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Montero DA, Vidal RM, Velasco J, George S, Lucero Y, Gómez LA, Carreño LJ, García-Betancourt R, O’Ryan M. Vibrio cholerae, classification, pathogenesis, immune response, and trends in vaccine development. Front Med (Lausanne) 2023; 10:1155751. [PMID: 37215733 PMCID: PMC10196187 DOI: 10.3389/fmed.2023.1155751] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/14/2023] [Indexed: 05/24/2023] Open
Abstract
Vibrio cholerae is the causative agent of cholera, a highly contagious diarrheal disease affecting millions worldwide each year. Cholera is a major public health problem, primarily in countries with poor sanitary conditions and regions affected by natural disasters, where access to safe drinking water is limited. In this narrative review, we aim to summarize the current understanding of the evolution of virulence and pathogenesis of V. cholerae as well as provide an overview of the immune response against this pathogen. We highlight that V. cholerae has a remarkable ability to adapt and evolve, which is a global concern because it increases the risk of cholera outbreaks and the spread of the disease to new regions, making its control even more challenging. Furthermore, we show that this pathogen expresses several virulence factors enabling it to efficiently colonize the human intestine and cause cholera. A cumulative body of work also shows that V. cholerae infection triggers an inflammatory response that influences the development of immune memory against cholera. Lastly, we reviewed the status of licensed cholera vaccines, those undergoing clinical evaluation, and recent progress in developing next-generation vaccines. This review offers a comprehensive view of V. cholerae and identifies knowledge gaps that must be addressed to develop more effective cholera vaccines.
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Affiliation(s)
- David A. Montero
- Departamento de Microbiología, Facultad de Ciencias Biológicas, Universidad de Concepción, Concepción, Chile
| | - Roberto M. Vidal
- Programa de Microbiología y Micología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Instituto Milenio de Inmunología e Inmunoterapia, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Juliana Velasco
- Unidad de Paciente Crítico, Clínica Hospital del Profesor, Santiago, Chile
- Programa de Formación de Especialista en Medicina de Urgencia, Universidad Andrés Bello, Santiago, Chile
| | - Sergio George
- Programa de Microbiología y Micología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Yalda Lucero
- Programa de Microbiología y Micología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Departamento de Pediatría y Cirugía Infantil, Hospital Dr. Roberto del Rio, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Leonardo A. Gómez
- Departamento de Microbiología, Facultad de Ciencias Biológicas, Universidad de Concepción, Concepción, Chile
| | - Leandro J. Carreño
- Instituto Milenio de Inmunología e Inmunoterapia, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Programa de Inmunología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Richard García-Betancourt
- Programa de Inmunología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Miguel O’Ryan
- Programa de Microbiología y Micología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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McCarty JM, Cassie D, Bedell L. Immunogenicity of partial doses of live oral cholera vaccine CVD 103-HgR in children in the United States. Vaccine 2023; 41:2739-2742. [PMID: 36959054 DOI: 10.1016/j.vaccine.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/25/2023]
Abstract
In a phase 4, placebo-controlled, double-blind, multi-center study performed to assess the immunogenicity of a single oral dose of live, attenuated cholera vaccine, volunteers aged 2-17 years were randomized 6:1 to receive 1 × 109 colony forming units of PXVX0200 or placebo. In the subset of subjects who consumed < 80 % of the vaccine dose, seroconversion rates were calculated and stratified by amount consumed. Of 468 subjects dosed, a subset of 33 (7 %) received < 80 % of the vaccine dose. SVA seroconversion occurred in 75.8 % of these subjects, including 100 % (7/7) of those who took 50-80 % and 69.2 % (18/26) of those who took < 50 %, versus 98.5 % of those who consumed 80 % or more. Vaccination with PXVX0200 produced an immune response in most children who received partial dosing. Since SVA seroconversion is a strong correlate of protection, PXVX0200 may protect against cholera infection in children who ingest only part of the vaccine dose.
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Affiliation(s)
| | - David Cassie
- Emergent BioSolutions Inc., Gaithersburg, MD, United States
| | - Lisa Bedell
- Emergent BioSolutions Inc., Gaithersburg, MD, United States
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Collins JP, Ryan ET, Wong KK, Daley MF, Ratner AJ, Appiah GD, Sanchez PJ, Gutelius BJ. Cholera Vaccine: Recommendations of the Advisory Committee on Immunization Practices, 2022. MMWR Recomm Rep 2022; 71:1-8. [PMID: 36173766 PMCID: PMC9536201 DOI: 10.15585/mmwr.rr7102a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This report summarizes all recommendations from CDC’s Advisory
Committee on Immunization Practices (ACIP) for the use of lyophilized CVD
103-HgR vaccine (CVD 103-HgR) (Vaxchora, Emergent BioSolutions,
Gaithersburg, MD) in the United States. The live attenuated oral cholera
vaccine is derived from Vibrio cholerae O1 and is administered in a single dose. Cholera is a
toxin-mediated bacterial gastrointestinal illness caused by
toxigenic V. cholerae serogroup O1 or, uncommonly,
O139. Up to 10% of infections manifest as severe cholera (i.e., cholera
gravis), profuse watery diarrhea that can cause severe dehydration and
death within hours. Fluid replacement therapy can reduce the fatality
rate to <1%. Risk factors for cholera gravis include high dose
exposure, blood group O, increased gastric pH (e.g., from antacid
therapy), and partial gastrectomy. Cholera is rare in the United States,
but cases occur among travelers to countries where cholera is endemic or
epidemic and associated with unsafe water and inadequate sanitation.
Travelers might be at increased risk for poor outcomes from cholera if
they cannot readily access medical services or if they have a medical
condition that would be worsened by dehydration, such as cardiovascular
or kidney disease. This report describes previously published ACIP
recommendations about use of CVD 103-HgR for adults aged 18–64
years and introduces a new recommendation for use in children and
adolescents aged 2–17 years. ACIP recommends CVD 103-HgR, the
only cholera vaccine licensed for use in the United States, for
prevention of cholera among travelers aged 2–64 years to an area
with active cholera transmission. Health care providers can use these
guidelines to develop the pretravel consultation for persons traveling
to areas with active cholera transmission.
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Choy RKM, Bourgeois AL, Ockenhouse CF, Walker RI, Sheets RL, Flores J. Controlled Human Infection Models To Accelerate Vaccine Development. Clin Microbiol Rev 2022; 35:e0000821. [PMID: 35862754 PMCID: PMC9491212 DOI: 10.1128/cmr.00008-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The timelines for developing vaccines against infectious diseases are lengthy, and often vaccines that reach the stage of large phase 3 field trials fail to provide the desired level of protective efficacy. The application of controlled human challenge models of infection and disease at the appropriate stages of development could accelerate development of candidate vaccines and, in fact, has done so successfully in some limited cases. Human challenge models could potentially be used to gather critical information on pathogenesis, inform strain selection for vaccines, explore cross-protective immunity, identify immune correlates of protection and mechanisms of protection induced by infection or evoked by candidate vaccines, guide decisions on appropriate trial endpoints, and evaluate vaccine efficacy. We prepared this report to motivate fellow scientists to exploit the potential capacity of controlled human challenge experiments to advance vaccine development. In this review, we considered available challenge models for 17 infectious diseases in the context of the public health importance of each disease, the diversity and pathogenesis of the causative organisms, the vaccine candidates under development, and each model's capacity to evaluate them and identify correlates of protective immunity. Our broad assessment indicated that human challenge models have not yet reached their full potential to support the development of vaccines against infectious diseases. On the basis of our review, however, we believe that describing an ideal challenge model is possible, as is further developing existing and future challenge models.
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Affiliation(s)
- Robert K. M. Choy
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
| | - A. Louis Bourgeois
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
| | | | - Richard I. Walker
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
| | | | - Jorge Flores
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, USA
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McCarty J, Bedell L, De Lame PA, Cassie D, Lock M, Bennett S, Haney D. Update on CVD 103-HgR single-dose, live oral cholera vaccine. Expert Rev Vaccines 2021; 21:9-23. [PMID: 34775892 DOI: 10.1080/14760584.2022.2003709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cholera remains endemic in >50 countries, putting millions at risk, especially young children for whom killed vaccines offer limited protection. An oral, live attenuated vaccine - CVD 103-HgR (Vaxchora vaccine) - was licensed by the US FDA in 2016 for adults aged 18-64 years traveling to endemic regions, based on clinical trials in human volunteers showing the vaccine was well tolerated and conferred 90% efficacy within 10 days. The evidence base for Vaxchora vaccine has expanded with additional clinical trial data, in older adults (aged 46-64 years) and children (aged 2-17 years), demonstrating that the vaccine produces a strong vibriocidal antibody response. Over 68,000 doses have been administered in the United States, with no new safety signals. The dose volume has been reduced in children to improve acceptability, and cold chain requirements are less st ringent, at +2°C─+8°C. The vaccine has recently been licensed in the Untied States for children aged 2-17 years, in Europe for individuals aged ≥2 years, and for home administration in Europe. Next steps include a Phase 4 study in infants (6-23 months). Additional information is needed regarding duration of immunity, the need for and timing of revaccination, and efficacy data from lower-middle-income countries.
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Affiliation(s)
- James McCarty
- Stanford University School of Medicine, 291 Campus Drive, Stanford, California, USA
| | - Lisa Bedell
- Emergent Travel Health, Redwood City, California, USA
| | | | - David Cassie
- Emergent Travel Health, Redwood City, California, USA
| | - Michael Lock
- Emergent Travel Health, Redwood City, California, USA
| | - Sean Bennett
- Adjuvance Technologies, Inc., Lincoln, Nebraska, USA
| | - Douglas Haney
- Emergent Travel Health, Redwood City, California, USA
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McCarty JM, Cassie D, Bedell L, Lock MD, Bennett S. Long-Term Immunogenicity of Live Oral Cholera Vaccine CVD 103-HgR in Adolescents Aged 12-17 Years in the United States. Am J Trop Med Hyg 2021; 104:1758-1760. [PMID: 33819178 PMCID: PMC8103473 DOI: 10.4269/ajtmh.20-1576] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/28/2021] [Indexed: 12/11/2022] Open
Abstract
As part of a phase 4, randomized, double-blind, placebo-controlled trial to assess the immunogenicity and safety of PXVX0200 in children and adolescents aged 2-17 years, a subset of 73 adolescent subjects aged 12-17 years was followed for 2 years after vaccination and had blood collected for antibody assays on days 1, 11, 29, 91, 181, 365, 547, and 730. Endpoints included serum vibriocidal antibody (SVA) seroconversion, defined as a 4-fold or greater rise in antibody titer over baseline; geometric mean titers (GMTs); and geometric mean fold increase (GMFI) over baseline. Serum vibriocidal antibody seroconversion persisted in most subjects, with a rate of 64.5% noted at day 730. Geometric mean titers and GMFI both peaked at day 11 and remained greater than baseline at all time points, including day 730. Vaccination with PXVX0200 produces an immune response which persists for at least 2 years in adolescents aged 12-17 years.
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Affiliation(s)
- James M. McCarty
- Stanford University School of Medicine, Stanford, California;,Address correspondence to James M. McCarty, Stanford University School of Medicine, 291 Campus Dr., Stanford, CA 94305. E-mail:
| | - David Cassie
- Emergent BioSolutions Canada, Inc., Winnipeg, Canada
| | - Lisa Bedell
- Emergent Travel Health, Inc., Redwood City, California
| | | | - Sean Bennett
- Emergent Travel Health, Inc., Redwood City, California
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7
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Akter A, Kelly M, Charles RC, Harris JB, Calderwood SB, Bhuiyan TR, Biswas R, Xu P, Kováč P, Qadri F, Ryan ET. Parenteral Vaccination with a Cholera Conjugate Vaccine Boosts Vibriocidal and Anti-OSP Responses in Mice Previously Immunized with an Oral Cholera Vaccine. Am J Trop Med Hyg 2021; 104:2024-2030. [PMID: 33872211 PMCID: PMC8176512 DOI: 10.4269/ajtmh.20-1511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/15/2021] [Indexed: 11/20/2022] Open
Abstract
Oral cholera vaccination protects against cholera; however, responses in young children are low and of short duration. The best current correlates of protection against cholera target Vibrio cholerae O-specific polysaccharide (anti-OSP), including vibriocidal responses. A cholera conjugate vaccine has been developed that induces anti-OSP immune responses, including memory B-cell responses. To address whether cholera conjugate vaccine would boost immune responses following oral cholera vaccination, we immunized mice with oral cholera vaccine Inaba CVD 103-HgR or buffer only (placebo) on day 0, followed by parenteral boosting immunizations on days 14, 42, and 70 with cholera conjugate vaccine Inaba OSP: recombinant tetanus toxoid heavy chain fragment or phosphate buffered saline (PBS)/placebo. Compared with responses in mice immunized with oral vaccine alone or intramuscular cholera conjugate vaccine alone, mice receiving combination vaccination developed significantly higher vibriocidal, IgM OSP-specific serum responses and OSP-specific IgM memory B-cell responses. A combined vaccination approach, which includes oral cholera vaccination followed by parenteral cholera conjugate vaccine boosting, results in increased immune responses that have been associated with protection against cholera. These results suggest that such an approach should be evaluated in humans.
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Affiliation(s)
- Aklima Akter
- 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,2icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Meagan Kelly
- 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - Richelle C Charles
- 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,3Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jason B Harris
- 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,4Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,5Division of Global Health, MassGeneral Hospital for Children, Boston, Massachusetts
| | - Stephen B Calderwood
- 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,3Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Taufiqur R Bhuiyan
- 2icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Rajib Biswas
- 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,2icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Peng Xu
- 6NIDDK, LBC, National Institutes of Health, Bethesda, Maryland
| | - Pavol Kováč
- 6NIDDK, LBC, National Institutes of Health, Bethesda, Maryland
| | - Firdausi Qadri
- 2icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Edward T Ryan
- 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,3Department of Medicine, Harvard Medical School, Boston, Massachusetts.,7Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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McCarty JM, Cassie D, Bedell L, Lock MD, Bennett S. Safety and Immunogenicity of Live Oral Cholera Vaccine CVD 103-HgR in Children Aged 2-5 Years in the United States. Am J Trop Med Hyg 2020; 104:861-865. [PMID: 33319739 PMCID: PMC7941807 DOI: 10.4269/ajtmh.20-0917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/07/2020] [Indexed: 12/28/2022] Open
Abstract
In a phase 4, randomized, placebo-controlled, double-blind, multicenter study, to assess the safety and immunogenicity of live, attenuated cholera vaccine PXVX0200 in children aged 2-5 years in the United States, 172 volunteers were randomized 6:1 to receive a single dose of 1 × 109 CFU of PXVX0200 or placebo. Immunogenicity endpoints included serum vibriocidal antibody (SVA) levels on days 1, 11, and 29. Safety was assessed by comparing solicited signs and symptoms on days 1-8, unsolicited adverse events through day 29, and serious adverse events (SAEs) through day 181. The SVA seroconversion rates 10 days after immunization were 98.1% and 0% in vaccine and placebo recipients, respectively, and the vaccine seroconversion rate was non-inferior to the 93.5% rate seen in the bridging population of adults aged 18-45 years from a lot consistency study. Most reactogenicity was mild to moderate, and there were no study-related SAEs. PXVX0200 appears safe and immunogenic in children aged 2-5 years.
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Affiliation(s)
- James M McCarty
- Stanford University School of Medicine, Stanford, California
| | - David Cassie
- Emergent Travel Health, Inc., Redwood City, California
| | - Lisa Bedell
- Emergent Travel Health, Inc., Redwood City, California
| | | | - Sean Bennett
- Emergent Travel Health, Inc., Redwood City, California
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Gabutti G, Rossanese A, Tomasi A, Giuffrida S, Nicosia V, Barriga J, Florescu C, Sandri F, Stefanati A. Cholera, the Current Status of Cholera Vaccines and Recommendations for Travellers. Vaccines (Basel) 2020; 8:E606. [PMID: 33066373 PMCID: PMC7711912 DOI: 10.3390/vaccines8040606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 12/14/2022] Open
Abstract
Cholera is endemic in approximately 50 countries, primarily in Africa and South and Southeast Asia, and in these areas, it remains a disease associated with poverty. In developed nations, cholera is rare, and cases are typically imported from endemic areas by returning travellers. Cholera is readily preventable with the tools available to modern medicine. In developing nations, cholera transmission can be prevented through improved water, sanitation, and hygiene services and the use of oral cholera vaccines (OCVs). For travellers, risk can be mitigated by practicing regular hand hygiene and consuming food and water from safe sources. OCVs should be considered for high-risk travellers likely to be exposed to cholera patients or contaminated water and food. There are currently three World Health Organization pre-qualified OCVs, which are based on killed whole-cell strains of Vibrio cholerae. These established vaccines offer significant protection in adults and children for up to 2 years. A novel live attenuated vaccine that provides rapid-onset protection in adults and children is licensed in the USA and Europe only. Live attenuated OCVs may mimic the natural infection of V. cholerae more closely, generating rapid immune responses without the need for repeat dosing. These potential benefits have prompted the ongoing development of several additional live attenuated vaccines. The objective of this article is to provide a general review of the current landscape of OCVs, including a discussion of their appropriate use in international travellers.
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Affiliation(s)
- Giovanni Gabutti
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Andrea Rossanese
- Department of Infectious Tropical Diseases and Microbiology, IRCCS “Sacro Cuore-Don Calabria”, Negrar di Valpolicella, 37024 Verona, Italy;
| | - Alberto Tomasi
- Italian Society of Travel and Migration Medicine (SIMVIM), 00185 Rome, Italy;
| | - Sandro Giuffrida
- Local Health Unit, Department of Prevention, 89121 Reggio Calabria, Italy;
| | - Vincenzo Nicosia
- Head of Health and Occupational Medicine Saipem SpA, 20097 Milan, Italy;
| | - Juan Barriga
- Department of Medical Affairs Europe, Emergent BioSolutions, 1455 Madrid, Spain;
| | - Caterina Florescu
- Postgraduate School of Hygiene and Preventive Medicine, University of Ferrara, 44121 Ferrara, Italy; (C.F.); (F.S.)
| | - Federica Sandri
- Postgraduate School of Hygiene and Preventive Medicine, University of Ferrara, 44121 Ferrara, Italy; (C.F.); (F.S.)
| | - Armando Stefanati
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
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