Translating Genomics Research Into Control of Tuberculosis: Lessons Learned and Future Prospects Digby F Warner1,2,3 and Valerie Mizrahi1,2,3*

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Translating Genomics Research Into Control of Tuberculosis: Lessons Learned and Future Prospects Digby F Warner1,2,3 and Valerie Mizrahi1,2,3* Warner and Mizrahi Genome Biology 2014, 15:514 http://genomebiology.com/2014/15/11/514 REVIEW Translating genomics research into control of tuberculosis: lessons learned and future prospects Digby F Warner1,2,3 and Valerie Mizrahi1,2,3* Abstract spite of recent gains in the battle against TB, the current rate of decline in TB incidence of 2% per annum falls far Genomics research has enabled crucial insights into short of this target [5]. This alarming situation under- the adaptive evolution of Mycobacterium tuberculosis scores the urgent need for new tools to control this dev- as an obligate human pathogen. Here, we highlight astating disease. major recent advances and evaluate the potential for Fundamental TB research poses very specific practical genomics approaches to inform tuberculosis control and financial challenges. As an infectious pathogen, M. efforts in high-burden settings. tuberculosis can only be manipulated in purpose-built biosafety level 3 containment laboratories by specialist personnel. The construction and maintenance of such Introduction facilities requires significant financial investment; more- Tuberculosis (TB) is a leading cause of death as a result over, the running costs necessary to ensure continued of an infectious bacterial agent, claiming 1.4 million lives compliance with the stringent safety regulations are each year [1]. With an estimated global burden of 8.7 high, and are incurred in addition to standard laboratory million incident cases per annum, TB remains a major operating expenses. From a practical perspective, M. tu- public health threat. In high-burden regions such as berculosis is an intractable experimental subject: the ba- sub-Saharan Africa, the TB epidemic is exacerbated by cillus is notorious for its slow growth rate in vitro and co-morbidities, including HIV and diabetes, as well as for its tendency to form aggregates in liquid media. As a demographic, socioeconomic, and programmatic factors result, experiments are technically demanding, long in [2]. The magnitude of the TB problem has been further duration and prone to contamination. The combined ef- amplified by the evolution and global spread of strains fect, therefore, is that the achievement of definitive re- Mycobacterium tuberculosis of that are resistant to con- sults can be very slow. ventional first- and second-line antitubercular drugs. Of Even more challenging are the scientific problems particular concern, drug resistance is worsening, having posed by the natural lifecycle of M. tuberculosis as an progressed from multi-drug resistant (MDR), to exten- obligate human pathogen. By definition, all experiments ‘ ’ sively drug resistant (XDR), to functionally untreatable conducted outside infected individuals - whether in vitro [3] TB - that is, disease for which no therapeutic options or in vivo - are performed in model systems that have ‘ remain. This progression has led to calls for visionary varying capacities to recapitulate specific aspects of the ’ ‘ political leadership [4] and increased funding to sustain host-pathogen interaction. Although advances in experi- ’ global control efforts, research and advocacy [3]. In mental mycobacteriology have provided key insights into order to reach the aspirational goal of global TB elimin- the metabolic and regulatory pathways that are critical ation by 2050, TB incidence will need to be reduced by for bacillary survival and pathogenesis, it remains ex- approximately 16% each year for the next 40 years. In tremely difficult to determine the precise physiological status of tubercle bacilli during different stages of infec- * Correspondence: [email protected] 1MRC/NHLS/UCT Molecular Mycobacteriology Research Unit, Institute of tion and in discrete anatomical and cellular (micro)envi- Infectious Disease and Molecular Medicine, Faculty of Health Sciences, ronments. As noted elsewhere [6], an important University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South consequence is that direct investigations of mycobacter- Africa 2DST/NRF Centre of Excellence for Biomedical TB Research, Institute of ial function in the context of the complete biological Infectious Disease and Molecular Medicine, University of Cape Town, Anzio system - the M. tuberculosis-infected host - remain rare. Road, Observatory, Cape Town 7925, South Africa In turn, this means that the barriers to translating the Full list of author information is available at the end of the article © 2014 Warner and Mizrahi; licensee BioMed Central Ltd. The licensee has exclusive rights to distribute this article, in any medium, for 12 months following its publication. After this time, the article is available under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Warner and Mizrahi Genome Biology 2014, 15:514 Page 2 of 12 http://genomebiology.com/2014/15/11/514 observations from basic research into practical outcomes much greater diversity within the MTBC. In turn, this im- are sizeable. plies that existing scenarios for the evolution of the The application of genomics and other ’omics tech- human- and animal-adapted strains might be overly sim- nologies in developing a systems biology of TB is central plistic, and limited by the availability of isolates, especially to global efforts towards the development of new vac- from wild mammals [11]. Defining the point in time, as cines, diagnostics and drugs for TB. The landmark pub- opposed to the phylogenetic position, at which MTBC lication in 1998 by Stewart Cole and colleagues [7] of strains originated from a last common ancestor has the first genome sequence of a strain of M. tuberculosis proven very difficult [8,12,13]; nevertheless, both com- ushered in a new era in TB research in which genome- parative genomics and bioarcheological evidence support scale studies have provided crucial insights into the the extended co-evolution of M. tuberculosis with its ancient and modern evolutionary history of M. tubercu- obligate host [14]. In turn, this implies the evolution of losis, the genomics of drug resistance, the biology of M. a conserved host-pathogen interaction that enables repeti- tuberculosis as an intracellular pathogen, and the host tive cycles of infection, disease, and transmission while response to infection with this organism (Figure 1). In this accommodating bacillary adaptation to major human article, we highlight the major advances in TB research demographic shifts. Although not conclusive, evidence of that have been enabled by the genomics revolution. We selective pressure on specific mycobacterial antigens pro- then identify key areas of research and development that vides some support for this idea [15], as does the observa- will be required in order to harness the full potential of tion that diverse M. tuberculosis strains engage a core genomics approaches for the control of TB in endemic transcriptional response following macrophage infection, regions, discuss some of the major challenges and obsta- while exhibiting hallmarks of lineage-specific adaptation cles that will need to be addressed and overcome in this to geographically varied host populations [16]. Notably, endeavor, and conclude by considering the implications the interaction between a particular locally adapted of the lessons learned from TB in the context of other M. tuberculosis strain and its corresponding geographically infectious diseases. matched host appears to depend on a functional immune response: these sympatric interactions are disrupted by The evolutionary history of M. tuberculosis HIV co-infection [17]. M. tuberculosis is one member of the M. tuberculosis com- Unlike most other bacterial pathogens, a defining char- plex (MTBC), a collection of phylogenetically linked or- acteristic of M. tuberculosis is its reliance on chromosomal ganisms comprising eight closely related lineages [8] and rearrangements and mutations as drivers of genomic evo- the outlying M. canettii group, in which the so-called lution [14]. Horizontal gene transfer (HGT) certainly ‘smooth tubercle bacilli’ are situated [9]. M. tuberculosis played an important role in the evolution of M. tubercu- sensu stricto from lineages L1 to L4 and L7, together with losis as a human pathogen [14,18,19]; however, despite the the Mycobacterium africanum lineages L5 and L6, are proposal that ongoing recombination provides a source of human-adapted, whereas the L8 lineage - which includes genetic variation [20], there is very little evidence in sup- Mycobacterium bovis and the TB vaccine strain, BCG port of a role for HGT in the modern evolution of this or- (Bacille Calmette Guérin) - contains the animal-adapted ganism [21]. This feature is likely to result from the pathogens. The recent discovery of chimpanzee and mon- ecological isolation of the bacillus as an obligate pathogen goose bacilli [10,11] suggests, however, that there might be that primarily targets the host pulmonary and lymphatic Genome-scale phenotypic compensatory Completion Global population Genome-scale and of the by Tn structure of Mtb phenotypic drug-resistance genome mutagenesis associated with -associated sequence of and expression sympatric host mutations in 2010 by Tn-Seq and
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