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Schistosomiasis Vaccines: Where Do We Stand? Biniam Mathewos Tebeje1,2,3*, Marina Harvie1, Hong You1, Alex Loukas4 and Donald P

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Schistosomiasis Vaccines: Where Do We Stand? Biniam Mathewos Tebeje1,2,3*, Marina Harvie1, Hong You1, Alex Loukas4 and Donald P Tebeje et al. Parasites & Vectors (2016) 9:528 DOI 10.1186/s13071-016-1799-4 REVIEW Open Access Schistosomiasis vaccines: where do we stand? Biniam Mathewos Tebeje1,2,3*, Marina Harvie1, Hong You1, Alex Loukas4 and Donald P. McManus1* Abstract Schistosomiasis, caused mainly by S. mansoni, S. haematobium and S. japonicum, continues to be a serious tropical disease and public health problem resulting in an unacceptably high level of morbidity in countries where it is endemic. Praziquantel, the only drug currently available for treatment, is unable to kill developing schistosomes, it does not prevent re-infection and its continued extensive use may result in the future emergence of drug-resistant parasites. This scenario provides impetus for the development and deployment of anti-schistosome vaccines to be used as part of an integrated approach for the prevention, control and eventual elimination of schistosomiasis. This review considers the present status of candidate vaccines for schistosomiasis, and provides some insight on future vaccine discovery and design. Keywords: Schistosoma mansoni, Schistosoma haematobium, Schistosoma japonicum, Immune response, Schistosomiasis, Vaccine, Immune protection, Antigen discovery Background is supplied regularly in timely fashion to all parts of an The World Health Organization (WHO) considers endemic area. schistosomiasis to be second only to malaria as the most Originally used as a major preventative measure [6], devastating parasitic disease in terms of socioeconomic snail control, through the use of molluscicides (e.g. importance and public health impact [1]. Human infec- niclosamide), is now not the recommended method in tion is due to three main species, namely Schistosoma isolation for the prevention of schistosomiasis [5]. In mansoni and S. japonicum which cause intestinal/hepatic order to control and finally eliminate schistosomiasis, a schistosomiasis [2, 3] and S. haematobium, which results vaccine will likely be a key component of an integrated in urinogenital disease [4]. approach (i.e. involving mass chemotherapy, targeted Human treatment with praziquantel (PZQ) is playing a mollusciciding, environmental modification, health educa- central role in the control and prevention of schistosom- tion, improved sanitation and vaccination). A transmission iasis, being the only effective drug currently available [5]. blocking vaccine for use in bovines could serve as a vital However, the drug does not prevent re-infection and its component in the control of S. japonicum [7], whereas exclusive use for the prevention and control of schisto- clinical vaccines against S. mansoni and S. haematobium somiasis is problematic; having been used for more than need to be developed. However, it is a sobering thought three decades, the emergence of PZQ-resistant schisto- that no commercial vaccine is available currently against somes is a constant threat. Other drawbacks with PZQ any of the human schistosomes, thereby emphasising the are its poor activity against immature schistosomes, need for continued efforts towards achieving this goal. resulting in sub-optimal outcomes during mass drug This review evaluates the current status of schistosome administration campaigns and, as its mechanism of vaccine development. action remains unclear, the design of alternative drug formulations has proven difficult [5]. Furthermore, a substantial infrastructure is required to ensure the drug Strategies for vaccine development Although complex, the schistosome life-cycle, with its various stages each expressing distinct antigens, provides * Correspondence: [email protected]; [email protected] 1QIMR Berghofer Medical Research Institute, Brisbane, Australia a vehicle for identifying many alternative molecules for Full list of author information is available at the end of the article vaccine development. The fact that the different stages © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tebeje et al. Parasites & Vectors (2016) 9:528 Page 2 of 15 reside in different host niches (larvae in the skin and tetraspanin (Sm-TSP-2) and S. haematobium glutathione lungs, adults in the liver and intestine or bladder capil- S-transferase (Sh28GST), have entered human clinical trials laries) can help in the design of possible vaccines to pre- with Smp80 (calpain) undergoing testing in non-human vent the migration of schistosome parasites and their primates [15]. maturation to adult worms. Importantly, the fact that A recent report has suggested that the murine model of schistosomes do not replicate in the definitive host makes schistosomiasis may be intrinsically flawed for pre-clinical partial reduction of the parasite burden sufficient to testing of vaccine candidates as a result of the fragility of control schistosomiasis, strengthening the argument for the pulmonary capillaries in mice which can prevent mat- developing an effective vaccine as a control intervention uration of a large proportion of schistosome cercariae [8]. When identifying a suitable vaccine candidate, it is upon challenge; this may lead to the incorrect assumption prudent to select key schistosome molecules in the live that vaccine antigen-induced acquired protective immun- parasite that are (a) exposed to the host immune system; ity has been generated [16]. This article has stimulated and (b) are essential for parasite survival. Such compo- vigorous debate and its conclusions require rigorous test- nents may, for example, function in migration, immune ing but, with this caveat, some of the S. mansoni and S. evasion, nutrient uptake or attachment. haematobium vaccine candidates that have been identified Adjuvant selection and mode of vaccine formulation are now highlighted below and in Table 1. and delivery are other important considerations in vaccine design and deployment as they can have a con- Sm14 siderable impact on the protective effectiveness of the Schistosomes lack an oxygen-dependent pathway for the vaccine. It is well known that, in contrast to attenuated synthesis of sterols and fatty acids. Therefore, they are en- cercarial vaccines, other types, such as subunit vaccines, tirely dependent on the mammalian host to provide these require an appropriate adjuvant to help stimulate the essential lipids. Schistosomes use fatty acid binding pro- immune system. A number of different adjuvants are teins (FABPs) to absorb, transport and compartmentalize available such as gels, emulsions, particulates, cytokines, fatty acids from the host and, because of this critical bio- microbial products (e.g. CpG, cholera toxin) and prote- logical function, Sm14 has long been considered a poten- ases. Adjuvants can overcome immune senescence in tial vaccine candidate [17]. Recombinant Sm14 (rSm14) older individuals, prolong the immunological memory of provided up to 67 % protection in terms of reduced a vaccine, broaden the antibody repertoire and direct the S. mansoni worm burden in outbred Swiss mice with- immune system to a Th1 biased, Th2 biased or mixed out the use of an adjuvant, and encouragingly, no auto- Th1/Th2 biased response [9]. For example, a Th1 driving immune response was observed even though its structure adjuvant such as IL-12, administered with irradiated is identical in basic form with mammalian host homo- cercariae, provided up to 90 % protection in murine logues [18]. It has been shown to be cross-species protec- schistosomiasis [10, 11]. Currently, in order to increase tive against both S. mansoni and Fasciola hepatica the protective efficacy of schistosome vaccines, a strategy infection. Development of a dual vaccine effective against of combining existing adjuvants with novel ones, deve- both fluke infections has great appeal in terms of human loped based on emerging immunological targets, has and animal health. Recombinant Sm14 with glucopyra- been muted [11]. nosyl lipid adjuvant stable emulsion (GLA-SE) adjuvant Some of the other challenges in schistosomiasis vaccine entered and successfully completed a phase 1 clinical trial development are the risk of an atopic IgE response to a in healthy adult volunteers in Brazil, confirming its status candidate vaccine [12], a lack in understanding of the as safe and immunogenic [19]. Further immunogenicity nature of the immune response and the correlates of and safety phase 2 trials of rSm14 (adjuvanted with protective immunity in humans and other mammalian GLA-SE) are planned for schistosomiasis-endemic areas hosts, the transmission of other pathogens in schistoso- in Brazil and Africa [20]. miasis endemic areas resulting in co-infected individuals which can impact on vaccine efficacy, and antigenic poly- Sh28GST morphism [13]. Schistosome 28 kDa glutathione S-transferase enzymes play a role in fatty acid metabolism and prostaglandin Schistosoma mansoni and S. haematobium vaccine D2 synthesis and may help the parasite evade the host candidates immune system. The enzyme present in S. mansoni Over 100 schistosome vaccine antigens
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