What is Leprosy and is there a Leprosy Vaccine?

"Mycobacterium leprae." www.who.int/lep/disease/frmain.htm

Leprosy (or Hansens Disease) is a communicable disease caused by Mycobacterium leprae. M.leprae is an acid-fast, rod-shaped bacillus that mainly affects the skin, peripheral nerves, mucosa of the upper respiratory tract and also the eyes. It mainly affects the skin and nerves and progresses slowly with an average incubation period of three years. The earliest documented account of leprosy is around 1550 B.C. on Egyptian papyrus. Throughout its history, leprosy has been feared and misunderstood, often thought to be a hereditary disease, a curse, or a punishment from God. Leprosy has been treated in many ways throughout history, from using the oil of a chaulmoogra nut in the early twentieth century, prominin in 1941, Dapsone pills in 1950, to the highly effective multi-drug therapy regimen (consisting of rifampin, clofazimine, and dapsone). Fortunately, if detected early and treated with multi-drug therapy, leprosy will not lead to deformities and leprosy patients can lead completely normal lives. Global efforts have been trying to reduce the disease burden of leprosy and proceed toward eradication for over twenty years. Elimination of an infectious disease such as leprosy requires a highly effective vaccine. This website focuses on the development of the leprosy research and progression towards a universally accepted vaccine. Various countries around the world, namely India and Brazil, currently use the Bacillus Calmette Guerin (BCG) vaccine for tuberculosis to double as a leprosy vaccine, as the two diseases are caused by similar mycobacterial agents. However, the effectiveness of this approach is widely disputable, and the quest still continues, in the United States and worldwide, for a universally accepted and unquestionably effective leprosy vaccine.

A Brief History of Leprosy Vaccine Research

1921 Bacillus Calmette-Guerin vaccine produced by two French scientists, Albert Calmette and Camille Guerin 1928 BCG vaccine adopted by the Health Committee of the League of Nations 1979 - Human trials with ICRC Anti-leprosy Vaccine began in Mumbai, India 1980 ICRC (cultivable leprosy derived mycobacteria belonging to M. avium intracellulare complex) Vaccine developed February 1998 Leprosy vaccine developed and approved at the National Institute of Immunology in New Delhi, the first to stimulate the immune system to kill M.leprae. The vaccine is prepared from a killed non-pathogenic strain

of Mycobacterium, first isolated in the mid-1970s from the sputum of a patient with tuberculosis. First commercial batch released in June 1998 and sold in India at six rupees a dose

October 2003 Identification of M. leprae antigens May 2005 Completed screening of the leprosy bacillus for proteins strongly recognized by the human immune system March 2006 Identified two specific antigens (MLO405 and ML2331) which, combined with the existing PGL-1 antibody test, give a significantly greater sensitivity to the test. These antigens can also potentially form the basis of a specific vaccine against leprosy.
The Bacillus Calmette Guerin (BCG) Vaccine

The Bacillus Calmette Guerin (BCG) vaccine (photo courtesy of Pasteur Merieux Connaught, Canada).www.lung.ca/tbtoday/prevention/bcg.html
Mycobacterium bovis BCG is the vaccine most studied in association with leprosy. The BCG vaccine is used as a vaccine against tuberculosis in many countries worldwide (not the U.S.) with variable efficacy. The effectiveness of the BCG vaccine in providing immunity against leprosy is quite controversial, however. Researchers have done complementary analysis of the BCG vaccine to see its effect on leprosy and levels of protection have varied from no effect to up to 80%. The BCG vaccine provides considerable efficacy against tuberculosis, however, there are distinct similarities and differences between M.tuberculosis andM.leprae (see below). Various factors such as biological differences in BCG strains, exposure to environmental mycobacteria, and ineffective boosting against reinfection with or reactivation of tuberculosis may give rise to the varying levels of efficacy of BCG against tuberculosis. These reasons may also suggest the variability of BCG against leprosy. The vaccine is a live, attenuated vaccine, meaning that it infects the individual but does not give them any disease (unless the person is immunocompromised). The BCG vaccine contains weakened forms of the organism M.tuberculosis through attenuation. The attenuated form of M.tuberculosis is obtained by serial passage or culture of the active organism in culture media or cells.

How different are M.tuberculosis and M.leprae?

Looking at the two mycobacteria on a stain, they appear very similar. They have similar cell walls and similar enzymatic capabilities. However, their chromosomes are sequenced quite differently. M.tuberculosis has about 4000 gene capabilities, and therefore a greater capability of making and degrading

compounds. M.leprae has about 1600 genes. The two mycobacteria have about the same number of molecules.

How the Vaccine Works
The BCG vaccine is a live, attenuated vaccine, meaning that it infects the individual but does not give them any disease (unless the person is immunocompromised, they can then contract a systemic BCG infection). The BCG vaccine contains weakened forms of the organism M.tuberculosis through attenuation. The attenuated form of M.tuberculosis is obtained by serial passage or culture of the active organism in culture media or cells. The vaccine is based on the concept of cross reacting antigens where the killed Mycobacterium strain is used to stimulate the immune system into mounting an attack on M.leprae.

Potential Side Effects

The BCG vaccine may cause redness and mild swelling where the injection was given. However, these symptoms should improve over time. Other minor side effects include red bumps at the injection site, loss of appetite, muscle or joint pain, low grade fever 1-2 days after vaccination, or enlarged lymph node. Serious side effects are rare, but may include signs of allergic reaction such as difficulty breathing, wheezing, chest tightness, severe rash, or hives, fever of 103 degrees F or higher, and skin ulcer at the injection site. BCG vaccination may cause a positive reaction to the tuberculin skin test (TST) which may complicate decisions about prescribing treatment.

Prophylactic or Therapeutic Vaccine Options

A potential leprosy vaccine can be either prophylactic (preexposure) or therapeutic (postexposure). Dr. Tom Gillis, Chief of the National Hansens Disease Programs Lab Research, remarks that it is not necessarily easier to create either version of the vaccine. However, in America, because of the low incidence of leprosy, it makes much more sense to focus on a therapeutic vaccine to administer only to those who are actually affected by the disease.

Pros of a Prophylactic Vaccine:

An effective prophylactic vaccine could break transmission by giving individuals immediate as well as extended protection from infection of leprosy. A prophylactic vaccine should also help stop the emergence of drug resistance since it would protect against both drug-susceptible and drug-resistant strains. Can be given to all newborns as the BCG vaccine is to provide protective immunity against future infection.

Pros of a Therapeutic Vaccine:

A therapeutic vaccine could improve a patients response to multidrug therapy by possibly reducing the occurrence of relapse cases. A therapeutic vaccine can be given in conjunction with multidrug therapy for people already infected with leprosy, therefore targeting only those who actually have the disease and saving money (may be more helpful for areas where leprosy is not a major problem, where it does not make sense to vaccinate everyone). Easier to test because you can target subjects easier (people who already have leprosy and are in the process of treatment). Could speed treatment and recovery for those already infected with M.leprae.

Leprosy Vaccine in the United States

Logo for the American Leprosy Missions, an organization dedicated to leprosy research and eradication. www.leprosy.org
In the United States, these is no official, nationally accepted vaccine for leprosy. For over 15 years, researchers have be en doing complementary analysis of tuberculosis vaccines, such as the BCG (Bacillus Calmette Guerin) vaccine, to see if they have an effect on the closely related Mycobacterium leprae. Throughout the process of attempting to sequence the M.leprae genome and bioinformatic processing of the data, researchers have changed the way the U.S. investigates potential antigens for new vaccines. The debate still continues, however, as to whether there is a need for a vaccine in the overall strategy to control and/or eradicate leprosy on a national and international scale. The BCG vaccine is not used in the United States as a leprosy vaccine because of the unproven effectiveness of the BCG vaccine as well as the low incidence of leprosy patients in America. According to Dr. Barbara Stryjdwska, Clinician at the National Hansens Disesase Pr ograms in Louisiana, there are only approximately 150 new leprosy cases each year in the United States, and most of these are in immigrants coming from countries where Hansens Disease is endemic. In 2002, 96 cases were reported to the Center for Disease Control and Prevention. The incidence may be greater however, because many patients do not want to be reported because of their immigrant status. Additionally, if patients do not seek or purchase treatment, they are hard to be tracked.

When will we see a vaccine being used in the United States?

Because leprosy is such a small problem in the United States, and since 90% of cases are imported (immigrants from countries where leprosy is endemic), there is little reason for a leprosy vaccine to actually be utilized in the United States even if an effective vaccine is created. Once identified, patients with leprosy in the United States are immediately put on antibiotics and usually cured in six to nine months. However, this does not thwart the efforts of American researchers to continue in-depth research on future leprosy vaccines that can be used on an international level, and possibly help to eradicate leprosy in the future.

Leprosy Vaccine Used Internationally

"Summary of Estimates of BCG and other vaccines against leprosy." http://cmr.asm.org/cgi/content/full/19/2/338/T12

Different populations with different genetic backgrounds may explain why certain countries have and have not found success in the BCG vaccine against leprosy. Two recent studies in India (54% effectiveness, Zopdey) and Brazil (74% with neonatal vaccination, Cunha ) provide clear evidence that BCG protects against leprosy. Brazilian investigators argue that their results show the importance of neonatal vaccination and that environmental mycobacteria may not affect vaccine efficacy, at least in the Amazon region of Brazil. Three relatively recent vaccine trials have studied the efficacy of combining the BCG vaccine with killed M.leprae. The main reason for testing this combination is to figure out whether M.leprae-specific antigens are able to improve the efficacy of BCG against leprosy. The first of these three studies was conducted in Venezuela and concluded that the protective efficacy of BCG was proportional to the number of doses (i.e. the number of scars from BCG vaccination) and that protection against leprosy was not necessarily improved with the BCG and M.lepae combination. In a trial done in Malawi, no improvements were seen as well. However, scar-positive individuals showed a further protection against leprosy with a second BCG vaccination. A trial in southern India showed no positive effect for vaccinating BCG scar-positive individuals, but enhanced protection was shown in individuals who received BCG plus heat-killed M.leprae. They also showed enhanced protection with vaccines that contained Mycobacterium w or ICRC (cultivable leprosy derived mycobacteria probably belonging to M. avium intracellulare complex). ICRC alone and BCG plus heat-killed M.leprae gave approximately the same level of protection (64% (Kartikeyan) and 65% (Gormus), respectively) showing that a killed mycobacterial vaccine containing M.leprae cross-reactive antigens is as effective as a live, attenuated BCG vaccine. But these results are specific to this population and setting. Thus, the controversy still continues over what elements of a leprosy vaccine are superior, though it is generally accepted that the positive effects of vaccination to reduce leprosy are confirmed.

When will we see a universally approved vaccine?

Dr. Tom Gillis of the National Hansens Disease Programs says that it is safe to say that in the next five years, there will be one to two new vaccin es for tuberculosis that might include a leprosy component. As far as a vaccine exclusively for leprosy, we might see one in the next 5-10 years, then it would take 5-10 years to follow up on it and test it. His estimate is that it could be about 10-20 years before we see an official leprosy vaccine that is universally accepted worldwide.

dentifying Mycobacterium leprae Antigens

Armadillo used for Leprosy research. Photo courtesy of Leprosy Research Support at Colorado State University. http://www.cvmbs.colostate.edu/mip/leprosy/globalleprosy3.html
The genome of M.leprae has been sequenced, however, M.leprae still cannot be cultivated without contamination or association with other organisms. Before completion of the sequence of M.leprae, the only highly purified bacilli originated from infected armadillo tissues, which caused difficulty because certain secreted proteins were lost upon purification of the bacilli from the armadillos. New approaches to identifying genes from completed M.leprae genome sequences are being applied using standard bioinformatics tools that can identify proteins with special features like

unique or shared amino acid sequence homologies with proteins of M.tuberculosis or other mycobacteria, and the presence of specialized peptide signatures suggesting their cellular location and possible secretion across the cell membrane (Scollard et. al). Proteins of interest can be prioritized based on potential B-cell and T-cell epitopes. Then the proteins selected for further study can be purified as recombinant proteins for an endless supply of the protein for vaccine research. Once a DNA vaccine is injected, it produces a protein. At the National Hansens Disease Programs Lab, they are currently work ing with three different proteins, M.leprae antigen 85a, 85b, and 85c. They have been looking into DNA vaccines as an approach to studying may types of proteins that can possibly be used in vaccines, and this particular complex of proteins have been shown in tuberculosis. The proteins are prepared as DNA vaccines and injected into animals like mice. (No human subject studies are currently being conducted). From the two experiments run thus far, antigen 85c seems to have the best efficacy against leprosy infection. Leprosy infection is measured in mice by observation of the footpad. A gene is purified and then put into the mice, then they are exposed to M.leprae. In an unvaccinated animal, there is a small growth in the footpad that indicates infection. In experimental animals, you can test whether the vaccine has slowed or stopped the growth in the footpad of the mouse.

The Future of Leprosy Vaccine Research and Treatment

The number of new leprosy cases identified annually worldwide has probably not changed over the last twenty years, though the number of registered cases has declined as a result of improved treatment and removal from registries. Elimination of an infectious disease such as leprosy requires a highly effective vaccine. Global elimination of leprosy has been the goal of laboratory research and world health organizations for almost twenty years. The current primary intervention for leprosy eradication is early diagnosis in order to attempt to interrupt transmission with treatment as early as possible. Still, this leaves major implications for the treatment of asymptomatic leprosy patients. There has been much progress in the field of leprosy vaccine research over the years. The genome of M.leprae has been sequenced. The availability of knockout mice deficient in selected immunologic abilities will enable dissection of the roles of different cytokines and T-cell subsets in response to infection. The armadillo genome has been partially sequenced and is currently in the process of annotation, which will hopefully enable researchers to be able to identify and synthesize immunologically relevant cytokines and probes for use in the animal model. The Laboratory Research Branch of the National Hansens Disease Programs remarks, In addition to newly available search algo rithms for genes of interest, new vehicles for delivery of protein antigens have been identified from research on recombinant DNA over the last 20 years. Much of this technology is being used to create vaccines to be administered in concert with BCG, either as recombinant BCG overexperssing one or more antigenic proteins or in a prime-boost scenario where antigen is given first in an adjuvant (priming) and then followed by BCG vaccination to boost the initial response (Scollard et al.). Dr. Tom Gillis says that it would be a real achievement to improve on current tuberculosis vaccines, and find one that is better able to protect against both infections (leprosy and tuberculosis).

References

Cunha et al. Neonatal BCG protection against leprosy: a study in Manaus, Brazilian Amazon. Leprosy Reviews. Vol 75, Issue 4 . Dec 2004. p. 357-66. Gillis, Tom. Chief National Hansens Disease Programs Lab Research. Personal Interview. 22 May 2006. Gormus et al. Anti-leprosy protective vaccination of rhesus monkeys with BCG or BCG plus heat-killed Mycobacterium leprae: lepromin skin test results. Leprosy Reviews. Vol 73, Issue 3. Sep 2002. p. 254 -61. Hansens Disease (Leprosy). Division of Bacterial and Mycotic Diseases. Centers for Disease Control and Prevention. 12 Oct 2005.http://www.cdc.gov/ncidod/dbmd/diseaseinfo/hansens_t.htm Hansens Disease Research. National Hansens Disease Programs. Bureau of Primary Health Care. April 2006. http://www.bphc.hrsa.gov/nhdp/ Kartikeyan et al. Anti-leprosy vaccines: current status and future prospects. Journal of Postgraduate Medicine. Vol 37, Issue 4. 1991. p.198-204. Leprosy Research Support. Colorado State University. 13 Jan 2005. http://www.cvmbs.colostate.edu/mip/leprosy/globalleprosy3.html Strydjswka, Barbara. Clinician at the National Hansens Disease Programs. Personal Interview. 22 May 2006. The Continuing Challenges of Leprosy. Scollard, Gillis, Truman, et al. Clinical Microbiology Reviews. April 2006, p.338 -381, Vol. 19, No.2.http://cmr.asm.org/cgi/content/full/19/2/338

Treatment Timeline. Global Project on the History of Leprosy. International Leprosy Association. http://www.leprosyhistory.org/cgibin/treatmentyearrange.pl

Zopdey et al. Effectiveness of Bacillus Calmette Guerin (BCG) vaccination in the prevention of leprosy: a population -based case-control study in Yavatmal District, India. Public Health. Vol 119, Issue 3. March 2005. p. 209 -216.