Mucosal Immunity Learning Goal

Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D.

MUCOSAL IMMUNITY

LEARNING GOAL You will be able to describe the mucosal immune system.

OBJECTIVES To attain the goal for these lectures you will be able to:

• Describe the components of the mucosal immune system. • Describe the structure of secretory IgA. • Explain the mechanism of IgA transport across mucosal surfaces. • Explain how a response to antigen is generated in the mucosal system. • Identify the differences in tolerogenic versus immunogenic responses to mucosal antigen administration. • Delineate the functions of the mucosal immune system, including M cells. • Describe how the mucosal immune system might be used for immunization. • Describe the characteristics of selective IgA deficiency. • Describe how intestinal commensal bacteria interact with the host to promote a healthy environment

READING ASSIGNMENT Janeway, et. al., (2008), Chapter 11, and Article “Mucosal Vaccines: the Promise and the Challenge” by Marian R. Neutra and Pamela A. Kozlowski, attached at end of lecture notes.

LECTURER Katherine L. Knight, Ph.D.

Page 1 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D.

CONTENT SUMMARY

I. INTRODUCTION TO MUCOSAL IMMUNITY

II. ORGANIZATION OF THE MUCOSAL IMMUNE SYSTEM A. Components of the Mucosal Immune System B. Induction of a Response C. Features of Mucosal Immunity D. Intraepithelial lymphocytes (IEL)

III. IgA SYNTHESIS, STRUCTURE AND TRANSPORT

IV. FUNCTIONS OF IgA AT MUCOSAL SURFACES A. Barrier Functions B. Intraepithelial Viral Neutralization C. Excretory Immunity D. Passive Immunity E. IgA Deficiency State

V. MUCOSAL IMMUNIZATION

VI. MUCOSAL TOLERANCE A. The Induction of Tolerance via Mucosal Sites B. The interaction Between Gut Bacteria and the Intestine

I. INTRODUCTION TO MUCOSAL IMMUNITY

Mucosal surfaces are continually exposed to external infectious agents, and consequently, immunologic defense against pathogens is paramount at these surfaces. Specific immunologic defense at mucosal surfaces is mediated by a specialized arm of the immune system that is termed the mucosal immune system. The mucosal immune system includes lymphoid tissues of the gastrointestinal tract, respiratory tract, salivary glands, lacrimal glands, mammary glands, and genito-urinary tract. The mucosal, or secretory, branch of the immune system is quite extensive, as the mucosal surfaces of the human body represent an area 100 times greater that of the skin. The importance of this system is underscored by the fact that 70 to 80% of all immunoglobulin producing cells in the body are physically located within the tissues of the mucosal immune system. Worldwide, over 12 million (1.2 x 107) deaths result from mucosal infections.

Page 2 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D.

Mucosal tissues are exposed to a large number of both potentially harmful and benign antigens from the environment, food, and microorganisms. For example, the intestine is host to hundreds/thousands of different bacteria. The mucosal immune system must therefore continually control responsiveness and unresponsiveness. Unlike many other components of the immune system, our understanding of the regulation of mucosal immunity remains somewhat incomplete.

II. ORGANIZATION OF THE MUCOSAL IMMUNE SYSTEM

A. Components of the Mucosal Immune System Mucosal immunity is triggered by the coordinated interaction of multiple cell types within the mucosal tissues. The process involves the initiation of the response at an inductive site, leading to an immune response at multiple effector sites.

Components of the mucosal immune system (MALT) include: • Gastrointestinal tract – gut associated lymphoid tissue (GALT) • Respiratory tract – bronchial associated lymphoid tissue (BALT) • Nasal associated lymphoid tissue (NALT) • Genitourinary tract • Lacrimal glands • Salivary glands • Mammary glands

B. Induction of a Response The inductive process has been best described for the GALT, which can be used as a prototype to explain the generation of mucosal immunity. Another inductive site that is gaining attention is the NALT, as inductive sites that are similar to those found in the GI tract are also present in nasal mucosa. Evidence for induction through BALT is also available.

Page 3 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D.

Lymphocytes reside in defined compartment of MALT (GALT is best defined example).

Mechanistically, the induction process can be divided into the following steps:

• Antigens entering the digestive tract are taken up by specialized mucosal cells called M cells. M cells internalize the antigen and transport it across the epithelium where antigen can be taken up by APCs such as dendritic cells (DC). “M” cells are formed in mucosal epithelium in response to signals from lymphocytes. • Antigen can be taken up by DC that have dendrites extending through the epithelial tight junction into the lumen (drawing on right). Antigen is captured from the lumen by dendritic cells that extend across the epithelial layer.

• Antigens are then presented to lymphocytes (in the intestine, these are located in Peyer’s patches).

Page 4 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D.

• Lymphocytes (both B and T cells) leave the mucosal site and travel to the mesenteric lymph nodes, then into the lymph.

• Via the thoracic duct, the lymphocytes exit the lymph and enter the circulation.

• Circulating lymphocytes “home” to positions within the mucosal lamina propria throughout the body, including sites distant from the original antigenic encounter. The homing of lymphocytes to mucosal sites involves specific interactions of both adhesion molecules and chemokines.

• B Lymphocytes within the peripheral tissues proliferate and differentiate into IgA secreting plasma cells at effector sites.

Page 5 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D.

C. Features of Mucosal Immunity

1. The administration of antigen at one mucosal site results in specific antibody production at distant mucosal sites. Some regional preference seems to occur, however. For example, induction via NALT leads to a more robust response in the respiratory sites than in gastrointestinal sites.

2. B cells in the mucosa are selectively induced to produce dimeric IgA rather than other isotypes. The selective switch of B cells to IgA is believed to be mediated by specific cytokines produced by T cells in the inductive sites.

3. Conventional T cells, particularly CTLs, are also an important component of the mucosal immune response. The induction and homing requirements for these cells are not as well described as those for mucosal B cells.

4. Induction of a response via a mucosal site generally elicits a systemic immune response as well, such that serum antibodies can be detected. This indicates that a mucosal encounter with antigen generates subsets of T and B cells that home to mucosal sites and also to spleen and regional nodes.

D. Intraepithelial Lymphocytes (IEL)

A distinct population of lymphocytes, mostly CD8+ T cells are found in the gut epithelium. The function of these cells is still not clear but they may readily kill infected epithelial cells.

E. IgA Deficiency States

Page 6 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D. Selective IgA deficiency is the most common primary immune deficiency, with an estimated incidence of 1 per every 500 to 1000 persons. The precise characteristics of the deficiency are variable, as some patients have complete IgA deficiency but others have decreased but detectable levels of IgA.

Patients present with low or no levels of serum IgA, but have normal cell mediated immunity and serum antibody responses. Not all patients exhibit increased susceptibility to infection. Reasons to suspect selective IgA deficiency include 1) a family history of IgA deficiency of agammaglobulinemia, 2) a high incidence of oral infections, 3) frequent respiratory infections, and 4) chronic diarrhea.

Autoimmune diseases, including SLE, juvenile rheumatoid arthritis, and thyroiditis, are often associated with selective IgA deficiency. Immunoglobulin therapy is generally not indicated, as the patient’s normal antibody response can produce anti-IgA antibody in response to IgA treatment. People with a complete absence of IgA may develop allergies or even anaphylactic shock if given gammaglobulin.

III. IgA SYNTHESIS, STRUCTURE AND TRANSPORT

The predominant immunoglobulin in mucosal secretions is IgA. Serum Ig – 12% IgA class, primarily monomeric Secreted Ig at mucosal sites – 96% IgA, primarily dimeric IgA in mucous secretions is called secretory IgA, or sIgA.

The production of secretory IgA (sIgA) requires both plasma cells in the lamina propria and epithelial cells of the mucosa.

• Dimeric IgA (2 monomeric IgA units covalently joined a J chain) is produced by plasma cells within the mucosal lamina propria. • Dimeric IgA binds to the polymeric immunoglobulin receptor (pIGR) on the basal surface of mucosal epithelial cells. • The IgA-pIGR complex is endocytosed and transported through the epithelial cell to the lumenal surface for release. • During this transport, the pIGR is cleaved and a small fragment is lost. • The remaining large component, secretory component, is covalently bound to the dimeric IgA.

Page 7 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D. • IgA is secreted at the mucosal surface as dimeric IgA covalently bound to secretory component.

• Secretory IgA production requires two different cell types. • Only polymeric immunoglobulins (dimeric IgA or pentameric IgM) are capable of binding and being transported by pIgR. • Mice that are genetically deficient for pIgR exhibit the expected decreases in IgA transport. PIgR deficiency also leads to an increased mucosal leakiness.

IV. FUNCTIONS OF IgA AT MUCOSAL SURFACES

Page 8 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D. A. Barrier Functions

Secretory IgA can bind to bacteria and viruses and prevent their adherence and invasion into mucosal tissues. Secretory IgA can neutralize many viruses in this way, including polio, herpesvirus, coxsackie virus, and rotaviruses. Secretory IgA can also neutralize bacterial toxins at mucosal surfaces

B. Intraepithelial Viral Neutralization

IgA that is internalized by mucosal epithelial cells (via the pIgR) may contribute to intracellular viral inactivation.

C. Excretory Immunity

Viral particles that complex with dimeric IgA in the lamina propria may be endocytosed and transported out by the pIgR pathway.

D. Passive Immunity sIgA in breast milk provides passive immunity to the infant.

V. MUCOSAL IMMUNIZATION

Mucosal surfaces are portals of entry for many pathogens (e.g. cholera, HIV, influenza).

The development of immunization strategies that would produce a robust mucosal immune response is a high priority.

When compared to systemic immunization by intramuscular, intraperitoneal, or intradermal routes, immunization with mucosally administered antigens has both advantages and disadvantages.

ORAL IMMUNIZATION

Advantages Disadvantages • Ease of administration (oral) • Difficulty in eliciting robust response • Generates both mucosal and systemic • Response may not be long-lasting immunity

An example of an effective oral immunization is the polio vaccine. Effective nasal spray vaccines for influenza have recently been developed.

Page 9 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D. New strategies for oral immunization include the use of cholera toxin chimeric molecules as well as recombinant avirulent bacteria (e.g. avirulent salmonella expressing S. pneumoniae proteins). Can also target M cells using bacteria and viruses that preferentially bind M cells or antigen encased in biodegradable particles such as latex. These strategies attempt to boost the uptake of foreign antigen at mucosal induction sites.

VI. MUCOSAL TOLERANCE

A. The Induction of Tolerance via Mucosal Sites

• The mucosa is exposed to many environmental antigens such as food that are not infectious. To operate in an effective manner, the mucosal immune system must distinguish between pathogenic antigens, which require a response, and non-dangerous antigens, such as those in food and in the commensal bacteria that make the gut their home. The response to most antigens is tolerance, and the type of antigen is critical to eliciting the appropriate response. The key feature that appears to distinguish between the induction of a response and the induction of tolerance is inflammation. Antigen encounters that occur alongside inflammation generally illicit an immune response. Antigen encounterd in the absence of inflammation generally induces tolerance. Thus: − Food antigens generally induce tolerance.

− Microbes (bacteria and viruses) that cause inflammation generally evoke a mucosal immune response. − Peptides generally induce tolerance, unless attached to a mucosal adjuvant, such as cholera toxin. • The induction of tolerance might be exploited therapeutically in autoimmune diseases, or to limit transplant rejection.

B. Interaction Between Gut Bacteria and the Intestine

Page 10 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D. • >1000 commensal bacterial species coinhabit the gut; 10X more bacterial cells than total human cells • Intestinal bacteria responsible for development of immune system; germfree animals have almost no secondary lymphoid tissues including mucosal tissues • The mechanism by which the mucosal administration of some antigens induces tolerance, rather than immunity, is incompletely understood. Recent studies suggest that mucosal tolerance is mediated by mucosal dendritic cells.

− • Commensal bacteria prevent pathogenic bacteria from colonizing the gut and/or prevent inflammatory responses in the intestine.

• Immune response to commensal bacteria can lead to inflammatory bowel disease (IBD). It is not clear if all commensals, or a subset of them can promote IBD. • Regulatory T cells are a prominent feature at mucosal sites, and may synergize with suppressive dendritic cells. Regulatory populations have been isolated from draining lymph nodes of mucosal sites.

Page 11 Host Defense 2012 Mucosal Immunity April 18, 2012 Katherine L.Knight, Ph.D.

Page 12

REVIEWS

Mucosal vaccines: the promise and the challenge

Marian R. Neutra*‡ and Pamela A. Kozlowski* Abstract | Most infectious agents enter the body at mucosal surfaces and therefore mucosal immune responses function as a first line of defence. Protective mucosal immune responses are most effectively induced by mucosal immunization through oral, nasal, rectal or vaginal routes, but the vast majority of vaccines in use today are administered by injection. As discussed in this Review, current research is providing new insights into the function of mucosal tissues and the interplay of innate and adaptive immune responses that results in immune protection at mucosal surfaces. These advances promise to accelerate the development and testing of new mucosal vaccines against many human diseases including HIV/AIDS.

Mucosal surfaces are enormous surface areas that are of mucosal T cells is labour intensive and technically vulnerable to infection by pathogenic microorganisms. challenging. As a result, only a few mucosal vaccines The adaptive immune system is designed to distinguish have been approved for human use in the United States antigens, pathogens and vaccines that enter the body or elsewhere. These include oral vaccines against polio- through mucosal surfaces from those that are introduced virus3, Salmonella typhi1, V. cholerae 1 and rotavirus4, directly into tissues or the bloodstream by injection and a nasal vaccine against influenza virus5. However, or injury. It is becoming increasingly clear that local research and testing of mucosal vaccines is currently mucosal immune responses are important for protection accelerating, stimulated by new information on the muco- against disease: for example, mucosal antibodies against sal immune system and by the threat of the mucosally Vibrio cholerae bacteria and cholera toxin are associated transmitted virus, HIV6,7. with resistance to cholera1. In this Review, we provide an overview of the events Mucosal immune responses are most efficiently within mucosal tissues that lead to protective mucosal induced by the administration of vaccines onto muco- immune responses, and we consider key biological and sal surfaces, whereas injected vaccines are generally technical aspects of mucosal vaccine design. We then poor inducers of mucosal immunity and are therefore summarize current progress in the development of less effective against infection at mucosal surfaces1,2. mucosal vaccines against HIV. Nevertheless, clinical vaccine research has been based largely on injection of antigens, and most vaccines Mechanisms of mucosal protection in use today are administered intramuscularly or Innate defences at mucosal surfaces. Mucosal surfaces subcutaneously. This is understandable because an of the respiratory, gastrointestinal and urogenital tracts

*GI Cell Biology Research injection delivers a known quantity of antigen into are separated from the outside world by delicate epithe- Laboratory, Children’s the body and results in the generation of specific anti- lial barriers. In the gastrointestinal tract, for example, a Hospital and Department bodies and lymphoid cells that are readily measured single layer of epithelial cells joined by tight junctions of Pediatrics, Harvard in blood samples. By contrast, our understanding faces a complex luminal environment that is rich in Medical School, Boston, of mucosal immunity and development of mucosal microorganisms. Epithelia and their associated glands Massachusetts 02115, USA. ‡Children’s Hospital, Enders vaccines has lagged behind, in part because admin- (such as the salivary glands) produce nonspecific 720, 300 Longwood Avenue, istration of mucosal vaccines and measurement of or innate defences including mucins and antimicrobial Boston, Massachusetts mucosal immune responses are more complicated. proteins8. Nevertheless, foreign antigens and micro- 02115, USA. The dose of mucosal vaccine that actually enters the organisms frequently breach the epithelial barrier and Correspondence to M.R.N. e-mail: marian.neutra@ body cannot be accurately measured because anti- mucosal tissues are sites of intense immunological childrens.harvard.edu bodies in mucosal secretions are difficult to capture activity. In the intestinal mucosa, dispersed lymphoid doi:10.1038/nri1777 and quantitate, and recovery and functional testing and antigen-presenting cells are particularly abundant;

REVIEWS

Antibody-dependent it has been estimated that there are more antibody- sterile environment, such as muscle, might be ‘ignored’ cell-mediated cytoxicity producing cells in the intestinal mucosa than in the when given mucosally, where the tissue is constantly (ADCC). A mechanism by spleen and lymph nodes combined9,10. exposed to microorganisms. which natural killer cells are Epithelial cells are active participants in muco- targeted to antibody-coated sal defence. They function as sensors that detect Adaptive immune protection at mucosal surfaces. cells, resulting in the lysis of the antibody-coated cells. dangerous microbial components through pattern- Diverse strategies are used by mucosal pathogens to recognition receptors such as Toll-like receptors (TLRs). infect humans. Some pathogens such as V. cholerae and They respond by sending cytokine and chemokine sig- enteropathogenic Escherichia coli cause disease by colo- nals to underlying mucosal cells, such as dendritic cells nizing epithelial surfaces. Pathogens such as rotavirus (DCs) and macrophages, to trigger innate, nonspecific and influenza virus infect the epithelium, whereas oth- defences and promote adaptive immune responses8,11,12. ers such as Shigella flexneri and S. typhimurium establish In the intestine, where bacteria are abundant, epithelial local infection in the lamina propria. Other pathogens, cells, together with intraepithelial lymphocytes and including HIV and S. typhi, use the intestinal mucosa underlying phagocytic cells, can modulate and dampen as a staging area for systemic spread of infection. these signals to prevent undesirable responses to non- Protection against such diverse threats involves multiple threatening nutrients and the normal intestinal flora immune effector strategies that operate on both sides of that could lead to mucosal inflammation13–15. Therefore, the epithelial barrier (FIG. 1). mucosal tissues are in a constant state of alert, but they An important characteristic of the mucosal adaptive are adapted to the presence of foreign microorganisms immune response is the local production and secretion and their products. As a result, vaccines that would of dimeric or multimeric immunoglobulin A (IgA) anti- produce vigorous immune responses if injected into a bodies that, unlike other antibody isotypes, are resistant to degradation in the protease-rich external environments of mucosal surfaces. In humans, more IgA is Entrapment produced than all the other immunoglobulin isotypes 10 Lumen and clearance combined , and high concentrations of IgA antibodies (over 1 mg per ml) are present in the secretions that are 16,17 Block adherence sIgA associated with mucosal surfaces in normal humans . and invasion Epithelial cell Mucus The protease resistance of secretory IgA (sIgA) is a result of its dimerization and high degree of glycosylation during its synthesis in mucosal plasma cells18, and its association with a glycosylated fragment (the secre- Antigen DC tory component) derived from the epithelial polymeric capture Dimeric IgA immunoglobulin receptor (pIgR) that mediates transport by DCs of dimeric IgA across epithelial cells to the lumen19. B cell 2 Opsonization sIgA has multiple roles in mucosal defence . It promotes the entrapment of antigens or micro- Neutralization organisms in the mucus, preventing direct contact of pathogens with the mucosal surface, a mechanism that IgG ADCC is known as ‘immune exclusion’. Alternatively, sIgA of Egress the appropriate specificity might block or sterically Macrophage of cells NK cell hinder the microbial surface molecules that mediate 20 HEV epithelial attachment , or it might intercept incoming Egress of pathogens within epithelial-cell vesicular compart- antibody 2,19 CTL ments during pIgR-mediated transport . Interstitial fluids of mucosal tissues that underlie the epithelial barrier contain dimeric IgA that is synthesized by Lymph Fenestrated Blood local IgA-secreting plasma cells and this might prevent Cell-mediated capillary killing mucosal-cell infection, by mediating the transport of pathogens that have breached the epithelial barrier Figure 1 | Mechanisms of immune protection at mucosal surfaces. Multiple back into the lumen through pIgR21 or by mediating immune effector mechanisms contribute to protection at mucosal surfaces. antibody-dependent cell-mediated cytotoxicity (ADCC) Antigen-specific effector B and T cells in the bloodstream recognize mucosal that leads to the destruction of local infected cells10,22. high endothelial venules (HEVs) and enter the mucosa. Mucosal B cells terminally Local IgG synthesis also can occur in the mucosal differentiate to become mucosal plasma cells, most of which produce dimeric IgA tissues following the administration of antigen or that is exported into secretions as secretory IgA (sIgA) to intercept antigens and vaccine to mucosal surfaces17,18,23,24. Large numbers of pathogens, and to prevent mucosal invasion. Neutralizing IgG is also present within mucosal tissues; mucosal IgG might be derived from local plasma cells or from IgG-secreting plasma cells are present in the female 23 blood, by diffusion from local fenestrated capillaries. Infected cells might be killed genital tracts of macaques and humans , and high by specific cytotoxic T lymphocytes (CTLs) or by antibody-dependent cell-mediated concen trations of IgG as well as IgA have been measured cytotoxicity (ADCC), a collaboration between natural killer (NK) cells and antibodies. in human cervical and vaginal secretions17,18. This IgG, Pathogens can also be captured by dendritic cells (DCs) and macrophages, and as well as sIgA, could play a significant role in blocking carried to draining lymph nodes. infection by sexually transmitted pathogens at this site,

REVIEWS

Oral cavity and vagina Nose and airways Follicle-associated epithelium: small intestine, colon, rectum, tonsils and adenoids M cell

T cell B cell

B-cell zone T-cell DC zone

Organized mucosal lymphoid tissue

Draining lymph node Draining lymph node Draining lymph node

Figure 2 | Antigen sampling at mucosal surfaces: collaboration of epithelial cells and dendritic cells. Antigen sampling strategies are adapted to the diverse epithelial barriers that cover mucosal surfaces throughout the body, but all involve collaboration with dendritic cells (DCs). DCs might congregate immediately under epithelia, migrate into the epithelial layer, and even extend dendrites into the lumen to capture antigens. DCs from any mucosal surface might travel to the nearest draining lymph node to present antigen to T cells. At sites of organized mucosal lymphoid tissues, specialized microfold (M) cells in the lymphoid follicle-associated epithelium deliver antigens across the epithelial barrier directly to subepithelial DCs that then present antigen locally in adjacent mucosal T-cell areas.

as has been shown for infection with herpes simplex infections. For example, mucosally immunized (but not virus type 2 in mice25. Concentrations of IgG and IgA in systemically immunized) mice were protected against secretions of the female reproductive tract are affected infection after mucosal challenge with a recombinant by hormonal signals and change dramatically during the vaccinia virus expressing HIV glycoprotein 160 (gp160), menstrual cycle24, and this might be an important factor but this protection was abrogated by treatment of the in the effectiveness of mucosal vaccines against sexually mice with CD8-specific antibodies30. Immunologically transmitted diseases. In the human intestine, 5–15% of active mucosal tissues, such as the intestinal tract, con- mucosal plasma cells secrete IgG9, but IgG is suscep- tain abundant CD4+ T cells that are targets for HIV. As a tible to degradation by luminal intestinal and bacterial result, the intestinal mucosa becomes a reservoir of HIV proteases. In large intestinal secretions, for example, infection regardless of the site of initial viral entry31,32. M cells (Microfold cells). Specialized IgG concentrations are generally 30- to 100-fold lower Both CTLs and antibodies within mucosal tissues might 26 epithelial cells that deliver than those of sIgA . Nevertheless, intact IgG in mucosal contribute to preventing the establishment of such antigens by transepithelial tissues, whether locally produced or from serum, can mucosal reservoirs. vesicular transport from potentially neutralize pathogens that enter the mucosa the gut lumen directly to Induction of mucosal immune responses intraepithelial lymphocytes and prevent systemic spread. and to subepithelial lymphoid It is often assumed that mucosal or serum IgG dif- Antigen sampling at mucosal surfaces. The induction tissues. fuses across epithelial barriers and into secretions by of mucosal immune responses against foreign antigens, para cellular leakage. However, receptor-mediated IgG microorganisms and vaccines requires the presence of Peyer’s patches transport might also occur. Recent studies have shown organized lymphoid tissue, either within the mucosa or Large clusters of lymphoid 9 follicles localized in the mucosa that an IgG-specific Fc receptor (neonatal Fc receptor, in draining lymph nodes (FIG. 2). Organized mucosal of the distal small intestine. FcRn) is expressed by epithelial cells in the intestine and inductive sites are concentrated in areas where pathogens Each B-cell follicle is capped by airways, and can mediate IgG transport in both direc- are most likely to enter the body (for example, the palatine a dome area and is flanked tions across epithelial barriers27. Therefore, this system and lingual tonsils and adenoids in the oral and naso- by interfollicular T-cell areas. might export IgG, and might also mediate the uptake pharyx) and at sites of high microbial density (such as the 27 Inductive sites of antigens into the mucosa . In addition, a new IgA- lower intestinal tract). In humans, aggregates of organized Organized lymphoid tissues specific receptor has been identified on apical surfaces mucosal lymphoid follicles form the Peyer’s patches in containing B-cell follicles, T-cell of microfold cells (M cells) that can mediate uptake of the distal ileum, and abundant isolated follicles are pres- areas and antigen-presenting luminal IgA into Peyer’s patches28. The immunological ent in the appendix, colon and rectum33. The presence dendritic cells, specialized for induction of adaptive immune significance of these uptake mechanisms has yet to be of a mucosal lymphoid follicle influences the overlying responses. Mucosal inductive determined, but there is some evidence that they might epithelium by inducing differentiation of a specialized sites in the gastrointestinal facilitate the sampling of luminal immune complexes by follicle-associated epithelium (FAE), which contains tract include the Peyer’s the mucosal immune system27,29. M cells34. M cells form intraepithelial pockets into which patches, appendix, and isolated lymphoid follicles Cytotoxic T lymphocytes (CTLs) in mucosal tissues lymphocytes migrate, and they deliver samples of foreign throughout the small intestine, cannot prevent pathogen entry, but they might have a material by vesicular transport from the intestinal lumen colon and rectum. crucial role in clearance or containment of mucosal viral directly into the pocket and to underlying DCs.

REVIEWS

In the intestine, the entire FAE is distinct from the memory responses45 or immune tolerance46, or they absorptive epithelium that lines the vast majority of could exit the mucosa through lymphatics to present the intestinal surface area34. The FAE of a mouse small- antigens to naive T cells in organized lymphoid tissues of intestinal Peyer’s patch produces chemokines, includ- draining lymph nodes41. There is evidence that different ing CC-chemokine ligand 20 (CCL20; also known as subpopulations of DCs have distinct roles in determin- MIP3α) and CCL9 (also known as MIP1γ), that attract ing the nature of immune responses in vivo, including lymphocytes and DCs that express CC-chemokine those in the Peyer’s patches40. In addition, much remains receptor 6 (CCR6) or CCR1, respectively35–37. Attraction to be learned about DC migration patterns. For example, of DCs to the FAE results in a high density of phagocytic transcutaneous immunization can result in mucosal cells at sites of entry of foreign antigens and pathogens, immune responses, and DCs from skin have been found presumably to promote local antigen sampling and mini- to migrate to Peyer’s patches47. mize the likelihood of systemic infection (FIG. 3). Particles and live bacteria that are transported across the FAE by Focusing the mucosal immune response. B and T cells M cells can be captured by DCs in the subepithelial that are activated in organized mucosal lymphoid tis- dome (SED) regions of Peyer’s patches in mice38,39. DCs sues upregulate the expression of tissue-specific adhe- in the SED region are phenotypically immature, but after sion molecules and chemokine receptors that function antigen capture they migrate to adjacent interfollicular as ‘homing receptors’ to guide the lymphocytes back T-cell zones (FIG. 4), where they upregulate the expression to the mucosa through recognition of endothelial of maturation markers and MHC molecules39,40. Some counter-receptors in the mucosal vasculature48,49. Peyer’s patch DCs might also carry antigen to draining Some of these receptors and chemokines are broadly lymph nodes, where they interface with the systemic expressed or exhibit redundancy. For example, IgA- immune system41. secreting B cells that are activated in mucosa-associated In the absence of organized mucosal lymphoid organized lymphoid tissues express CCR10, the recep- tissues, antigens and pathogens might also be sampled on tor for CCL28, which is secreted by epithelial cells mucosal surfaces through another type of epithelial–DC throughout the small and large intestines, salivary collaboration. Throughout stratified, pseudostratified and glands, tonsils, respiratory tract and lactating mam- simple epithelia, motile DCs can migrate into the narrow mary glands48. Therefore, CCR10+IgA+ B cells can be spaces between epithelial cells and even to the outer limit attracted to all of these tissues. This broad recognition of the epithelium42–44, where they can obtain samples of system explains why mucosal immunization at one site foreign material directly from the luminal compartment can result in the secretion of specific IgA antibodies in (FIG. 2). This might be most immunologically significant other mucosal or glandular tissues; this is referred to at mucosal locations such as the female genital tract, as the ‘common mucosal immune system’50. where there are no organized lymphoid follicles and As well as this common system, however, there are the epithelium lacks M cells. Intraepithelial and sub- receptor-mediated recognition systems that serve to epithelial DCs that have captured pathogens could focus the immune response at the site where an antigen potentially interact with local lymphocytes to stimulate or pathogen was initially encountered. For example, IgA+ B cells that are generated in intestinal inductive Intestinal lumen sites enter the bloodstream, but they preferentially Bacterial adherance/ TLR Entero- migrate back into the intestinal mucosa because they invasion ligands toxins α β express the homing receptor 4 7-integrin that inter- acts strongly with MADCAM1, an ‘addressin’ that T cell M cell is expressed by venules in the small and large intestine (and lactating mammary glands) but not in other 48 α β mucosal tissues . Circulating 4 7-integrin-expressing T cells that are activated in the small intestine also express CCR9, which attracts them to CCL25, a chemokine that is secreted by epithelial and perhaps Intestinal B cell 51 epithelium Chemokines CCR6 endothelial cells of the small (but not large) intestine . such as CCL9 Additional soluble factors that are synthesized by epi- and CCL20 thelial cells, DCs and other cells at sites of vaccination, infection or inflammation can upregulate the expres- 52, Cytokines DC CCR1 sion of addressins by local endothelial cells and also probably dictate the patterns of homing molecules Figure 3 | Functions of the follicle-associated epithelium. The follicle-associated expressed by locally activated T cells53. For example, epithelium (FAE) contains microfold (M) cells that are specialized for endocytosis interleukin-12 (IL-12)-mediated upregulation of and rapid transepithelial transport of intact antigens and microorganisms into P-selectin glycoprotein ligand 1 expresion by CD4+ intraepithelial pockets that contain B and T cells and occasional dendritic cells (DCs). The majority of FAE cells are enterocytes with apical microvilli coated by a thick T cells that are activated in Peyer’s patches was recently brush border glycocalyx. FAE enterocytes do not transport antigens, but they might linked to the entry of T helper (TH) cells to the small- contribute to antigen sampling by sensing luminal pathogens and their products intestinal lamina propria54. The regional nature of and releasing cytokine and chemokine signals that attract and activate DCs. CCL, mucosal immune responses has been clearly shown in CC-chemokine ligand; CCR, CC-chemokine receptor; TLR, Toll-like receptor. non-human primates and humans (TABLE 1).

REVIEWS

Intestinal lumen has induced specific mucosal IgA antibody responses in Epithelial c the salivary glands, upper and lower respiratory tracts, cell d male and female genital tracts, and the small and large intestines17,56–58. The nasal route can also induce CTLs b in distant mucosal tissues including the female geni- M cell tal tract59. In addition, nasal immunization studies in humans and mice produced greater systemic antibody e responses than other mucosal immunization routes17,56, DC SED presumably because antigens or antigen-presenting cells were readily trafficked to draining lymph nodes from this site. In mice and monkeys, nasal immunization with certain live viral vectors generated systemic antiviral CTLs FDC and IgG at concentrations that were comparable to those induced by parenteral vaccination routes60,61. However, B-cell rectal immunization of mice with a non-living peptide- zone T-cell zone Germinal centre based vaccine was more effective than nasal or oral a f Lymph routes at inducing systemic CTLs62. Taken together, the HEV evidence suggests that the choice of mucosal vaccination route requires consideration of the species, the nature of the vaccine and the expected site of challenge. Although Blood nasal immunization might be particularly effective for protection against respiratory pathogens, optimal protection of the gastrointestinal tract, the rectum and female Figure 4 | Cellular traffic in organized mucosal lymphoid tissues. The choreography of cellular movements in organized mucosal lymphoid tissues is genital tract might still require oral, rectal or vaginal complex and only partly understood. A simplified version based on studies of Peyer’s vaccines (TABLE 1). However, the response to vaginal vac- patches is shown here; for more details refer to the text and REFS 40,48. a | Naive and cines might be affected by the stage of the menstrual cycle memory lymphocytes as well as immature dendritic cells (DCs) enter the mucosa during which immunization is carried out17. through high endothelial venules (HEVs). Some of these cells are attracted to the For many pathogens, optimal protection is likely to subepithelial dome (SED) region by chemokines released from the follicle-associated require both mucosal and systemic immune effectors, epithelium (FAE). b | Some B and T cells migrate into microfold (M)-cell pockets, and the most effective mucosal vaccine strategies might where they express maturation or memory markers. c | Most immature DCs remain be prime–boost combinations that involve both mucosal in the SED region but a few migrate into the FAE. d | Antigens and microorganisms and systemic delivery. Which should come first? There transported by M cells are captured by DCs. e | Antigen capture along with other is evidence that in naive human vaccine recipients, signals induces DC maturation and movement into interfollicular T-cell areas, the B-cell zone, and perhaps into draining lymphatics. f | In interfollicular areas, mucosal immunization can prime the immune system DCs process and present antigen to naive T cells. FDC, follicular dendritic cell. for both systemic and mucosal responses, presumably by inducing the expression of both mucosal and systemic homing receptors by responding lymphocytes48. By con- Mucosal immunization routes also can induce the trast, parenteral priming might not prime the immune production of serum IgA and IgG because a fraction system for subsequent mucosal vaccination50. of the B cells that are activated in the mucosa or in the draining lymph nodes express the peripheral homing Challenges in mucosal vaccine design α β 48 receptors, 4 1-integrin and leukocyte (L)-selectin . In Mucosal vaccines that are given orally or deposited addition, mucosal DCs can migrate and carry antigen directly on mucosal surfaces face the same gauntlet to systemic inductive sites such as the lymph nodes and of host defences as do microbial pathogens: they are spleen41. By contrast, systemic immunization is generally diluted in mucosal secretions, captured in mucus gels, ineffective for the induction of mucosal IgA antibody attacked by proteases and nucleases, and excluded by α β responses because expression of CCR10, 4 7-integrin epithelial barriers. So, relatively large doses of vaccine and other mucosal homing receptors is not induced on are required and it is impossible to determine exactly B cells that are activated in the peripheral lymph nodes48. what dose actually crosses the mucosa. Soluble, non- CD8+ T cells that are activated in response to mucosal adherent antigens are taken up at low levels, if at all, antigen might initially have a fairly unrestricted migra- and in the intestine, such antigens generally induce tion pattern, but in the long term, memory CD8+ T cells immune tolerance46. The vaccine formulations and show a preference for the tissue in which antigen was delivery strategies that have been used to address originally encountered55. these challenges have been reviewed elsewhere63. In general, mucosal vaccines are likely to be most effec- What is the best immunization route? Ideally, vaccina- tive when they mimic successful mucosal pathogens in tion at a single site would provide both humoral and key respects: they would ideally be multimeric and/or cell-mediated protection, not only at the relevant muco- particulate, adhere to mucosal surfaces (or even bet- sal surface, but also throughout the body. In this regard, ter, adhere selectively to M cells), efficiently stimulate nasal vaccination has shown particular potential. In mice, innate responses, and evoke adaptive immune responses monkeys and humans, nasal administration of vaccines that are appropriate for the target pathogen.

REVIEWS

Table 1 | Effect of immunization route on local and distal antibody responses in humans Immunogen Route Specific Responses of specific IgA antibodies* References serum IgG Small Large Cervix/ Salivary Nasal intestine intestine vagina glands cavity Cholera toxin Nasal +++++ ND ++ +++ _ +++ 16,17, _ B subunit Oral +++ ++++ ++ +/– + 114–116 _ Rectal +++ ND ++++ +/– ND Vaginal ++ ND +/– +++ +/– ND Live Oral ++ +++ _ +/– +/– _ 117,118 _ _ attenuated Rectal + +/– ++ +/– Salmonella typhi Ty21a Poliovirus Oral ++++ +++ ++ _ ND + 119,120 _ vaccine Colonic ++++ ND +++ ND ND _ _ Vaginal ND ND +++ ND *Responses are based on geometric mean post-vaccination increases in specific antibody corresponding to: +++++, >50-fold; ++++, 25–49.9-fold; +++, 10–24-fold; ++, 5–9.9-fold; +, 2.5–4.9-fold; +/–, >2.5-fold in a minority of vaccine recipients; –, <2.5-fold in all vaccine recipients. ND, not determined.

Breaching the epithelial barrier. The effectiveness of live because microparticles tend to be trapped in mucus and pathogens as mucosal vaccines and vaccine vectors is only a small fraction of the administered dose is likely to partly a result of their adaptation to survive in lume- enter mucosal inductive sites. nal environments and to efficiently invade organized mucosal lymphoid tissues. Indeed, two of the most Alerting the mucosal immune system. Non-living macro- effective oral vaccines, live attenuated poliovirus3 and molecules, protein-subunit antigens and non-microbial live attenuated S. typhi1, are derived from pathogens particles generally evoke weak or undetectable adap- that preferentially adhere to M cells and exploit M-cell tive immune responses when applied mucosally. To be transport to invade organized mucosal lymphoid tissues distinguished from harmless substances and nutrients, in the intestine64,65. The efficiency of non-living mucosal mucosal vaccines must raise alarms in the mucosa by vaccines is unlikely to be comparable to these successful including substances that activate innate signalling invaders, but uptake into the mucosa can be significantly pathways in epithelial cells and/or in the underlying increased. Protein, peptide and DNA vaccines as well as antigen-presenting cells. The best-known mucosal live vaccines can be partially protected from degradation adjuvants are the secreted enterotoxins of V. cholerae by oral delivery in enteric-coated gelatin capsules1 or by and E. coli, cholera toxin and E. coli heat-labile entero- inclusion in copolymeric microparticles66, liposomes67 toxin75. As microgram oral doses of these toxins induce or proteosomes68. The retention of vaccine antigens on severe diarrhoea in humans, several genetically modi- mucosal surfaces by delivery in adherent gel-forming fied forms have been engineered to reduce or eliminate polymers, such as chitosan, has been shown to increase the toxicity associated with the enzymatic A subunits of antigen uptake and immune responses69. The coupling these toxins75. Interest in mutated toxins as adjuvants of antigen with proteins that themselves are adherent to for nasal vaccines has been dampened by the observa- epithelial surfaces has also enhanced mucosal immune tion of B-subunit-dependent retrograde transport to responses, presumably by promoting adherence and the brain by olfactory nerves in experimental animals76 entry into epithelial-cell transport pathways34. and association with adverse neurological effects in Particulate vaccines have several theoretical advan- humans77. Recently, alternative chimeric toxins that tages for mucosal delivery. M cells are particularly acces- couple an enzymatic A subunit with more restricted sible to microparticles and actively transport them into cell-targeting molecules show promise for safe nasal Peyer’s patches. Microparticles that are are small (up to use in humans78. 1 µm diameter) and adherent to M cells are taken up Meanwhile, new information about the functions of most efficiently34,70,71. Ligands and antigens can therefore immunomodulatory cytokines in mucosal immunity be targeted to Peyer’s patches by association with micro- and the discovery of TLRs have provided promising new Virus-like particles particles. Particulate vaccines that enter mucosal induc- alternatives. For example, there is evidence that mucosal Particles composed of viral tive sites have the additional advantage of being readily immune responses to vaccines can be increased by the proteins, having native taken up by mucosal DCs and providing antigen depots. incorporation of cytokines such as IL-12, granulocyte/ viral surface structures but 72,73 lacking nucleic acids and Virus-like particles and small vesicles derived from macrophage colony-stimulating factor (GM-CSF) or a 68,74 79 therefore unable to replicate bacterial outer-membrane components are particu- combination of both . Various TLR ligands including in cells or cause infection. larly promising as mucosal vaccines because their size is CpG-containing oligonucleotides80, flagellin81 and bacte- They can be formed by appropriate for uptake by M cells and DCs, their surface rial porins68 have shown adjuvant activity when admin- spontaneous assembly of recombinant viral proteins structures mimic those of mucosal pathogens, and they istered mucosally together with antigens. TLR ligands in vitro or by budding from can activate an innate immune response. In practice, how- and toxins function as mucosal adjuvants, presumably transfected cells in culture. ever, large amounts are needed for mucosal immunization because they activate key innate signalling pathways

REVIEWS

and stimulate the appropriate mucosal DCs that in turn Epithelial cells themselves are not productively orchestrate adaptive immune responses that are designed infected by HIV, but they serve as gateways for the deliv- for defence against live pathogens. ery of infectious HIV parasites to antigen-presenting DCs Many live attenuated mucosal vaccine vectors, includ- and macrophages. As mucosal antigen-presenting cells ing poliovirus, adenovirus and enteric bacteria, are cur- interact with local CD4+ T cells, they unwittingly infect rently under development and have been extensively and ultimately disable the very cells that are needed to reviewed1,82. The superiority of live attenuated pathogens mount an effective immune response. Infection of local as mucosal vaccines and vaccine vectors is due in part target cells can occur rapidly after deposition of virus on to their ability to activate multiple innate responses, and mucosal surfaces86. However, dissemination of virus to the importance of innate immunity in the development regional lymph nodes and other tissues might be delayed of adaptive immune responses is becoming increasingly for up to several days88,89, providing a window of opportu- clear. Nevertheless, some live vaccines present safety and nity for local control of the infection by mucosal immune acceptability issues that might reflect innate immune effectors. In any case, whether transmitted mucosally or responses and inflammation, such as mild enteritis-like injected, HIV and SIV replicate preferentially in mucosal symptoms in the case of oral administration of certain tissues, such as the intestinal mucosa, that are rich in CD4+ live attenuated bacteria1. An additional concern for live T cells31,32. Therefore, the ultimate goals of anti-HIV vac- nasal vaccines is the possibility of retrograde transport cines should be first to interrupt mucosal transmission at to the brain through olfactory nerves, as has been found its earliest stages, before the virus has crossed the epithelial with live attenuated adenovirus83. Live vaccine vectors barrier and infected its first target cell, and then to prevent and adjuvants that cannot be used orally or nasally might the establishment of viral reservoirs in mucosal tissues. be safe and effective if administered by the rectal or vagi- To achieve these goals, HIV-specific vaccines must nal route, however, and this possibility warrants testing generate multiple immune effectors, including HIV- in human studies. envelope-specific antibodies in mucosal secretions, and CTLs and neutralizing HIV-envelope-specific antibod- Developing a mucosal vaccine for HIV ies in the mucosa and circulation. Given what we know The role of mucosal immunity in protection against about the induction of mucosal immune responses, it HIV. HIV might be considered as a mucosal pathogen, is unlikely that injected HIV vaccines alone will induce because transmission occurs mainly through exposure the mucosal responses that are required. Although of mucosal surfaces to HIV and HIV-infected cells. correlates of mucosal protection are not yet estab- Mucosal transmission of simian immunodeficiency lished (BOX 1), there is evidence from highly exposed, virus (SIV) in non-human primates, and presumably uninfected human subjects that mucosal HIV-specific of HIV in humans, can occur without epithelial-cell CTLs and IgA antibodies in secretions are associated damage of the oral, rectal and genital mucosae6,84,89. with resistance to sexually transmitted HIV infec- HIV presents a daunting challenge to vaccinologists. tion90,91. The challenge is to identify the key effectors that It seems to exploit mucosal antigen-sampling mecha- are required and then to design a vaccination strategy nisms at these sites, including vesicular transepithelial that induces them. Many candidate mucosal vaccines, transport pathways of M cells and uptake by intra- adjuvants and delivery strategies have been tested in epithelial DCs85,86. The mucosal tissues of the rectum mice and found to induce mucosal (as well as systemic) and tonsils both contain abundant mucosal lymphoid HIV-specific humoral and cell-mediated immune follicles and associated M cells33,87, and M cells provide responses6,7,82. However, only a minority of these strate- a short and rapid pathway across the epithelial bar- gies have been taken to the next preclinical step: testing rier34,87. This could explain the observed transmission immunogenicity and protective efficacy after mucosal of HIV to adults through infected semen, or to babies vaccination of non-human primates (TABLE 2). through infected milk. Evidence from non-human primates. Most of the vac- Box 1 | Correlates of mucosal protection cine formulations that have undergone preclinical testing in macaques were designed to induce antiviral CTLs To guide the design of mucosal vaccine strategies, investigators have been hoping to rather than antibodies, and of these only a few have been define the ‘correlates of mucosal protection’; that is, the concentrations, epitope evaluated specifically for their ability to generate CTLs specificities and locations of immune effectors that would be likely to protect most in mucosal tissues (TABLE 2). Nevertheless, several studies vaccinees during mucosal exposure to HIV. Attempts to define realistic correlates of have shown that local mucosal CTLs that are induced by mucosal protection through challenge studies in vaccinated non-human primates have been compromised by the use of large mucosal-challenge doses of highly infective SIV. mucosal immunization can reduce plasma viral loads 82,92–95 Such challenges are intended to assure infection of most or all unvaccinated control after mucosal challenge . For example, rectal but animals after a single exposure, but might overwhelm the immune response elicited by not parenteral vaccination with a cocktail of peptides the vaccine. New experimental models in which monkeys are repeatedly exposed to derived from HIV envelope, SIV group-specific antigen low doses of challenge virus through the rectum or vagina are more likely to identify (gag) and SIV polymerase induced specific CTLs in the effective mucosal vaccine candidates113. It is unlikely that exact quantitative correlates colonic mucosa and resulted in a dramatic reduction will be established for humans, given real-life disparities in exposure levels and local in viraemia after rectal challenge with a pathogenic mucosal conditions. Nevertheless, there is evidence from highly exposed, uninfected SHIV (chimeric SIV containing the HIV envelope subjects that HIV-specific cytotoxic T lymphocytes and mucosal IgA antibodies are glycoprotein)92. Similarly, nasal but not intravenous 90,91 associated with resistance to sexually transmitted HIV infection . administration of non-pathogenic SHIV in macaques

REVIEWS

Table 2 | Relative immunogenicity of vaccines administered by mucosal routes in non-human primates Vaccine and vaccination route* Challenge virus HIV- or SIV-specific immune responses‡ Protection§ Refs and challenge Prime Boost Cell-mediated Humoral route Colon– Blood Serum Rectal Vaginal rectum IgG IgA IgA Adenovirus–SIV SIV gp120 (with MPL) SIVmac251 82 Nasal plus oral, then Intramuscular Rectal ND +++ ++++ +/– _ +|| intratracheal Attenuated SHIV None SHIV89.6P 61 Nasal Rectal ND + ++++ + + ++ Intravenous Rectal ND _ ++++ __ +/– Poliovirus1–SIV Poliovirus2–SIV SIVmac251 99 Nasal Nasal Vaginal ND +/– ++++ ++ ++ + SIV p55 particles SIV p55 particles None 57, 121 (with cholera toxin) (with cholera toxin) Oral Oral ND ++ ++++ +++ _ NA Nasal Nasal ++¶ ++ ++++ +++ ++ NA HIV gp140 gp140 and p55 None 122 (with mLT) (with MF-59) Nasal Intramuscular ND ++ ++++ +/– ++++ NA HIV/SIV peptides HIV/SIV peptides SHIVKu2 92 Rectal (with mLT) Rectal (with mLT) Rectal +++ ++ NA NA NA ++++ Subcutaneous Subcutaneous Rectal ND ++ NA NA NA + (with Montanide 51) (with Montanide 51) DNA–SIV particles DNA–SIV particles SIVmac251 123 Intradermal Intradermal Rectal ND ++ + +/– NA ++ Intradermal plus rectal Intradermal plus rectal Rectal ND +/– +/– +++ NA ++ Intradermal plus rectal Intradermal plus rectal Rectal ND +/– ++ +/– NA None plus intramuscular plus intramuscular DNA–SHIV particles MVA–SHIV SHIV89.6P 94 (with DNA encoding IL-2–Ig fusion protein) Nasal Nasal Rectal +++ +++ +/– + NA +++ *Vaccine adjuvants are indicated in parentheses. ‡Immune responses are measured before challenge. These responses are based on median post-vaccination increases of: ++++, 25–100-fold; +++, 10–24.9-fold; ++, 5–9.9-fold; +, 2.5–4.9-fold in a majority of vaccine recipients; +/–, >2.5-fold in a minority of vaccine recipients; –, <2.5-fold in all vaccine recipients. In grading cellular immune responses, the results of all T-cell assays were considered. §Based on the percentage of vaccinated animals that showed a lack of disease progression after challenge and reduction in plasma viraemia with sustained control. None, <20%; +/–, 20–39%; +, 40–59%; ++, 60–79%; +++, 80–99%; ++++, 100%. ||This vaccine has induced sterilizing immunity in some animals. ¶In the small-intestinal lamina propria. Ig, immunoglobulin; IL-2, interleukin-2; mLT, mutant form of Escherichia coli heat-labile enterotoxin; MPL, monophosphoryl lipid A; MVA, modified vaccinia virus Ankara; NA, not applicable; ND, not determined; p55, HIV gag protein; SHIV, chimeric SIV with HIV envelope proteins; SIV, simian immunodeficiency virus.

was found to prevent disease after vaginal challenge attenuated SIV96,97, which induces antiviral CTLs in the with a heterologous pathogenic virus (SHIV89.6P)61. rectal and genital tract mucosa because of its ability to Priming of macaques by nasal administration of DNA proliferate at these sites98. Live attenuated HIV is generally encoding non-replicating SHIV89.6P particles, followed considered to be too risky for use as a human vaccine, but by boosting by nasal administration of modified vaccinia studies in monkeys have shown the advantages of using virus Ankara (MVA) expressing SHIV proteins, induced other live vectors for stimulating mucosal immunity greater percentages of SHIV-specific CD8+ T cells in (TABLE 2). For example, mucosally administered, recombi- the rectum than in the blood and afforded significant nant SIV-expressing adenoviruses have been effective in protection against rectal challenge with SHIV89.6P94. preventing rectal transmission of highly pathogenic SIV In other studies, DNA-vaccine-mediated induction of in macaques, perhaps because adenovirus can replicate in SIV-specific CTLs (and antibodies) in the rectal mucosa intestinal tissues82. Nasal administration of vaccines, such was associated with protection against rectal challenge as live non-pathogenic SHIVs or poliovirus that expresses with heterologous virus95. SIV proteins in macaques, provided significant protection Until now, the greatest success in preventing mucosal against mucosal SHIV or SIV transmission61,99. Although transmission of immunodeficiency viruses has been these data do not establish which of these various vac- achieved through the vaccination of macaques with live cine strategies is best, they have exploited our current

REVIEWS

knowledge about the regional nature of mucosal immune HIV–galactosylceramide interaction, but not by CD4- responses and have shown the protective potential of specific antibodies107–110. mucosal vaccines against HIV. Clinical studies have sought to identify correlates of mucosal protection in humans (BOX 1). In several cohorts Secretory antibodies and protection against HIV. of HIV-uninfected people who were repeatedly exposed Prevention of HIV infection will clearly require specific to HIV through sexual intercourse, resistance to infection antibodies100. HIV-specific serum antibodies might neu- was associated with serum and secretory IgA antibodies tralize virus that has entered mucosal tissues by blocking directed against the coiled-coil pocket region of gp41 the attachment and/or entry of virus to target cells100,101. (REF. 111). Although a few HIV-specific vaccines have been On mucosal surfaces, secreted HIV-specific antibod- administered mucosally in human trials, so far none of ies could provide an additional layer of protection by these vaccines has resulted in measurable concentrations preventing virus from contacting mucosal surfaces, of HIV-specific secretory IgA112. However, it is important adhering to epithelial cells or crossing the epithelial to note that these vaccines were not specifically designed barrier6. Indeed, large doses of vaginally administered for mucosal application, and the lack of mucosal immune gp120-specific monoclonal antibodies (denoted as b12) response could be attributed to poor internalization of the prevented vaginal SHIV transmission in macaques102. vaccine at mucosal surfaces, the presence of pre-existing A few mucosally administered vaccines have elicited immunity against the vaccine vector used, and/or the lack mucosal IgA antibodies in macaques (TABLE 2). However, of effective mucosal adjuvants. the potential role of vaccine-induced secretory antibodies in protection against HIV or SIV has yet to be Concluding remarks adequately tested. Meanwhile, studies using cultured Much has been learned from animal studies about the monolayers of polarized epithelial cells have provided attributes of effective mucosal vaccines and the immune information about the interactions of HIV and HIV- effectors that could function together to prevent and infected cells with epithelial barriers and the specific control mucosal transmission of HIV and other muco- antibodies capable of blocking these interactions. For sally transmitted diseases. The current challenge is to adhering to mucosal surfaces, HIV uses receptors on apply this knowledge to vaccine design and to carry out epithelial cells that are distinct from the CD4 receptor– collaborative, comparative clinical trials that system- chemokine co-receptor pairs that are required for the atically monitor all parameters of the immune response infection of target mononuclear cells. Although apical — humoral and cellular, mucosal and systemic — in surfaces of epithelial cells in the rectum and female geni- serum, local secretions and mucosal tissues. Available tal tract might contain the chemokine co-receptors CCR5 data indicate that mucosal HIV vaccines should be par- and CXC-chemokine receptor 4 (CXCR4) that might ticulate or live vectored, include components that alert facilitate HIV transport103, they are CD4 negative104. the innate immune system, and include immunogenic, However, epithelial-cell membranes contain galacto- conserved forms of the envelope protein gp41 as well as sylceramide, a glycolipid that is recognized by a conserved gp120. Mucosal HIV vaccines would ideally be adminis- region in the tip of the V3 loop of HIV gp120 (REF. 105) tered as part of a prime–boost strategy that induces both and by a highly conserved region (amino acids 650–668) mucosal and systemic immunity. Much work remains in the gp41 ectodomain106. Transepithelial transport to be done, but current research continues to clarify the of HIV across cultured epithelia was inhibited by gp120- concepts and provide the tools that are needed to exploit specific or gp41-specific antibodies that prevented the the full potential of mucosal vaccines.

1. Levine, M. M. Immunization against bacterial 9. Brandtzaeg, P. et al. Regional specialization microflora by Toll-like receptors is required for diseases of the intestine. J. Pediatr. Gastroenterol. in the mucosal immune system: what happens in the intestinal homeostasis. Cell 118, 229–241 (2004). Nutr. 31, 336–355 (2000). microcompartments? Immunol. Today 20, 141–151 Recent evidence that TLR-mediated responses 2. Lamm, M. E. Interactions of antigens and antibodies (1999). to non-pathogenic bacteria in the gut prevent local at mucosal surfaces. Annu. Rev. Microbiol. 51, 10. van Egmond, M. et al. IgA and the IgA Fc receptor. inflammation and are required for maintenance 311–340 (1997). Trends Immunol. 22, 205–211 (2001). of a healthy epithelial barrier. 3. Modlin, J. F. Poliomyelitis in the United States: 11. Kagnoff, M. F. & Eckmann, L. Epithelial cells as 15. Backhed, F., Ley, R. E., Sonnenburg, J. L., the final chapter? JAMA 292, 1749–1751 sensors for microbial infection. J. Clin. Invest. Peterson, D. A. & Gordon, J. I. Host-bacterial (2004). 100, S51–S55 (1997). mutualism in the human intestine. Science 307, 4. Kapikian A. Z. et al. Efficacy of a quadrivalent rhesus 12. Izadpanah, A., Dwinell, M. B., Eckmann, L., 1915–1920 (2005). rotavirus-based human rotavirus vaccine aimed Varki, N. M. & Kagnoff, M. F. Regulated MIP-3α/ A fascinating overview of our long and intimate at preventing severe rotavirus diarrhea in infants CCL20 production by human intestinal epithelium: symbiotic relationship with commensal intestinal and young children. J. Infect. Dis. 174, S65–S72 mechanism for modulating mucosal immunity. bacteria. (1996). Am. J. Physiol. Gastroint. Liver Physiol. 280, 16. Kozlowski, P. A., Cu-Uvin, S., Neutra, M. R. & 5. Belshe, R. B. et al. The efficacy of live attenuated, G710–G719 (2001). Flanigan, T. P. Comparison of the oral, rectal, cold-adapted, trivalent, intranasal influenza virus One of a series of studies by this group, and vaginal immunization routes for induction of vaccine in children. N. Engl. J. Med. 338, 1405–1412 documenting the signals produced by epithelial antibodies in rectal and genital tract secretions (1998). cells in response to microorganisms and their of women. Infect. Immun. 65, 1387–1394 (1997). 6. Kozlowski, P. A. & Neutra, M. R. The role of mucosal products. 17. Kozlowski, P. A. et al. Differential induction of mucosal immunity in prevention of HIV transmission. Curr. Mol. 13. MacDonald, T. T. & Monteleone, G. Immunity, and systemic antibody responses in women after nasal, Med. 3, 217–228 (2003). inflammation and allergy in the gut. Science rectal, or vaginal immunization: influence of the 7. Belyakov, I. M. & Berzofsky, J. A. Immunobiology of 307, 1920–1925 (2005). menstrual cycle. J. Immunol. 169, 566–574 (2002). mucosal HIV infection and the basis for development A timely review of the basic cellular mechanisms A detailed description of methods for analysis of of a new generation of mucosal AIDS vaccines. underlying common gastrointestinal diseases antibodies in human secretions, and the influence Immunity 20, 247–253 (2004). that are associated with dysfunction of the mucosal of vaccination site on local antibody production. 8. Neutra, M. R. & Kraehenbuhl J. P. in Mucosal immune system. 18. Mestecky, J., Moro, I., Kerr, M. A. & Woof, J. M. in Immunology 3rd edn (eds Ogra, P. L. et al.) 14. Rakoff-Nahoum, S., Pagliano, J., Esalmi-Varzaneh, F., Mucosal Immunology, 3rd edn (eds Ogra, P. L. et al.) 111–130 (Academic Press, San Diego, 2005). Edberg, S. & Medzhitov, R. Recognition of commensal 153–182 (Academic Press, San Diego, 2005).

REVIEWS

19. Kaetzel, C. S., Robinson, J. K., Chintalacharuvu, K. R., 39. Shreedhar, V. K., Kellsall, B. L. & Neutra, M. R. 60. Egan, M. A. et al. Immunogenicity of attenuated Vaerman, J. P. & Lamm, M. The polymeric Cholera toxin induces migration of dendritic cells vesicular stomatitis virus vectors expressing HIV immunoglobulin receptor (secretory component) from the sub-epithelial dome region to T and B cell type 1 Env and SIV Gag proteins: comparison of mediates transport of immune complexes across areas of Peyer’s patches. Infect. Immun. 71, 504–509 intranasal and intramuscular vaccination routes. epithelial cells: a local defense function for IgA. (2003). AIDS Res. Hum. Retroviruses 20, 989–1004 (2004). Proc. Natl Acad. Sci. USA 88, 8796–8800 (1991). 40. Iwasaki, A. & Kelsall, B. Unique functions of CD11b+, 61. Enose, Y. et al. Protection by intranasal immunization 20. Hutchings, A. B., Helander, A., Silvey, K. J., CD8α+, and double negative Peyer’s patch dendritic of a nef-deleted, nonpathogenic SHIV against Lucas, W. T. & Neutra, M. R. Secretory IgA antibodies cells. J. Immunol. 166, 4884–4890 (2001). intravaginal challenge with a heterologous pathogenic against the σ1 outer capsid protein of reovirus type 1 41. MacPherson, G. G. & Liu, L. M. Dendritic cells and SHIV. Virology 298, 306–316 (2002). Lang prevent infection of mouse Peyer’s patches. Langerhans cells in the uptake of mucosal antigens. 62. Belyakov, I. M. et al. Mucosal immunization with J. Virol. 78, 947–957 (2004). Curr. Top. Microbiol. Immunol. 236, 33–53 (1999). HIV-1 peptide vaccine induces mucosal and systemic 21. Robinson, J. K., Blanchard, T. G., Levine, A. D., 42. Holt, P. G., Schon-Hegrad, M. A. & McMenamin, P. G. cytotoxic T lymphocytes and protective immunity Emancipator, S. N. & Lamm, M. E. A mucosal Dendritic cells in the respiratory tract. Int. Rev. in mice against intrarectal recombinant HIV-vaccinia IgA-mediated excretory immune system in vivo. Immunol. 6, 139–149 (1990). challenge. Proc. Natl Acad. Sci. USA. 95, 1709–1714 J. Immunol. 166, 3688–3692 (2001). 43. Miller, C. J., McChesney, M. & Moore, P. F. (1998). 22. Black, K. P., Cummins, J. E. & Jackson, S. Serum Langerhans cells, macrophages and lymphocyte 63. Ryan, E. J., Daly, L. M. & Mills, H. G. Immunoregulators and secretory IgA from HIV-infected individuals subsets in the cervix and vagina of rhesus macaques. and delivery systems for vaccination by mucosal routes. mediate antibody-dependent cellular cytotoxicity. Lab. Invest. 67, 628–634 (1992). Trends Biotechnol. 19, 293–304 (2001). Clin. Immunol. Immunopathol. 81, 182–190 (1996). 44. Niess, J. H. et al. CX3CR1-mediated dendritic cell A review of mucosal adjuvants and strategies 23. Eriksson, K. et al. Specific-antibody-secreting cells in access to the intestinal lumen and bacterial clearance. to increase the uptake of antigens into mucosal the rectums and genital tracts of nonhuman primates Science 307, 254–258 (2005). tissues. following vaccination. Infect. Immun. 66, 5889–5896 Identification of a novel mechanism for migration 64. Jones, B. D., Ghori, N. & Falkow, S. Salmonella (1998). of DCs into the intestinal epithelium. typhimurium initiates murine infection by penetrating 24. Kutteh, W. H., Mestecky, J. & Wira, C. R. in 45. Fagarasan, S. & Honjo, T. Intestinal IgA synthesis: and destroying the specialized epithelial M cells of Mucosal Immunology, 3rd edn (eds Ogra, P. L. et al.) regulation of front-line body defences. Nature Rev. the Peyer’s patches. J. Exp. Med. 180, 15–23 1631–1646 (Academic Press, San Diego, 2005). Immunol. 3, 63–72 (2003). (1994). 25 Parr, E. L. & Parr, M. B. Immunoglobulin G is the main Evidence for a mechanism whereby local IgA 65. Sicinski, P. et al. Poliovirus type 1 enters the human protective antibody in mouse vaginal secretions after production can be rapidly increased during a host through intestinal M cells. Gastroenterology vaginal immunization with attenuated herpes simplex mucosal memory response. 98, 56–58 (1990). virus type 2. J. Virol. 71, 8109–8115 (1997). 46. Mayer, L. & Shao L. Therapeutic potential of 66. Seong, S. Y., Cho, N. H., Kwon, I. C. & Jeong, S. Y. 26. Kozlowski, P. A. et al. Modified wick method using oral tolerance. Nature Rev. Immunol. 4, 407–419 Protective immunity of microsphere-based mucosal Weck-Cel sponges for collection of human rectal (2004). vaccines against lethal intranasal challenge with secretions and analysis of mucosal HIV antibody. 47. Belyakov, I. M., Hammond, S. A., Ahlers, J. D., Streptococcus pneumoniae. Infect. Immun. 67, J. Acquir. Imm. Defic. Syndr. 24, 297–309 (2000). Glenn, G. M. & Berzofsky, J. A. Transcutaneous 3587–3592 (1999). 27. Yoshida, M. et al. Human neonatal Fc receptor immunization induces mucosal CTLs and protective 67. Baca-Estrada, M. E., Foldvari, M., Babiuk, S. L. & mediates transport of IgG into luminal secretions immunity by migration of primed skin dendritic cells. Babiuk, L. A. Vaccine delivery: lipid-based delivery for delivery of antigens to mucosal dendritic cells. J. Clin. Invest. 113, 998–1007 (2004). systems. J. Biotechnol. 83, 91–104 (2000). Immunity 20, 769–783 (2004). Some nice detective work explaining how 68. Chabot, S. et al. A novel intranasal Protollin-based 28. Mantis, N. J. et al. Selective adherence of immunization through the skin can result in measles vaccine induces mucosal and systemic immunoglobulin A to murine Peyer’s patch M Cells: mucosal immune responses. neutralizing antibody responses and cell-mediated evidence for a novel IgA receptor. J. Immunol. 48. Kunkel, E. J. & Butcher, E. C. Plasma-cell homing. immunity in mice. Vaccine 23, 1374–1383 (2005). 169, 1844–1851 (2002). Nature Rev. Immunol. 3, 822–829 (2003). 69. McNeela, E. A. et al. A mucosal vaccine against 29. Corthesy, B. et al. A pathogen-specific epitope 49. Mora, J. R. et al. Selective imprinting of gut-homing diptheria: formulation of crossreacting material inserted into recombinant secretory immunoglobulin T cells by Peyer’s patch dendritic cells. Nature 424, (CRM97) of diptheria toxin with chitosan enhances

is immunogenic by the oral route. J. Biol. Chem. 88–93 (2003). local and systemic antibody and TH2 responses 52, 33670–33677 (1996). 50. Mestecky, J. The common mucosal immune system following nasal delivery. Vaccine 19, 1188–1198 30. Belyakov, I. M. et al. The importance of local and current strategies for induction of immune (2000). mucosal HIV-specific CD8+ cytotoxic T lymphocytes responses in external secretions. J. Clin. Immunol. 70. Frey, A. et al. Role of the glycocalyx in regulating for resistance to mucosal viral transmission in mice 7, 265–276 (1987). access of microparticles to apical plasma membranes and enhancement of resistance by local administration 51. Hieshima, K. et al. CC chemokine ligands 25 and of intestinal epithelial cells: implications for microbial of IL-12. J. Clin. Invest. 102, 2072–2081 (1998). 28 play essential roles in intestinal extravasation attachment and oral vaccine targeting. J. Exp. Med. 31. Veazey, R. S. & Lackner, A. A. Getting to the guts of IgA antibody-secreting cells. J. Immunol. 173, 184, 1045–1060 (1996). of HIV pathogenesis. J. Exp. Med. 200, 697–700 3668–3675 (2004). 71. Mantis, N. J., Frey, A. & Neutra, M. R. Accessibility (2004). 52. Lindholm, C., Naylor, A., Johansson, E. L. of glycolipid and oligosaccharide epitopes on rabbit A review of the predilection of HIV and SIV for the Quiding-Jarbrink, M. Mucosal vaccination increases villus and follicle-associated epithelium. Am. J. Physiol. intestinal mucosa and implications for pathogenesis endothelial expression of mucosal addressin cell Gastrointest. Liver Physiol. 278, G915–G923 (2000). and vaccines. adhesion molecule 1 in the human gastrointestinal 72. Choi, W. S., Pal-Ghosh, R. & Morrow, C. D. Expression 32. Brenchley, J. M. et al. CD4+ T cell depletion during tract. Infect. Immun. 7, 1004–1009 (2004). of human immunodeficiency virus type 1 (HIV-1) gag, all stages of HIV disease occurs predominantly in the 53. Stagg, A. J., Kamm, M. A. & Knight, S. C. pol, and env proteins from chimeric HIV-1-poliovirus gastrointestinal tract. J. Exp. Med. 200, 749–759 Intestinal dendritic cells increase T cell expression minireplicons. J. Virol. 65, 2875–2883 (1991). α β (2004). of 4 7 integrin. Eur. J. Immunol. 32, 1445–1454 73. Tacket, C. O., Sztein, M. B., Losonsky, G. A., 33. O’Leary, A. D. & Sweeney, E. C. Lymphoglandular (2002). Wasserman, S. S. & Estes, M. K. Humoral, mucosal, complexes of the colon: structure and distribution. 54. Haddad, W. et al. P-selectin and P-selectin and cellular responses to oral Norwalk virus-like Histopathology 10, 267–283 (1986). glycoprotein ligand 1 are major determinants for particles in volunteers. Clin. Immunol. 108, 241–247

34. Neutra, M. R., Mantis, N. J. & Kraehenbuhl, J.-P. TH1 cell recruitment to nonlymphoid effector sites (2003). Collaboration of epithelial cells with organized in the intestinal lamina propria. J. Exp. Med. 198, 74. Haneberg, B., Herland Berstad, A. K. & Holst, J. mucosal lymphoid tissues. Nature Immunol. 369–377 (2003). Bacteria-derived particles as adjuvants for 2, 1004–1009 (2001). 55. Qimron, U. et al. Non-replicating mucosal and non-replicating nasal vaccines. Adv. Drug Deliv. 35. Cook, D. N. et al. CCR6 mediates dendritic cell systemic vaccines: quantitative and qualitative Rev. 51, 143–147 (2001). localization, lymphocyte homeostasis, and immune differences in the Ag-specific CD8+ T cell population 75. Elson, C. O. & Dertzbaugh, M. T. Mucosal adjuvants. responses in mucosal tissue. Immunity 12, 495–503 in different tissues. Vaccine 22, 1390–1394 (2004). in Mucosal Immunology 3rd Edn. (eds Ogra, R. et al.) (2000). 56. Staats, H. F., Montgomery, S. P. & Palker, T. J. 967–986 (Academic Press, New York, 2005). 36. Iwasaki, A. & Kelsall, B. L. Localization of distinct Intranasal immunization is superior to vaginal, gastric, 76. van Ginkel, F. W., Jackson, R. J., Yuki, Y. & Peyer’s patch dendritic cell subsets and their or rectal immunization for induction of systemic and McGhee, J. R. The mucosal adjuvant cholera toxin recruitment by chemokines macrophage inflammatory mucosal anti-HIV antibody responses. AIDS Res. Hum. redirects vaccine proteins into olfactory tissues. protein (MIP)-3α, MIP-3β, and secondary lymphoid Retroviruses 13, 945–952 (1997). J. Immunol. 165, 4778–4782 (2000). organ chemokine. J. Exp. Med. 191, 1381–1394 57. Imaoka, K. et al. Nasal immunization of nonhuman 77. Mutsch, M. et al. Use of the inactivated intranasal (2000). primates with simian immunodeficiency virus p55gag influenza vaccine and the risk of Bell’s palsy in

An excellent analysis of the DCs of Peyer’s and cholera toxin adjuvant induces TH1/TH2 help for Switzerland. N. Engl. J. Med. 350, 896–903 patches, and their functions in the specialized virus-specific immune responses in reproductive (2004). microcompartments within organized mucosal tissues. J. Immunol. 161, 5952–5958 (1998). 78. Lycke, N. From toxin to adjuvant: basic mechanisms lymphoid tissues. 58. Rudin, A., Riise, G. & Holmgren, J. Antibody for the control of mucosal IgA immunity and tolerance. 37. Zhao, X. et al. CCL9 is secreted by the follicle- responses in the lower respiratory tract and male Immunol. Lett. 97, 193–198 (2005). associated epithelium and recruits dome region urogenital tract in humans after nasal and oral A review of the promise and problems of bacterial Peyer’s patch CD11b+ dendritic cells. J. Immunol. vaccination with cholera toxin B subunit. Infect. enterotoxins as mucosal adjuvants, and description 171, 2797–2803 (2003). Immun. 67, 2884–2890 (1999). of a new approach. 38. Hopkins, S. A., Niedergang, F., Corthesy-Theulaz, I. E. 59. Gallichan, W. S. & Rosenthal, K. L. Long-term 79. Belyakov, I. M., Ahlers, J. D., Clements, J. D., & Kraehenbuhl, J. P. A recombinant Salmonella immunity and protection against herpes simplex virus Strober, W. & Berzofsky, J. A. Interplay of cytokines typhimurium vaccine strain is taken up and survives type 2 in the murine female genital tract after mucosal and adjuvants in the regulation of mucosal and within murine Peyer’s patch dendritic cells. Cell. but not systemic immunization. J. Infect. Dis. 177, systemic HIV-specific CTL. J. Immunol. 165, Microbiol. 2, 59–68 (2000). 1155–1161 (1998). 6454–6462 (2000).

REVIEWS

80. Gallichan, W. S. et al. Intranasal immunization 96. Nilsson, C. et al. Live attenuated simian 113. McDermott, A. B. et al. Repeated low-dose mucosal with CpG oligodeoxynucleotides as an adjuvant immunodeficiency virus (SIV)mac in macaques can simian immunodeficiency virus SIVmac239 challenge dramatically increases IgA and protection against induce protection against mucosal infection with results in the same viral and immunological kinetics herpes simplex virus-2 in the genital tract. SIVsm. AIDS 12, 2261–2270 (1998). as high-dose challenge: a model for the evaluation J. Immunol. 166, 3451–3457 (2001). 97. Tenner-Racz, K. et al. Early protection against of vaccine efficacy in nonhuman primates. J. Virol. 81. McSorley, S. J., Ehst, B. D., Yu, Y. & Gewirtz, A. T. pathogenic virus infection at a mucosal challenge 78, 3140–3144 (2004). Bacterial flagellin is an effective adjuvant for site after vaccination with attenuated simian 114. Wassén, L., Schön, K., Holmgren, J., Jertborn, M. & CD4+ T cells in vivo. J. Immunol. 169, 3914–3919 immunodeficiency virus. Proc. Natl Acad. Sci. USA Lycke, N. Local intravaginal vaccination of the female (2002). 101, 3017–3022 (2004). genital tract. Scand. J. Immunol. 44, 408–414 82. Malkevitch, N. & Robert-Guroff, M. A call for 98. Cromwell M. A. et al. Induction of mucosal homing (1996). replicating vector prime-boost strategies in HIV virus-specific CD8+T lymphocytes by attenuated 115. Rudin, A., Johansson, E.-L., Bergquist, C. & vaccine design. Expert Rev. Vaccines 4, S105–S117 simian immunodeficiency virus. J. Virol. 74, Holmgren, J. Differential kinetics and distribution (2004). 8762–8766 (2000). of antibodies in serum and nasal and vaginal An extensive review of studies using live and 99. Crotty, S. et al. Protection against simian immuno- secretions after nasal and oral vaccination of non-living viral and bacterial vectors, and various deficiency virus vaginal challenge by using Sabin humans. Infect. Immun. 66, 3390–3396 (1998). systemic and mucosal vaccine strategies, to induce poliovirus vectors. J. Virol. 75, 7435–7452 (2001). 116. Quiding, M. et al. Intestinal immune responses anti-HIV immune responses in monkeys. This paper reports the exploitation of a viral vector in humans: oral cholera vaccination induces strong 83. Lemiale, F. et al. Enhanced mucosal immunoglobulin A that naturally invades organized mucosal lymphoid intestinal antibody responses and interferon-γ response of intranasal adenoviral vector human tissues to deliver SIV genes and induce partial production and evokes immunological memory. immunodeficiency virus vaccine and localization in the protection against subsequent mucosal challenge. J. Clin. Invest. 88, 143–148 (1991). central nervous system. J. Virol. 77, 10078–10087 100. Burton, D. R. Antibodies, viruses, and vaccines. 117. Kantele, A. et al. Differences in immune (2003). Nature Rev. Immunol. 2, 706–713 (2002). responses induced by oral and rectal immunizations 84. Milman, G. & Sharma, 0. Mechanisms of HIV/SIV A thorough discussion of the potential importance with Salmonella typhi Ty21a: evidence for mucosal transmission. AIDS Res. Human Retroviruses of antibodies and their mechanisms of action in compartmentalization within the common mucosal 10, 1305–1312 (1994). prevention and control of HIV. immune system in humans. Infect. Immun. 66, 85. Amerongen, H. M. et al. Transepithelial transport 101. Parren, P. W. H. I. et al. Antibody protects macaques 5630–5635 (1998). of HIV-1 by intestinal M cells: a mechanism for against vaginal challenge with a pathogenic R5 118. Forrest, B. D., Shearman, D. J. C. & LaBrooy, J. T. transmission of AIDS. J. Acquir. Immune Defic. simian/human immunodeficiency virus at serum Specific immune responses in humans following Syndr. 4, 760–765 (1991). levels giving complete neutralization in vitro. delivery of live typhoid vaccine. Vaccine 8, 209–212 86 Hu, J., Gardner, M. B. & Miller, C. J. Simian J. Virol. 75, 8340–8347 (2001). (1990). immunodeficiency virus rapidly penetrates the 102. Veazey, R. S. et al. Prevention of virus transmission to 119. Ogra, P. L. & Karzon, D. T. Distribution of poliovirus cervicovaginal mucosa after intravaginal inoculation macaque monkeys by a vaginally applied monoclonal antibody in serum, nasopharynx and alimentary tract and infects intraepithelial dendritic cells. J. Virol. 74, antibody to HIV-1 gp120. Nature Med. 9, 1–4 (2003). following segmental immunization of lower alimentary 6087–6095 (2000). 103. Fotopoulos, G. et al. Transepithelial transport of HIV-1 tract with poliovaccine. J. Immunol. 102, 1423–1430 87. Fujimura, Y. Evidence of M cells as portals of entry by M cells is receptor mediated. Proc. Natl Acad. Sci. (1969). for antigens in the nasopharyngeal lymphoid tissue USA 99, 9410–9414 (2002). 120. Ogra, P. L. & Ogra, S. S. Local antibody response of humans. Virchows Arch. 436, 560–566 (2000). 104. Janoff, E. N. & Smith, P. D. Emerging concepts in to poliovaccine in the human female genital tract. 88. Spira, A. I. et al. Cellular targets of infection and gastrointestinal aspects of HIV-1 pathogenesis and J. Immunol. 110, 1307–1311 (1973). route of viral dissemination after an intravaginal management. Gastroenterology 120, 607–621 121. Kubota, M. et al. Oral immunization with simian inoculation of simian immunodeficiency virus into (2001). immunodeficiency virus p55gag and cholera toxin elicits rhesus macaques. J. Exp. Med. 183, 215–225 105. Fantini, J. et al. Synthetic and soluble analogues of both mucosal IgA and systemic IgG immune responses (1996). galactosylceramide (GalCer) bind to the V3 domain in nonhuman primates. J. Immunol. 158, 5321–5329 89. Zhang, Z.-Q. et al. Sexual transmission and of HIV-1 gp120 and inhibit HIV-1-induced fusion and (1997). propagation of SIV and HIV in resting and activated entry. J. Biol. Chem. 272, 7245–7252 (1997). 122. Vajdy, M. et al. Mucosal and systemic anti-HIV CD4+ T cells. Science 286, 1353–1357 (1999). 106. Alfsen, A. & Bomsel, M. HIV-1 gp41 envelope residues responses in rhesus macaques following combinations 90. Mazzoli, S. et al. HIV-specific mucosal and cellular 650–685 exposed on native virus act as a lectin to of intranasal and parenteral immunizations. AIDS Res. immunity in HIV-seronegative partners of HIV- bind epithelial cell galactosyl ceramide. J. Biol. Chem. Hum. Retroviruses 20, 1269–1281 (2004). seropositive individuals. Nature Med. 3, 1250–1257 277, 25649–25659 (2002). 123. Wang, S.-W. et al. Effective induction of simian (1997). 107. Bomsel, M. Transcytosis of infectious human immunodeficiency virus-specific systemic and 91. Kaul R. et al. New insights into HIV-1 specific cytotoxic immunodeficiency virus across a tight human epithelial mucosal immune responses in primates by T-lymphocyte responses in exposed, persistently cell line barrier. Nature Med. 3, 42–47 (1997). vaccination with proviral DNA producing intact seronegative Kenyan sex workers. Immunol. Lett. 108. Alfsen, A., Iniguez, P., Bouguyon, E. & Bomsel, M. but noninfectious virions. J. Virol. 74, 10514–10522 79, 3–13 (2001). Secretory IgA specific for a conserved epitope on gp41 (2000). 92. Belyakov, I. M. et al. Mucosal AIDS vaccine reduces envelope glycoprotein inhibits epithelial transcytosis disease and viral load in gut reservoir and blood of HIV-1. J. Immunol. 166, 6257–6265 (2001). Acknowledgements after mucosal infection of macaques. Nature Med. 109. Hocini, H. et al. High-level ability of secretory IgA to The authors’ laboratories are supported by National Institutes 7, 1320–1326 (2001). block HIV type 1 transcytosis: contrasting secretory of Health (NIH) research grants HDI7557 and AI58896, and 93. Mäkitalo, B. et al. Enhanced cellular immunity and IgA and IgG responses to gp160. AIDS Res. Hum. by NIH Center grant DK34854. systemic control of SHIV infection by combined Retroviruses 13, 1179–1185 (1997). parenteral and mucosal administration of a DNA 110. Matoba, N. et al. A mucosally targeted subunit Competing interests statement prime MVA boost vaccine regimen. J. Gen. Virol. vaccine candidate eliciting HIV-1 transcytosis- The authors declare no competing financial interests. 85, 2407–2419 (2004). blocking antibodies. Proc. Natl Acad. Sci. USA 94. Bertley, F. M. N. et al. Control of simian/human 101, 13584–13589 (2004). immunodeficiency virus viremia and disease 111. Clerici, M. et al. Serum IgA of HIV-exposed uninfected DATABASES progression after IL-2-augmented DNA-modified individuals inhibit HIV through recognition of a region The following terms in this article are linked online to: vaccinia virus ankara nasal vaccination in nonhuman within the α-helix of gp41. AIDS 16, 1731–1741 Entrez Gene: http://www.ncbi.nlm.nih.gov/entrez/query. primates. J. Immunol. 172, 3745–3757 (2004). (2002). fcgi?db=gene 95. Fuller, D. H. et al. Induction of mucosal protection 112. Wright, P. F. et al. Comparison of systemic and mucosal α β 4 7 | CCL9 | CCL20 | CCL28 | CCR1 | CCR5 | CCR6 | CCR10 | against primary, heterologous simian immunodeficiency delivery of 2 canarypox virus vaccines expressing CXCR4 | HIV | IL-12 | MADCAM1 virus by a DNA vaccine. J. Virol. 76, 3309–3317 either HIV-1 genes or the gene for rabies virus Access to this interactive links box is free online. (2002). G protein. J. Infect. Dis. 189, 1221–1231 (2004).

Multiple Immune Compartments • Peripheral lymph nodes and spleen • Adaptive immune response to antigen in blood • Peritoneum • Skin • Mucosal immune system (MALT) • Mucosa is exposed to billions of foreign antigens • Must protect against invading pathogens Lymphocytes have tissue-specific (compartment-specific) homing receptors

Challenge for the Mucosal Immune System:

• Distinguish between foreign antigens such as food (no response) and pathogenic organisms (respond)

• In the context of 1014 commensal bacteria

1 2/7/2012

Basketball court = 400 m2

Mucosal Tissues (MALT) • Gastrointestinal tract (GALT) • Respiratory tract (BALT) • Nasal mucosa (NALT) • Salivary glands • Lacrimal glands • Mammary glands • Genito-urinary tract

2 2/7/2012

Intestinal Lymphoid Tissues

Isolated lymphoid follicle

Mucosal Immunology(2008) 1, 31–37 10.1038/mi.2007.9

Intestinal IgA, CD4 T and CD8 T cells

Mucosal Immunology (2008) 1, 31–37 10.1038/mi.2007.9

70% to 80% of all Ig producing cells are in mucosal areas

…and most of these are IgA plasma cells

3 2/7/2012

Epithelium and Lamina Propria

Inductive vs Effector Sites

Induction of Mucosal Immune Response: Antigen taken-up by M cells

4 2/7/2012

Antigen can also be captured by Dendritic Cells

T cells in Peyer’s patches Become Activated and Migrate to Lamina Propria of Small Intestine

Lymphocytes Activated in Mucosa Home to Other Mucosal Sites

5 2/7/2012

Induction of Mucosal Immunity

Mucosal Immunology (2008) 1, 31–37 10.1038/mi.2007.9

Features of Mucosal Immunity:

• Ag at one mucosal sites Ab at a distant mucosal site • B cells in MALT selectively produce dimeric IgA • T cells, especially CTLs important • Mucosal immunity also results in systemic immunity

Intraepithelial Lymphocytes (IEL) (kill infected epithelial cells)

6 2/7/2012

IgA Deficiency

• 1 in 500 to 1000 persons

• Often no clinical symptoms

• Some with increased susceptibility to infection

STRUCTURE OF SECRETORY IgA

IgA1

Secretory Component

IgA2 Secretory Component

Transport of IgA across the epithelium Figure 9-20

7 2/7/2012

IgA Function

sIgA in breast milk provides passive immmunity

The Potential of Oral (Mucosal) Immunization

Advantages: • Ease of Administration • Generate both mucosal and systemic immunity Disadvantages: • Response may be short-lived • Difficult to elicit robust immune response - because of tolerance

Tolerance vs Immunity

• Food antigens result in tolerance • Pathogenic microorganisms lead to inflammation and immunity • Commensals – local induction of IgA antibodies that bind the microorganisms, thereby confining them to the lumen

8 2/7/2012

Protective Immunity vs Oral Tolerance

Mucosal (oral) Tolerance

Tolerance

Vaccination

Systemic provides no mucosal immunity

Mucosal provides both mucosal and systemic immunity

But, how to induce mucosal immunity in the tolerogenic environment? • Need to induce inflammation

9 2/7/2012

Mucosal Tolerance Mediated by Dendritic Cells

Commensal bacteria can prevent inflammatory responses in intestine

The Danger of Antibiotics

10 2/7/2012

Tipping the balance between sickness and health

Science (2005) 307:1914

11 Host Defense 2012 Small Group Problem Solving Sessions B-Cell Deficiency

HOST DEFENSE

SMALL GROUP PROBLEM SOLVING SESSION

B-CELL, T CELL, AND B&T CELL DEFICIENCIES Small Group Classrooms

LEARNING GOALS You will be able to identify the implication(s) of impaired/defective T & B-cell function.

To achieve this goal, you will be able to:

• Predict the clinical implications of antibody deficiency. • Predict the clinical implications of T cell deficiency. • Predict the clinical implications of a combined B & T cell deficiency • Develop appropriate therapeutic strategies for each type of defect

BACKGROUND READING Janeway: 470-478, 488-490 and Figs. 11.11 and 13.42. Do NOT memorize the Table 11.8! You will not be able to do Case #4 without reading the posted Science article on the Forum. DO NOT WORRY ABOUT THE TECHNICAL DETAILS IN THE ARTICLE-WORRY ABOUT THE CONCEPTS.

DEVELOPED BY John A. Robinson, MD

Rev 12/14/2010 Page 1 Host Defense 2012 Small Group Problem Solving Sessions B-Cell Deficiency For the remaining small groups, your room assignment may change. Changes will be posted on classroom doors and the lecture hall board.

HOW TO SUCCEED IN SMALL GROUPS

Before coming to class:

1. Read assigned chapters/ pages and develop answers for ALL the questions in the 4 clinical vignettes

During the Small Group Session:

2. Each small group (should be 4-5 peers- please do not sort yourselves into large groups-you will learn much less) should discuss the four case studies and decide the best solutions to the specific integrating questions associated with each case.

3. After approximately an hour of discussion by the subgroups, the facilitator will recapitulate the answers to the integrating questions by selecting a subgroup to present a synthesis of their relevant discussions to the entire group. Facilitators will select, at their discretion, a small group for the discussion of the individual cases.

4. History has shown that students who don’t contribute to the Small Groups do not do well in the Course (remember that about 25-30% of the final comes from small groups!) and also have been assaulted by their fellow group members

5. At the end of the session, a master answer sheet will be posted on the Host Defense website.

B- CELL, T CELL, AND B&T CELL DEFICIENCY STATES

Potential discussion areas for this group of questions can vary widely. B & T cell differentiation, antibody structure, receptors related to cellular function and potential points of intervention for therapy that include use of intact antibody (IVIg), cytokines, bone marrow replacement and gene therapy are topics of interest. They should have already read how to clinically recognize and diagnose B and T cell immunodeficiencies.

Rev 12/14/2010 Page 2 Host Defense 2012 Small Group Problem Solving Sessions B-Cell Deficiency

SPECIFIC INTEGRATING QUESTIONS THAT FACILITATORS NEED TO ADDRESS AT THE END OF THE SESSION:

1. How the clinical history and lab findings make it simple to recognize where the defect is?

2. How does specific antibody make the inflammatory response to bacteria more efficient?

3. Why is it important to know the physiology of B & T cell development and antibody production when trying to formulate a clinical solution to a specific deficiency?

4. Why is it important to remember that although things look ‘normal’ they may not be normal? Example: B cells in the common variable immunodeficiency case.

------

CASE 1 An eight month old male developed a fulminant bacterial pneumonia but survived after prolonged use of intensive intravenous antibiotic therapy. The nurses noted that the venous puncture sites where the lines for antibiotic therapy were placed rapidly became infected. This infant was the product of a normal, full term pregnancy and developed normally until this pneumonia occurred. A chest x-ray revealed the presence of thymus, pneumonia, and a curious absence of ‘tonsillar tissue’ Routine laboratory testing during his illness revealed the expected rise in neutrophil counts in his peripheral blood during this infection; but it was noted that the serum protein electrophoresis had almost no protein fraction migrating to the globulin range. A FACS (technique discussed in a previous small group) analysis of his lymphocytes is pending

This serum protein electropheresis is NORMAL. The patient’s wasn’t.

Rev 12/14/2010 Page 3 Host Defense 2012 Small Group Problem Solving Sessions B-Cell Deficiency

Faculty DX: X- linked agammaglobulinemia

1. Is the patient’s gender and isolated abnormal laboratory finding related to his severe infection? Are his future sisters at risk? Outline the rationale for ordering the serum protein electrophoresis, predict how it would differ from the normal above and discuss what CD markers should be included in the FACS analysis.

2. Why did this child do so well during the first eight months of life? Were his leukocytes (neutrophils), which appeared ‘normal’ in response to this infection, really functioning optimally now? 3. Recurrence of certain types of bacterial infections are important clues to several specific immunologic defects - discuss what defense mechanism(s) some bacteria use to escape killing by neutrophils and why they are relatively resistant to standard antibiotic therapy? 4. Once the specific B-cell defect known, what type of therapy may be lifesaving?

Case 2 A one month old female, the 7th child in the family, was noted to have a perforate nasal septum. The pediatrician, in an attempt to screen for associated upper respiratory tract congenital abnormalities, ordered several x-ray views of her throat, sinus and chest. An alert radiologist noted that there was neither thymus nor tonsillar shadows. Two weeks later the child developed a bacterial pneumonia and required admission and intensive antibiotic therapy. Six weeks later, she developed a severe disseminated fungal infection. Laboratory examination revealed that her white cell lineages (neutrophils, monocytes, basophils and eosinophils) were normal but there were no detectable lymphocytes in her peripheral blood. The child had a very slow response to aggressive anti-fungal therapy. Serum protein electrophoresis and FACS analysis of the child’s peripheral blood cells are pending.

DX: Severe combined immunodeficiency

1. a. Is the clinical observation that neutrophils, platelets were normal but her lymphocytes were markedly reduced in the peripheral blood helpful in suggesting where the actual defect in cell development in this patient might be? For help, look at the figure on p1791 of the posted New England journal Perspective article.

b. Predict and justify the results of the electrophoresis and FACS.

2. What studies on this patient’s lymphocytes could be done that might define the specific immune defects present? Set up a FACS analysis of aspirated bone marrow that could clarify

Rev 12/14/2010 Page 4 Host Defense 2012 Small Group Problem Solving Sessions B-Cell Deficiency where the defect might be.

3. This patient had no detectable B, T or NK cells. Using the figure on page 1791 of the New England J Medicine “perspective” article, predict the probable deficiency and the types of infections that would be found in this patient with a RAG-1 deficiency, a patient with a JAK- 3 deficiency and a patient with an adenosine deaminase (ADA) deficiency. The latter deficiency was found in our patient.

4. Why is identification of a specific immunopathologic defect and a specific immunologic diagnosis important for the child’s immediate treatment, prophylaxis and definitive therapy? Ten years later the patient was taking no medications, doing well in school and even thought Justin Bieber was “very cool”. Does this fortunate outcome have anything to do with being a member of a large family?

CASE 3 A twenty-three year old RN, an intravenous drug abuser, develops 3 episodes of acute bacterial pneumonia within three months. All episodes require hospitalization and intravenous antibiotics. She insists that she uses only her own needles (appropriated from her employer). She has several striking laboratory abnormalities: an elevated number of normal appearing lymphocytes in her peripheral blood, a normal number of neutrophils, but a very low serum total protein and an abnormal serum protein electrophoresis. A FACS analysis has already been done and it revealed a normal amount of CD3, 4 & CD3,8 lymphocytes and slightly elevated number of B cells. Unfortunately, the FACS operator forgot to set up the analysis for a subset of lymphoid cells in the peripheral blood.

1. The diagnosis seems straight forward-she has HIV infection (or does she)? If she does not have an AIDS related illness, where might the basic immune defect be?

2. The patient then suffered a ruptured spleen during a motor vehicle accident. The alert internist requested a pathologic report on the organ after its removal at surgery. What were the most likely immunohistologic findings?

3. She obviously does not have x-linked agammaglobulinemia. Where are the possible defects in her B-cell response sequence? Before you decide on the mechanism, you remember to ask for a repeat FACS analysis that will detect T regulator cells. What reagents would you want the technician to use? The repeat FACS shows that the % of T regs is triple the normal number! Postulate replacement strategies to ameliorate the immunodeficiency..

4. Ultimately this patient died of a lymphoma- a neoplasm of lymphoid tissue? Is this a surprising complication?

Rev 12/14/2010 Page 5 Host Defense 2012 Small Group Problem Solving Sessions B-Cell Deficiency CASE 4 A 26 month old male presented with almost the identical clinical and laboratory findings as the girl in Case #2. This child however was adopted, the father was unknown and the mother had been killed in a car accident. No siblings were known to exist.

1. How does the ill-starred, additional history about this child change your treatment strategies? Outline the possible ways if any that a cure might be possible.

2. After an extensive search of the national data base for potential bone marrow donors no suitable donor could be found. Gene therapy was then considered after a specific defect was found. Outline the technique(s) and rationale for the treatment modality. This can be found in the articles on the HD web site.

3. The child undergoes gene therapy and recovers. He does very well for three years and had no serious infections. Then, on a routine blood count, very high numbers of lymphocytes are found and the spleen is enlarged. Curiously, a very large proportion of the lymphocytes have a γδ T cell receptor. Convince your peers, and ultimately your facilitator, that you understand how this happened. You will only be able to do this if you read the posted article.

4. Be sure, as a group, you can discuss the pros and cons of gene therapy.

Rev 12/14/2010 Page 6