Combination vaccines against diarrheal diseases

Figures & data

Table 1. Global etiology of diarrheal disease. The population evaluated for each list is given in parenthesis under each listed column

GBD 2010^1,8	GEMS study^12-15	TD^21,23,28,30-32,46,143	US study^20	WHOstudy^5,6
Rotavirus	Rotavirus	ETEC	Salmonella	Rotavirus
Shigella	ST-ETEC	EAEC	Campylobacter	Norovirus
ETEC	Shigella	Campylobacter	Shigella	EPEC
Campylobacter	Cryptosporidia	Salmonella	Cryptosporidia	ETEC
Cryptosporidia	EPEC	V. cholera	Norovirus	Shigella
EPEC	Campylobacter	Shigella	ST-ETEC	Campylobacter
Salmonella	V. cholerae	EPEC	(FoodNet study)	Adenovirus
V. cholerae	(<5 years)	Norovirus		Salmonella
Entamoeba		Rotavirus		Astrovirus
(across all ages)		Cyclospora		Giardia
		Cryptosporidia		Cryptosporidia
		Entamoeba		V. cholerae
		Giardia		(0–59 months)
		(travelers)

ETEC, enterotoxigenic E. coli, EPEC, enteropathogenic E. coli, EAEC, enteroaggregative E. coli, ST-ETEC, heat stable toxin-producing ETEC.

Table 2. Diarrheal disease-causing pathogens for combination vaccine development

Bacteria
• ETEC enterotoxigenic E. coli, most common diarrheal pathogen in TD, strains produce heat stable (ST) and/or heat labile (LT) toxins, ST-ETEC most associated with disease^6,8,10,14,21,108,113,120,122,123,131,135,141,147
• EAEC enteroaggregative E. coli, important emerging cause of persistent pediatric diarrhea, important cause of TD^1 in S. Asia, Latin America, Africa^8,37,40,156
• EPEC enteropathogenic E. coli, important cause of diarrhea related illness in children <5 years of age, identified by Hep 2 cell cultures, presence of adherence plasmid and intimin gene^1,6,8,12,14
• Shigella cause of bacillary dysentery, S. sonnei prevalent in developed countries, S. flexneri 2a, 3a, 6 in developing countries, ˜8-12% of all cause diarrhea^12 15,24,25,39,45,111,118,121,125,140,142
• Campylobacter associated in the US mostly with contaminated chicken, important cause of diarrheal illness in TD in SE Asia^8,25,32,38,114-116
• Vibrio choleracauses high mortality rates during epidemics due to voluminous watery diarrhea leading to dehydration, endemic in some countries, seen in SE Asia, in TD^4,5,19,48,107-110,136
• Salmonella typhicauses typhoid, Important cause of enteric fever^8,53,95-97,100
• Salmonella important cause of diarrheal illness in children and in adults in developed and in developing non-typhoidal countries, in TD^11,41,42,98,99,155
Viruses
• Rotavirus most important cause of hospitalization for childhood diarrhea in the US and high mortality rates due to diarrhea in the developing world ^6-8,101-106)
• Norovirus higher risk for severe disease in the elderly, transmission in day-care centers, cruise ships, nursing homes, military, in TD, in children <5 years in developing countries^32,36,143,157
Parasites
• Cryptosporidia high global mortality rates from diarrhea in the developing world^6,14,32,34,143,154
• Entamoeba acute and persistent diarrhea in children in developing countries, bloody stools^6,10,19,23,32,34

* Vaccine candidates in clinical trial.

** licensed vaccines available¹ TD, Traveler's diarrhea.

Table 3. Current ETEC vaccine landscape

Type	Preclinical	Phase 1, route, dose	Ref.
Live, ACE527	+	oral 10^10–10^11	^120,122,131
Formalin killed cells overexpressing CFs with LTCBA	+	oral 10^10–10^11 2 doses, d0, d14	^131,141,147
Fimbrial tip protein	+	ongoing study, TCI & ID multiple doses	^113,123
dmLT		adjuvant	^24,131
EtpA glycoprotein	+		^128
STa toxoid fusions	+		^127
Plant-based	+		^129
e.g.MucoRice-CTB	+		^136

^a composed of 3 strains expressing CFA/I & LTB, CS5, CS6 & LTB, CS1, CS2, CS3 & LTB, tac promoter-driven genes integrated on chromosome.

^b hybrid LTB/CTB toxoid, provides better LTB neutralizing responses than CTB in animals, CFs, colonization factors.

^c double-mutated LT, LTR192G/L211A, to be used mainly as an adjuvant with vaccine candidates.

^d ST toxoid with amino acid substitutions that is fused to carrier protein such as LTB, CTB or a CFA subunit.

^e CTB and LTB also expressed in potatoes, carrots, corn, tobacco, CTB can provide some protection against LT-ETEC.

^f rice-expressed CTB with a KDEL signal at the C-terminal of CTB, has been fed orally to mice and non-human primates.

Figure 1. Hypothetical scenario for combination live or whole cell-killed diarrheal vaccine.

Figure 2. Hypothetical scenario for combination of subunit diarrheal vaccines.

Table 4. Current Shigella vaccine landscape

Type	Preclinical	Phase 1, route, dose,	Ref
Live CVD series	+	oral, 10^9–10^10	^118,140,142
Live WRAIR series	+	ongoing	^118,134,138,140,142
Live S. typhi Ty21a with Shigella LPS genes	+		^130
Formalin killed cells, trivalent	+	oral, 10^10–10^11	^117,125
Invaplex	+	Intranasal	^14,119,125-126
LPS conjugates	+	parenteral	^121,125,142
Synthetic oligo-saccharides	+		^133,142
Bioglycoconjugates	+	parenteral	^132
Purified Ipa proteins	+		^139
OM vesicles	+		^137

^a based on guaBA mutations, multiple serotypes, limited intracellualr replication.

^b based on virG(icsA) mutations, multiple serotypes, inability to spread intercellularly.

^c trivalent product with S. sonnei, S. flexneri 2a and 3a.

^d combination of serotype-specific LPS and conserved antigens IpaB and IpaC proteins, LPS from different serotypes can be substituted.

^e LPS conjugates with CRM, a non-toxic recombinant variant of diptheria toxin with a single amino acid substitution.

^f Shigella O-antigen expressed in an E. coli with Campylobacter glycosylation secretion machinery.

^g OM, outer membrane.

Table 5. Manufacturing issues for combination vaccines

• Use of human-derived or animal-derived materials and use of   preservatives in manufactured products can become an issue

• Developing a formulation process for the combination vaccine   that ensures lot to lot consistency, minimizes interference   between antigens and maintains safety and efficacy profile simi  lar to the individual components

• Manufacturing process should be amenable to scale-up   prodution; the profile of the final product should mimic the   safety, efficacy, potency and preclinical testing profile of the   pilot scale vaccine

• Combination vaccine must show acceptable toxicity levels,   animal studies may be necessary and animal data must reflect   clinical results

• Multiple clinical trials will be necessary for determining safety,   efficacy, and impact of different vaccination schedules in   infants and adults

• Manufacturing product should pass all regulatory rules of the   FDA for licensure

* Abridged from Vose, J. 2001, CID, 33: S334–339, Van Hoof, J. CID, 2001, 33: S346–350.

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