of pathogenesis in leptospirosis.

Human leptospirosis in eastern Croatia, 1969-2003: epidemiological, clinical, and serological features

This survey presents epidemiological, serological and clinical features of 270 patients (85% males, 18% children) treated for leptospirosis from 1969 to 2003 at the Clinic for Infective Diseases, University Hospital Osijek, Osijek, eastern Croatia. 75% of the admissions were between July and October. The route of transmission was mostly by indirect contact with domestic animals, less frequently by direct contact with urine or tissue of infected animals. Clinical presentation included signs and symptoms with expected and common frequency, with the exception of jaundice (62%) and aseptic meningitis (60%), which occurred with higher incidence than previously reported. Acute renal failure ensued in 53% of patients, 7% of whom required haemodialysis. No deaths were observed. Therapy consisted of antimicrobials (penicillin and doxycycline) and symptomatic measures. Diagnosis was confirmed by microscopic agglutination test (MAT). There were in total 18 serological types of Leptospira detected, and types L. sejroe, L.pomona, L. australis and L. icterohaemorrhagiae prevailed. During the last 10 y some new types were observed. Leptospirosis was not rare in the region of eastern Croatia, and its course could be life-threatening if not recognized and adequately treated.

Leptospirosis: a zoonotic disease of global importance

In the past decade, leptospirosis has emerged as a globally important infectious disease. It occurs in urban environments of industrialised and developing countries, as well as in rural regions worldwide. Mortality remains significant, related both to delays in diagnosis due to lack of infrastructure and adequate clinical suspicion, and to other poorly understood reasons that may include inherent pathogenicity of some leptospiral strains or genetically determined host immunopathological responses. Pulmonary haemorrhage is recognised increasingly as a major, often lethal, manifestation of leptospirosis, the pathogenesis of which remains unclear. The completion of the genome sequence of Leptospira interrogans serovar lai, and other continuing leptospiral genome sequencing projects, promise to guide future work on the disease. Mainstays of treatment are still tetracyclines and beta-lactam/cephalosporins. No vaccine is available. Prevention is largely dependent on sanitation measures that may be difficult to implement, especially in developing countries.

Leptospirosis

Leptospirosis is a worldwide zoonotic infection with a much greater incidence in tropical regions and has now been identified as one of the emerging infectious diseases. The epidemiology of leptospirosis has been modified by changes in animal husbandry, climate, and human behavior. Resurgent interest in leptospirosis has resulted from large outbreaks that have received significant publicity. The development of simpler, rapid assays for diagnosis has been based largely on the recognition that early initiation of antibiotic therapy is important in acute disease but also on the need for assays which can be used more widely. In this review, the complex taxonomy of leptospires, previously based on serology and recently modified by a genotypic classification, is discussed, and the clinical and epidemiological value of molecular diagnosis and typing is also evaluated.

Immunological reactivity and passive protective activity of monoclonal antibodies against protective antigen (PAg) of Leptospira interrogans serovar lai

Monoclonal antibody (MAb) AG1 against the protective antigen (PAg) was produced and characterized. It had been extracted from Leptospira interrogans serovar lai by the chloroform-methanol-water method and was of glycolipid nature (23-30Kd). The fact that the PAg was a serogroup-specific antigen was shown by MAb AG1, because MAb AG1 agglutinated serovars of serogroup Icterohaemorrhagiae. Purified MAb LW2 and LW3 which are agglutinating antibodies of serovar lai and AG1 passively protected hamsters from leptospiral infection. Induction of the reactive oxygen intermediates by MAbs from peritoneal exudate macrophages of mice were observed in the chemical luminescence assay and the MAbs reacted with the PAg in the dot enzyme-linked immunosorbent assay. However, MAb LW4a against the genus-specific antigen present in the sub-surface of leptospiral cells did not show protective and reactive-oxygen-inducing activities; they reacted with the non-protective glycolipid antigen of low molecular weight (Fr I, 10-15Kd) in the dot enzyme-linked immunosorbent assay. These results indicated that anti-PAg antibody exhibited opsonic activity against Leptospira and the production of reactive oxygens by macrophages led to leptospiricidal action as one of the defence mechanisms of the host against leptospiral infection. However, the antibody against the genus-specific glycolipid antigen may not be important for protection against leptospiral infection.

One-point method for serological diagnosis of leptospirosis: a microcapsule agglutination test

This paper describes a simple and rapid microcapsule agglutination (MCA) test. The results obtained by this new test have been compared with those obtained by the microtitre MCA and the microscopic agglutination (MA) test. The procedures required for the new test are easier and can be performed more rapidly than those necessary for the microtitre MCA test. Furthermore, the new test is more sensitive than the MA test in the early stages of leptospirosis. This new test appears satisfactory as a screening test for the early diagnosis of leptospirosis.

Serodiagnosis of leptospirosis in China by the one-point MCA method

The one-point MCA method is very simple to perform and useful as a screening test in diagnosing leptospirosis in routine clinical laboratories. The kit, sensitized with six serovars occurring in Japan, was also useful in detecting serum antibodies of patients with leptospirosis in China.