1. Introduction
While finding a cure and treating the disease is an essential aspect of medicine, of equal importance are prevention measures to stop contracting the disease in the first place. Because extreme and totally drug resistant strains of
1.1. Vaccine development
The hallmark of an effective vaccine is one that can be given to a young population, with no adverse side effects, and which will provide lifelong immunity against a particular pathogen. The basis of a functional vaccine is dependent on the immune system’s ability to ‘remember’ an encounter with a foreign pathogen. Typically, immunological memory is established upon the first encounter with a pathogen by the creation of memory T cells. These memory T cells are specific to a particular antigen and will reside in tissues and lymph nodes until they recognize their specific pathogen and become activated. Upon activation by a second exposure, the memory T cells will quickly and efficiently initiate a response to eliminate the pathogen and prevent disease. The creation of memory T cells and life-long immunity can be obtained either by primary exposure to the pathogen followed by disease and eventual recovery, or by being given a vaccine. Vaccines act to prime the immune system by exposing a person to a non-lethal, milder version of the pathogen’s antigens so that those memory T cells can be created without causing disease in the individual. Ideally, a vaccine is made of pathogen-derived components that are critical for induction of protective immunity and consequently, are often composed of either an attenuated (non-virulent) or killed version of the bacteria, inactivated bacterial toxins, or subunits of the pathogen. The vaccines will have antigens similar to the virulent version of the pathogen but would lack factors necessary for disease. Thereafter, if a vaccinated individual is exposed to that particular set of antigens a second time, the immune system will quickly eliminate the pathogen and prevent disease. The immune system is therefore required to respond in a proper manner both to vaccination and to subsequent challenges with the pathogen.
In the case of
CD4+T cells are the hallmark of the immune response to
This chapter will focus on the varied and unique aspects of
2. The BCG vaccine
Bacillus Calmette-Guérin (BCG) is the most widely used vaccine having been delivered to nearly 3 billion people [8-10]. Despite its widespread use, BCG delivers only minimal protection and has failed to eradicate or reduce the disease burden of TB. The mechanisms by which BCG works to provide its marginal protection are incompletely understood. Even though BCG provides an imperfect defense against
2.1. History
Albert Calmette and Camille Guérin developed BCG at the beginning of the 20th century. Developed from a virulent strain of
2.2. World use
BCG is very cheap to produce and at only $2-3USD per dose, it is one of the most cost effective ways to provide at least partial protection against
2.3. Safety and efficacy
A huge reason for the widespread use of BCG is that it is considered to be one of the safest vaccines on the market [15]. Side effects of BCG are very rare with the most common complication being swelling around the injection site [15]. The most significant issue to arise from BCG vaccination is in HIV infected and other immunocompromised individuals. The increased risk of dissemination in HIV infected children lead the WHO to change its policy and recommend that they not be given BCG [15, 16]. Even so, BCG is still part of the WHO’s expanded program of vaccination [8].
Studies into the efficacy of BCG have revealed wide-ranging results from vaccination programs with some reports suggesting 80% efficacy and others showing no protection at all [15, 17]. BCG is thought to convey protection against dissemination of the mycobacteria to other organs during childhood, an event that is highly fatal if left untreated. BCG does not, however, provide protection against adult pulmonary disease, which is the main route by which
2.4. Variability in efficacy
There are several possible reasons behind the huge variability in the reported efficacy of BCG; we will discuss some of these reasons in this section. It is important to keep in mind that some of the issues surrounding BCG efficacy variability are also issues which apply to the new
2.4.1. Variation in the strain of BCG that is used for vaccination
There are at least 11 different types of BCG vaccines currently available throughout the world [8]. A major reason for the different types of BCG and the genetic variability between the strains is mainly a product of the time period when the vaccine was developed. When Calmette and Guérin first developed BCG, they sent it out to several other laboratories around the word. Those laboratories cultured, grew, and stored BCG, each in their own way. It must be remembered that this occurred in the early part of the 20th century, before the advent of current molecular techniques and storage methods that can maintain parent strain homogeneity. Instead, as BCG was grown and cultured in these various laboratories, it accumulated a series of independent mutations that continued to build upon themselves [8]. It was not until the 1960s, with the introduction of culture seed stocks that soon became the norm, that the standardization of these lines became possible. By that time, however, the various strains of BCG had diverged and modern analysis has demonstrated that there is significant variability in the genetic make-up of these strains [8, 10]. The genetic variation in BCG strains can lead to variation in how well they protect against infection due to difference in the cell surface proteins that would elicit an immunogenic response [10]. However, all of these BCG strains have remained non-virulent and a commonality among all of the strains is the loss of the ESX-1 excretion system. It is still not completely understood how the loss of the ESX-1 system blocks virulence since its re-addition to at least two separate BCG strains does not restore virulence back to wild type levels [10, 18]. Due to this variation in BCG strains, it is essential that accurate record keeping be in place when conducting efficacy studies for the vaccine [8].
2.4.2. The genetic diversity of the tested population
The genetic diversity of a population can affect the outcome of any clinical research study and this is an important factor to consider when examining vaccine efficacy. Various single nucleotide polymorphisms (SNPs) within a genome can affect a person’s susceptibility to disease and how their immune system responds to a vaccine. The spectrum of immune system responses to a vaccine can vary from no response to complete activation and protection. Variations within a person’s genome could prevent their immune system from properly responding to the vaccine and therefore it would not convey protection when the person is exposed to the pathogen. For instance, it has been found that mutations in the IFN-γ receptors leads to an increased risk of developing disseminated disease from BCG vaccination rather than protection from
Therefore, it is essential when designing a vaccine study in humans to have a large population that is statistically powerful enough that some variability in immune response will not skew the data. Additionally, no matter where a study is being conducted, the genetic diversity of the population must be considered. An ethnically homogenous population is more desired for a research study since that population will be more likely to share SNPs, and therefore more likely to respond to a vaccine in a similar manner. It also follows that it may also be useful to test multiple ethnic groups; indeed, some studies have suggested that the reason some vaccine trails show high protection with BCG is because they were conducted within certain population groups [15].
2.4.3. Pre-vaccination exposure to the pathogen
Another issue that is of huge importance when conducting vaccine efficacy tests is whether or not an individual has been pre-exposed to the pathogen. The immune response of an individual who has already been exposed may be quite different than someone without prior exposure. Especially in areas where TB is endemic, it is likely that a child will have already been exposed to
2.4.4. Inaccurate diagnostic methods
Because of the complications that result from pre-exposure to the pathogen, it is essential to have accurate diagnostic methods available when deciding which individuals to include in a study. A non-homogeneous population (a mixture of non-and pre-exposed individuals) can produce misleading results that can hinder accurate interpretation of vaccine efficacy. In the case of
3. Specific difficulties associated with M. tuberculosis vaccine development
The complications involved with studying
3.1. Biosafety considerations
When a researcher decides to investigate the development of a vaccine against
These biosafety mechanisms can be a limiting factor when attempting to study
3.2. Slow growth of the pathogen
3.3. Disease stages
As mentioned previously, infection with
The immune response that humans develop against
Ideally, the best vaccine would be one that provides protection from all stages of infection, i.e. a vaccine must be effective against primary infection, latency, reactivation, and reinfection [1, 2].
3.4. Vaccination in immunocompromised individuals
Of the estimated 1.3 million people who died of TB in 2013 around 25% of them were co-infected with HIV [3]. In fact, TB is the number one killer of HIV infected individuals [7, 28-30]. The resurgence of
Another group of immunocompromised individuals that must be considered are those with poor living conditions and poor nutrition. TB is a disease of the poor and mainly affects those who are already at a socioeconomic disadvantage. Poor nutrition and living conditions increases a person’s susceptibility to disease and dampens their immune response to a challenge. These living conditions could impair the ability of the immune system to respond properly both to a vaccination and exposure to a pathogen. Other conditions, such as diabetes or vitamin D deficiency, can also impair the ability of the immune system to produce a robust response and indeed, both conditions have been associated with an increased risk for developing TB [35-37].
3.5. Vaccination post exposure to the pathogen
In the case of TB, it is important to consider if the vaccine is aimed at pre or post-exposure to the pathogen. As mentioned in the previous section, a person’s immune system will respond differently to a vaccine if they have already been exposed to the pathogen. Since the immune system will have already been primed to respond to particular
3.6. Laboratory strains versus clinical isolates
Mycobacteria from clinical isolates are often quite different than the strains commonly used in laboratory practice. Laboratories, by necessity for the repeatability of their experiments, must maintain an unchanging common lab strain. There are currently several strain types used in laboratories throughout the world (H37Rv, HN878, Erdman, CDC1551, etc.) that vary in their virulence and antigenic composition. Variation can also occur within a strain depending on how it is handled in the laboratory. Unfortunately, however, these strains can be significantly different than the mycobacteria isolated from infected patients. The mycobacteria found ‘in the wild’ is going to be constantly changing and mutating depending on various selection factors. The extent of the divergence between laboratory strains and clinical isolates will depend upon the strength of the selection factor. These selection factors can include incomplete drug treatments or the strength of a non-drug treated person’s immune response to the pathogen. Additionally, there is a natural mutation rate for the genome of all organisms independent of selection factors due to DNA replication errors or un-repaired DNA damage. The selection factors and mutational changes observed in clinical isolates are most apparent with the emergence of multi, extreme, and totally drug resistant organisms. While it is hoped that there is enough similarity between laboratory strains and the clinical isolates that vaccination against one will provide protection from all forms of
3.7. Intrinsic properties of M. tuberculosis which make it difficult to immunize against
Currently, almost all vaccines that have proven to be efficacious in humans against infectious pathogens convey protection through the production antibodies [1, 38]. These antibodies will coat a pathogen and signal to the immune cells that it should be removed from the system.
All of the elimination avoidance methods developed by
4. Animal models used for vaccine development
In some cases where the pathogen is non-lethal or there are readily available treatment options (such as malaria or influenza), it is possible to test the efficacy of a vaccine in a human model. In these instances, a willing volunteer is vaccinated, and then exposed to the pathogen by the researcher in a controlled manner [16]. In the case of
4.1. Mouse model
4.1.1. Advantages
4.1.2. Disadvantages
A major disadvantage of the mouse model is that the immune system is not the same as that of a human. The underlying genomic inflammatory response to infection in a mouse has been shown to bear little correlation to what occurs in humans [40]. Many drugs that have been designed to modify inflammatory responses in mice, have failed human clinical trials [40]. While humanized mice (a mouse containing human genes, cells, or tissue) may allow for an immune response closer to that of a human, it is impossible to create an identical response. Additionally, unlike in humans, BCG vaccination of a mouse model does convey some protection from
4.2. Guinea pig model
4.2.1. Advantages
Historically, the guinea pig was the first animal model used for tuberculosis research. Guinea pigs are considered the gold standard by which
One aspect of guinea pig research that is both an advantage and a disadvantage is the lack of in-bred laboratory strains. There are only a handful of laboratory guinea pig strains available commercially and these are mostly out-bred stock that will not be genetically identical at every locus. This provides greater genetic diversity within an animal strain with which to tests vaccine efficacy. Obviously when vaccines move into human trials, genetic diversity will be unavoidable (as mentioned previously), and therefore the guinea pig provides a more realistic model of what will happen in humans. However, this does limit the exact repeatability of an experiment due to the lack of genetically identical animals.
4.2.2. Disadvantages
A disadvantage of the guinea pig model is that they are very susceptible to infection, but humans are relatively resistant. While the phenotype observed during disease progression does resemble that of humans with active disease, this represents only a small fraction of people infected with
The guinea pig also has the disadvantage that, because it is a larger animal, housing costs tend to be much higher than for mice. Guinea pigs require larger cages with fewer animals per cage and thus facility space limitations may reduce the number of animals included in a study. Additionally, because they are not as commonly used as the mouse model, it is more difficult to find the facilities and veterinary expertise necessary to house and care for guinea pigs.
Of great importance is the lack of genetically modified guinea pig models for the researcher to use. This can severely limit the ability of the researcher to develop and improve upon vaccine models.
4.3. Other animal models
The mouse and guinea pig are the most commonly used animal models for research into
Macaques are an NHP that are a promising model to use for the development of a tuberculosis vaccine. The pathophysiology of TB infection in a macaque closely resembles that of what occurs in human populations, including latency – an aspect of infection that has been difficult to model in other animals [43, 45]. Due the size of the animals, their limited availability, the cost of housing and care, as well as ethical considerations, use of NHP, while highly informative, is extremely limited and generally only done after a vaccine has been tested in smaller animal models.
One of the biggest disadvantages to use of any of these non-mouse models is that there are very few reagents available for post-mortem tissue analysis. Few antibodies or other commonly used immunological reagents are available for the study of the immune response in many animal models. Sometimes there is enough overlap in antigens between mouse and humans and other animals that some tests can be conducted, but this is a fairly rare occurrence. While these are not limitations that preclude the use of non-mouse animal models, it does limit the information that can be acquired from using them [46]. There is therefore a huge need to expand our animal model base beyond just the mouse. Genetic evaluation of and the ability to produce inbred strains of other animal models would be an unbelievable advantage to all clinical research beyond just tuberculosis vaccine development.
We can garner important information from all of these animal models and it is clear that their use is absolutely essential for progress in medical researcher to be made. However, it must be remembered that these models are imperfect and there are scientific limitations to the results from studies using them. For instance, in a laboratory setting, animals tend to be exposed only once and to only one strain of pathogen. We know this will not be the case for humans since, as discussed above,
Another important question to consider when examining results from animal models is if we are missing vaccines that would be highly efficacious in a human, but discarding them because they do not act well in our animal models. This is a problem for all areas of clinical research and is, unfortunately, unavoidable given our current knowledge. The only way to overcome this limitation is for research to continue to close the gap in our understanding of how animal and human immune systems differ. The continued refinement of our animal models will provide us with the tools necessary to produce an effective vaccine. This is another reason why the use of multiple animal models is often needed in order to improve the translatability of the research. Most animal models recapitulate some, but not all, aspects of the human features of a disease. If multiple animal models are tested, it increases the likelihood of finding a vaccine that will work in humans.
5. The future of M. tuberculosis vaccine development
There is a profound lack of understanding about what exactly a good immune response to
There are at least 12 new vaccines candidate that have entered the pipeline for efficacy and safety testing and are the first to be put through the approval process in over 100 years [2, 48]. It is encouraging to note that there are so many vaccines being tested as it increases the likelihood of finding a formulation that will be effective. The arrival of these new vaccines, even those that fail, is a promising step forward in our understanding of immunity and what protection will look like. In this section we will discuss some of the characteristics of these vaccines as well as the steps that must be gone through before they can be put into widespread use.
5.1. Common tactics taken for vaccine development
There are two main tactics for the development of a new vaccine against
Many of the vaccines that are being developed contain one or more of a select group of antigens for the initiation of an immune response. Antigen 85A/B (Ag85A/B) and the 6kD early secreted antigenic target (ESAT-6) are proteins that are commonly included in a vaccine make up [2]. Ag85A/B are
In addition to multiple combinations of proteins found to be immunogenic, there has also been testing of which delivery route will provide the best protection. For instance, some vaccines provide better immune protection if they are delivered via aerosol route rather than through intradermal injection. Therefore, many studies are being conducted looking at both multiple delivery routes as well as vaccine make-up.
5.2. Ethical considerations
There are also important ethical considerations that must be addressed when developing a new vaccine. When testing out a vaccine, it is important to consider the health and safety of the control groups as well as those receiving the novel vaccine. For instance, if you have in your possession a vaccine (i.e BCG) that conveys at least some protection against TB, you ethically cannot withhold access to that vaccine simply because you need a placebo control group for your research study. Additionally, a researcher attempting to test out an entirely new vaccine must also consider the possibility that their vaccine will not work and therefore those test subjects are at an increased risk of developing disease. While there are ways to circumvent these issues and still produce an ethically sanctioned and scientifically sound vaccine trial, it does require additional preparation and manpower to execute. Because of these significant ethical complications, however, much of the recent research into TB vaccines has been for the development of adjuvants to boost BCG rather than to develop completely new vaccines.
5.3. MVA85A
The most notable of these new vaccines is MVA85A, which is the first modern day
5.4. Vaccine approval process
The WHO offers a set of guidelines for the approval of a vaccine, and many countries adopt these standards or use them as a basis for their own set of regulations. The point of these regulations is to do as much as possible to ensure the safety and efficacy of the vaccine before it is put into widespread use. In the United States, the Federal Drug Administration (FDA) regulates and oversees the approval process for the development of all vaccines. This discussion will give a quick overview of the FDA regulations specific to the US as an example of what must be undertaken before a vaccine is approved for use. The FDA approval process involves an exploratory stage, a pre-clinical stage, an Investigational New Drug (IND) application, and finally a three phase clinical trial in human subjects [56]. The FDA has the authority to stop a vaccine trial at any point if safety becomes a concern.
The exploratory stage is the basic science side of the vaccine development process. It is in this stage where researchers investigate the potential of various antigens to induce an immune response and are frequently done
The pre-clinical stage involves animal model testing of the various antigens that were discovered in the exploratory stage. In this stage, animals are immunized using a new antigen or vaccine make up and then challenged with
Phase 1 clinical trials are small studies designed to test the safety and immunogenicity of the vaccine. Phase 2 clinical trials are larger and used for further refine dosage and efficacy of the vaccine as well as determining what population it can be most effectively used on. Phase 3 clinical trials involve thousands of individuals and require additional safety documentation to complete [56].
Once all of these stages have been completed, a cross-disciplinary committee from the FDA must then approve a lengthy Biologics License Application (BLA). The BLA will include not only safety and efficacy information but also guidelines for the mass manufacture and distribution of the vaccine as well. As may be obvious from this brief description, the process of vaccine approval can be quite lengthy and will often last 10-15 years. The enormous cost associated with undertaking such an endeavor often requires the collaboration of both private and public funds at multiple institutions in order to be completed.
6. Conclusions
The development of a vaccine against
The urgency to find of an effective vaccine is nowhere as apparent as the emergence of drug resistant tuberculosis that been appearing with increasing frequency in the last decade. The currently available drugs are expensive and require a lengthy course of treatment; increasing the likelihood of non-adherence by sick people and therefore increasing the possibility of even more resistant strains evolving. Because a person does not naturally develop immunity to the pathogen when they are infected, they can become re-infected if they are exposed to the pathogen a second time and have to endure the same drug regimen as before. Only by providing continuous, protective immunity against recurrent infection can we hope to eradicate this devastating disease from the population.
Acknowledgments
This work was supported by the NIH/NIAD program Advanced Small Animal Models for the Testing of Candidate Therapeutic and Preventative Interventions against Mycobacteria (HHSN272201000009I-003, task order 12) at Colorado State University.
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