Serologic studies of naturally acquired infection with Vibrio cholerae serogroup O1 in the United States

Protection afforded by previous Vibrio cholerae infection against subsequent disease and infection: A review

BACKGROUND

Cholera is an acute, diarrheal disease caused by Vibrio cholerae O1 or 139 that is associated with a high global burden.

METHODS

We analyzed the estimated duration of immunity following cholera infection from available published studies. We searched PubMed and Web of Science for studies of the long-term immunity following cholera infection. We identified 22 eligible studies and categorized them as either observational, challenge, or serological.

RESULTS

We found strong evidence of protection at 3 years after infection in observational and challenge studies. However, serological studies show that elevated humoral markers of potential correlates of protection returned to baseline within 1 year. Additionally, a subclinical cholera infection may confer lower protection than a clinical one, as suggested by 3 studies that found that, albeit with small sample sizes, most participants with a subclinical infection from an initial challenge with cholera had a symptomatic infection when rechallenged with a homologous biotype.

CONCLUSIONS

This review underscores the need to elucidate potential differences in the protection provided by clinical and subclinical cholera infections. Further, more studies are warranted to bridge the gap between the correlates of protection and cholera immunity. Understanding the duration of natural immunity to cholera can help guide control strategies and policy.

Cholera Toxin Modulates the Systemic Immune Responses againstVibrio choleraeSurface Antigens after Repeated Inoculations

The immunomodulating properties of a low cholera toxin (CT) dose over the systemic antibody response against Vibrio cholerae antigens after a comparatively extensive period of time were evaluated. Groups of 10 mice were injected intraperitoneally three times at 0, 30 and 86 days with 500 microl of buffer or 10(8) viable recombinant V. cholerae bacteria (lacking cholera toxin A subunit) with or without 100 ng of CT. Sera were obtained from inoculated mice at 0, 14, 28, 37, 58, 80, 93, 114, 236 and 356 days after the first injection. Vibriocidal activity and IgM and IgG anti-lipopolysaccharide (LPS) or outer membrane protein (OMP) antibodies levels were estimated by ELISA in sera of inoculated mice. Anti-LPS IgG subclasses were measured 2 weeks after each immunization by ELISA. Treatment of mice with CT markedly influenced the immune response to LPS but not against OMP of V. cholerae. Simultaneous intraperitoneal administration of CT with V. cholerae resulted in marked enhancement of both IgM anti-LPS and vibriocidal titers which subsisted for a relatively extensive period of time after repeated antigen administration. No differences were observed in IgM and IgG anti-OMP titers after extended periods of time between CT and control treatments. A similar pattern of IgG anti-LPS subclasses was observed in the serum samples analyzed. These results suggest that long term CT administration modulates the IgM anti-V. cholerae LPS response and the serum vibriocidal activity.

Safety and immunogenicity of single-dose live oral cholera vaccine strain CVD 103-HgR, prepared from new master and working cell banks

Currently, no cholera vaccine is available for persons traveling from the United States to areas of high cholera transmission and who for reasons of occupation or host factors are at increased risk for development of the disease. A single-dose oral cholera vaccine with a rapid onset of protection would be particularly useful for such travelers and might also be an adjunct control measure for cholera outbreaks. The attenuated Vibrio cholerae O1 vaccine strain CVD 103-HgR harbors a 94% deletion of the cholera toxin A subunit gene (ctxA) and has a mercury resistance gene inserted in the gene encoding hemolysin A. We undertook a phase I randomized placebo-controlled two-site trial to assess the safety and immunogenicity of a preliminary formulation of CVD 103-HgR prepared from new master and working cell banks. Healthy young adults were randomized (5:1 vaccinees to placebo recipients) to receive a single oral dose of ∼4.4 × 10(8) CFU of vaccine or a placebo. Blood serum vibriocidal and cholera toxin-specific IgG antibodies were measured before and 10, 14, and 28 days following vaccination or placebo. Excretion of the vaccine strain in the stool was assessed during the first week postvaccination. A total of 66 subjects were enrolled, comprising 55 vaccinees and 11 placebo recipients. The vaccine was well tolerated. The overall vibriocidal and anti-cholera toxin seroconversion rates were 89% and 57%, respectively. CVD 103-HgR is undergoing renewed manufacture for licensure in the United States under the auspices of PaxVax. Our data mimic those from previous commercial formulations that elicited vibriocidal antibody seroconversion (a correlate of protection) in ∼90% of vaccinees. (This study has been registered at ClinicalTrials.gov under registration no. NCT01585181.).

Análise dos anticorpos vibriocidas e aglutinantes na população urbana do Município do Manacapuru/AM (1992/1993)

Foi realizado um estudo sorológico em 1.196 indivíduos residentes na área urbana do município de Manacapuru/AM, visando analisar o perfil dos anticorpos vibriocidas e aglutinantes. Empregou-se o procedimento de amostragem aleatória sistemática na obtenção da amostra populacional. Um ano após, obteve-se uma 2a amostra de soro de 120 indivíduos (10% da amostra inicial), escolhidos aleatoriamente entre os participantes do inquérito, com o objetivo de avaliar o comportamento dos anticorpos nesse intervalo de tempo. Foram empregados os métodos de microtitulação de anticorpos vibriocidas e de soroaglutinação em tubos. A associação entre os anticorpos estudados foi determinada pelo coeficiente de correlação, calculado com base na distribuição de freqüência dos títulos detectados. A análise dos resultados revelou forte correlação positiva entre os anticorpos (r = 1,0) e queda nos títulos em grande proporção das amostras após um ano.

Cholera

Despite more than a century of study, cholera still presents challenges and surprises to us. Throughout most of the 20th century, cholera was caused by Vibrio cholerae of the O1 serogroup and the disease was largely confined to Asia and Africa. However, the last decade of the 20th century has witnessed two major developments in the history of this disease. In 1991, a massive outbreak of cholera started in South America, the one continent previously untouched by cholera in this century. In 1992, an apparently new pandemic caused by a previously unknown serogroup of V. cholerae (O139) began in India and Bangladesh. The O139 epidemic has been occurring in populations assumed to be largely immune to V. cholerae O1 and has rapidly spread to many countries including the United States. In this review, we discuss all aspects of cholera, including the clinical microbiology, epidemiology, pathogenesis, and clinical features of the disease. Special attention will be paid to the extraordinary advances that have been made in recent years in unravelling the molecular pathogenesis of this infection and in the development of new generations of vaccines to prevent it.

Current perspectives on the epidemiology and pathogenesis of clinically significant Vibrio spp

Recent taxonomic advances have now implicated several different Vibrio species as human pathogens. While the most common clinical presentation of Vibrio infection continues to be gastroenteritis, an increasing number of extraintestinal infections are being reported, particularly in immunocompromised individuals. Detection of Vibrio infections requires a good clinical history and the use of appropriate isolation and identification procedures by the laboratory to confirm illnesses attributed to Vibrio species. Except for Vibrio cholerae O1 and Vibrio parahaemolyticus, there is little direct evidence linking the production of a myriad of cell-associated or extracellular factors produced by each species with human disease and pathogenesis. Many questions regarding pathogenic Vibrio species remain unanswered, including their frequency and distribution in environmental specimens (water, shellfish), infective doses, virulence potential of individual isolates, and markers associated with such strains.

Seroepidemiology of cholera in Gulf coastal Texas

Single serum samples from 559 volunteers from a Texas Gulf Coast area were examined for vibriocidal antibody to Vibrio cholerae O1 (biotype El Tor, serotype Inaba) by a microtiter method. Elevated levels of vibriocidal antibody were present in 14% of the subjects. Also, 6.8% of the subjects had elevated levels of antibody to the enterotoxin of V. cholerae O1 by the immunoglobulin G enzyme-linked immunosorbent assay. Recent infection, defined on the basis of elevations in both vibriocidal and antitoxin antibodies, had occurred in 1.3% of the subjects. When subjects who reported Brucella infection, travel to a cholera-endemic area, and/or cholera vaccination within a year of the study were removed from the analysis, a prevalence of recent infection of 0.89% was obtained. Significantly higher titers of vibriocidal antibody were found in those with exposure to seawater (fishermen, shrimpers, merchant marines, and dock workers) than in those without such exposure (P less than 0.005). Furthermore, titers of antitoxin antibody were significantly higher in those who consumed shellfish than in nonconsumers. Finally, titers of vibriocidal antibody were significantly higher in Vietnamese subjects than in non-Vietnamese subjects. The results of this study indicate that an endemic focus of infection with V. cholerae occurs in this area.

Clinical and laboratory features of an outbreak of Vibrio cholerae O1 infections in the United States

A point source outbreak of Vibrio cholerae O1 El Tor Inaba infections occurred aboard an oil rig south of Port Arthur, Texas, in September 1981. Sixteen crew members had V. cholerae O1 infections as determined by serology or stool specimens; 15 were symptomatic. The high percentage of symptomatic infections was attributed in part to the ingestion of a large number of V. cholerae O1 organisms by susceptible individuals. Symptoms included diarrheal stools (100%), weakness (60%), abdominal cramps (53%), nausea (40%), and vomiting (27%). Only one of the three patients who sought medical attention was diagnosed by his physician as having cholera. Physicians who treat patients who live near or travel to the Gulf Coast should consider cholera in patients with watery stools. If cholera is suspected, laboratories should use thiosulfate-citrate-bile salts-sucrose (TCBS) agar in addition to routine enteric media for processing stool specimens.

Cholera on a Gulf Coast oil rig

A single case of severe diarrhea on a floating Texas oil rig was followed two days later by what proved to be the largest outbreak of cholera in the United States in over a century. After isolation of toxigenic Vibrio cholerae El Tor Inaba of the typical United States phage type from the index patient's stool, the ensuing investigation detected 14 additional cases of cholera and one asymptomatic infection serologically. Infection was associated with eating rice on the oil rig on a particular day (P = 0.03) when an open valve permitted the rig's drinking-water system to be contaminated by canal water containing sewage (including that from the index patient) discharged from the rig. The rice had been rinsed in the contaminated water after cooking, and before being served it had been maintained at a temperature that allows V. cholerae 01 to multiply. Toxigenic V. cholerae 01 is persisting in the United States, and large common-source outbreaks of cholera can occur if proper sanitation is not maintained.