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Expert Opinion on Biological Therapy

ISSN: 1471-2598 (Print) 1744-7682 (Online) Journal homepage: http://www.tandfonline.com/loi/iebt20

Successes and failures in human tuberculosis
vaccine development
Roberto Zenteno-Cuevas
To cite this article: Roberto Zenteno-Cuevas (2017): Successes and failures in
human tuberculosis vaccine development, Expert Opinion on Biological Therapy, DOI:
10.1080/14712598.2017.1378641
To link to this article: http://dx.doi.org/10.1080/14712598.2017.1378641

Published online: 19 Sep 2017.

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Date: 21 September 2017, At: 04:49

EXPERT OPINION ON BIOLOGICAL THERAPY, 2017
https://doi.org/10.1080/14712598.2017.1378641

REVIEW

Successes and failures in human tuberculosis vaccine development
Roberto Zenteno-Cuevas
Instituto de Salud Pública, Universidad Veracruzana, Xalapa, México
ARTICLE HISTORY

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ABSTRACT

Introduction: Tuberculosis (TB) is an infectious disease caused mainly by Mycobacterium tuberculosis. In 2016, the WHO estimated 10.5 million new cases and 1.8 million deaths, making this disease
the leading cause of death by an infectious agent. The current and projected TB situation necessitates the development of new vaccines with improved attributes compared to the traditional BCG
method.
Areas covered: In this review, the authors describe the most promising candidate vaccines against TB
and discuss additional key elements in vaccine development, such as animal models, new adjuvants
and immunization routes and new strategies for the identification of candidate vaccines.
Expert opinion: At present, around 13 candidate vaccines for TB are in the clinical phase of evaluation;
however, there is still no substitute for the BCG vaccine. One major impediment to developing an
effective vaccine is our lack of understanding of several of the mechanisms associated with infection
and the immune response against TB. However, the recent implementation of an entirely new set of
technological advances will facilitate the proposal of new candidates. Finally, development of a new
vaccine will require a major coordination of effort in order to achieve its effective administration to the
people most in need of it.

1. Introduction
Tuberculosis is an infectious disease caused mainly by members of Mycobacterium tuberculosis complex. Transmission is
primarily from person to person via droplets expelled into
the air when an infected person coughs, sneezes, or talks.
The current TB epidemic is greater than previously expected.
In 2015, there were an estimated 10.4 million new TB cases
worldwide. Six countries accounted for 60% of these new
cases: India, Indonesia, China, Nigeria, Pakistan, and South
Africa. There were an estimated 480,000 new cases of multidrug-resistant TB (MDR-TB) and 1.4 million deaths from TB in
2015. An additional 0.4 million deaths occurred from TB
among people living with HIV in 2015, making TB the leading
cause of death from an infectious disease, exceeding even HIV
itself [1].
Goal number three of the 13 Sustainable Development
Goals (SDGs) for 2030, adopted by the United Nations in
2015, establishes the need to ‘Ensure healthy lives and promote well-being for all at all ages.’ Target 3.3 states the
specific goal of ending epidemics of tuberculosis, as well as
other communicable diseases such as AIDS and malaria, by
2030. For this reason, the End TB Strategy of the WHO calls for
a 90% reduction in TB deaths and an 80% reduction in the TB
incidence rate by 2030 [2].
One of the three major pillars of the End TB strategy
pledges ‘intensified research and innovation, focused on the
discovery, development and rapid uptake of new tools, interventions and strategies. Likewise, research to optimize
CONTACT Roberto Zenteno-Cuevas
robzencue@gmail.com; rzenteno@uv.mx
s/n, Col. Industrial Animas, Xalapa, Veracruz 91190, México
© 2017 Informa UK Limited, trading as Taylor & Francis Group

Received 23 March 2017
Accepted 8 September 2017
KEYWORDS

Tuberculosis; vaccine;
development; BCG;
challenges

implementation and impact, and promote innovations.’ In
this sense, there are three major integrated concerns; diagnostic tests, development and implementation of new drugs,
and development of new vaccines [3].
This situation could help to explain why three new diagnostic probes were reviewed and recommended by the
WHO in 2016: The loop-mediated isothermal amplification
test (TB-LAMP), one line probe assay (LPA) for the detection
of resistance to second-line drugs and another LPA for the
detection of resistance to isoniazid and rifampicin. Nine
drugs are in advanced phases of clinical trials for the treatment of drug-susceptible, drug-resistant, or latent tuberculosis infection (LTBI): Bedaquiline, delamanid, rifampicin
(high-dose), pretomanid, linezolid, PBTZ169, Q203, rifapentine, and sutezolid [1].
Thirteen candidate vaccines are under evaluation in different stages of clinical trials. These include vaccines for the
prevention of infection and LTBI. In addition, according to
the StopTB partnership, several candidate vaccines are
under development in preclinical stages [3]. This is the
highest number of candidates vaccines under evaluation in
the history of TB and has raised the hope that at least one
new vaccine will be licensed and approved by the WHO
before 2020 [1].
The aim of this review is to describe the main characteristics of the most prominent vaccines against TB and to briefly
describe some aspects that have an important influence on
the development and implementation of new TB vaccines.

Instituto de Salud Pública, Universidad Veracruzana, Av. Luis Castelazo Ayala

2

R. ZENTENO-CUEVAS

Article highlights








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This review describes the current state of development of vaccines
against Tb, considering vaccines in both the experimental and clinical
trial stage.
A description of the animal models used for tuberculosis vaccine
research is included and the urgent requirement for inclusion of
the concepts of replacement, reduction and refinement of animal
use in testing is highlighted.
The impact of new procedures such as reverse vaccinology, proteomics
and plant-based expression of Tb antigens is discussed, as well as their
potential contribution in the development of new Tb vaccines.
The development and use of new adjuvants and delivery systems are
described and the future of mucosal immunization and the new
concept of trained immunity in Tb is discussed.
Finally, the biological, social and economic difficulties faced by new
future tuberculosis vaccines are discussed, highlighting the need for a
new paradigm to meet this challenge.

This box summarizes key points contained in the article.

1.1. BCG vaccine
The only vaccine currently recommended and included in the
WHO vaccination schedule in countries with a high incidence of
TB is Bacillus Calmette–Guérin (BCG). It is considered the most
widely used vaccine in human history and was developed by
Calmette and Guérin from the original strain of M. bovis. This
vaccine has been in use since 1921, saving millions of lives to
date [4]. Protection against TB by the BCG vaccine is mainly linked
to the prevention of childhood forms, including extrapulmonary
and meningeal TB. Unfortunately, protection against respiratory
forms has considerable variations, which could be related to
several factors, such as environmental influences and aspects of
host genetics; however, no conclusive explanation has been
found. [4–6]. One additional element that has been described as
important in variation of the effectiveness of the immune
response produced by a vaccination is the heterogeneity of BCG
strains used as vaccines [7,8]. It has been estimated that 14 BCG
strains are currently in use worldwide as vaccines against tuberculosis, all of which are derived from the Calmette and Guérin strain,
but with different morphological, biochemical, and immunological characteristics [9]. BCG, compared with Mycobacterium bovis
and Mycobacterium tuberculosis, has lost several dominant antigens such the Region of Difference 1 (RD1), which encodes immunodominant antigens such as ESAT6, CFP10, and the ESX-1 type
VII secretion system (T7SS) and this mycobacteria therefore
remains restricted to the phagosome of host cells on internalization [10,11]. In addition, single-nucleotide polymorphisms (SNPs),
insertion sequences (IS6110), deletions and tandem duplications
have also been described, with an associated loss of antigenic
potential, modifying the protective efficacy of the strains [12]. This
is an additional aspect that requires consideration when developing new vaccines, especially by using recombinant BCG or a
vaccine that considers prior immunization with BCG.

elements that evidence the critical state of TB and necessitate
the development of new candidate vaccines against the disease. Currently, around 13 new vaccines aimed either at preventing infection (pre-exposure), progression of the disease,
and reactivation of LTBI (post-exposure), are all under different
stages of evaluation.
Tuberculosis vaccine researchers have considered three major
approaches in the development of new vaccines: (1) Engineering
a new recombinant BCG (rBCG) to be more immunogenic; these
vaccines are based on the use of the current BCG as a backbone
with which to express known T-cell immunogens. (2) Booster
vaccines, considering previous BCG immunity. The principle of
these candidates is to boost the anti-TB immunity induced by
prior vaccination with BCG. This process involves immunization
with BCG in neonates followed by subsequent boosting at an
older age using another TB vaccine, thus increasing immunity
and protection against TB. Booster vaccines usually use viral
vectors (poxvirus and adenovirus), which are highly immunogenic and well documented as vaccine delivery systems. (3)
Novel therapeutic vaccines. The goal of these vaccines is to
strengthen the immune system of the patient in order to eliminate M. tuberculosis infected cells, preventing TB reactivation
and reducing the required duration of chemotherapy. This is
also expected to direct the immune system against dormant M.
tuberculosis, using latency-associated antigens to prevent and
eliminate latent infection, as well as to minimize the development of drug resistance, shorten treatment duration for drug
sensitive TB, and improve therapy efficacy for MDR- and XDR-TB.
Two major lines of research are being pursued in this type of
vaccine: (1) fusion-proteins, subunit-proteins, and bacterial fragments delivered with liposomes, and (2) different species of heatinactivated mycobacteria.
Preclinical trials of new candidate vaccines are conducted
in the first instance using animal models. In the case of obtaining promising results, safety tests and immunogenicity evaluations are then conducted with humans (phase I). This is carried
out first in a small number of healthy adults, secondly in
children and finally, where possible, the inclusion of
immune-compromised individuals, such as those with HIV
infection or type 2 diabetes mellitus would be valuable.
These groups include both naive and experienced populations
with mycobacterium by prior BCG immunization. On gaining
satisfactory results, the vaccines then proceed to detailed
human immunogenicity testing (phase II) in an increased
number of individuals of the same population groups. At this
stage, important elements of immunity are characterized,
including polyfunctional and memory responses against
mycobacterial antigens by CD4+ and CD8 + T cells, antibody
responses and assays of immune cell proliferation. Subsequent
phase III studies are designed to determine optimal doses and
schedules of vaccination. These controlled efficacy trials can
be targeted to high-risk subjects in order to reduce sample
sizes and follow-up periods. Household contacts and people
with early HIV infection are also considered suitable subjects.

2. Tuberculosis vaccines under development

2.1. Clinical trials of candidate vaccines against TB

The lack of effectiveness of BCG, the slow decline in incidence
of TB, and the increase in that of DR- and MDR-TB, are

Recent years have witnessed increased development and evaluation of new candidate vaccines, making this a fast-moving

EXPERT OPINION ON BIOLOGICAL THERAPY

Table 1. The pipeline of TB vaccine candidates in clinical trials, according to the Global tuberculosis Report 2016.
Name
Delivery/adjuvant
Antigens
Clinical trial phase III
Vaccae/MOD- Mycobacterium vaccae/M. obtuense
Polyantigenic
901 [3]
MIP [3]
Mycobacterium indicus panii
Polyantigenic

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Clinical trial phase IIb
VPM1002 [1] rBCG ΔureC:hly (PEST motif) L. monocytogenes listeria-lysin O (access of BCG
antigens to MHC-I antigen presentation)
Mtb72F/
Recombinant protein with AS01 and
AS01/
AS02 adjuvant system
ASO2A [3]
Clinical trial phase IIa
DAR-901 [3]
Heat-inactivated M. vaccae/M. obtuense
RUTI [3]
H1/H56/IC31
[3]
H4:IC31 [3]

[14]

Lysterolysin and urease
deletion domain
Mtb39a (Rv1196)
Mtb32a (Rv0125)

New rBCG

[16]

Polyantigenic

Heat-inactivated
mycobacteria
Bacterial fragments
Fusion protein

Polyantigenic
ESAT6 (Rv3785) R2660

Recombinant protein with IC-31

TB10.4 (Rv0288) Fused to
Ag85B
Rv3619, Rv1813c, Rv3620c,
Rv2608

Ad5-Ag85A
Recombinant adenovirus serotype 5
[3]
ChAdox1.85A/ Simian adenovirus
MVA85A [3]
TB/FLU-04L
Influenza vectored vaccine
[3]

Reference

Heat inactivated
mycobacteria
Heat-inactivated
mycobacteria

M. tuberculosis fragments delivered in liposomes, therapeutic vaccine
Fused to Ag85B recombinant protein with both Ag IC-31 or CAF01

ID93/GLA-SE ID93 (fusion of four proteins) with GLA-SE (synthetic glucopyranosyl lipid A)
[3]
Clinical trial phase I
MTBVAC [3]
Deletion of phoP and fadD26 genes

Approach

3

Fusion protein

[15]

[17,18]

[19]
[20]
[21,22]

Fusion protein

[23]

Fusion protein

[24,25]
[26]

Ag85A (Rv3804c)

Inactivated
mycobacteria
Viral vector

Ag85A (Rv3804c)

Viral vector

[28]

Ag85A and ESAT-6

Viral Vector

[29]

Polyantigenic.

[27]

(1) rBCG, (2) Booster vaccine, (3) Novel therapeutic.

field of research. The nonprofit organization Aeras considers
that there are more than 35 candidates vaccines to be evaluated and more than 25 trials under development [13];
Table 1 summarizes the main characteristics of the 13 candidate vaccines recognized by the WHO 2016 TB report as
currently under evaluation in one of the three clinical trials
and with the possibility of use in the near future [1].

2.1.1. Candidate vaccines in clinical phase III
There are two candidates in this phase: The Vaccae/MOD-901
vaccine uses a heat-killed whole-bacilli lysate of Mycobacterium
vaccae/M. obtuense as an immunotherapeutic agent to help
shorten the duration of TB treatment for patients with drugsusceptible TB. It is also being implemented to assess its efficacy and safety in preventing development of the TB disease in
people with LTBI [14].
The second candidate is MIP; this is the species Mycobacterium
indicus pranii, which belongs to the Mycobacterium avium complex. The mechanisms of action in this candidate are mainly based
on induction of a Th1 response and it has shown significant
bacillary decrease in an experimental model with mice [15].

2.1.2. Candidate vaccines in clinical phase IIa and IIb
Seven candidates are included in this stage: VPM1002 is a
recombinant BVC mutant expressing listeriolysin O (a secreted
thiol-activated cholesterol-binding hemolysin from Listeria
monocytogenes). This protein allows VPM1002 to be processed
by the MHC Class I machinery and presented to the CD8 + T
cells [16]. A phase II trial is underway in South Africa to assess
the safety and immunogenicity of the vaccine in HIV exposed

and unexposed neonate, it is hoped that use of this candidate
can avoid the risk of disseminated BCGosis. A phase III trial for
prevention of TB disease in adults is planned in India.
Mtb72/ASO1/ASO2A consists of a recombinant fusion protein
containing Mtb32 (Rv1196) and Mtb39 (Rv0125). These are antigens that induce strong CD4+ and CD8 + T cell responses. This
protein is combined with the AS02A adjuvant (oil-in-water emulsion with 3-deacylated monophosphoryl lipid A (MPL) and QS21 detergent) [17]. The formula based on liposomes (AS01) has
been used in clinical trials, and has shown important induction
and regulation of T cell immunity [18,19,30].
DAR-901 booster is a heat-inactivated whole cell of M.
vaccae/M. obtuense. It was shown to be effective in a phase
III trial among HIV-positive subjects in the United Republic of
Tanzania. A phase I booster trial in the USA among BCGprimed adults, with and without HIV infection, found that it
was safe and well tolerated [19].
RUTI, which is a heat-inactivated M. tuberculosis cellular
fragment transported with detoxified liposomal fragments
[20]. It has demonstrated efficacy in controlling LTBI in
mouse and guinea pig models. A phase II study to investigate
the safety, tolerability, and immunogenicity of RUTI1, following one month of isoniazid treatment in subjects with LTBI,
has recently been completed.
H1/H56-IC31 contains the latency-associated TB antigen,
Rv2660c, along with antigens Ag85B, ESAT-6 and IC31 adjuvant [21]. A phase I study to evaluate its safety and immunogenicity in HIV-negative adults, with and without LTBI, and
with no history or evidence of TB disease has been completed.
Two phase I trials have been completed to determine the

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4

R. ZENTENO-CUEVAS

safety and immunogenicity profile of H56:IC31 in HIV-negative,
BCG-vaccinated adults, with and without LTBI, and in patients
who have recently been treated for pulmonary TB disease.
These phase I trials demonstrated an acceptable safety profile
and found the vaccine to be immunogenic at all doses studied [22].
H4/IC31 is a booster vaccine to BCG and contains a fusion
protein of antigens Ag85B and TB10.4, with the IC31 adjuvant
(oligodeoxy-nucleotide and peptide KLKL5KLK). It is being
tested in South Africa in a phase II pre-proof in HIV-negative
adolescents and is also being evaluated in a phase I/II trial in
infants. A phase II trial including H4:IC31, H56:IC31, and BCG in
84 adolescents is currently under development [23].
ID93/GLA-SE is a fusion protein including three immunedominant mycobacterial antigens Rv2608, Rv3619, and Rv3620
and one latency-associated antigen Rv1813, combined with
the adjuvant glucopyranosyl lipid A (GLA-SE), a potent Th1inducer, and increaser of IFN-γ producing CD4-T cells
[24,25,31]. A phase I trial in BCG-vaccinated, Quantiferon TBGold-negative and -positive healthy adults has been completed in South Africa

Table 2. TB vaccine candidates in discovery/preclinical developmenta.
Name
Oral Ad4
attMtb Rv1503c
Native and recombinant
HBHA
MTBVAC+
rBCG::Ac2SGL (2 isoforms)
ChAd 68 – Ag85A
ChAd 63 – Antigen
Cassette
rec Human PIV2 with TB
antigens
VPM1002NUOG
BCGΔzmp1
MtbΔsigH
sigE mutant
ΔleuD ΔpanCD
mc26020
ΔsecA2
ΔlysA ΔsecA2
mc26030
BCG::ESAT6-L28A/L29S

2.1.3. Vaccines in clinical phase I
Four candidates are included in this stage:

BCGΔsapM

Type/Approach/Description

Reference/
source

Ad
Infant vaccine
Ad

[13]
[13]
[13]

Ad
Infant vaccine
Ad
Ad

[33]
[13]
[13]
[13]

Recombinant

[13]

Infant vaccine
Rec. BCG live zmp1 deletion
Rec. Mtb. live sigH deletion
Rec. Mtb. live sigE deletion
Rec. Mtb live leuD and panCD
deletions
Rec. Mtb. live lysA and panCD
deletions
Rec. Mtb. live secA2 deletion
Rec. Mtb. live lysA and secA2
deletion
Rec. Mtb. live RD1 and panCD
deletions
Rec. BCG Live Reconstituted with
ESX-1,
ESAT-6 mutated L28A/L29S
Recombinant BCG Live sapM
deletion

[3]
[34]
[35]
[36]
[37]
[38,39]
[40]
[41]
[38,39]
[42]
[43]

a

Adapted from Working group of TB partnership [3] and Scriba et al., 2016 [44].

(1) MTBVAC. This is a live M. tuberculosis strain attenuated
via deletions of the phoP and fadD26 genes. The primary target populations include neonates (BCG replacement vaccine) with a secondary target being
adolescents and adults (booster vaccine) [26].
(2) Ad5 Ag85A. This is a replication-deficient strain adenovirus serotype 5 (Ad5) that elicits a high magnitude of
CD4+ and CD8 + T cell responses and expresses the
antigen 85A [27]. It has been evaluated for safety and
immunogenicity in 24 healthy human volunteers
where, overall, it was found to be safe, well tolerated,
and immunogenic, stimulating polyfunctional T cell
responses. More potent immunogenicity was observed
in volunteers who had been BCG-vaccinated previously.
A safety and immunogenicity study of the aerosol
administration of this vaccine was recently completed.
[32]
(3) ChAdox1.85A/MVA85A. Chimpanzee adenovirus (ChAd)
vectors in TB vaccine development are emerging as a
promising new class of genetic vaccine carriers. ChAdAg85A (ChAdOx1 85A) is a simian adenovirus expressing 85A antigen, which has been developed to boost
BCG and is under trial in healthy adults [28].
(4) TB/FLU-04L, TB/FLU-04. In this new candidate vaccine,
the influenza virus strain A/Puerto Rico/8/34 (H1N1)
was used for construction of an attenuated replication
deficient vector expressing two M. tuberculosis antigens
Ag85A and ESAT-6. It was designed as a mucosal ‘boost’
vaccine for infants, adolescents, and adults. A phase I
trial in BCG-vaccinated QuantiFERON-TB-Gold-negative
healthy adult volunteers was recently completed using
intranasal administration, and a phase IIa trial is
planned [29].

2.1.4. Preclinical and additional set of candidate vaccines
An additional set of vaccines are in early clinical phases or
preclinical development (Table 2). These include the recombinant BCG, rBCG30, which overexpresses and produces five
times more Ag85B antigen than conventional BCG, while inducing a greater immune response. AERAS-402/Crucell uses the
nonreplicating adenovirus serotype 35 and expresses the antigens 85A, 85B, and TB10.4 [45], and AERAS-44/H4, which is a
fusion protein consisting of TB10.4 (Rv0288) antigen fused to
antigen 85B and combined with adjuvant IC31 [46]. Several of
these early preclinical candidates are recognized in the 2016
Pipeline report on HIV and TB. Final assessment of these
candidates will require intensification of pre- and clinical trials,
in addition to significant economic investment [47].

2.1.5. Contradictory results in the development of vaccines
Despite the great expectations that exist for such a considerable number of candidate vaccines, it is always important to
consider the possibility of contradictory results that will
require major analysis. One such example is provided by the
MVA85A vaccine. This is a replication-deficient vaccinia virus
strain Ankara (MVA), used as a delivery system for the mycobacterial antigen 85A, which augments BCG-induced immunity in humans [48]. Its safety and immunogenicity were
tested further in 24 BCG vaccinated adults in the UK in a
phase I trial [49]. The trial demonstrated that aerosol vaccination with MVA85A appeared to be safe and feasible compared
with intradermal MVA85A and produced a stronger CD4 + T
cell response. However, a placebo-controlled phase IIb trial
showed a statistical lack of efficacy when it was tested as a
boosting vaccine for intradermal injection in South African

EXPERT OPINION ON BIOLOGICAL THERAPY

infants previously vaccinated with BCG [50]. This contradictory
data evidence the need for more clinical data and an
improved understanding of several aspects of the natural
history, infection process, and immune protection mechanisms of M. tuberculosis [51,52].

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3. Animal models for evaluation of candidate
vaccines
In recent years, there has been renewed emphasis on acquiring more effective preclinical data about vaccine efficacy,
such that funding agencies now oblige the development of
vaccine studies with meaningful results in nonhuman primates as an important requirement for support late-phase
human trials [53,54]. This emphasizes wise selection of the
animal model and appropriate design of the experimental
study as the key elements to consider for appropriate evaluation of candidate vaccine efficacy. The criteria for selection of
an appropriate animal model are then based on improvement of protection with BCG, the characteristics of the vaccine to be evaluated, improved safety, remembrance of
human immune response, and the costs associated with
maintenance of the animals [55].
There are three classic categories of animal models for the
preclinical evaluation of new TB vaccines.
The first includes mice; this is used for initial screening of
candidate vaccine, because of the homogeneous genetic
background and low maintenance costs. However, the main
disadvantage of this model is the differences in the immune
response generated by humans against TB, such as natural
resistance to the infection, as well as differences in the composition and organization of granuloma [55].
Guinea pig [56], rabbit [57], and cow [58] models constitute
the second category, and these animal models more closely
resemble the human response. Guinea pigs and rabbits
develop granulomas and are susceptible to a TB infection
similar to humans. However, the main disadvantages of this
category are related to the high maintenance costs and limited availability of immunological reagents for further evaluation of the immune response. The quality and quantity of
information that has been generated in recent years relating
to the pathological processes and mechanisms of immune
response, specifically in the guinea pig model [59,60], validate
its importance as a relevant and cost-effective animal model.
The last group includes nonhuman primates; this is the
third animal model and includes two major species of macaques: Rhesus (Macaca mulatto) [61] and Cynomolgus (Macaca
fascicularis). Rhesus is highly susceptible to TB infection
whereas Cynomolgus is resistant. The latter model has a better
level of protection by BCG, making it suitable for the evaluation of new subunit vaccines [62] and of alternative routes of
administration [63]. The main advantage of this non-human
model is the similarity it has to the human immune response.
The main limitations of these models are the small population
size available for trial, which acts to limit the validation of the
results and justification of the maintenance costs [62].
Animal models remain useful for the initial evaluation of
candidate vaccines and protection against challenge in nonhuman primates may be more likely to predict efficacy in

5

humans. However, while cellular immune responses are
required for protection against TB, the specificity, quality and
level of responses that are likely to be protective are unknown.
Final evaluation of protection will therefore demand validation
in humans.

3.1. Replacement, reduction, and refinement of the use
of animals in tuberculosis vaccine
The 3Rs concept (replacement, reduction, and refinement) was
first proposed by Russell and Burch in the 1950s, with the aim
of ensuring the ethical use of animals in research [64]. These
principles are beginning to be strongly considered in the animal challenge models used in the vaccine development of TB
[65]. Replacement refers to methods that avoid or replace the
use of animals defined as ‘protected’ in experiments, where
they would have otherwise been used. Alternatives include
the use of humans, in vitro/cell culture models and computational/mathematical modeling. Reduction implies methods that
minimize the number of animals used per experiment, either
enabling researchers to obtain comparable levels of information
from fewer animals or to obtain more information from the
same number of animals, thereby minimizing animal use.
Refinement refers to measures taken to ‘minimize the pain,
suffering, distress or lasting harm that may be experienced by
the animals.’ However, there are two major concerns derived
from the 3Rs concept in the context of the search for TB
vaccines; limitation in the number of the animals available for
study and the costs of maintenance.

4. New strategies for identification of vaccine
candidate antigens
In the history of TB vaccine development, the first generation
of vaccines was taken from bacteria cultured in vitro until
these became attenuated or lost their virulent properties
(BCG is an example). The second category is the so-called
subunit vaccines, which contain fragments of pathogen, such
as the surface proteins, glycoproteins, or short peptide
sequences. The third generation of vaccines includes the
DNA or RNA vaccines, where DNA or RNA codifying tuberculosis antigens are administered to the host. These are then
codified by the host cells and further activate the immune
system against them.
However, traditional approaches in the search for TB vaccines have excluded human/pathogen genetic variations and
their consequences for the immune response. For these reasons, a new paradigm is emerging in vaccine development,
with the aim of developing a new generation of vaccines
against complex infectious diseases such as HIV and TB [66].
This new concept of vaccinology encompasses the utilization
and integration of diverse fields and techniques of study,
including reverse vaccinology, immunogenomics, immunogenetics, systems biology, immune profiling, proteomics, wholegenome sequencing, transcriptomics, host–pathogen interaction, bioinformatics, and computational modeling. Several of
these procedures have the aim of circumventing barriers to
current vaccine development and designing new, safe, and

6

R. ZENTENO-CUEVAS

Table 3. Plant-based tuberculosis candidate vaccinesa.

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Description of the vaccine
candidate

Expression strategy

Administration

Ag85B and Acr antigens fused to a Nuclear expression driven by the CaMV35S
heavy chain antibody against Acr,
promoter Agrobacterium-mediated stable
expressed in tobacco
transformation
ESAT-6 and CFP10 expressed in
Nuclear expression driven by the CaMV35S
carrot
promoter. Agrobacterium-mediated stable
transformation respectively
ESAT-6 and Mtb72F (Mtb32/Mtb39) Chloroplast expression
fused to CTB or LipY, expressed Biolistic-mediated transformation
in tobacco and lettuce
Ag85B, MPT83, MPT64 and ESAT-6 Nuclear expression driven by the tuber specific
antigens expressed in potato
class I patatin Promoter Agrobacteriummediated stable transformation
Ag85B and ESAT-6 antigens fused Nuclear expression driven by the CaMV35S
to ELP, expressed in tobacco
promoter Agrobacterium-mediated stable
transformation
ESAT-6 fused to LTB, expressed in Nuclear expression driven by the CaMV35S
Arabidopsis thaliana
promoter Agrobacterium-mediated stable
transformation

Major immune findings

Reference

Induced IgG and T-cell-mediated response in
mice. Reduced infection in challenged
mice
None induced IgG systemic responses and Tcell-mediated responses in mice

[79]

None

Inhibited hemolysis of red
blood cells

[81]

Oral

Induced IgG systemic responses and T-cell
mediated responses in mice

[82]

Subcutaneous

Induced IgG systemic response and T-cellmediated responses in mice. Induced IgG
systemic response in piglets
None/saponin (Quillaja extract) Induced IgG
systemic responses and T cell responses in
mice

[83]

Intranasal
Oral

Oral

[80]

[84]

a

Adapted from Rosales-Mendoza, S., et al.,
CTB: Cholera toxin B-subunit; LTB: Heat labile Escherichia

effective vaccines that consider host and pathogen heterogeneity and specific characteristics [67]. The true significance and
effectiveness of these new procedures in the development of
new vaccines against TB will be the subject of future evaluation; however, it is clear that the traditional ‘isolate-inactivateinject’ paradigm is no longer valid in the context of TB vaccine
research [66,68]. Perhaps it is now time to think beyond global
and overcrowded TB vaccines, to regional, national and even
personalized TB vaccines.
The urgent need for innovative approaches to the development of TB has given rise to new technologies. Three
procedures have been making important contributions in
this field in recent years: proteomics, reverse vaccinology,
and plant-derived tuberculosis vaccines [69].

4.1. Proteomics
This is a powerful tool for the rapid and large-scale analysis
and identification of potential protein antigens. It has rapidly
expanded the list of novel candidate antigens for TB, considering different mycobacterial stages. The main challenges for
these assays are the selection and evaluation of the most
promising antigens, in terms of their ability to stimulate T
cells. [70–73]

4.2. Reverse vaccinology
Based on the genomic sequence and bioinformatics tools, it is
now possible to search in silico for novel candidate antigens in
a more rapid and cost-effective manner [74]. This ‘reverse
vaccinology’ is an unbiased approach that uses known homologous sequence data to search for multiple immunogenic
antigens throughout an entire genome. Under this procedure,
several T cell epitopes have been identified and are currently
under evaluation [75]. Implementation of this procedure certainly does have important implications for the design of
vaccines against TB and should contribute to an increase in
the list of candidate vaccines in the future [76,77].

4.3. Plant-based TB vaccines
The use of plant-based vaccines has been explored, considering two major aspects; robust vaccination approaches must
ideally be based on low-cost production platforms, they
should be easily delivered and will greatly facilitate massive
immunization [78]. This model has some very interesting characteristics; e.g. plants can be ingested and serve as delivery
vehicles for oral vaccination and stimulate the mucosal
immune response. It requires minimal processing stages and
consequently has very low formulation costs. To date, seven
oral plant-based TB vaccines have been evaluated in experimental/preclinical and phase I clinical trials (Table 3): ESAT-6
fused to LTB, expressed in Arabidopsis thaliana [84,85] Ag85B,
MPT83, MPT64, and ESAT-6 antigens expressed in potato [82];
ESAT-6 and CFP10 expressed in carrot [80]; Ag85B and ESAT-6
antigens fused to ELP, expressed in tobacco [83]; Ag85B and
Acr antigens expressed in tobacco [79]; and ESAT-6 and
Mtb72F (Mtb32/Mtb39) fused to CTB, expressed in tobacco
and lettuce [81] (Table 3).

5. Adjuvants, immunomodulators, and delivery
systems
One of the key aspects for the development of a vaccine
against TB is the correct activation of the immune response
and satisfactory stimulation of antigen specific cells, which is
necessary to achieve an appropriate level of response. For this
reason, there have been important developments in the identification and use of new adjuvants in recent years.
Early TB adjuvants were highly complex preparations where
optimal activity was considering by combining the cell mycobacteria wall, liposomes and oil droplets. For a TB vaccine to
be successful, activation and participation of CD4+ and CD8 +
T cells are required. For this reason, adjuvants that stimulate
these cell groups and trigger a better response against TB are
currently under research and development. At present, the
characteristics of adjuvants in TB rely on two major activities:
as immunomodulators stimulating through a pathogen-

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EXPERT OPINION ON BIOLOGICAL THERAPY

recognition receptor (PRR) and as delivery systems for efficient
vaccine targeting. Several families of PRRs recognize mycobacterial pathogen-associated molecular patterns (PAMPs), including membrane-bound C-type lectin receptors, membranebound and cytosolic Toll-like receptors (TLRs) and cytosolic
NOD-like receptors [86].
Delivery systems have traditionally been considered inert
carriers of the vaccine components, basically serving to ensure
that the vaccine antigen is not excreted immediately after
injection. Alum-containing adjuvant is the classical example,
where activity has been mainly attributed to the ability to
carry antigens [87].
It has been reported that delivery systems can also serve a
number of important functions in relation to targeting the
vaccine components to specific cells of the immune system,
enhancing antigen presentation, prolonging immune
responses and reducing unwanted, adverse effects of PAMPs.
In addition, delivery systems previously regarded as inert
material have been shown to have many direct immune stimulatory properties.
There are a range of different delivery systems, including
mineral salts, emulsions, liposomes, virosomes, and biodegradable polymer microspheres, of which liposomes are considered the most promising TB adjuvants. [88–90]
Some of the new generation of adjuvants used in vaccines
under clinical trials are; Glucopyranosyl-lipid A (GLA). This is a
nontoxic synthetic molecule, formulated with squalene,
which forms a stable oil-in-water emulsion (GLA-SE) and is
strong stimulator of Th1. A GLA-SE formulation with four TB
antigens, Rv2608, Rv3619, Rv3620, and Rv1813, has recently
been developed [91,92], as well as a-galactosyl ceramide (aGalCer, or KRN7000), which is a glycol-sphingolipid that activates natural killer T cells to produce immune-regulatory
cytokines. The use of BCG combined with orally administered
a-GalCer produces protection against TB in mice [93].
Lactoferrin, is an iron-binding glycoprotein that promotes
the maturation of T- and B lymphocytes and immature dendritic cells, used in conjunction with BCG, improve host protective responses [94]. CAF01, is a cationic liposomal
adjuvant that primes strong and complex immune responses
[95], and has been used with recombinant fusion proteins
Hybrid1 (H1 Ag85B-ESAT-6) and Hybrid 56 (Ag Ag85B-ESAT6-Rv2660c) [96].
Additional novel adjuvants, such as Carbomers (polymers of
acrylic acid); siRNA molecules; nontoxic type II heat-labile
enterotoxin (LT-IIb-T13I); TLR9 ligand (CpG 7909); and mucosal
adjuvants, among many others, are under consideration for
use with TB antigens or in combination with rBCG [97,98].

6. Mucosal immunization, new hope and further
work
Initial immunization of BCG was conducted orally in infants in
Paris, France, in 1921; however, parenteral immunization is the
traditional route of TB vaccination, despite the fact that M.
tuberculosis is a pathogen that displays a strong interaction
with the mucosal system. The mucosal immune response
considers two major elements: the systemic and the mucosal
immune systems. The mucosal surfaces are the first point of

7

contact for many pathogens and therefore constitute their
ports of entry. Mycobacterium tuberculosis enters the body
through the airways and the immune response of the host is
made by cooperation between the innate and acquired
immune systems. Recognition of the pathogen, followed by
activation of the innate response and final recruitment of the
acquired immunity are the initial steps related to the immune
response against TB [99]. Upon entering the lungs, the tuberculosis encounters macrophages and dendritic cells, whereupon some bacilli are destroyed but others replicate within
the macrophages. Activated macrophages, dendritic cells and
T cells produce IL-12 and IL-18 that induce natural killer (NK)
and IFN-γ, respectively. The latter cytokine plays an important
role in immunity against MTB, through activation of macrophages and killing the bacteria [100].
Mucosal immune response is vital for protection against TB;
however, the vast majority of new candidate vaccines in clinical phase trials are parenteral/systemically administered. They
induce strong systemic but weak mucosal immune responses,
which may be insufficient to confer long-lasting protection.
The site of challenge is an additional factor that needs to be
taken into account, considering that nasal or sublingual vaccines have been shown to be the most powerful of the mucosal vaccines in terms of inducing systemic responses,
sometimes comparable to parenteral vaccination [101].
Several efforts have been made to create vaccines specifically
for use in different challenge route sites, including oral (ESAT6-Ag85B-MPLSE [102]), nasal (H-KkBCG-Eurocrine, [103]), and
intranasal (AdAg85A [27], TB-RICS [79], and rhPIV2-Ag85B [104]
Despite the fact that mucosal responses toward specific
antigens are currently under research, the limited number of
clinical trials involving mucosal vaccine delivery systems for TB
is a result of the scarce knowledge regarding mucosal immunology and tuberculosis infection [49,99,105]. Further efforts
are required in terms of the biological characteristics of
immune mucosal response against TB, in order to address
the development of highly efficient vaccines administered
through the mucosal immune response.

7. Trained immunity and TB vaccines
Recently, a checkpoint model has been proposed for TB disease progression. [106] The first checkpoint includes the
innate immune system; where initial infection is established,
then it passes to the second ‘checkpoint,’ which is represented
by the adaptive immunity and the innate immunity working
together. If the bacteria pass this last checkpoint, then tuberculosis is able to cause active disease and spread to other
individuals. Under this model, adaptive immunity has a major
role to play in the control of infection; however, there is a
period of time during which innate immune mechanisms can
eliminate TB infection, and this is referred to as ‘early
clearance.’
It has been suggested that the effectiveness of these two
immune checkpoints depends on genetic, comorbidity, and
environmental factors [107,108], including the potential
impact of previous exposure of innate immunity to the infection or administration of vaccines and how this interaction
could ‘coach’ the innate immune defenses to induce a more

8

R. ZENTENO-CUEVAS

strong and effective response. This property is known as
‘trained immunity’ and has been demonstrated in plants,
invertebrates, and animals [109]. There is no doubt that this
‘trained immunity’ phenomenon could open completely new
opportunities for the development of vaccines that reinforce
innate immunity and induce a stronger response against initial
TB infection [110].

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8. Conclusion
Progress in the identification of new antigen candidate vaccines against TB has increased substantially over the first two
decades of the 21st century. More than 13 candidate vaccines
are currently under evaluation at several clinical trial stages
and a similar number of candidates are in preclinical evaluation. Within the next few years, it is expected that at least one
candidate will go on to become a successful vaccine against
TB and to help achieve the Sustainable Development Goals by
2030.

9. Expert opinion
Despite the significant number of vaccines at various levels of
evaluation in clinical trials, there is still no candidate that can
be used to replace the traditional BCG vaccine. Without doubt,
one of the major impediments to developing an effective
vaccine against TB to date has been our poor understanding
of several immune-pathological mechanisms. These include
virulence factors related with the latent and active infectious
process of TB, the immune responses at the humoral, cellular
and mucosal levels implemented by the host against the
infection and the mechanisms used by M. tuberculosis to resist
both innate and adaptive immune responses.
The recent implementation of an entirely new group of technological advances such as proteomic, reverse vaccinology,
among others, will be very useful for the characterization of
molecular determinants of pathogenesis and will provide a clear
dissection of the different steps of TB infection, which should help
to identify the most promising antigen candidates and the types
of cellular response that vaccines elicit in the immune system.
The mucosal system, as a promising new path for the administration of vaccines, as well as the development of new adjuvants, immune modulators, and delivery systems, will provide a
new understanding of immunity against TB and should greatly
contribute to the rational design of new vaccines.
The development of new or improved animal models, considering the 3Rs concept, that can accurately replicate TB
infection, will be of great help to investigate the early steps
of the infectious process, biology of the active, latent infection
or reactivation processes of TB. It can be of invaluable help in
terms of evaluating in greater detail the potential of antiinfective vaccines at the preclinical level.
All of the information generated by these technological
developments will allow the development of different types
of vaccines with different antigenic compositions and
immunological capacities; so that they can be directed to
a particular event; for example, a vaccine against a latent
infection or prevention of infection. Moreover, it should be
possible to consider particularities of individuals or

populations for whom the specific vaccine is intended; e.g.
a first boost for a newborn child or an improvement to
specific protection in adults with HIV infection living in
high prevalence TB regions.
In this context, it might be possible to contemplate a
combination of immunization strategies, with an improved
live attenuated vaccine and boosting with a vectored or subunit vaccine that may vary in antigen composition and immunogenicity depending on the status of the individual to be
protected, or in order to strengthen different aspects of the
anti-TB immunity.
Despite the promising scientific and technological landscape,
it must be noted that it can take up to 16 years for a candidate
vaccine to progress from preclinical to phase III studies. The
costs implied by this process rank between US$15–25 million
per year for clinical study; US$6–12 million for phase I and IIa
studies, US$20–40 million for phase IIb studies and US$115–170
million for phase III studies, while success rates are around 20%
for discovery/preclinical studies, 33% each for phase I/IIa and
phase IIb studies, and 85% for phase III studies [13].
The 2016 global TB report recognizes the critical economic
conditions for the control and care of TB in the future.
Investments in low- and middle-income countries fall almost
US$ 2 billion short of the US$ 8.3 billion required in 2016
(annual report 2016). At least US$ 2 billion is needed per
year for TB research and development; however, funding
over the period 2005–2014 never exceeded US$ 0.7 billion
per year. It is of utmost importance to ensure that any new
vaccines can be affordable and available for countries where
the need is greatest. Unfortunately, with a few exceptions,
these countries are poor and/or underdeveloped.
It is evident that the economic contribution of a single
foundation or government is insufficient and there is a need
for the development of an economic consortium for funding
to support the development, acquisition and application of
any new vaccine. There is no doubt that economic aspects will
play an important role in the evolution of any new tuberculosis vaccine over the next few years.
While there have been numerous advances, many challenges remain for the development of any new vaccine(s)
against TB. Thanks to its particular characteristics, M. tuberculosis has remained one of the most important infectious diseases in human history and it will require an extraordinary
organization on the part of mankind, implying a global coordination of efforts, if we are to achieve the control and possible eradication of tuberculosis.

Funding
This manuscript was funded by CONACyT Proyecto de Desarrollo
Científico para Atender Problemas Nacionales 213712.

Declaration of Interest
The author has no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.

EXPERT OPINION ON BIOLOGICAL THERAPY

ORCID
Roberto Zenteno-Cuevas

http://orcid.org/0000-0001-9597-127X

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