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Infection and Immunity, April 1999, p. 1694-1701, Vol. 67, No. 4
Division of Infectious Diseases,
Massachusetts General Hospital, Boston, Massachusetts
021141; Department of Microbiology and
Immunology, Tulane University Medical Center, New Orleans, Louisiana
701122; and Department of
Microbiology and Molecular Genetics, Harvard Medical School,
Boston, Massachusetts 021153
Received 20 August 1998/Returned for modification 4 November
1998/Accepted 31 December 1998
Vibrio cholerae secretes cholera toxin (CT) and the
closely related heat-labile enterotoxin (LT) of Escherichia
coli, the latter when expressed in V. cholerae.
Both toxins are also potent immunoadjuvants. Mutant LT molecules that
retain immunoadjuvant properties while possessing markedly diminished
enterotoxic activities when expressed by E. coli have
been developed. One such mutant LT molecule has the substitution of a
glycine residue for arginine-192 [LT(R192G)]. Live
attenuated strains of V. cholerae that have been used
both as V. cholerae vaccines and as vectors for
inducing mucosal and systemic immune responses directed against
expressed heterologous antigens have been developed. In order to
ascertain whether LT(R192G) can act as an immunoadjuvant
when expressed in vivo by V. cholerae, we introduced a
plasmid (pCS95) expressing this molecule into three vaccine strains of
V. cholerae, Peru2, ETR3, and JRB14; the latter two
strains contain genes encoding different heterologous antigens in the
chromosome of the vaccine vectors. We found that LT(R192G)
was expressed from pCS95 in vitro by both E. coli and
V. cholerae strains but that LT(R192G) was detectable in the supernatant fraction of V. cholerae
cultures only. In order to assess potential immunoadjuvanticity, groups of germfree mice were inoculated with the three V. cholerae vaccine strains alone and compared to groups inoculated
with the V. cholerae vaccine strains supplemented with
purified CT as an oral immunoadjuvant or V. cholerae
vaccine strains expressing LT(R192G) from pCS95. We found
that mice continued to pass stool containing V. cholerae strains with pCS95 for at least 4 days after oral
inoculation, the last day evaluated. We found that inoculation with
V. cholerae vaccine strains containing pCS95 resulted
in anti-LT(R192G) immune responses, confirming in vivo
expression. We were unable to detect immune responses directed against
the heterologous antigens expressed at low levels in any group of
animals, including animals that received purified CT as an
immunoadjuvant. We were, however, able to measure increased vibriocidal
immune responses against vaccine strains in animals that received
V. cholerae vaccine strains expressing LT(R192G) from pCS95 compared to the responses in animals
that received V. cholerae vaccine strains alone. These
results demonstrate that mutant LT molecules can be expressed in vivo
by attenuated vaccine strains of V. cholerae and that
such expression can result in an immunoadjuvant effect.
Vibrio cholerae is able
to secrete to the cell supernatant cholera toxin (CT) and the closely
related heat-labile enterotoxin (LT) of Escherichia coli,
the latter when expressed in V. cholerae (17,
25). CT and LT are approximately 80% homologous and are thought
to have descended from a common ancestral toxin (24). CT and
LT each comprise an enzymatically active A subunit and receptor binding
B subunits. Proteolytic cleavage of the A subunit results in a fully
active A1 fragment and an enzymatically inactive A2 stalk-like structure covalently joined to A1
via a disulfide bond. A pentamer of B subunits associates with the A
subunit through the A2 stalk. The B subunits mediate
binding of the holotoxin to carbohydrate molecules on intestinal
epithelial cells. After internalization of the toxin and reduction of
the A subunit, the A1 fragment mediates ADP ribosylation of
the Gs In addition to being enterotoxins, CT and LT are both potent
immunoadjuvants (11, 22). The immunoadjuvant properties of CT and LT differ in several aspects, including the induction of different cytokine profiles and the more frequent induction of anaphylaxis-associated immunoglobulin E (IgE) antibodies with CT than
with LT (13, 35). Recently, a number of mutant LT molecules
that retain immunoadjuvant properties while possessing markedly
diminished enterotoxic activity have been developed (13, 14, 29,
30). Dickinson and Clements have constructed one such mutant LT
by using site-directed mutagenesis to create a single amino acid
substitution within the disulfide-subtended region of the A
subunit separating A1 from A2 (13).
This molecule, LT(R192G), has a glycine
residue substituted for arginine-192 (13). This
single amino acid change has altered the proteolytically sensitive site
within this region, rendering the mutant insensitive to trypsin
activation. The physical characteristics of this mutant have been
examined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis,
its biological activity has been examined with mouse Y-1 adrenal tumor
cells and Caco-2 cells, its enzymatic properties have been determined
with an in vitro NAD:agmatine ADP ribosyltransferase assay, and its
immunogenicity and immunomodulating capabilities have been determined
by testing for the retention of immunogenicity and adjuvanticity.
Subsequent reports have confirmed the efficacy of LT(R192G)
as an effective mucosal adjuvant (8, 18, 26), and
LT(R192G) has recently been evaluated in two phase I safety
studies (27, 39).
A number of oral, attenuated V. cholerae vaccines that
are currently undergoing evaluation for safety and efficacy have been developed (20, 21, 40). The ability to boost the
immunological responses induced by such vaccine constructs may be
beneficial. In addition, V. cholerae has a number of
attributes that make it an attractive candidate for use as a vaccine
vector for inducing mucosal immunity against heterologous antigens.
V. cholerae is noninvasive but induces long-lasting
mucosal and systemic immune responses (19, 31).
V. cholerae has been well studied, and attenuated
strains of V. cholerae that have been shown to be both safe and immunogenic in humans have already been developed (4, 20,
23, 28, 37, 40). V. cholerae strains that are
capable of secreting large heterologous antigens have been developed
(32), and such attenuated strains have already been shown to
act successfully as vaccine vectors for inducing mucosal immunity and
systemic immunity that are protective against the action of
heterologous antigens (3, 7, 32, 33). The ability to boost
the immune responses induced by V. cholerae vector
strains expressing heterologous antigens might increase their effectiveness.
In order to ascertain whether mutant LT expressed in vivo can act as an
immunoadjuvant, we expressed LT(R192G) in a number of
vaccine strains of V. cholerae. We administered such
strains orally to mice and assayed the subsequent systemic and mucosal humoral immune responses induced against V. cholerae
antigens as well as against three heterologous antigens, including a
fusion protein of the B subunit of CT (CTB) and an immunogenic
dodecapeptide-repeating subunit of the serine-rich
Entamoeba histolytica protein (SREHP-12) (33), the B subunit of E. coli Shiga
toxin 1 (StxB1) (5), and a large fragment of the EaeA
protein from enterohemorrhagic E. coli EDL933
(5). The heterologous antigen-expressing vaccine vectors of V. cholerae chosen for this study have been
shown previously to produce low levels of the heterologous antigens and
to induce poor immunological responses directed against these
antigens (1, 5, 33).
Bacterial strains and media.
The bacterial strains
and plasmids used in this study are described in Table
1. All strains were maintained at
0019-9567/99/$04.00+0
Copyright © 1999, American Society for Microbiology. All rights reserved.
In Vivo Expression and Immunoadjuvancy of a Mutant of Heat-Labile
Enterotoxin of Escherichia coli in Vaccine and Vector
Strains of Vibrio cholerae
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ABSTRACT
Top
Abstract
Introduction
Materials and Methods
Results and Discussion
References
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INTRODUCTION
Top
Abstract
Introduction
Materials and Methods
Results and Discussion
References
subunit of adenylate cyclase, leading to an
increase in intracellular cyclic AMP levels and secretory diarrhea
(2, 12, 15). Full enzymatic activity of LT and CT requires
proteolytic cleavage of the A subunit to produce the A1
fragment (10). In E. coli, CT and LT remain
within the periplasmic space, and neither is proteolytically cleaved (10, 25). In V. cholerae, proteolytic
cleavage is associated with extracellular secretion of CT. It is
unclear, however, whether proteolytic cleavage is associated with
extracellular secretion of LT in V. cholerae
(17). In vivo, proteolytic cleavage of LT may be due to the
action of proteases external to E. coli and V. cholerae.
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MATERIALS AND METHODS
Top
Abstract
Introduction
Materials and Methods
Results and Discussion
References
70°C in Luria-Bertani (LB) broth medium (34) containing
15% glycerol. Streptomycin (100 µg/ml) and ampicillin (100 µg/ml)
were added as appropriate. Cultures were grown at 37°C with aeration.
Quantitative culturing was done on LB agar plates containing
appropriate antibiotics and confirmed on thiosulfate-citrate-bile
salts-sucrose plates.
TABLE 1.
Bacterial strains and plasmid used in this study
Genetic methods. Isolation of plasmid DNA, restriction enzyme digestion, and agarose gel electrophoresis were performed by standard molecular biological techniques (34).
Construction of pCS95. Plasmid pCS95 is a pUC-based plasmid carrying the genes for LT from human enterotoxigenic E. coli H10407 with a single point mutation resulting in the substitution of glycine for arginine at amino acid position 192 within the A subunit. Plasmid pCS95 is identical to the previously described plasmid pBD95 (13); however, pCS95 includes the Shine-Dalgarno sequence of ltxA. Plasmids were electroporated into V. cholerae with a Gene Pulser (Bio-Rad Laboratories, Richmond, Calif.) as instructed by the manufacturer and modified for electroporation into V. cholerae as described previously (16). Electroporation conditions were 2,500 V at 25 mF capacitance, producing time contants of 4.8 to 4.9 ms.
In vitro expression of LT(R192G).
In vitro
expression of LT(R192G) was analyzed with E. coli JM83 and V. cholerae Peru2, both containing
pCS95. Overnight cultures were centrifuged at 12,000 × g for 20 min, supernatant fractions were recovered, and pellets
were resuspended in 2 ml of lysozyme in sterile water (1 mg/ml).
Resuspended pellets were subjected to repeated freezing-thawing at 37 and
70°C and centrifuged, and lysates were recovered. Lysate
samples were concentrated approximately 10-fold compared with
unprocessed supernatant samples. Supernatant and lysate samples were
analyzed in an enzyme-linked immunosorbent assay (ELISA) for LT. Serial
dilutions of samples in phosphate-buffered saline (PBS)-0.05% Tween
20 (PBS-T; Sigma Chemical Co., St. Louis, Mo.) (undiluted to 1:64
diluted) were applied to 96-well microtiter plates previously coated
with 1.5 µg of type III ganglioside (Sigma) in 50 mM carbonate buffer
(pH 9.6) per well. Samples were analyzed with goat polyclonal anti-LT
subunit B (LTB) and anti-LT subunit A (LTA) antibodies, followed by
rabbit anti-goat IgG-alkaline phosphatase conjugates. Reactions were
developed with 2 mg of p-nitrophenyl phosphate per ml
diluted in diethanolamine buffer (pH 9.8). Reactions were stopped
with 3 N NaOH, and optical density was read at 405 nm.
Inoculation and colonization of germfree mice. Immediately upon removal of mice from their germfree shipping carton, nine groups of 6 to 12 germfree female Swiss mice, 3 to 4 weeks old (Taconic Farms, Inc., Germantown, N.Y.), were orally inoculated via gastric intubation with 250-µl inocula containing approximately 109 organisms of V. cholerae strains resuspended in 0.5 M NaHCO3 (pH 8.0). Groups of 6 to 12 mice each received inoculations of Peru2, JRB14, or ETR3; Peru2, JRB14, or ETR3 supplemented with 5 µg of purified CT (List Biological Laboratories, Inc., Campbell, Calif.) as an immunoadjuvant; or Peru2(pCS95), JRB14(pCS95), or ETR3(pCS95). Two mice were treated identically but remained unvaccinated as controls. Mice were subsequently housed in non-germfree conditions (6). All mice received a second oral inoculation at day 14. To ascertain the presence of pCS95, fresh stool samples were collected immediately upon passage from mice until day 4 after oral inoculation, resuspended in 500 µl of LB broth medium, vortexed, and allowed to settle. One hundred-microliter aliquots were plated on LB agar medium containing ampicillin and streptomycin, and colonies were subsequently confirmed as V. cholerae on thiosulfate-citrate-bile salts-sucrose medium. Plasmid preparations from randomly selected, ampicillin-resistant colonies from stool samples collected 72 h after oral inoculation were examined to confirm the presence of pCS95.
Immunological sampling.
Mice were sacrificed on day 28, at
which time blood was collected via intracardiac puncture. Blood was
allowed to clot, and serum was separated by centrifugation. Bile (3 to
6 µl) was collected via hepatic dissection and subsequent aspiration
of the gallbladder (33). Fresh stool pellets were collected
for immunological evaluation and stored at
20°C until processed.
Each pellet was then placed in 1 ml of a 3:1 mixture of PBS-0.1 M EDTA
containing soybean trypsin inhibitor (type II-S; Sigma) at a
concentration of 0.1 mg/ml and vortexed until it was broken
(33). The mixture was centrifuged twice. Twenty microliters
of 100 mM phenylmethylsulfonyl fluoride (Sigma) was added to each 1 ml
of final recovered supernatant (41). Stool, bile, and serum
samples were divided into aliquots and stored at
70°C for
subsequent analysis.
Measurement of systemic and mucosal anti-CTB, anti-SREHP-12, anti-StxB, and anti-EaeA antibody responses. To detect anti-CTB antibody responses, microtiter plates were coated with 100 ng of type III gangliosides (Sigma) in 50 mM sodium carbonate buffer (pH 9.6) per well. Following overnight incubation at room temperature and three washes in PBS-T, 100 ng of CTB (List) in carbonate buffer was applied to each well, and the plates were again incubated overnight at room temperature. After being washed in PBS-T, the plates were blocked with PBS-1% bovine serum albumin (BSA; Sigma). To detect anti-SREHP-12 antibodies, plates were coated with E. histolytica HM1:IMSS trophozoites in PBS (104 per well) overnight at 4°C and then blocked with PBS-BSA as previously described (41, 42). To detect anti-StxB antibodies, plates were coated with 10 µg of ceramide trihexoside (Matreya, Inc., Pleasant Gap, Pa.) per ml in methanol. After evaporation of the methanol at 37°C for 2 h, 100 ng of StxB in carbonate buffer (pH 9.6) per well was added (5). Plates were incubated overnight at room temperature and then blocked with PBS-BSA. To detect anti-EaeA antibodies, plates were coated with 100 ng of a purified histidine-tagged intimin protein (RIHisEae) containing 900 of the 935 carboxy-terminal amino acids of EaeA from E. coli O157:H7 (strain 86-24) (5) in carbonate buffer (pH 9.6) per well. After overnight incubation at room temperature, the plates were blocked with PBS-BSA.
To detect specific anti-CTB, anti-SREHP-12, anti-StxB, and anti-EaeA IgG and IgA antibodies in sera, 100-µl duplicate samples of 1:1,000 (IgG) and 1:100 (IgA) dilutions of sera in PBS-T were placed in wells of microtiter plates previously coated with ganglioside-CTB, E. histolytica trophozoites, ceramide trihexoside-StxB, and RIHisEae, respectively, as described above. Plates were incubated at room temperature overnight and washed in PBS-T. A 1:2,000 dilution in PBS-T of goat anti-mouse IgG conjugated to biotin or goat anti-mouse IgA conjugated to biotin (Kirkegaard & Perry Laboratories, Gaithersburg, Md.) was applied to each well, and the plates were again incubated overnight at room temperature. After the plates were washed in PBS-T, a 1:4,000 dilution of streptavidin-horseradish peroxidase conjugate (Zymed Laboratories, Inc., South San Francisco, Calif.) was added to each well, and the plates were incubated at room temperature for 3 h. After being washed in PBS-T, the plates were developed with a solution containing 1 mg of 2,2'-azinobis(3-ethylbenzthiazolinesulfonic acid) (Sigma)/ml and 0.1% H2O2 (Sigma), and the optical density at 405 nm was determined kinetically with a Vmax microplate reader (Molecular Devices Corp., Sunnyvale, Calif.). Plates were read for 5 min at 19-s intervals, and the maximum slope for an optical density change of 0.2 U was reported as milli-optical density units per minute (32). To detect specific IgA antibody responses in stool and bile, measurements of total stool and bile IgA were first taken. Duplicate serial twofold dilutions of stool (1:50 to 1:6,400) and bile (1:800 to 1:3,200) samples in PBS-T were added to wells previously coated with 100 ng of rat monoclonal anti-mouse IgA antibody R5-140 (PharMingen, San Diego, Calif.) and previously blocked with PBS-BSA. Samples were incubated at 37°C for 1 h and then washed with PBS-T. A 1:2,000 goat anti-mouse IgA-horseradish peroxidase conjugate (Southern Biotechnology Associates, Birmingham, Ala.) in PBS-T was added to each well. After 1 h of incubation at 37°C, the plates were washed with PBS-T and developed for horseradish peroxidase activity as described above. Comparisons were made to a mouse IgA standard (Kappa TEPC 15; Sigma). To detect specific anti-CTB, anti-SREHP-12, anti-StxB, and anti-EaeA IgA antibodies in stool and bile, single (bile) or duplicate (stool) samples of 100 µl of PBS-T containing 750 ng of total IgA (stool) or 125 ng of total IgA (bile) were added to wells previously coated with ganglioside-CTB, E. histolytica trophozoites, ceramide trihexoside-StxB, and RIHisEae, respectively. Plates were incubated at room temperature overnight. After the plates were washed with PBS-T, a 1:2,000 dilution of goat anti-mouse IgA-biotin conjugate (Kirkegaard & Perry) in PBS-T was added. After overnight incubation at room temperature, the plates were developed for horseradish peroxidase activity, and the optical density at 405 nm was determined kinetically.Detection of vibriocidal antibodies. Serum vibriocidal antibody titers were measured by a microassay as follows. The endogenous complement activity of test sera was inactivated by heating the sera to 56°C for 1 h. Fifty-microliter aliquots of serial twofold dilutions of test sera in PBS (1:25 to 1:25,600) were placed in wells of 96-well tissue culture plates; 50 µl of 108 CFU of V. cholerae Peru2 per ml in PBS with 22% guinea pig complement (Gibco BRL Life Technologies, Gaithersburg, Md.) was added to the serum dilutions. The mixtures were incubated for 1 h at 37°C. One hundred-fifty microliters of brain heart infusion broth (Difco Laboratories, Detroit, Mich.) was added to each well, and the plates were incubated for approximately 2 h at 37°C. The optical density at 600 nm was then measured; the vibriocidal titer was calculated as the dilution of serum causing a 50% reduction in optical density compared with that in wells containing no serum (3, 33).
Statistics and graphs. Statistical analysis for the comparison of geometric means was performed for normally distributed data with the independent-sample Student t test or with the Mann-Whitney U test for nonparametric data by use of SPSS for Windows 7.0. Data were plotted with Microsoft Excel 7.0a and CA-Cricket Graph Software (Computer Associates, Garden City, N.Y.).
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RESULTS AND DISCUSSION |
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In vitro expression of LT(R192G) from pCS95. Whole-cell lysates and supernatant fractions of JM83(pCS95) and Peru2(pCS95) were assayed for LT(R192G) by a ganglioside binding ELISA with antibodies specific for LTA and LTB, respectively. LT(R192G) was found in both whole-cell lysates and supernatant fractions of the V. cholerae strain but was found only in the lysates and not in the supernatant fractions of the E. coli strain (Fig. 1). Previous work has shown that native LT is secreted extracellularly by V. cholerae but remains cell associated in E. coli (10, 17, 25). Our results suggest, therefore, that LT(R192G) is expressed in E. coli and V. cholerae strains in fashions similar to those of native LT.
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Intestinal colonization and retention of plasmid pCS95 in mice following oral inoculation of vaccine constructs. Prior to oral inoculations of mice, overnight cultures of attenuated strains of V. cholerae containing pCS95 were grown in medium containing antibiotics selective for the plasmid. Selective pressure was not maintained in vivo. Quantitative cultures of the vaccine inocula of Peru2(pCS95), ETR3(pCS95), and JRB14(pCS95) disclosed that approximately 109 V. cholerae organisms/inoculum contained pCS95 at the time of oral administration.
Previous studies have shown that germfree mice orally inoculated on days 0 and 14 with Peru2-based attenuated strains of V. cholerae pass these organisms in the stool for 7 to 14 days after the first inoculation and for approximately 2 days after the second inoculation (33) and that plasmids contained in these strains are retained in vivo for 3 to 5 days after the first inoculation and for 1 day after the second inoculation, even when no specific selection pressure for the plasmid exists in vivo. In the current study, 92% of mice inoculated with the V. cholerae vaccine strains Peru2(pCS95), ETR3(pCS95), and JRB14(pCS95) continued to pass V. cholerae organisms containing pCS95 in the stool 2 days after the first inoculation, and 50% continued to pass V. cholerae organisms containing pCS95 in the stool 4 days after the first inoculation. These numbers match the previously described results (33). Plasmid preparations of ampicillin-resistant colonies isolated from stool freshly passed 72 h after oral inoculation confirmed the ongoing intestinal presence of V. cholerae organisms containing pCS95.In vivo expression of LT(R192G) and measurement of antibodies directed against LT(R192G) or CTB. Immunological responses to CT and LT are predominantly directed against the B subunit of each holotoxin, and immunological responses to LTB and CTB are cross-reactive in immunological assays (9, 36). In order to ascertain whether LT(R192G) is expressed in vivo by V. cholerae strains containing pCS95, the immunological responses to CTB (and, by inference, LTB) in serum, stool, and bile samples of mice inoculated with Peru2(pCS95) were compared to those of mice receiving Peru2 alone. Anti-CTB and -LTB responses were also measured in mice that received Peru2 supplemented with CT as an immunoadjuvant and in mice that were vaccinated with V. cholerae vaccine strains producing the heterologous antigen CTB-SREHP-12. As shown in Fig. 2, animals that were exposed to LT(R192G) from vaccine strain Peru2(pCS95) had significant increases in serum anti-CTB (LTB) IgG (P, <0.01) and IgA (P, <0.01) levels and significant increases in anti-CTB (LTB) IgA levels in bile (P, <0.05), confirming the in vivo expression of LT(R192G).
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Measurement of immune responses to SREHP-12, StxB, and EaeA expressed by the vaccine vectors. The attenuated strains of V. cholerae used in this study express their heterologous antigens at very low levels from stable chromosomal modifications (5, 33). Serum IgG and IgA responses directed against the heterologous antigens were not prominent and were not boosted by LT(R192G) expressed from pCS95 or by supplemental CT in this study (data not shown). Specifically, the levels of antiamebic serum IgG and IgA antibodies were not increased in animals that received ETR3 compared with animals inoculated with Peru2, nor were antiamebic serum IgG and IgA immune responses boosted in animals that received ETR3(pCS95) or ETR3 supplemented with CT compared with animals that received ETR3 alone. In comparison to antibody levels in animals that received Peru2 alone, animals that received JRB14 did have increased serum IgG antibody responses directed against StxB and EaeA, but these differences did not reach statistical significance, nor were serum IgG and IgA responses against these antigens boosted in animals that received JRB14(pCS95) or JRB14 supplemented with CT. Analysis of stool IgA antibody responses to the heterologous antigens also did not disclose any significant differences among the various groups of animals (Fig. 3). Analysis of bile IgA antibody responses did, however, disclose that the most prominent anti-StxB and anti-EaeA responses were detected in animals that received JRB14(pCS95); these differences, however, did not achieve statistical significance (Fig. 4).
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Measurement of serum vibriocidal antibodies. Vibriocidal antibodies were measured in day-28 serum samples (Fig. 5). Compared with the responses in unvaccinated germfree mice that had otherwise been treated in the same manner as study animals, all groups of animals inoculated with V. cholerae vaccine strains developed vibriocidal antibody responses. In comparison to the vibriocidal antibody responses in animals that received attenuated V. cholerae strains not supplemented with an immunoadjuvant, the highest mean vibriocidal antibody response was seen in animals that received attenuated V. cholerae strains expressing LT(R192G) from pCS95 (P, <0.05). This response was even higher than that measured in animals that received V. cholerae strains supplemented with the known immunoadjuvant CT.
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ACKNOWLEDGMENTS |
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This work was supported by Public Health Service grants K08AI01332 (to E.T.R.), K08AI01386 (to J.R.B.), AI28835 (to J.D.C.), and AI40725 (to S.B.C.), all from the National Institute of Allergy and Infectious Diseases.
We are extremely grateful to Marian R. Wachtel, Marian L. McKee, and Alison O'Brien for RIHisEae; David W. Acheson for StxB; Samuel L. Stanley, Jr., Tonghai Zhang, and Lynne Foster for E. histolytica HM1:IMSS trophozoite-coated plates and CTB-SREHP-12; and John Mekalanos for V. cholerae Peru2.
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FOOTNOTES |
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* Corresponding author. Mailing address: Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114. Phone: 617-726-3811. Fax: 617-726-7416. E-mail: scalderwood{at}partners.org.
Editor: J. T. Barbieri
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