Antigen-Specific Memory B-Cell Responses to Vibrio cholerae O1 Infection in Bangladesh

Cholera, caused by Vibrio cholerae, is a noninvasive dehydrating enteric disease with a high mortality rate if untreated. Infection with V. cholerae elicits long-term protection against subsequent disease in countries where the disease is endemic. Although the mechanism of this protective immunity is unknown, it has been hypothesized that a protective mucosal response to V. cholerae infection may be mediated by anamnestic responses of memory B cells in the gut-associated lymphoid tissue. To characterize memory B-cell responses to cholera, we enrolled a cohort of 39 hospitalized patients with culture-confirmed cholera and evaluated their immunologic responses at frequent intervals over the subsequent 1 year. Memory B cells to cholera antigens, including lipopolysaccharide (LPS), and the protein antigens cholera toxin B subunit (CTB) and toxin-coregulated pilus major subunit A (TcpA) were enumerated using a method of polyclonal stimulation of peripheral blood mononuclear cells followed by a standard enzyme-linked immunospot procedure. All patients demonstrated CTB, TcpA, and LPS-specific immunoglobulin G (IgG)and IgA memory responses by day 90. In addition, these memory B-cell responses persisted up to 1 year, substantially longer than other traditional immunologic markers of infection with V. cholerae. While the magnitude of the LPS-specific IgG memory B-cell response waned at 1 year, CTB- and TcpA-specific IgG memory B cells remained significantly elevated at 1 year after infection, suggesting that T-cell help may result in a more durable memory B-cell response to V. cholerae protein antigens. Such memory B cells could mediate anamnestic responses on reexposure to V. cholerae.Vibrio cholerae, the etiologic agent of cholera, causes an estimated 3 to 5 million cases of secretory diarrhea, resulting in over 100,000 deaths annually (24). Strains of V. cholerae can be differentiated serologically by the O side chain of the lipopolysaccharide (LPS) component of the outer membrane. Although more than 200 different serogroups have been isolated from the environment, the vast majority of strains that produce cholera belong to serogroup O1 or O139, both of which consist of noninvasive pathogens that colonize the mucosal surface of the small intestine (19). V. cholerae O1 biotype El Tor is currently the predominant cause of cholera globally and in Bangladesh.The mechanisms of protective immunity to cholera are not known. Volunteer and epidemiologic studies demonstrate that clinically apparent infection with V. cholerae confers long-term protection of at least 3 years against subsequent disease (7, 12, 13). The best-studied marker of protective immunity is the vibriocidal antibody, a complement-dependent bactericidal antibody; however, there is no vibriocidal antibody titer at which complete protection is achieved (20). Furthermore, the vibriocidal response wanes rapidly, and it is hypothesized that the vibriocidal antibody may reflect other longer-lasting, protective immune responses occurring at the mucosal surface (3).Patients with cholera develop additional humoral immune responses to several antigens including cholera toxin subunit B (CTB), toxin-coregulated pilus major subunit A (TcpA), and LPS (1). We have recently shown that serum anti-CTB immunoglobulin A (IgA) antibody levels are also associated with protective immunity independent of the vibriocidal antibody on exposure to cholera, but serum IgA levels also wane rapidly after infection (10). Although levels of serum anti-LPS and anti-CTB IgG antibodies increase considerably after infection, these have not been shown to correlate with protection from V. cholerae infection in humans (8, 10).Cholera patients develop substantial mucosal immune responses after infection. These can be measured by the transient increase of antigen-specific IgA antibody-secreting cells (ASC) in the circulation. The ASC assay quantifies lymphocytes that are activated in the gut-associated lymphoid tissue (GALT) when they transiently circulate in blood before rehoming to mucosal effector sites (6, 16, 17). These predominantly gut-homing ASC peak in the circulation between 5 and 10 days after onset of illness but are no longer detected during late convalescence as they return to populate the GALT (1, 11). Because V. cholerae is a noninvasive pathogen, it is hypothesized that protective immunity is derived from the activity of the secretory IgA system of the GALT (14, 22, 23). Volunteer studies of subjects receiving CTB orally demonstrate local and systemic generation of anti-CTB IgA antibodies that peak at 7 days following ingestion but decline to baseline by 15 months; however, these volunteers mount anamnestic responses with a rapid return to peak mucosal antibody titers in as few as 3 days after subsequent challenge with oral CTB (22, 23). It is thus hypothesized that protection from cholera may be mediated by rapid anamnestic responses of memory B cells in the GALT to V. cholerae antigens.In this study, we examined the memory B-cell immune responses to V. cholerae infection, using a polyclonal stimulation method to enhance the detection of memory B cells in the circulation by inducing their proliferation and differentiation into antibody-secreting plasmablasts (4, 5). A standardized two-color enzyme-linked immunospot (ELISPOT) assay allows for the quantification of small numbers of circulating V. cholerae antigen-specific memory B cells as a proportion of total memory B cells (2, 4, 5, 21). Using this system, we have previously shown that cholera patients develop CTB-specific IgG memory B-cell responses that persist for at least 3 months after infection (11). The present study further characterizes memory B-cell responses to CTB, TcpA, and LPS for both IgA and IgG isotypes for a period of 1 year following acute infection and examines differences between the memory B-cell responses to the T-cell-dependent protein antigens CTB and TcpA and the T-cell-independent antigen LPS.     

Antibody-Secreting Cell Responses after Vibrio cholerae O1 Infection and Oral Cholera Vaccination in Adults in Bangladesh

Infection with Vibrio cholerae and oral cholera vaccines (OCVs) induce transient circulating plasmablast responses that peak within approximately 7 days after infection or vaccination. We previously demonstrated that plasmablast responses strongly correlate with subsequent levels of V. cholerae-specific duodenal antibodies up to 6 months after V. cholerae infection. Hence, plasmablast responses provide an early window into the immunologic memory at the mucosal surface. In this study, we characterized plasmablast responses following V. cholerae infection using a flow cytometrically defined population and compared V. cholerae-specific responses in adult patients with V. cholerae O1 infection and vaccinees who received the OCV Dukoral (Crucell Vaccines Canada). Among flow cytometrically sorted populations of gut-homing plasmablasts, almost 50% of the cells recognized either cholera toxin B subunit (CtxB) or V. cholerae O1 lipopolysaccharide (LPS). Using a traditional enzyme-linked immunosorbent spot assay (ELISPOT), we found that infection with V. cholerae O1 and OCVs induce similar responses to the protein antigen CtxB, but responses to LPS were diminished after OCV compared to those after natural V. cholerae infection. A second dose of OCV on day 14 failed to boost circulating V. cholerae-specific plasmablast responses in Bangladeshi adults. Our results differ from those in studies from areas where cholera is not endemic, in which a second vaccination on day 14 significantly boosts plasmablast responses. Given these results, it is likely that the optimal boosting strategies for OCVs differ significantly between areas where V. cholerae infection is endemic and those where it is not.     

Memory T-Cell Responses to Vibrio cholerae O1 Infection

Vibrio cholerae O1 can cause diarrheal disease that may be life-threatening without treatment. Natural infection results in long-lasting protective immunity, but the role of T cells in this immune response has not been well characterized. In contrast, robust B-cell responses to V. cholerae infection have been observed. In particular, memory B-cell responses to T-cell-dependent antigens persist for at least 1 year, whereas responses to lipopolysaccharide, a T-cell-independent antigen, wane more rapidly after infection. We hypothesize that protective immunity is mediated by anamnestic responses of memory B cells in the gut-associated lymphoid tissue, and T-cell responses may be required to generate and maintain durable memory B-cell responses. In this study, we examined B- and T-cell responses in patients with severe V. cholerae infection. Using the flow cytometric assay of the specific cell-mediated immune response in activated whole blood, we measured antigen-specific T-cell responses using V. cholerae antigens, including the toxin-coregulated pilus (TcpA), a V. cholerae membrane preparation, and the V. cholerae cytolysin/hemolysin (VCC) protein. Our results show that memory T-cell responses develop by day 7 after infection, a time prior to and concurrent with the development of B-cell responses. This suggests that T-cell responses to V. cholerae antigens may be important for the generation and stability of memory B-cell responses. The T-cell proliferative response to VCC was of a higher magnitude than responses observed to other V. cholerae antigens.Vibrio cholerae is a gram-negative bacterium that can cause a severe, acute secretory diarrhea. Serological differentiation of V. cholerae strains is based on the O-side chain of the lipopolysaccharide (LPS) component of the outer membrane. Of the more than 200 serogroups of V. cholerae identified, only the O1 and O139 serogroups can cause epidemic cholera (44). These pathogens are noninvasive and colonize the mucosal surface of the small intestine (44).Natural infection with V. cholerae is known to provide protection against subsequent disease, but the mechanism of this protective immunity is not fully characterized. The vibriocidal antibody is a complement-dependent bactericidal antibody that is associated with protection from infection. However, no known threshold level of the vibriocidal antibody confers complete protection from V. cholerae infection, and some individuals with low serum vibriocidal antibody titers are still protected. This suggests that the vibriocidal titer may be a surrogate marker (16, 45). Elevated serum immunoglobulin A (IgA) antibody levels specific for the B subunit of cholera toxin (CTB), the major structural subunit of a type IV pilus (TcpA), and LPS are also associated with protective immunity in areas where cholera is endemic (19). However, after natural infection, the serum levels of these antibodies wane more rapidly than protective immunity (19). Patients with cholera develop memory B-cell responses of both the IgG and the IgA isotype to at least two V. cholerae protein antigens, CTB and TcpA. These responses are detectable for at least 1 year after infection and persist even after V. cholerae antigen-specific antibody-secreting cells and serum antibody titers have returned to baseline (18). B-cell memory responses also develop for the T-cell independent antigen LPS, but these responses wane more rapidly than memory B-cell responses to protein antigens, suggesting that durable memory B-cell responses to some V. cholerae antigens may be T-cell dependent (18).We have recently demonstrated that cholera patients mount a primed T-cell response in the mucosa after V. cholerae O1 infection (6). We hypothesize that protection from cholera may be mediated by memory B cells capable of an anamnestic response in the gut mucosa and that these memory B cells may depend on stimulation provided by memory T cells for their development and maintenance. T cells may contribute to the activation of B cells during V. cholerae infection by secreting stimulatory cytokines and direct contact with B cells in lymph nodes. Therefore, T cells may have an important role in protective immunity to V. cholerae infection.We characterized the memory T-cell responses to V. cholerae antigens following natural V. cholerae infection and compared these with serological responses to the same antigens. Previously, our group has studied various V. cholerae antigens, including mannose-sensitive hemagglutinin, TcpA, CTB, and LPS (22, 33, 37). We also included in the present study responses to a novel antigen, V. cholerae cytolysin/hemolysin (VCC) (31, 32). The hly gene that encodes the VCC protein is widespread across both pathogenic and environmental strains of V. cholerae, suggesting that VCC may impart an advantage to the organism (42). Although the precise role of VCC in V. cholerae infection is unknown, VCC is the primary virulence factor in V. cholerae infection with non-O1, non-O139 strains that do not produce cholera toxin (12, 46). The immune response to VCC is not well understood; however, recent studies suggest that VCC may promote a Th2 response in V. cholerae infection (2). In addition, the cytolytic activity of VCC may generate epithelial destruction that allows other V. cholerae antigens to penetrate the mucosa and promote the inflammatory response observed in V. cholerae infection (35, 39).     

Comparison of Immune Responses to the O-Specific Polysaccharide and Lipopolysaccharide of Vibrio cholerae O1 in Bangladeshi Adult Patients with Cholera

Immunity against Vibrio cholerae O1 is serogroup specific, and serogrouping is defined by the O-specific polysaccharide (OSP) part of lipopolysaccharide (LPS). Despite this, human immune responses to V. cholerae OSP have not previously been characterized. We assessed immune responses against V. cholerae OSP in adults with cholera caused by V. cholerae O1 El Tor serotype Inaba or Ogawa in Dhaka, Bangladesh, using O1 OSP-core–bovine serum albumin (OSPc:BSA) conjugates; responses targeted OSP in these conjugates. Responses of Inaba-infected patients to Inaba OSP and LPS increased significantly in IgG, IgM, and IgA isotypes from the acute to convalescent phases of illness, and the responses correlated well between OSP and LPS (R = 0.86, 0.73, and 0.91, respectively; P < 0.01). Plasma IgG, IgM, and IgA responses to Ogawa OSP and LPS in Ogawa-infected patients also correlated well with each other (R = 0.60, 0.60, and 0.92, respectively; P < 0.01). Plasma IgM responses to Inaba OSP and Ogawa OSP correlated with the respective serogroup-specific vibriocidal antibodies (R = 0.80 and 0.66, respectively; P < 0.001). Addition of either OSPc:BSA or LPS, but not BSA, to vibriocidal assays inhibited vibriocidal responses in a comparable and concentration-dependent manner. Mucosal IgA immune responses to OSP and LPS were also similar. Our study is the first to characterize anti-OSP immune responses in patients with cholera and suggests that responses targeting V. cholerae LPS, including vibriocidal responses that correlate with protection against cholera, predominantly target OSP. Induction of anti-OSP responses may be associated with protection against cholera, and our results may support the development of a vaccine targeting V. cholerae OSP.     

Cholera due to altered El Tor strains of Vibrio cholerae O1 in Bangladesh

We determined the types of cholera toxin (CT) produced by a collection of 185 Vibrio cholerae O1 strains isolated in Bangladesh over the past 45 years. All of the El Tor strains of V. cholerae O1 isolated since 2001 produced CT of the classical biotype, while those isolated before 2001 produced CT of the El Tor biotype.     

O-Specific Polysaccharide-Specific Memory B Cell Responses in Young Children,Older Children,and Adults Infected with Vibrio cholerae O1 Ogawa in Bangladesh

Cholera caused by Vibrio cholerae O1 confers at least 3 to 10 years of protection against subsequent disease regardless of age, despite a relatively rapid fall in antibody levels in peripheral blood, suggesting that memory B cell responses may play an important role in protection. The V. cholerae O1-specific polysaccharide (OSP) component of lipopolysaccharide (LPS) is responsible for serogroup specificity, and it is unclear if young children are capable of developing memory B cell responses against OSP, a T cell-independent antigen, following cholera. To address this, we assessed OSP-specific memory B cell responses in young children (2 to 5 years, n = 11), older children (6 to 17 years, n = 21), and adults (18 to 55 years, n = 28) with cholera caused by V. cholerae O1 in Dhaka, Bangladesh. We also assessed memory B cell responses against LPS and vibriocidal responses, and plasma antibody responses against OSP, LPS, and cholera toxin B subunit (CtxB; a T cell-dependent antigen) on days 2 and 7, as well as days 30, 90, and 180 after convalescence. In all age cohorts, vibriocidal responses and plasma OSP, LPS, and CtxB-specific responses peaked on day 7 and fell toward baseline over the follow-up period. In comparison, we were able to detect OSP memory B cell responses in all age cohorts of patients with detectable responses over baseline for 90 to 180 days. Our results suggest that OSP-specific memory B cell responses can occur following cholera, even in the youngest children, and may explain in part the age-independent induction of long-term immunity following naturally acquired disease.     

Cholera Caused by Vibrio cholerae O1 Induces T-Cell Responses in the Circulation

Considerable effort is being made to understand the acute and memory antibody responses in natural cholera infection, while rather less is known about the roles of cellular immune responses involving T and B lymphocytes. We studied responses in adult patients hospitalized with cholera caused by Vibrio cholerae O1. Peripheral blood mononuclear cells from patients (n = 15) were analyzed by flow cytometry after stimulation with V. cholerae O1 membrane protein (MP) or toxin-coregulated pilus antigen (TcpA). The gamma interferon (IFN-γ) and interleukin-13 (IL-13) responses in stimulated-lymphocyte supernatants were studied. The responses were compared with those of healthy controls (n = 10). Patients responded with increased frequencies of gut-homing CD4⁺ T cells (CD4⁺ β7⁺), gut-homing CD8⁺ T cells (CD8⁺ β7⁺), and gut-homing B cells (CD19⁺ β7⁺) at the early and/or late convalescent stages compared to the acute stage. After stimulation with MP or TcpA, proliferation of CD4⁺ and CD8⁺ T cells was increased at the acute stage and/or early convalescent stage compared to healthy controls. Increased IL-13 and IFN-γ responses were observed after antigenic stimulation at the acute and convalescent stages compared to healthy controls. Thus, increases in the levels of gut-homing T and B cells, as well as involvement of CD8 and CD4 Th1-mediated (IFN-γ) and CD4 Th2-mediated (IL-13) cytokine responses, take place in acute dehydrating disease caused by V. cholerae O1. Further studies are needed to determine if such responses are also stimulated after immunization with oral cholera vaccines and if these responses play a role in protection following exposure to cholera.Vibrio cholerae O1 is a common causative agent of acute watery diarrhea in children and adults in the developing world (1, 3, 10, 19). After colonizing the proximal small intestine, this bacterium produces cholera toxin, which induces a profuse secretory diarrhea. Cholera remains a key public health problem that results in epidemics in resource-poor settings.It is believed that the immune response to cholera is initiated by antigen presentation in the Peyer''s patches of the gastrointestinal mucosa, followed by migration of the stimulated antigen-specific B cells to regional lymph nodes and differentiation of these cells into specific antibody-secreting cells (28). Stimulation of the common mucosal immune system leads to production of both local and systemic antibodies (2, 15, 27) to virulence antigens of V. cholerae (25, 28).Natural cholera infection is believed to give rise to long-term protection against subsequent disease. Robust systemic and mucosal antibodies are produced to the V. cholerae lipopolysaccharide, to cholera toxin, and to colonization factors, including the major subunit of the toxin-coregulated pilus, TcpA (2, 24, 25, 28). We have recently shown that there is induction of memory B-cell responses following infection, which may play a role in longer-lasting protection (14). In addition, recent evidence suggests that an innate component of the immune system may also play a role in the host response to cholera (9, 22, 26). Studies with experimental animals have shown that the mucosal immune response to cholera toxin is T cell dependent and that CD4 T helper cells have an important role (7, 12, 13). However, not much is known about the role of the adaptive cellular immune responses in patients with cholera. The aim of the present study was to decipher the role of T- and B-cell-mediated immune responses in natural cholera infection in adults hospitalized with dehydrating illness, who were followed from the acute stage to convalescence.     

Memory B Cell and Other Immune Responses in Children Receiving Two Doses of an Oral Killed Cholera Vaccine Compared to Responses following Natural Cholera Infection in Bangladesh

Current oral cholera vaccines induce lower protective efficacy and shorter duration of protection against cholera than wild-type infection provides, and this difference is most pronounced in young children. Despite this, there are limited data comparing immune responses in children following wild-type disease versus vaccination, especially with regard to memory responses associated with long-term immunity. Here, we report a comparison of immune responses in young children (2 to 5 years of age; n = 20) and older children (6 to 17 years of age; n = 20) given two doses of an oral killed cholera vaccine containing recombinant cholera toxin B subunit (CtxB) 14 days apart and compare these responses to those induced in similarly aged children recovering from infection with Vibrio cholerae O1 Ogawa in Bangladesh. We found that the two vaccine groups had comparable vibriocidal and lipopolysaccharide (LPS)-specific plasma antibody responses. Vaccinees developed lower levels of IgG memory B cell (MBC) responses against CtxB but no significant MBC responses against LPS. In contrast, children recovering from natural cholera infection developed prominent LPS IgG and IgA MBC responses, as well as CtxB IgG MBC responses. Plasma LPS IgG, IgA, and IgM responses, as well as vibriocidal responses, were also significantly higher in children following disease than after vaccination. Our findings suggest that acute and memory immune responses following oral cholera vaccination in children are significantly lower than those observed following wild-type disease, especially responses targeting LPS. These findings may explain, in part, the lower efficacy of oral cholera vaccination in children.     

Development of Immunoglobulin M Memory to Both a T-Cell-Independent and a T-Cell-Dependent Antigen following Infection with Vibrio cholerae O1 in Bangladesh

Vibrio cholerae O1 can cause severe watery diarrhea that can be life-threatening without treatment. Infection results in long-lasting protection against subsequent disease. Development of memory B cells of the immunoglobulin G (IgG) and IgA isotypes to V. cholerae O1 antigens, including serotype-specific lipopolysaccharide (LPS) and the B subunit of cholera toxin (CTB), after cholera infection has been demonstrated. Memory B cells of the IgM isotype may play a role in long-term protection, particularly against T-cell-independent antigens, but IgM memory has not been studied in V. cholerae O1 infection. Therefore, we assayed acute- and convalescent-phase blood samples from cholera patients for the presence of memory B cells that produce cholera antigen-specific IgM antibody upon polyclonal stimulation in in vitro culture. We also examined the development of serological and antibody-secreting cell responses following infection. Subjects developed significant IgM memory responses by day 30 after infection, both to the T-cell-independent antigen LPS and to the T-cell-dependent antigen CTB. No significant corresponding elevations in plasma IgM antibodies or circulating IgM antibody-secreting cells to CTB were detected. In 17 subjects followed to day 90 after infection, significant persistence of elevated IgM memory responses was not observed. The IgM memory response to CTB was negatively correlated with the IgG plasma antibody response to CTB, and there was a trend toward negative correlation between the IgM memory and IgA plasma antibody responses to LPS. We did not observe an association between the IgM memory response to LPS and the vibriocidal titer.Vibrio cholerae continues to be a significant global health burden as a cause of severe secretory diarrhea, resulting in an estimated three to five million annual cases, with more than 100,000 deaths from rapid dehydration (47); cholera has recently become endemic in new regions (44, 45). V. cholerae is a noninvasive pathogen that colonizes the mucosal surface of the small intestine. Strains can be distinguished serologically by the O antigen of the lipopolysaccharide (LPS); V. cholerae O1 is the most common cause of cholera in South Asia as well as globally. The O1 serogroup has two major biotypes, El Tor and classical, and two major serotypes, Inaba and Ogawa (35). Natural infection with V. cholerae O1 El Tor induces protective immunity that lasts for at least 3 to 10 years in both areas where cholera is not endemic and areas where it is endemic (21). It remains unknown, however, what aspects of the adaptive immune response to cholera confer this long-term protection.V. cholerae-infected patients mount immunologic responses to both protein and polysaccharide antigens, including rises in both serum immunoglobulin G (IgG) and IgA antibodies (14). A number of these serological responses have been shown to correlate with protection against reinfection; these include the complement-dependent serum vibriocidal antibody (14) and IgA (but not IgG) responses to LPS, cholera toxin B subunit (CTB), and toxin coregulated pilus A (TcpA) (17). These serological responses, however, are short-lived (4, 32), and the association of the vibriocidal titer with protection is not absolute (36), suggesting that these responses may reflect protection from more recent exposure but that other immunologic mechanisms mediate longer-term protection. In addition to serological responses, development of mucosal immune responses to intestinal antigens can be detected in the blood, when B cells activated by antigen in the gut-associated lymphoid tissues circulate transiently in the blood as antibody-secreting cells (ASCs), before homing back to intestinal mucosal surfaces (11, 26). Circulation of ASCs specific to both LPS and CTB is seen after cholera infection, peaking around the seventh day after infection and declining by day 11 (32).Responses of the IgM isotype to cholera antigens have been less thoroughly investigated than the IgG and IgA responses. However, IgM defenses may be an important component of the overall immunologic response to cholera, since vibriocidal antibodies are principally of the IgM isotype (22) and IgM levels of pooled convalescent-phase serum samples correspond closely with vibriocidal activity (24), which in turn correlates with immunity (14). The pentameric structure of IgM facilitates strong cross-linking of antigens and activation of complement in the defense against other gram-negative enteric bacteria (2).We have recently shown development of memory B cells of both the IgG and IgA isotypes to LPS, CTB, and TcpA; these cells persisted in the circulation beyond 1 year for the protein antigens CTB and TcpA, but were not measurably above baseline levels by 9 to 12 months after infection for the polysaccharide-containing antigen LPS (16, 18). These circulating memory B cells can be detected by ex vivo polyclonal stimulation of peripheral blood mononuclear cells (PBMCs); stimulated memory B cells mature into ASCs detectable by enzyme-linked immunospot (ELISPOT) assay. Alternatively, memory B-cell responses can be detected by measuring antigen-specific antibodies secreted by maturing ASCs during the ex vivo stimulation of PBMCs in the memory B-cell assay (18).Memory B cells relevant for cholera immunity may include IgM⁺ as well as switched-memory (IgA⁺ and IgG⁺) populations. The majority of circulating IgM⁺ cells are naïve B cells, but some IgM⁺ cells bear the memory cell marker CD27⁺, and recent evidence suggests that these IgM⁺CD27⁺ cells are true memory B cells whose immunoglobulin variable region genes have undergone somatic hypermutation in response to antigen in early-stage germinal centers (39). IgM⁺ memory cells can undergo isotype switching to produce IgG, IgA, or IgE antibody, but they also have a role in producing rapid, high-affinity IgM antibody responses to acute infection (19, 37, 46). In this study, we have measured the development of memory B-cell responses of the IgA, IgG, and IgM isotypes to both a protein (CTB) and a nonprotein (LPS) antigen, and we compared these memory responses with other immunologic responses in patients after V. cholerae infection in Bangladesh.     

Mitogenic Responses to Lipopolysaccharide by B Lymphocytes from Patients with Systemic Lupus Erythematosus

Peripheral blood lymphocytes from 43 patients with systemic lupus erythcmatosus (SLE) and from age- and sex-matched normal controls were cultured with lipopolysaccharide (LPS) to examine the response to the polyclonal B-cell activator. Lymphocytes from active SLE patients incorporated 4840±471 (mean ± SE) cpm in response to LPS, whereas lymphocytes from inactive SLE patients incorporated 6906 ± 897 cpm. In contrast, lymphocytes from normal individuals incorporated 7452 ± 1126 cpm. Ig synthesis of lymphocytes from active SLE in response to LPS stimulation was also less than that of normal individuals. The helper T-cell function of active SLE, as examined by co-culturing irradiated SLE lymphocytes with unirradiated normal lymphocytes, was normal. These results thus suggested that a defect of B lymphocytes exists in active SLE patients. This B-cell defect and T suppressor cells apparently play an important role in the pathogenous of SLE.     

Genetic diversity of El Tor strains of Vibrio cholerae O1 with hybrid traits isolated from Bangladesh and Mozambique

Vibrio cholerae O1 strains that are hybrids between the classical and El Tor biotypes were isolated during two consecutive years (2004-2005) from diarrheal patients in Mozambique. Similar variants isolated in Bangladesh and recently isolated El Tor strains were analyzed for genetic diversity. Pulsed-field gel electrophoresis (PFGE) analysis using the restriction enzyme NotI, resulted in 18-21 bands showed five closely related PFGE patterns that were distributed similarly in both years (2004-2005) among the 80 strains tested in Mozambique. Overall based on the PFGE patterns the hybrids indicated an El Tor lineage. The restriction patterns of whole-chromosomal DNA grouped the hybrid strains from Mozambique into a separate cluster from Bangladeshi clinical and environmental hybrid strains. A high molecular weight band of 398kb that contain rstR allele of the classical type was detected from all hybrid strains, which was absent in all conventional classical and El Tor strains. This band could be designated as a marker for the hybrid strains. This study suggests that hybrid strains from Mozambique are closely related to each other, different from Bangladeshi hybrid strains that are diverse in nature and all hybrid strains differed markedly from conventional classical and El Tor strains.     

Transcutaneous Immunization with a Vibrio cholerae O1 Ogawa Synthetic Hexasaccharide Conjugate following Oral Whole-Cell Cholera Vaccination Boosts Vibriocidal Responses and Induces Protective Immunity in Mice

A shortcoming of currently available oral cholera vaccines is their induction of relatively short-term protection against cholera compared to that afforded by wild-type disease. We were interested in whether transcutaneous or subcutaneous boosting using a neoglycoconjugate vaccine made from a synthetic terminal hexasaccharide of the O-specific polysaccharide of Vibrio cholerae O1 (Ogawa) coupled to bovine serum albumin as a carrier (CHO-BSA) could boost lipopolysaccharide (LPS)-specific and vibriocidal antibody responses and result in protective immunity following oral priming immunization with whole-cell cholera vaccine. We found that boosting with CHO-BSA with immunoadjuvantative cholera toxin (CT) or Escherichia coli heat-labile toxin (LT) following oral priming with attenuated V. cholerae O1 vaccine strain O395-NT resulted in significant increases in serum anti-V. cholerae LPS IgG, IgM, and IgA (P < 0.01) responses as well as in anti-Ogawa (P < 0.01) and anti-Inaba (P < 0.05) vibriocidal titers in mice. The LPS-specific IgA responses in stool were induced by transcutaneous (P < 0.01) but not subcutaneous immunization. Immune responses following use of CT or LT as an adjuvant were comparable. In a neonatal mouse challenge assay, immune serum from boosted mice was associated with 79% protective efficacy against death. Our results suggest that transcutaneous and subcutaneous boosting with a neoglycoconjugate following oral cholera vaccination may be an effective strategy to prolong protective immune responses against V. cholerae.     

Emergence of a new clone of toxigenic Vibrio cholerae O1 biotype El Tor displacing V. cholerae O139 Bengal in Bangladesh.

The emergence of Vibrio cholerae O139 Bengal in 1993, its rapid spread in an epidemic form, in which it replaced existing strains of V. cholerae O1 during 1992 and 1993, and the subsequent reemergence of V. cholerae O1 of the El Tor biotype in Bangladesh since 1994 have raised questions regarding the origin of the reemerged El Tor vibrios. We studied 50 El Tor vibrio strains isolated in Bangladesh and four other countries in Asia and Africa before the emergence of V. cholerae O139 and 32 strains isolated in Bangladesh during and after the epidemic caused by V. cholerae O139 and 32 strains isolated in Bangladesh during and after the epidemic caused by V. cholerae O139 to determine whether the reemerged El Tor vibrios were genetically different from the El Tor vibrios which existed before the emergence of V. cholerae O139. Analysis of restriction fragment length polymorphisms in genes for conserved rRNA, cholera toxin (ctxA), and zonula occludens toxin (zot) or in DNA sequences flanking the genes showed that the El Tor strains isolated before the emergence of V. cholerae O139 belonged to four different ribotypes and four different ctx genotypes. Of 32 El Tor strains isolated after the emergence of O139 vibrios, 30 strains (93.7%) including all the clinical isolates belonged to a single new ribotype and a distinctly different ctx genotype. These results provide evidence that the reemerged El Tor strains represent a new clone of El Tor vibrios distinctly different from the earlier clones of El Tor vibrios which were replaced by the O139 vibrios. Further analysis showed that all the strains carried the structural and regulatory genes for toxin-coregulated pilus (tcpA, tcpI, and toxR). All strains of the new clone produced cholera toxin (CT) in vitro, as assayed by the GM1-dependent enzyme-linked immunosorbent assay, and the level of CT production was comparable to that of previous epidemic isolates of El Tor vibrios. Further studies are required to assess the epidemic potential of the newly emerged clone of V. cholerae O1 and to understand the mechanism of emergence of new clones of toxigenic V. cholerae.     

Induction of the Lysogenic Phage Encoding Cholera Toxin in Naturally Occurring Strains of Toxigenic Vibrio cholerae O1 and O139

In toxigenic Vibrio cholerae, the CTX genetic element which carries the genes for cholera toxin (CT) is the genome of a lysogenic bacteriophage (CTXΦ). Clinical and environmental strains of V. cholerae O1 or O139 and stools that were culture positive for cholera were analyzed to study the induction and transmission of CTXΦ. To our knowledge, this is the first report of the examination of CTXΦ in clinical materials and in naturally occurring strains. DNA probe analysis revealed that 4.25% (6 of 141) of the isolated V. cholerae strains spontaneously produced a detectable level of extracellular CTXΦ particles in the culture supernatants whereas another 34.04% (48 of 141) produced CTXΦ particles when induced with mitomycin C. CTXΦ isolated from 10 clinical or environmental strains infected a CT-negative recipient strain, CVD103, both inside the intestines of infant mice and under laboratory conditions. All culture-positive stools analyzed were negative for the presence of CTXΦ both in the DNA probe assay and by in vivo assay for the infection of the recipient strain in infant mice. These results suggested that naturally occurring strains of toxigenic V. cholerae are inducible lysogens of CTXΦ but that cholera pathogenesis in humans is not associated with the excretion of CTXΦ particles in stools, indicating that induction of the phage may not occur efficiently inside the human intestine. However, in view of the efficient transmission of the phage under conditions conducive to the expression of toxin-coregulated pili, it appears that propagation of CTXΦ in the natural habitat may involve both environmental and host factors.     

Comparison of the vibriocidal antibody response in cholera due to Vibrio cholerae O139 Bengal with the response in cholera due to Vibrio cholerae O1.

Vibrio cholerae serogroup O139, now considered to be the second organism capable of causing epidemic severe dehydrating cholera, contains a capsular polysaccharide which makes it difficult for it to be used in the conventional vibriocidal antibody assay optimized for V. cholerae O1. After modification of the procedure, which involved the use of specific bacterial strains, a lower bacterial inoculum, and increased amounts of complement, the vibriocidal antibody responses to V. cholerae O139 were measured in acute- and convalescent-phase sera from 33 V. cholerae O139-infected and 18 V. cholerae O1-infected patients and in single serum samples from 20 healthy control subjects. The responses in these individuals to V. cholerae O1 strains were also determined. Significant elevations in the homologous antibody response were found only in the convalescent-phase sera from both groups of patients with cholera. These findings may explain the basis for the lack of heterologous protection between the two serogroups of V. cholerae. Healthy controls had higher background levels of vibriocidal antibody to V. cholerae O1 than to V. cholerae O139.     

New variants of Vibrio cholerae O1 biotype El Tor with attributes of the classical biotype from hospitalized patients with acute diarrhea in Bangladesh

The sixth pandemic of cholera and, presumably, the earlier pandemics were caused by the classical biotype of Vibrio cholerae O1, which was progressively replaced by the El Tor biotype representing the seventh cholera pandemic. Although the classical biotype of V. cholerae O1 is extinct, even in southern Bangladesh, the last of the niches where this biotype prevailed, we have identified new varieties of V. cholerae O1, of the El Tor biotype with attributes of the classical biotype, from hospitalized patients with acute diarrhea in Bangladesh. Twenty-four strains of V. cholerae O1 isolated between 1991 and 1994 from hospitalized patients with acute diarrhea in Matlab, a rural area of Bangladesh, were examined for the phenotypic and genotypic traits that distinguish the two biotypes of V. cholerae O1. Standard reference strains of V. cholerae O1 belonging to the classical and El Tor biotypes were used as controls in all of the tests. The phenotypic traits commonly used to distinguish between the El Tor and classical biotypes, including polymyxin B sensitivity, chicken cell agglutination, type of tcpA and rstR genes, and restriction patterns of conserved rRNA genes (ribotypes), differentiated the 24 strains of toxigenic V. cholerae O1 into three types designated the Matlab types. Although all of the strains belonged to ribotypes that have been previously found among El Tor vibrios, type I strains had more traits of the classical biotype while type II and III strains appeared to be more like the El Tor biotype but had some classical biotype properties. These results suggest that, although the classical and El Tor biotypes have different lineages, there are possible naturally occurring genetic hybrids between the classical and El Tor biotypes that can cause cholera and thus provide new insight into the epidemiology of cholera in Bangladesh. Furthermore, the existence of such novel strains may have implications for the development of a cholera vaccine.     

Study of Avidity of Antigen-Specific Antibody as a Means of Understanding Development of Long-Term Immunological Memory after Vibrio cholerae O1 Infection

The avidity of antibodies to specific antigens and the relationship of avidity to memory B cell responses to these antigens have not been studied in patients with cholera or those receiving oral cholera vaccines. We measured the avidity of antibodies to cholera toxin B subunit (CTB) and Vibrio cholerae O1 lipopolysaccharide (LPS) in Bangladeshi adult cholera patients (n = 30), as well as vaccinees (n = 30) after administration of two doses of a killed oral cholera vaccine. We assessed antibody and memory B cell responses at the acute stage in patients or prior to vaccination in vaccinees and then in follow-up over a year. Both patients and vaccinees mounted CTB-specific IgG and IgA antibodies of high avidity. Patients showed longer persistence of these antibodies than vaccinees, with persistence lasting in patients up to day 270 to 360. The avidity of LPS-specific IgG and IgA antibodies in patients remained elevated up to 180 days of follow-up. Vaccinees mounted highly avid LPS-specific antibodies at day 17 (3 days after the second dose of vaccine), but the avidity waned rapidly to baseline by 30 days. We examined the correlation between antigen-specific memory B cell responses and avidity indices for both antigens. We found that numbers of CTB- and LPS-specific memory B cells significantly correlated with the avidity indices of the corresponding antibodies (P < 0.05; Spearman''s ρ = 0.28 to 0.45). These findings suggest that antibody avidity after infection and immunization is a good correlate of the development and maintenance of memory B cell responses to Vibrio cholerae O1 antigens.     

Immunoglobulin G Subclass-Specific Responses against Plasmodium falciparum Merozoite Antigens Are Associated with Control of Parasitemia and Protection from Symptomatic Illness

Substantial evidence indicates that antibodies to Plasmodium falciparum merozoite antigens play a role in protection from malaria, although the precise targets and mechanisms mediating immunity remain unclear. Different malaria antigens induce distinct immunoglobulin G (IgG) subclass responses, but the importance of different responses in protective immunity from malaria is not known and the factors determining subclass responses in vivo are poorly understood. We examined IgG and IgG subclass responses to the merozoite antigens MSP1-19 (the 19-kDa C-terminal region of merozoite surface protein 1), MSP2 (merozoite surface protein 2), and AMA-1 (apical membrane antigen 1), including different polymorphic variants of these antigens, in a longitudinal cohort of children in Papua New Guinea. IgG1 and IgG3 were the predominant subclasses of antibodies to each antigen, and all antibody responses increased in association with age and exposure without evidence of increasing polarization toward one subclass. The profiles of IgG subclasses differed somewhat for different alleles of MSP2 but not for different variants of AMA-1. Individuals did not appear to have a propensity to make a specific subclass response irrespective of the antigen. Instead, data suggest that subclass responses to each antigen are generated independently among individuals and that antigen properties, rather than host factors, are the major determinants of IgG subclass responses. High levels of AMA-1-specific IgG3 and MSP1-19-specific IgG1 were strongly predictive of a reduced risk of symptomatic malaria and high-density P. falciparum infections. However, no antibody response was significantly associated with protection from parasitization per se. Our findings have major implications for understanding human immunity and for malaria vaccine development and evaluation.Effective immunity against Plasmodium falciparum malaria in humans develops slowly over time after repeated exposure and protects against the development of symptomatic and severe illness. Although the targets of protective immunity in humans remain ill-defined, substantial evidence suggests that antibodies against merozoite antigens play an important role, and several merozoite antigens are leading vaccine candidates (5, 15, 29, 35, 37, 45). Antibodies to merozoite antigens are thought to function in vivo by inhibition of merozoite invasion of erythrocytes, opsonization of merozoites for phagocytosis, and antibody-dependent cellular inhibition (3, 9, 13, 21, 24).The subclass of antibodies produced against antigens is likely to be important for protective activity, as immunoglobulin G (IgG) subclasses differ in their structures and mediate different immune effector functions (32). Knowledge of subclass responses associated with protection against malaria is important for understanding immunity and guiding vaccine development. IgG1 and IgG3 are the predominant subclasses produced in response to merozoite antigens (31, 37, 40, 43, 46, 48). IgG1 and IgG3 are cytophilic and T cell dependent, have high affinity for Fc receptors, and mediate phagocyte activation and complement fixation (7). It has been suggested that IgG3 is more efficient at mediating these processes (7). For reasons that are not well understood, different merozoite antigens induce different relative levels of IgG1 and IgG3 (14, 29, 31, 37, 40, 46, 48). It is unclear whether individuals have a bias toward producing a specific subclass regardless of the antigen or if instead the IgG subclass response is generated independently for each antigen and how this relates to protective immunity. While factors determining subclass responses to antigens are not clearly defined, antigen properties, host age, cumulative exposure, and genetic determinants have been linked with the nature of subclass responses (2, 4, 17, 33, 34, 41, 42, 47, 48). Some studies have suggested that increasing age (and therefore malaria exposure) leads to an increasing polarization of IgG subclass responses to merozoite antigens (41, 48).Antibodies to merozoite antigens have been linked with protection from malaria in humans in some longitudinal studies (6, 11, 15, 23, 25, 29, 31, 35, 37-39, 45). Results from these studies have been conflicting, which results partly from the use of different endpoints for evaluating the protective role of antibodies (i.e., different parasitemia thresholds versus symptomatic illness). It is thought that acquired immunity largely targets blood-stage antigens and acts by limiting parasite replication, thereby preventing the development of high-density parasitemia, but is less effective at protecting from parasitization per se (26). However, there are limited data that directly address this question and few studies have evaluated antibody associations with protection from symptomatic malaria, high-density parasitemia, and parasitization per se in the same cohort because of challenges in performing these studies in community-based settings. Additionally, the detection of parasitization has generally been performed using light microscopy, which is not sufficiently sensitive to detect parasitemias of very low density. The development of high-throughput molecular methods to detect parasitemia in cohort studies has provided new opportunities to better define these associations between immune responses and parasitization and symptomatic malaria. Furthermore, most studies of immunity have been conducted in sub-Saharan Africa, and there are little data from populations in Asia, where a large portion of the global malaria burden occurs (44).We addressed these important issues in a treatment-reinfection study of 206 children resident in an area of malaria endemicity in Papua New Guinea. We prospectively examined associations between subclass-specific responses to P. falciparum merozoite antigens (the 19-kDa C-terminal region of merozoite surface protein 1 [MSP1-19], apical membrane antigen 1 [AMA-1], and merozoite surface protein 2 [MSP2]) and the risks of high-density parasitemia, symptomatic malaria, and reinfection, as detected by sensitive molecular-based methods. Furthermore, we evaluated the influences of host age, exposure, and concurrent P. falciparum infection on the nature of responses and assessed whether individuals demonstrated a bias toward specific subclass responses and whether polymorphisms in antigens influenced the nature of subclass responses.