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Feature Review

An Overview of Novel
Adjuvants Designed for
Improving Vaccine Efficacy
Srinivasa Reddy Bonam,1,2 Charalambos D. Partidos,1,y
Sampath Kumar M. Halmuthur,2,* and Sylviane Muller1,3,*
Adjuvants incorporated in prophylactic and/or therapeutic vaccine formula-
Trends
tions impact vaccine efficacy by enhancing, modulating, and/or prolonging the
New-generation adjuvants are crucially
immune response. In addition, they reduce antigen concentration and the awaited to create new vaccines or
number of immunizations required for protective efficacy, therefore contribut- improve the efficacy of existing ones.

ing to making vaccines more cost effective. Our better understanding of the Pattern recognition receptors are cen-
molecular mechanisms of immune recognition and protection has led research tral to the innate immune response and
efforts to develop new adjuvants that are currently at various stages of devel- are considered as key targets for pro-
ducing effective vaccine generation.
opment or clinical evaluation. In this review, we focus mainly on several of these
promising adjuvants, and summarize recent work conducted in various labo- Several smart novel adjuvants have
emerged recently that act as immuno-
ratories to develop novel lipid-containing adjuvants
modulators or potent delivery systems.

Introduction Synthetic or natural adjuvants, with or


Vaccine immunology remains a valuable legacy of the pioneering research of scientists such as without a delivery system, are pre-
pared to sensitize the immune system
Edward Jenner, William B. Coley, Louis Pasteur, Gaston Ramon, and Alexander T. Glenny.
against infectious agents and induce
Many vaccines have been developed on the basis of trial and error and their immunological long-lasting memory immune
mechanisms of protection remain unknown. This lack of understanding results mainly from the responses.
shortage of predictive models that can be used to determine the outcome of interactions of
Novel adjuvants are also required as
various vaccine formulations with the host immune system. As a result, vaccine testing has components of vaccines generated
become time consuming and expensive, requiring in vivo testing to meet safety, immunoge- from novel technologies, such as
nicity, and efficacy requirements. reverse vaccinology, which starts with
the genome of pathogens and is used
for predicting pertinent epitopes.
Vaccines encompass ‘any preparation used as a preventive inoculation to confer immunity
against a specific disease, usually employing an innocuous form of the disease agent, as killed
or weakened bacteria or viruses (in the case of infection), to stimulate antibody production’ and
1
cellular immunity (see Glossary). Recent vaccines can also contain a protective antigen(s) of CNRS, Immunopathology and
therapeutic chemistry/Laboratory of
the pathogen (subunit vaccines), which can be expressed by an attenuated bacterial or virus excellence Medalis, Institut de
vector (recombinant vaccines) or encoded by DNA or RNA (DNA or RNA vaccines) [1–3]. Biologie Moléculaire et Cellulaire,
Strasbourg, France
2
Vaccine Immunology Laboratory,
Despite the rapid and successful development of antiviral drugs against some pathogenic viruses, Natural Products Chemistry Division,
such as HIV and hepatitis C virus (HCV), there is still an alarming paucity of antiviral drugs for many CSIR-Indian Institute of Chemical
clinically important viral pathogens. In fact, there is a lack of effective drugs against most infectious Technology, Hyderabad, India
3
University of Strasbourg Institute for
agents. To confront the ongoing emergence of new and previously known, but not yet controlled, Advanced Study (USIAS), Strasbourg,
infectious pathogens, as well as the problem of drug-resistant variants, there is a need to develop France
y
novel vaccines and, therefore, potent adjuvants that improve their efficacy [4]. The introduction of Current address: 4210 Bagley Pkwy,
Madison, WI, USA.
novel vaccines remains a challenge to public health systems worldwide. *Correspondence:
sampath@iict.res.in (S.K.M.
Inactivated, subunit, or recombinant vaccines in general are poorly immunogenic. Adjuvants
Halmuthur) and
have been used to augment and modulate the immunogenicity of vaccines without causing sylviane.muller@unistra.fr (S. Muller).

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 http://dx.doi.org/10.1016/j.tips.2017.06.002 771
© 2017 Elsevier Ltd. All rights reserved.
adverse effects. Their discovery often emerges from studies dissecting the immunostimulatory Glossary
properties of bacterial components [5]. Vaccine adjuvants in current clinical use are listed in C-type lectin receptors (CLRs):
Table 1 and their advantages are depicted in Figure 1. Adjuvants stimulate the innate immune include DEC 205, macrophage
system directly by acting on dendritic cells (DCs), macrophages, and neutrophils, leading to the mannose receptor (MMR), dectin-1,2
macrophage-inducible C-type lectin
activation of the adaptive immune system (Figure 2). (Mincle), dendritic cell natural killer
lectin group receptor-1 (DNGR-1),
The innate immune system (Figure 2) has a critical role as a first line of defense that allows and dendritic cell-specific intracellular
adhesion molecule 3-grabbing
primary responses against microbes to occur. It confers an immediate nonspecific mechanism
nonintegrin (DC-SIGN). CLRs are
conserved carbohydrate recognition
receptors with or without calcium
Table 1. Examples of Vaccine Delivery Formulationsa,b dependency and form part of the
innate immune system with an
Adjuvant Composition Proposed mechanism of action Refs essential role in antifungal immunity.
+ Co-stimulation: in addition to the
MF59 Squalene, Span 85, Tween 80, and Upon injection, recruited CD11b [135,136]
citrate buffer cells and MHC-II+ cells and also first antigen-specific signal involving
promoted systemic expression of IL- the major histocompatibility complex
12 (p40) and IL5; further assisted the (MHC) peptide–T cell receptor (TCR)
sustained release of Ag at the interaction, a co-stimulatory signal (or
injection site and activated muscle ‘second signal’) is crucial for T cell
fibers followed by tissue-resident DCs activation. Co-stimulatory molecules
expressed on the membrane of
AS01 Liposomes containing MPLS and Activated Ag-loaded monocytes and [137] antigen-presenting cells (APCs) and
QS21 MHC-IIhigh DCs T cells act in a tandem ligand–
AS02 O/W emulsion containing MPLA and Enhanced both cellular and humoral- [138] receptor system that, upon
QS21 mediated immune responses completion of the full signal, initiates
T cell maturation, differentiation, and
AS03 a-tocopherol, squalene, polysorbate Promoted recruitment of monocytes [139]
proliferation. Co-stimulatory
80, and PBS and granulocytes; also increased
molecules include CD28-CD80/
secretion of cytokines (CCL2, CCL3,
CD86, or ICOS-ICOL complexes. B
IL-6, CSF3, and CXCL1) from APCs,
cell co-stimulatory molecules include
thereby enhancing Ag-specific
CD40-CD40L and complement-
adaptive immune responses
complement receptors.
AS04 Contains MPLA adsorbed onto a Directly activated APCs by inducing [121] Damage-associated molecular
particulate form of aluminum salt NF-kB, cytokine production, and patterns (DAMPs): host cellular
antigen-specific T cell activation components released during tissue
injury or death. DAMPs activate the
Virosomes Contain inactivated virus Virosomal-adjuvanted influenza [140]
immune system through PRRs;
vaccine Inflexal1 V increased the
nonspecific activation of APCs
geometric mean titers of antibodies
through DAMPs causes several
along with cell-mediated immunity
autoimmune diseases,
CAF01 Cationic liposomal vehicle containing Induced cell-mediated immunity [98] atherosclerosis, and myocardial
DDA with a glycolipid through release of IFN-g and IL-17 infarction.
immunostimulator (TDB) from activated T cells Danger signal: the immune system
is well organized to recognize danger
CAF04 Cationic liposomal vehicle containing Induced higher IFN- g responses than [103]
elements by discriminating self and
DDA with monomycoloyl glycerol CAF01
non-self. Exogenous dangers, such
analog (MMG)
as PAMPs, DAMPs, or stress
CAF05 Cationic liposomal vehicle containing Induced higher IFN-g response than [103] molecules detected by the APCs,
DDA with the immunostimulators TDB CAF01 and CAF04 instantaneously release signals, such
and poly(I:C) as heat shock proteins, uric acid,
reactive oxygen species,
Montanide ISATM 720 W/O emulsion containing non-mineral Formed a depot and induced cell- [127,141]
neuromediators, matrix proteins, and
oil with mannide mono-oleate family mediated immunity
cytokines, including IFN-g, IL-1b,
emulsifier
and IL-6. Dangers signals are a
Montanide ISATM 51 W/O emulsion containing mineral oil Formed a depot and induced strong [127] significant focus for therapeutic
with mannide mono-oleate family cytotoxic T cell response applications and diagnoses.
emulsifier Immunomodulators: any substance
that activates, suppresses (weakens)
a
Selection based on hits in preclinical and clinical studies. or changes (deviates) immune
b
Abbreviations: Ag, antigen; APC, antigen-presenting cells; AS, adjuvant system; CAF, cationic adjuvant formulations; CC/ responses. Immunomodulators can
CX, chemokine; CSF, colony-stimulating factor; DC, dendritic cell; DDA, dimethyl dioctadecyl-ammonium; IFN, inter-
modulate cytokines and chemokines
feron; IL, interleukin; MHC, major histocompatibility complex; MPLA, 3-O-desacyl-40 -monophosphoryl lipid A; NF,
nuclear factor; O/W, oil in water; PBS, phosphate-buffered saline; poly(I:C), polyinosinic-polycytidylic acid; QS, Quillaja secretion, thereby altering immune
saponaria; TDB, trehalose 6,6-dibehenate; W/O, water in oil.

772 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


• Makes vaccine more cost effecve (fewer system strategies; examples include
doses required) CpG oligodeoxynucleotides (CpG
ODNs), a-galactosylceramide
• Effecve innate immune signals, including (a-GalCer), and liposomes.
danger signals Non-invasive vaccine delivery:
numerous vaccines have been
• Good immunomodulatory capacity committed for parenteral
administration with poor subject
acceptability. Novel delivery systems
• High specific anbody producon using non-invasive techniques offer a
Vaccine variety of benefits over traditional
adjuvant delivery using needles (e.g. painless,
• Angen-specific clonal expansion stability of the vaccine, and improved
protective systemic immunity via the
mucosa). For example, non-invasive
• Generaon of cytotoxic T cells vaccination against TB via the
intranasal or aerosol routes provided
protective immunity equivalent to that
• Long-lasng adapve immune response
generated after intradermal delivery.
Nucleotide-binding
• Makes angen more potent (less dose oligomerization domain, leucine-
required) rich repeat (NLRs): this family of
receptors comprises cytosolic
receptors, such as CARD, PYDs,
BIR, and AD, that are classified
Figure 1. Characteristic Properties of Vaccine Adjuvants. according to the sequence of their
N-terminal domain; there are 22
NLRs in humans. They are essential
of protection through pattern recognition receptors (PRRs), such as Toll-like receptors to the sensing of PAMPs and
(TLRs), nucleotide-binding, oligomerization domain (NOD)-like receptors (NLRs), and DAMPs. NLRs have been shown to
C-type lectin receptors (CLRs), or by the so-called ‘complement’ system. The interaction of have central role in chronic
inflammatory and autoimmune
PRRs with their corresponding ligands (e.g., bacterial components) controls and shapes the diseases. Among the NLR-CARD
subsequent adaptive immune response, which is specific to the invading pathogen [6]. The domains, CARD4 (NOD1) and
adaptive immune system (Figure 2) has the capacity for self and non-self-recognition and CARD15 (NOD2) have been
extensively studied and implicated in
induction of an immune response, which comprises effective lymphocytes, such as B cells, ab
adjuvant research through their
T helper and cytotoxic T cells, natural killer T (NKT), and gd T cells. These cells recognize recognition of peptidoglycan (PGN).
peptides or epitopes presented through classical and nonclassical major histocompatibility Muramyl dipeptide (MDP), a cell wall
complex (MHC)-I and MHC-II molecules. The interface interacts with many co-stimulatory component of bacteria, is recognized
by NOD2. Modification of the MDP
molecules, such as clusters of differentiation 40 (CD40)-CD40 ligand (L), CD28-CD80/86, and
structures also results in antigen-
inducible T cell co-stimulator (ICOS)-ICOSL complexes. The activation of this interface, often specific immune responses.
named the immune synapse, allows the amplification of cytokines and antigen-specific immune Pathogen-associated molecular
responses, which can kill or inactivate the pathogen. Such strong co-stimulation leads to the patterns (PAMPs): microbial
components or mimics of microbial
development of immunological memory [7].
components (synthesized) that are
recognized by specialized receptors
Over the past few decades, there has been significant progress in understanding the molecular of the innate immune system; they
mechanisms involved in antigen recognition and the induction of immune responses [8]. are potent immunostimulants.
Pathogen recognition receptors
Preclinical and clinical studies using TLR agonists alone or in combination with other adjuvants (PRRs): expressed mainly in
highlighted their potential use as adjuvants. For example, monophosphoryl lipid A (MPLA), a professional and nonprofessional
TLR4 agonist purified from Salmonella minnesota lipopolysaccharide (LPS), is currently used in cells of the innate immune system.
They recognize two types of distinct
human licensed vaccines for the prevention of human papillomavirus (HPV) and HBV infections
families of molecule, namely PAMPs
[9,10]. Several other adjuvants, including MF59, adjuvant system (AS) 01, AS03, AS04, and and DAMPs. Membrane-bound
virosomes, are now available in licensed vaccine products (Table 1) [11]. In other cases, PRRs include TLRs and CLRs, while
adjuvants were taken back to the bench for further evaluation due to their adverse effects, cytoplasmic PRRs include NLRs and
RLRs.
such as signs of arthritis and bowel disease [12,13]. This prompted efforts to design new
RIG-I-like receptors (RLRs):
molecules with better safety profiles and potent adjuvanticity. Using focused libraries that examples include RIG-I, MDA5, and
comprise collections of compounds that are designed to interact with a particular protein target LGP2; these are antiviral receptors of
or, more frequently, with a family of related bioactive targets, chemists were able to synthesize the innate immune system and
recognize viral RNA. Activation of the
novel molecules that exhibit immunostimulatory properties with minimal adverse effects.

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 773


Notable examples include analogs, which belong to the families of MurNAc-L-Ala-D-isoGln, RLR signaling pathway leads to
also known as muramyl dipeptide (MDP), MPLA, TLR2 agonist N-palmitoyl-S-[2,3-bis(palmi- increased production of IFN-g, which
controls viral infection. Poly(I:C) and
toyloxy)-(2RS)-propyl-R]-cysteinyl-[S]-seryl-[S]-lysyl-[S]-lysyl-[S]-lysyl-[S]-lysine (Pam3CSK4; 5' triphosphate double-stranded
see below for more detail), imiquimod, TLR9 ligand CpG oligodeoxynucleotides (ODNs; see RNA are ligands of RIG-I and MDA5.
below for more detail), QS-21, an acylated 3,28-bisdesmodic triterpene glycoside (see below They have shown effective vaccine
for more detail), and a-galactosylceramide (a-GalCer; see below for more detail). In general, adjuvanticity against viral infections.
Toll-like receptors (TLRs): first
these molecules have been evaluated in vitro and in vivo for their immunostimulating activity discovered in Drosophila and later in
using model antigens, such as ovalbumin (OVA), and disease-specific antigens [14]. Most of mammals. These receptors
these molecules are pathogen-associated molecular patterns (PAMPs), which can induce recognize a variety of antigens; 11
TLRs have been characterized in
immunity by interacting with receptors of the innate immune system, such as TLRs, NOD-like
humans and 13 in mice. TLRs react
receptors, and RIG-I (a family of cytoplasmic RNA helicases)-like receptors. The latter are with specific PAMPs and activate
transmembrane or cytosolic receptors, which can indirectly activate the innate and adaptive signaling pathways, notably the NF-
immune systems through the specific ligands mentioned above, such as MDP, MPLA, QS-21, kB signaling and MAPK pathways,
leading to secretion of
Pam3CSK4, CpG, and a-GalCer [13].
proinflammatory cytokines and
activation of co-stimulatory
In this review, we focus on newly developed and patented vaccine adjuvants, describing their molecules.
mode of action and immunostimulatory properties. In addition, we summarize recent work Vaccine adjuvant: the word
‘adjuvant’ originates from the Latin
conducted in various laboratories on novel lipid-based adjuvants. For more detailed informa- adiuvare, which means ‘to help’.
tion, please see the relevant references cited throughout the article. Vaccine adjuvants are components in
vaccine formulations that potentiate
Patented Vaccine Adjuvants and New Developments the immune response. They can be
immunomodulators and/or delivery
Adjuvants are compounds that, when admixed with vaccine antigens, enhance, modulate, systems. They generally act by
and/or prolong their immunogenicity and protective efficacy. Vaccines typically comprise an inducing a proinflammatory
antigen [e.g., a defined target antigen, short epitope(s)-encompassing protein fragments, or environment that favors the
recruitment and promotion of
inactivated pathogen] and an adjuvant. These two components are normally formulated for
infiltrating phagocytic cells to the site
delivery as emulsions or particulate delivery systems, such as liposomes, biodegradable of administration.
polymers, virosomes, immune stimulating complexes (ISCOMs), virus-like particles (VLPs), Vaccine delivery systems:
and nanoparticles/nanotubes (Figure 3) [13,15,16]. Each adjuvant has unique immunological formulations comprising antigens,
associated or not with adjuvants,
properties and, therefore, their selection criteria normally depends on the target pathogen and
which protect antigens from
required immune responses for protection (e.g., humoral versus cellular immunity or both) [17]. degradation and enhance their
Conventional vaccine strategies based on live attenuated pathogens do not require adjuvants presentation by targeting antigen
since they have intrinsic adjuvanticity (e.g., resulting from danger signals due to their nucleic delivery.

acid content).

Detailed information on vaccine components contained in currently marketed licensed vac-


cines is provided in Table 1. Characteristics of a selected set of these patented immunopo-
tentiating compounds are described below.

Lipopeptides
Macrophage-activating lipopeptide-2 (MALP-2), derived from the N-terminal moiety of Myco-
plasma and Escherichia coli, shows immunostimulatory activity that results from the induction
of B cell proliferation and increased secretion of TNF-a from macrophages [18]. Modification
studies on MALP-2 resulted in two analogs, Pam2CSK4 and Pam3CSK4 (Figure 4A,B), that
have proinflammatory properties. The N-terminal cysteine was shown to be a key residue in
these compounds [19]. Similar to MALP-2, both analogs were shown to interact with specific
receptors, namely TLR2 that heterodimerizes with TLR6 for the former, and TLR2 that
heterodimerizes with TLR1 for the latter (Figure 4C) [20,21]. This heterodimerization occurs
via an amide bond with distinct extra lipid chains [22]. Upon activation with Pam3CSK4, the
TLR2 receptor interacts with TLR1 and adopts a horse shoe-shape structure. The lipid portion
of Pam3CSK4 was found to fit into a narrow gap in the newly formed complex, while the
cysteine residue also inserted into the same gap. In the case of Pam2CSK4, in which an extra
amide bond is absent compared with Pam3CSK4, the lipid chain interacts with TLR2 and the

774 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


γδ T cell
Basophil
Monocyte Macrophage
Plasma cells

B cell

Cytokines/chemokines/ NKT cell


other signals Cytokines

Neutrophil Memory cells

TH cell

Eosinophil APC
Complement Lysed target cell
NK cell T cell CTL
(apoptosis)
Innate immunity Adapve immunity

CD40 CD40L
CD80/86 CD28 TLRs

NLRs
MHC-II TCR
CLRs

ICOSL ICOS

Co-smulaon

Figure 2. Innate and Adaptive Immune Systems. The innate immune system constitutes a front line of defense and provides a nonspecific response against
invading pathogens. This response is mediated by various cells (granulocytes, monocytes, macrophages, dendritic cells, neutrophils, basophils, and natural killer cells,
and active molecules as proteins of the complement cascade) through recognition of PAMPs or DAMPs by PRRs. The innate immune response shapes adaptive
immunity resulting in the production of antigen-specific T and B lymphocytes. Abbreviations: APCs, antigen-presenting cells; CD, cluster of differentiation; CLRs, C-type
lectin receptors; CTL, cytotoxic lymphocytes; DAMPs, damage-associated molecular patterns; ICOS, inducible T cell costimulatory; MHC, major histocompatibility
complex; NKT, natural killer T cells; NLRs, nucleotide-binding, oligomerization domain (NOD)-like receptors; PAMPs, pathogen-associated molecular patterns; PRRs,
pathogen recognition receptors; TCR, T cell receptor; TLRs, Toll-like receptors.

peptide moiety interacts with TLR6, a molecular hot core of links that resembles the CD1d–
invariant NKT (iNKT) interaction (see below for more detail) [23]. TLR2 agonists represent an
effective family of adjuvants tested in vaccine formulations against different infectious agents,
including HIV [24], HBV, HPV [25], Leishmania [26], and Chlamydia [27], and in certain cancers,
such as melanoma [28].

Research has led to the development of novel Pam3CSK4 analogs [14]. In particular, carbo-
hydrate di- and tri-lipidated cysteine-based 1,2,3-triazoles have been developed that exhibit
adjuvant properties in vaccine formulations against bacterial, viral, and protozoan infections,
and in cancer [29]. A construct was built in which the polycationic peptide entity was swapped

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 775


Receptor-specific
immune acvators
virosomes, and immune-

Vaccine delivery systems


[emulsions, liposomes,
smulang complexes

DC
(ISCOMs)]

Innate immunity
Adjuvant T and B cells
Adapve
immunity

Memory cells
Immunosmulators
and nonreceptor-specific immune
acvators

Figure 3. Interactions of Adjuvant with the Bioactive Actors of Innate and Adaptive Immunity. Novel delivery
systems (e.g., emulsions, liposomes, polymers, and nanocarriers) and immunostimulants activate the innate immune
system. Antigen fragments activate adaptive immunity in inducing (or not) immunological memory. Adjuvants and
immunostimulatory compounds enhance vaccine efficacy primarily by stimulating innate immunity. They also boost
adaptive immunity, thus providing a long-term memory response against pathogens and foreign antigens. Abbreviation:
DCs, dendritic cells (acting as antigen-presenting cells, APCs).

with a hydrophilic carbohydrate entity tethered to a triazolyl moiety. The aim of this new design
was to examine the possibility of generating a functional mimic of Pam3CSK4. The carbohy-
drate entity imparts hydrophilicity, whereas the triazolyl moiety mimics the cationic nature of the
peptide portion.

Synthesis of triazole-tethered hybrid conjugates of Pam3C involved two intermediates: azido


carbohydrate and propargylamido Pam3C moieties. The peracylated glycosyl moiety was treated
with TMSN3 and SnCl4 followed by deacylation with NaOMe to obtain the respective anomeric
azido sugars. By contrast, the propargylated Pam3C fragment was prepared starting from
cyclohexylidene mannitol subjected to diol cleavage using NaIO4 oxidation and subsequent
reduction to hydroxyl with a NaBH4 reagent. Hydroxyl was converted to iodo using I2/triphenyl-
phosphine and imidazole, which was further coupled with N-tert-butyloxycarbonyl (N-Boc)
cysteine, forming a protected cysteinyl glycerol unit. The cysteinyl intermediate thus obtained
was further treated with acid to remove the N-Boc and cyclohexyl protecting groups to afford
compound with free amine and diol moieties. This was subjected to palmitoylation using N,N0 -
diisopropylcarbodiimide, which gave the required triacylated entity. The free carboxylic acid was
condensed with propargyl amine to give the second fragment. Various glycosyl azides and
propargylated Pam3C fragments were subjected to a click reaction using CuSO4 and sodium
ascorbate to obtain the required novel 1,2,3 triazole tethered glycolated-P3C entities (Figure 4D,E).
All compounds were subjected to ex vivo immunological evaluation. It was found that the
galactosyl analog (compound 6h) exhibited increased T helper (Th)1-type (IL-2, IL-12, and
IFN-g) immunostimulatory activity compared with the control Pam3CSK4. Moreover, some of
the analogs bearing ribose (compound 6e) and maltose (compound 6h) moieties were also shown
to elicit a Th1-type response. However, this response was not superior to that of the cognate
Pam3CSK4 molecule. When the adjuvant activity of 6h, 6e, and Pam3CSK4 was tested in vivo
using OVA as a model antigen, the anti-OVA IgG titers in the 6e molecule were higher compared
with those of alum, but not compared with Pam3CSK4 (Figure 4F). The 6e analog was less active
than the 6h compound, alum, or Pam3CSK4 (Figure 4F). Both 6h and 6e analogs promoted a Th1
cytokine response (IL-2, IL-12, and IFN-g) in the serum and higher expression of CD4 and CD8
surface markers. Interestingly, the hit molecules 6h and 6e were found to exert their activity via the
TLR2 receptor, as does Pam3CSK4 (Figure 4C). This was confirmed by using the HEK-BlueTM-
hTLR2 reporter gene assay [14].

776 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


(C) Triacyl lipopepde Diacyl lipopepde

TLR2
T TLR2 TLR6
TLR1

(A) (B)

MyD88
TIRAP

IRAK

TRAF6

Nucleus

IKKγ
NF-κB IκB
NF-κB IKKα IKKβ

Proinflammatory cytokines

Pam3CSK4 Pam2CSK4

(D) (E)

6e 6h

(F) OVA-specific IgG

250 <0.001
<0.0001
Anbody ter (x 103 )

200

150

100

50

0
e

e
um

6h
4
on

6
SK

A+

A+
Al
al

3C

OV
A+

OV
A

m
OV

OV

Pa
A+
OV

(See figure legend on the bottom of the next page.)

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 777


Synthetic CpG oligodeoxynucleotides
CpG oligodeoxynucleotides (CpG ODNs) comprise unmethylated CG motifs (cytosine phos-
phate guanidine). They activate B lymphocytes and plasmacytoid DCs (pDCs) through TLR9.
Based on their capacity to stimulate B cells and pDCs and induce IFN-g and IL-6 secretion,
three classes of stimulatory CpG ODNs have been identified and classified as class A (Type D),
class B (Type K), and class C CpG ODNs (Figure 5A) [30,31]. CpG ODNs enter cells via the
endosomal pathway. After internalization in endosomes, CpG ODNs are recognized by endo-
somal TLR9 (Figure 5), leading to the immediate recruitment of MyD88, which is followed by the
activation of downstream signaling molecules, such as IRAK1, IRF7, TRAF6, and several
protein kinases, including ERK, p38, JNK, as well as IkB complex. These activation pathways
activate transcription factors, such as nuclear factor-kB (NF-kB) and activating protein 1 (AP1)
(Figure 5B), and proinflammatory cytokine production. Cytokines released from the activated
DCs and B cells directly activate T helper, NK, and cytotoxic CD8+ T cells as well as macro-
phages (Figure 5B).

There is abundant literature highlighting the adjuvanticity of CpG ODNs in preclinical and
clinical studies (Table 2) [32,33]. CpG ODNs conjugated with HBV surface antigen resulted in
a 1000-fold increase in the antibody response compared with antigen alone [34]. In contrast
to other TLR ligands, CpG ODNs have been shown to elicit superior CD8+ cell-mediated
immunity [35], due to the activation of Th1 cytokine production (Figure 5B) [36]. It has also
been shown that CpG ODN 1668 associated with carbon nanotubes and a Tat peptide of HIV
potentiated the immune response [37,38]. Vaccine formulations including CpG ODNs have
been shown to elicit strong humoral immune response against a variety of pathogens,
including anthrax, Leishmania, HBV, influenza, measles, orthopox, and tetanus toxoid
[39–43]. In a Phase I trial, a malaria vaccine comprising CpG ODNs and the apical membrane
antigen resulted in fivefold higher antibody titers compared with antigen alone [44]. Moreover,
CpG ODNs showed significant adjuvant activity against Engerix B (a HBV vaccine for adults)
by increasing antibody titers and enhancing T cell proliferative responses in HIV-infected
immunocompromised subjects [45]. Improved antibody and CD8+ T cell responses were also
described when CpG ODNs were combined with Melanoma A, New York-oesophageal
cancer 1, and anthrax vaccines [46–48]. Finally, the NuThraxTM vaccine candidate from
Bioemergent is based on BioThrax1 (Anthrax Vaccine Adsorbed) combined with the CpG
ODN 7909 as an adjuvant. A Phase III study is planned (first subject enrollment targeted for
2018). Millions of doses of NuThrax are being stockpiled and the US FDA is close to licensing
this product (making it the first CpG-containing vaccine to achieve licensure). The FDA could
authorize NuThrax for emergency as early as 2018 [49]. CpG ODNs have also been combined
with other adjuvants or chemically linked to different nanoparticles or antigens to improve
vaccine immunogenicity [50–52].

Figure 4. Acylated Peptide-Induced Signaling Pathway. Pam2CSK4 (A) and Pam3CSK4 (B) acyl lipopeptides bind to the TLR2 present on the cytoplasmic
membrane (C), resulting in TLR2 heterodimerization with TLR6 and TLR1, respectively. As a consequence, these heterodimers interact with MyD88, leading to activation
of the IRAK-TRAF6 cascade, followed by activation of various kinases, which finally leads to the binding of NF-kB to its promoter region. This final step is responsible for
the production of proinflammatory cytokines. (D,E) Newly developed Pam3CSK4 derivatives (the structure of the hit molecules is shown). (F) OVA-specific IgG response
in BALB/c mice that were immunized subcutaneously with OVA alone, OVA + alum (Alhydrogel1 adjuvant 2%), OVA + Pam3CSK4, OVA + 6e molecule, or OVA + 6h
molecule (100 mg/100 ml/mouse in each group; five mice per group). Mice received two injections at days 0 and 14 and were bled at day 28. Anti-OVA antibodies were
measured by indirect ELISA. Briefly, the plates were coated with OVA (1 mg/well) in carbonate buffer, pH 9.5, and then incubated at 4 C overnight. After three
consecutive washings in PBS containing 0.05% v/v Tween-20 (PBS-T), and blocking nonspecific binding sites remaining on the plastic plates by adding 200 ml 1% (v/v)
bovine serum albumin at room temperature for 1 h followed by three other washings, standards and samples diluted in PBS-T were added to the plates and incubated at
37 C for 2 h at room temperature. Plates were again washed three times with PBS-T, followed by addition of antimouse IgG-horseradish peroxidase (IgG-HRP; Jackson
ImmunoResearch diluted in PBS-T). After 30 min at room temperature, plates were again washed three times with PBS-T and the HRP substrate (H2O2) and 3,3',5,5;-
tetramethylbenzidine (TMB) chromogen were added. Plates were incubated at room temperature (4–30 min) for color development. Color reaction was stopped by
adding 50 ml HCl. Absorbance was measured at 450 nm [142]. The values are presented as mean titers  SD. **P <0.001, ***P <0.0001 (Mann–Whitney U test).
Abbreviations: ELISA, enzyme-linked immunosorbent assay; IRAK, IL-1 receptor-activated kinase; MyD88, adaptor protein myeloid differentiation gene 88; NF-kB,
nuclear factor-kB; OVA, ovalbumin; TIRAP, Toll-interleukin 1 receptor domain containing adaptor protein; TLR, Toll-like receptors; TRAF, tumor-necrosis factor
receptor-associated factor.

778 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


(A)
G
C A
GGTGCATCGATGCAGGGGGG TCCATGGACGTTCCTGAGCGTT TCGTCGTTCGAACGACGTTGAT
D type (A type) K type (B type) C type T T
A
G
C C A G
G
Phosphodiester and Unstructured G
T
phosphorothioate backbone phosphorothioate backbone Composion resembles G
with poly G tails; capable of of >12 bases; resistance to that of B-type ODNs G
G
forming a hairpin loop nuclease digeson G
G
containing the CpG mof (half-life 30–60 min) G

A type
Acvate maturaon of Acvate pDCs to secrete Acvate pDCs to produce
pDCs and their secreon TNF-α, and B cells to IFN-α, and
of IFN-α; no effect on B proliferate and secrete B cells to secrete IL-6 T
G T
cells IgM
C C
G T
A C
Mainly remain in early Quickly transported Have intermediate G
endosomes and interact through early properes of both A- and C
with adaptor proteins endosomes into late B-type ODNs T
(e.g., MYD88) to trigger endosomes for signal
the IFN-α signaling transducon
cascade
B type

CpGODN
(B)

Nucleus
Endosome
TL
R9

AP–1
MYD88
IRAK
NF-κB AP–1
TRAF6
CpG ODN
JNK

NF-κB IκB

DC B cell

•Maturaon
•Differenaon
•Proliferaon
Eosinophil Monocyte Macrophage TH1 cell CTL
NK cell

Cytokines (IL-1, IL-6, IL-12,


MHC II
IL-18,TNF-α, and IFN-γ)
Cytokines (IL-6 and IL-12)
MHC II
CD86 Plasma cells

DC CD80 B cell Fc Anbod ies


CD86

CD80
CD40
CD40
Chemokines (IP10, Mig, and I-TAC) Memory cells

Figure 5. Structure and Mode of Action of CpG Oligodeoxynucleotides (CpG ODNs). (A) The three different types of CpG ODN (A, B, and C), their structures,
and properties. (B) CpG ODNs modulate innate and adaptive immune responses in several ways. (A) The CpG ODN–TLR9 signaling pathway. TLR9 receptors are
present on the endosomal membrane. After internalization, CpG ODN activates elements of the MyD88/IRAK/TRAF6 pathway, leading to the simultaneously activation
of two kinase pathways (MAPK/c-JUN and NF-kB) and the AP-1 and NF-kB promoter genes. (B) CpG ODN activates directly DCs and B cells acting as APCs. Activated

(See figure legend on the bottom of the next page.)

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 779


QS-21
Saponins alter the membrane integrity of cells and induce danger signals that augment
immune responses [53]. Saponins acting as adjuvants were first reported as early as the 19th
century. Pioneering work on the immune stimulatory activity of saponins led to the development
of QS-21 [54]. In particular, testing crude extracts of the bark from the South American tree,
Quillaja saponaria Molina demonstrated potent vaccine adjuvant activity [55,56]. QS-21 is the
gold-standard vaccine adjuvant among the saponin family. As shown in Figure 6A, it comprises
branched tri-saccharides, triterpenes, linear tetra-saccharides, and an acyl chain. The linear
tetra-saccharides terminal domain has two isomeric units: QS-21-apiose and QS-21-xylose
[57,58]. QS-21 has been shown to exert adjuvant activity in vaccine formulations against
cancer [59,60], infections such as malaria [61,62], AIDS [63], hepatitis [64,65], and TB [66], and
also against Alzheimer’s disease [67].

The mechanism of action of QS-21 at the molecular level remains unclear. According to current
understanding, the free aldehyde side chains of QS-21 are the primary interacting components
that bind amino acid residues of proteins present on the surface of immune cells. This leads to
the formation of a Schiff base or imine [59]. This interaction, on T cells and antigen-presenting
cells (APCs), appears to contribute to the initial triggering signal for downstream signaling
(Figure 6B) [5,68].

A novel mechanism of action of saponins was recently proposed, based on inflammasome


activation that enhances antigen cross-presentation by forming unique intracellular lipid bodies.
In this scheme, lipid bodies escape from endosomes and translocate the antigens for cross-
presentation [53]. Although natural QS-21 has good immunostimulatory properties, there are
several important limitations in terms of adverse effects, such as hemolysis at higher doses, an
unfavorable dose:efficacy ratio, and an ecological burden resulting from its extraction from Q.
saponaria. In this context, and with the aim of enhancing efficacy and reducing the hemolytic
adverse effects, a focused library was synthesized of novel glycolipid mimics encompassing a
carbohydrate entity as the hydrophilic head group and a triterpenoid/steroid-based lipid moiety
tethered with a trizolyl spacer. Three different sugars (glucose, galactose, and xylose) were
converted to their respective anomeric azide via TMSN3 and SnCl4 treatment. Cholesterol,
betulin, and betulinic acid were propargylated on their secondary hydroxyl group via spacers
such as triethylene glycol or a succinate unit. Both the sugar azide and acetylenic triterpenoid/
cholesterol fragments were subjected to a Cu(I)-catalyzed click reaction to produce a library of
novel adjuvants (Figure 6C). Carbohydrates have a vital role in immune functions and molecules
containing carbohydrate moieties display strong safety and tolerability properties [69]. More-
over, vaccine adjuvants obtained from natural and synthetic sources have carbohydrate
moieties [69]. In a recent study, a carbohydrate was linked with steroid/triterpenoid using a
polyethylene glycol linker. Among a series of analogs that were synthesized and evaluated, a
lead compound was identified, called 15g, that exhibited lower hemolytic activity in vitro and
superior immunostimulatory activity compared with many of the other analogs that were tested
in parallel [70]. In particular, 15g increased B cell-mediated proliferation ex vivo and increased
levels of IL-2, TNF-a, IL-12, and IFN-g measured in the cell supernatants. More interestingly, it
exerted an adjuvant effect in vivo when co-administered with OVA [70]. Anti-OVA IgG antibody
responses were significantly higher compared with those induced by alum-adjuvanted OVA
(Figure 6D).

DCs and B cells also activate other immune cells, such as neutrophils, monocytes, macrophages, Th1-type CD4+ T cells, CTL, and NK cells, which then mature,
differentiate, and proliferate. APCs construct a base by forming co-stimulatory signals and provide strong memory responses. Abbreviations: APCs, antigen-presenting
cells; Fc, fragment crystallizable region; IFN, interferon; IP10, IFN-g-inducible protein 10 (or CXCL1); I-TAC, interferon-inducible T cell alpha chemoattractant (or
CXCL11); JNK, c-Jun N-terminal kinase; MAPK, mitogen-activated protein kinase; MHC-II, class II major histocompatibility complex; Mig, monokine-induced by IFN-g
(or CXCL9); pDC, plasmacytoid dendritic cells. For definitions of other abbreviations, please see the main text and the legend to Figure 2.

780 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


Table 2. Live Vaccine Adjuvant Patents (2016)a,b
Patent number Assignee Title Year Composition
(filed/
published)

US 5182109A National Institute of Health; Vaccine preparation comprising a 1993 Vaccine comprises different toxin
The Kitasato Institute, both of Tokyo bacterial toxin adjuvant antigens
(JP)

EP 0781 559 A2 Juridical Foundation, The Chemo- Oil adjuvant vaccine and method for 1996 W/O emulsion with different surfactant
Sero-Therapeutic Research Institute preparing same and polymer ratios
Kumamoto-ken (JP)

PCT/KR96/00053 LG Chemical Ltd., Seoul, (KR) Quillaja saponin adjuvant and vaccine 1998 Comprises saponin component from
formulation containing same the bark of Quillaja saponaria Molina as
an immune adjuvant

US 6,406,705 B1 University of Iowa Research Use of nucleic acids containing 2002 Unmethylated CpG ODN and non-
Foundation, Iowa City (USA); Coley unmethylated CpG dinucleotide as an nucleic acid adjuvant
Pharmaceutical GmbH, Langenfeld adjuvant
(DE); Ottawa Health Research Institute,
Ottawa (CA)

PCT/US98/08652 Protection Unlimited, Inc., Wilmington, Nerve growth factor as a vaccine 2003 Nerve growth factor acts as an adjuvant
DE (USA) adjuvant to enhance effectiveness of vaccine

US 2004/0101534 A1 Rothwell’ Figg’ Ernst & Manbeck, P.C. Adjuvant-free peptide vaccine 2004 Vaccine comprises fusion peptide
Washington (USA) synthetically derived from
cytomegalovirus with CpG ODN as an
adjuvant

US 6,881,561 B1 Cheil Jedang Corporation, Seoul (KR) Endonuclease of immune cell, process 2005 Immune adjuvant comprising
for producing the same, and immune approximately
adjuvant using the same 10-bp single-stranded oligonucleotide
with a CpG motif; produced by
treatment of bacterial DNA with
endonuclease

PCT/EP00/01046 Eurocine AB, Stockholm, Solna (SE) Vaccine composition 2005 TB vaccine that comprises
mycobacterial

US 2005/0158330 A1 NOF Corporation, Tokyo (JP); Juridical Oil adjuvant vaccine 2005 Vaccine comprises W/O/W-type oil
Foundation, Kurnarnoto-shi (JP) adjuvant

PCT/NL2004/000437 Bestewil Holding B.V., Amsterdam (NL) Functionally reconstituted viral 2009 Membrane protein from pathogens or
membranes containing adjuvant tumor cells with amphiphilic adjuvant

PCT/EP05/05786 SmithKlineBeecham Corporation Vaccine compositions comprising 2009 Vaccine comprises influenza viral
Corporate Intellectual Property, virosomes and a saponin adjuvant antigen, QS21, and sterol
Pennsylvania (USA)

PCT/KR2007/006889 SNU R&DB Foundation, Seoul (KR) a-GalCer derivatives, pharmaceutically 2010 a-GalCer-containing triazole moiety at
acceptable salts thereof, preparation the amide position
method, and pharmaceutical
composition for the immune adjuvant
containing the same as an active
ingredient

PCT/EP08/57998 GlaxoSmithKline Corporate Intellectual Vaccine comprising Streptococcus 2010 Vaccine comprises different
Property, North Carolina (USA) pneumoniae capsular polysaccharide Streptococcus pneumoniae capsular
conjugates saccharide conjugates

PCT/FR08/51807 Air Liquide USA LLC, Intellectual Method for preparing a vaccine 2010 Composition comprises an adjuvant
Property, Houston, Texas (USA) composition comprising at least one such as inverse latex or polymer mixed
antigen and at least one adjuvant into an antigenic medium

US 7,749,979 B2 National Pingtung University of Science CpG DNA adjuvant in avian vaccines 2010 CpG DNA
and Technology, Pingtung County (TW)

US 7,771,726 B2 New York University, New York (USA); Use of synthetic glycolipids as universal 2010 Synthetic a-C-GalCer
The Research Foundation of the City adjuvants for vaccines against cancer
University of New York, New York and infectious diseases

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 781


Table 2. (continued)
Patent number Assignee Title Year Composition
(filed/
published)
(USA); Aaron Diamond Aids Research
Center, New York (USA)

PCT/EP10/51882 GlaxoSmithKline Biologicals S.A. Inactivated dengue virus vaccine with 2011 Inactivated dengue virus antigen in
Rixensart (BE) aluminium-free adjuvant combination with aluminum-free
adjuvant

PCT/EP2006/069979 GlaxoSmithKline Biologicals S.A., Vaccine comprising an O/W emulsion 2012 O/W emulsion comprises
Rixensart (BE) adjuvant metabolizable oil, tocol, emulsifying
agent with various antigens and
methods of preparation

EP 2 589 392 A2 Sanofi Pasteur, Lyon (FR) Process for stabilizing an adjuvant 2013 Process for stabilizing a vaccine
containing a vaccine composition composition with a stabilizer

PCT/US2004/005152 HasumiLlc (Dba Shukokai International) Human lymphocyte vaccine adjuvant 2013 Supernatant collected from stimulated
New York (USA) cultured human lymphocytes

US 8,540,955 B2 Wyeth LLC, Madison (USA) Process for producing aluminium 2013 Provides improved methods for
phosphate producing the aluminium adjuvant
AlPO4

PCT/U52008/057355 The Regents of the University of Method of preparing an 2013 Preparation of freeze-dried vaccine
Colorado, A Body Corporate, Denver immunologically active adjuvant-bound comprising an aluminium salt adjuvant,
(USA) dried vaccine composition a recombinant Clostridium botulinum
neurotoxin protein, and a glass-forming
agent

US 8,624,004 B2 GlaxoSmithKline Biologicals S.A., Purification of HBV antigens for use in 2014 HBV antigen that includes cysteine
Rixensart (BE) vaccines

PCT/FR2011/050069 Société d’Exploitation de Produits pour Adjuvant for preparation of vaccine 2014 Short and long-chain hydrocarbons
les Industries Chimiques, Paris (FR) compositions intended for prevention with Coccidia
of coccidiosis

US 8,795,678 B2 Academia Sinica, Taipei (TW) TLR2 agonists and methods of use 2014 FMDV capsid proteins VP1 and VP3
thereof activate TLR2

US 8,889,616 B2 Oncothyreon Inc., Seattle (USA) MUC1-based glycolipopeptide vaccine 2014 Liposomal vaccine formulations
with adjuvant comprising an adjuvant and an
immunogen for immunotherapy

PCT/US2013/034372 Kansas State University Research Vaccine adjuvant 2015 Oil-based adjuvants comprise a plant-
Foundation, University of Tennessee derived surfactant, such as gum arabic,
Research Foundation, Manhattan an aqueous component, and an oil
(USA)

US2016/0200758A1 Council of Scientific and Industrial 1,2,3-Tiazole-tethered carbohydrate 2016 Lipidated cysteine-based triazoles as
Research, Delhi (India) di- and tri-lapidated cysteine vaccine adjuvants covered both
conjugates useful as vaccine therapeutic and prophylactic vaccines
adjuvants, and process for preparation against bacterial, viral, and protozoan
thereof infections, and cancer

a
The mentioned patents are all in the field of vaccines and vaccine adjuvants.
b
Abbreviations: bp, base pairs; CpG ODN, CpG dinucleotide; FMDV, Foot-and-mouth disease virus; TLR, Toll-like receptor; VP, viral protein; W/O/W, water/oil/water.

a-GalCer
The synthesis of a-GalCer, popularly known as KRN7000 (Figure 7A), was based on structure–
activity relationship (SAR) studies pertaining to Agelasphine-9b. The latter was first isolated
from the Okinawan sea (Japan) sponge Agelas mauritianus. The curiosity-driven discovery of
agelasphine-9b was based on the bioactive cerebrosides that it contains. Glycosphingolipids
are widely distributed in living organisms [71] and a-GalCer is mostly known as an activator of
type 1-murine and human iNKT cells. As NK cells, NKT cells express an invariant ab T cell

782 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


(A)

Parally
Oligosaccharide Oligosaccharide hydro- Pentose
philic lipid

(B)

Saponin
Ag CHO CH
NH2 Imine
N
Ca2+

Na+
K+ ERK2
Lipid body
MAPK
ER MHC-I TCR

Transcripo n
Pepde

Cell survival
Proliferaon
APC Migraon
CD8+ T cells

(C) (D)
OVA-specific IgG

<0.00 01
40
Anbody ter (x 103)

<0.000 1
30

20

10
15g
0
A g
OV um 15
+Al A+
VA OV
O

(See figure legend on the bottom of the next page.)

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 783


(A) (B)

Neutrophils IL-4 B cells

iNKT
IFN -γ
α-GalCer TCR
(C) Lipid angen
CD1d
Monocytes
NK cells
APC

IL-12

α-C-GalCer
(D)

Macrophages
CD8+ T cells

(E)
CD4+ T cells

Figure 7. CD1d–a-GalCer–iNKT Ternary Complex Activation of Bystander Cells. (A) Pictorial representation
summarizing the formation of the binary complex of CD1d–a-GalCer that releases IL-12 from APCs and the formation of
the ternary complex CD1d–a-GalCer-iNKT that releases cytokines IL-4 and IFN-g from iNKT cells. The release of large
amounts of cytokines activates bystander cells to migrate, proliferate, and differentiate. (B) a-GalCer; (C) a-C-GalCer
analog; (D,E) novel benzyloxyalkyl-substituted 1,2,3-triazolyl a-GalCer analogs (T1204B and T1206B). Abbreviations:
iNKT, invariant natural killer T cells. For definitions of other abbreviations, please see the main text.

receptor (TCR) and also markers, such as NK1.1, DX5, and CD161 [72]. Unlike conventional
CD4+ and CD8+ T cells, NKT cells recognize exogenous or endogenous glycolipids presented
by the MHC-I-like molecule CD1d. Although there are minor variations among human and
mouse NKT cells, the latter are considered to be 100% CD1d restricted. Interactions between
NKT and a-GalCer or between analogs and CD1d and their immunomodulatory properties
have been extensively studied over the past two decades. Many exogenous (natural and
synthetic) and endogenous CD1d-restricted iNKT stimulators have been reported [73–76].

X-ray crystallography studies revealed that a-GalCer is primarily recognized by the nonclassical
MHC-I or CD1d molecules present on APCs. CD1d forms two pockets, A’ and F’, for binding
two lipid chains in a-GalCer (the acyl and sphingosine chains) and forms an a-GalCer/CD1d
binary complex [77,78]. Furthermore, CD1d presents a-GalCer to the TCR of iNKT cells and
forms a NKT/a-GalCer/CD1d ternary complex. This ternary complex is one of the largest ever
recorded for any natural TCR ligands [79,80].

Figure 6. Mechanisms Involved in the Adjuvant Activity of Saponins. (A) Structural elements of QS-21. (B) Aldehyde-containing saponins (e.g., QS-21) act via
two different mechanisms. One is via the formation of a lipid body that participates in the presentation of MHC antigens by APCs. The second one is direct activation of T
cells by interacting with amino acid residues present in the TCRs. These interaction steps are followed by the activation of ERK2, MAPK, and transcription factors,
leading to cytokine release, and cell proliferation, migration, and differentiation. (C) Compound 15g, a novel 1,2,3-triazolyl conjugate with a carbohydrate-steroid entity.
(D) OVA-specific IgG response in BALB/c mice that were immunized subcutaneously with OVA alone, OVA + alum, and OVA + 15g (100 mg/mouse in each group; five
mice per group). Mice received two injections at days 0 and 14 and were bled at day 28. Anti-OVA antibodies were measured by indirect ELISA (please see the legend to
Figure 4 for technical details). The values are presented as mean  SD. ***P <0.0001 (Mann–Whitney U test). Abbreviations: Ag, antigen; ER, endoplasmic reticulum;
ERK2, extracellular signal-regulated kinases. For definitions of other abbreviations, please see the main text and the legends to Figures 2 and 3.

784 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


iNKT cells act as a bridge between the innate and adaptive immune systems. A distinct role of iNKT
cells is to produce copious amounts of Th1 (IFN-g) and Th2 (IL-4) cytokines in a short time [81].
However, activated iNKT cells also produce other cytokines, including IL-2, IL-5, IL-6, IL-9, IL-10,
IL-13, IL17, IL-21, TNF-a, TGFb, and granulocyte-macrophage colony-stimulating factor (GM-
CSF), along with numerous chemokines [82]. Independent studies have shown that iNKT cell-
secreted cytokines can activate bystander cells, such as NK cells, conventional CD4+ and CD8+ T
cells, macrophages, B cells, and myeloid DCs (Figure 7B). a-GalCer and its analogs (e.g., a-C-
GalCer) showed potential therapeutic benefits against infectious diseases, autoimmune diseases,
and tumors (Figure 7C). The introduction of 1,2,3-triazole at the amide linkage of a-GalCer
increased its stability for hydrolysis and induced the formation of two hydrogen bonds with
the Thr154 residue, two elements that are likely to contribute to raise immune response. A
focused library of novel a-GalCer analogs encompassing a triazolyl moiety linked to a variable
spacer with a terminal benzyloxy group has been generated using a Cu(I)-catalyzed azide alkyne
click chemistry approach. The design was based on the immunogenicity of two distinct, previously
published, structural analogs of a-GalCer [83], one bearing a triazolyl linker on the acyl chain of
GalCer framework instead of an amide linkage and the other with a benzyloxy alkyl group at the acyl
terminus. In the structural modification of the most versatile a-GalCer, the triazole linker is known to
favor Th2 responses, while an aromatic terminus of the acyl chain is known to favor Th1 responses.
Based on the immunogenicity of the individual glycolipid structures mentioned above, the authors
inferred that a combination of these two structural entities on a single molecular framework should
provide better immunostimulatory properties. The new design encompassed both structural
elements (i.e., 1,2,3-triazole and the benzyloxy lipid entity) in a single compound. To prepare the
analogs, one end of each consecutive diol (ethylene glycol to 1,12-dodecanediol) was benzylated,
while the other hydroxyl was propargylated. The acetylenes were modified by click chemistry with
the azido a-GalCer to provide the desired analogs in quantitative yields (e.g., Figure 7D,E). These
analogs comprised triazole with lipid chains of varying lengths containing a terminal benzyl group
with some intervening oxygen atoms. These structural modifications enhanced Th1 and Th2
responses and iNKT cell activation, and their activity as vaccine adjuvants is currently being
evaluated [84]. The possible molecular basis of the adjuvant activity of a-GalCer and a-GalCer-
derived molecules has been critically examined elsewhere [85–89]. These molecules were shown
to display good adjuvanticity in vaccine formulations against a range of infectious diseases,
including HIV infection, TB, influenza, malaria, and dengue, as well as tumors [74,75,90–95].

Liposomes
Liposomes are lipid vesicles with phospholipid bilayers. They have the capacity to act both as
delivery systems for antigens and as immunomodulators [96–98]. They protect antigens from
degradation, deliver them to APCs, and can be used for mucosal delivery. The lipid membrane
comprises phosphatidylcholine, which is nonimmunomodulatory but shows fusogenic activity,
thus facilitating better uptake by APCs. Frequently, other compounds, such as TLR ligands,
need to be incorporated for optimal adjuvanticity [99]. It has taken many years of research to
design liposome-containing formulations that are clinically usable as safe vaccine delivery
systems. Liposomes and virosomes are present in vaccine suspensions against influenza virus
(Inflexal V), HAV (Epaxal), and Plasmodium falciparum for malaria (RTS,S/AS01/MosquirixTM,
approved for use by European regulators in July 2015) [100]. In addition, some oral liposome
formulations with recombinant heat shock protein 60 were shown to be promising against
Helicobacter pylori infection in preclinical studies [101].

Cholesterol-containing liposomes have also been used to attenuate adjuvant toxicity. For
example, a liposome formulation was shown to reduce the toxic effects of QS-21 (hemolytic
activity) and MPLA (endotoxic activity) [102]. Moreover, liposomes containing cationic charges
have demonstrated superior delivery properties and elicited significantly higher protective
response against Mycobacterium spp. (Table 1) [103].

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 785


Virus-Like Particles
In recent years, virus-like particle (VLP)-based vaccine strategies have been frequently used for
novel vaccine design. VLPs are empty noninfectious viral capsids that structurally mimic the
conformation of native virions. VLPs are known to be highly immunogenic and elicit higher titer
neutralizing antibody responses than subunit vaccines based on individual proteins [104]. Such
VLPs present viral spikes and other surface components that display liner or conformational
epitopes in a repetitive array that effectively results in recognition by B cells [105]. This
recognition leads to B cell signaling and MHC-II upregulation that facilitates the generation
of high titers of specific antibodies. VLPs from viruses, including HBV, HPV, and Chikungunya
virus, elicit high-titer neutralizing antibody responses that contribute to protective immunity in
preclinical animal models and in humans [104,106–108].

Immune-Stimulating Complexes
Immune-stimulating complexes (ISCOMs) are spherical open cage-like structures (typically
40 nm in diameter) that spontaneously form when cholesterol, phospholipids, and specific
saponins (mostly Quil A) are mixed at a specific ratio. The ISCOM matrix can directly associate
with antigens or be formed first and then added to the formulation at a later point. Given their
structure, ISCOMs can achieve efficient antigen delivery into DCs that results in the induction of
antigen-specific T cell responses, longlasting antibody responses, and balanced Th1/Th2
immunity [109–111]. To improve their efficacy, ISCOMs have also been used in combination
with immune-stimulating molecules, such as TLR ligands or cholera toxin A (CTA) [112,113].

State of the Art of Emulsion-Based Delivery Systems and Novel


Developments
There are different types of emulsion in current use; water-in-oil (W/O), oil-in-water (O/W), and
multiple emulsions, such as water-in-oil-in-water (W/O/W) and oil-in-water-in-oil (O/W/O).

Table 3. Examples of Patented Emulsions and Their Compositiona


Patent number Oil Surfactant/adjuvant

WO2004087204 A2 Light mineral oil Lecithin, Tween 80, Span 80

US 5,961,970 Medium-chain triglyceride oil, Lecithin, Tween 80


vegetable oil

US 5,084,269 Mineral oil Lecithin

CA 2179779 A1 Metabolisable oil a-tocopherol, Tween 80,3 de-O-acylated


monophosphoryl lipid A, QS-21

CA2628206 A1 Animal (such as fish) or vegetable Tweens, Spans, Brijs, lecithin, triton X-100,
source copolymers of ethylene oxide, propylene oxide,
and/or butylene oxide; mixture of surfactants

US 5,376,369 Squalene or squalane PluronicTM L121, muramyldipeptide

US 5718904 A Squalene or squalane Glycerol, Tween 80

US 5690942 A Squalene, squalane, or mixture Lecithin, aluminum salt, polyoxyethylenesorbitan


ester, especially Tween 80

US 5885590 A Vegetable oil, animal oil, mineral oil, Polyoxyethylene polyoxy propylene block
isopropyl myristate, and copolymer, poloxamer 331, poloxamer 461,
polyoxypropylene poloxamer 520.5, sorbitan monooleate, sorbitan
tristearate, Arlacel 186, poloxamer 403,
polyoxyethylene sorbitan monooleate, poloxamer
188, and mixtures thereof

a
Selection based on the patented product (oil, surfactant, and adjuvant).

786 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


CD19+ CD86+
15
<0.0001
(A) Submicron size
<0.0001
Low viscosity 10

% populaon
High stability
5
Easily metabolizable in biological systems
0

)
)

μg
μg

μg

0
0

(5

(1
(1
MPLA

A
A

PL

PL
PL

+M

M
M

A+
A+

A
(B)

OV

OV
OV

E+

E+
Oil OVA-spec ific IgG

400 000 <0.0001


Aqueousphase Surfactant <0.001
300 000

Anbody ter
OVA
200 000
Emulsion
100 000

)
)

)
μg
μg

μg
0

0
(5
(1

(1
A

A
A

PL
PL

PL
M

M
M

A+

A+
A+

OV

OV
OV

E+

E+
OVA-specific IgA
0.5 <0.000 1

0.4
OD @ 630 nm

0.3

0.2
Immunizaon 0.1

0.0 on
A
PL

si
ul
M

Em
A+
OV

A+
PL
M
A+
OV

Figure 8. Emulsion-Based Vaccine Delivery Systems. (A) Prerequisites for emulsions to be used as adjuvants. (B) Efficacy of an oleic acid nanoemulsion for
vaccine delivery. An O/W emulsion comprising OVA as a model antigen and MPLA as an adjuvant was administered intranasally to C57/Bl6 mice (N = 5). Antigen-
specific IgA from nasal washes and IgG from the serum of immunized mice were revealed by indirect ELISA (please see the legend to Figure 4 for technical details).
Immunophenotyping for co-stimulator markers CD19+ and CD86+ was performed according to the method of Colovai et al. [143] with slight modifications. Briefly,
3  105 splenocytes (3  105cells/tube) were centrifuged at 2000 rpm for 15 min. BD Fc Block (10; 1 ml) was then added for 15–20 min at 4 C in the dark to block
TM

nonspecific Fc receptor-mediated antibody binding. After two successive washings with 1% (v/v)-fetal calf serum-containing PBS, cells were centrifuged at 2000 rpm
for 5 min. They were then labeled using 7 ml (determined according to previous titrations) of anti-CD19-PE and anti-CD86-allophycocyanin fluorochrome-conjugated
antibodies and 2 ml of fluorochrome-conjugated isotype control (all from BD Biosciences). Cells were then incubated on ice for 30 min in the dark, centrifuged with 1%
(v/v) fetal calf serum-containing PBS and analyzed using a BD FACSVerse flow cytometer. Compensation was established using BD Biosciences compensation beads.
Postacquisition flow cytometry analyses were performed using the FACS Suite software. Abbreviations: E, emulsion; ELISA, enzyme-linked immunosorbent assay; Fc,
fragment crystallizable region; MPLA, monophosphoryl lipid A; OVA, ovalbumin; PE, phycoerythrin.

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 787


Table 3 lists several novel, patented emulsions and their composition, while Figure 8A details
the prerequisites for vaccine adjuvant formulations.

Oil-in-Water Emulsions
O/W emulsions are extremely safe compared with W/O formulations. The antigen is available in
the continuous phase and can easily diffuse into tissues. However, the addition of immuno-
modulators, such as MPLA, QS21, MDP, or imiquimod, was found to be necessary to achieve a
strong immune response. The oil phase in most emulsions comprises metabolizable oils, such
as vegetable (sunflower, soybean, corn, olive, and mustard) and animal based-oils, such as fish
oils (cod liver oil, shark liver oils, or whale oil) and squalene and squalane. These oils are
biocompatible and biodegradable [114,115]. O/W emulsions associated with immunomodu-
lators with established mechanisms of action, such as MF59, AS02, AS03, and AS04, showed
efficacy in preclinical and clinical studies against infectious diseases (Table 1). MF59 composi-
tion contains squalene with varying amounts of muramyl tripeptide phosphatidyl-ethanolamine
(MTP-PE). Fluad1, seasonal influenza vaccine with MF59 was shown to produce high antibody
titers against influenza in older patients [116,117]. An AS02 emulsion associated with 3-O-
desacyl-40 -MPLA (a TLR4 agonist) and QS-21 has been associated with many antigenic
vaccine preparations. For example, RTS,S/AS02 effectively elicited protective immune
responses against P. falciparum [118]. Others, such as TB vaccines, comprising Mtb72f
(Mycobacterium tuberculosis fusion protein), Mtb41, or Ag85B-ESAT-6 (secreted antigenic
proteins) with AS02; HBV vaccines, comprising HBV hyperimmunoglobulin (HBIG) or SL* (small
HBV envelope protein) with AS02; HIV vaccines, comprising gp120 (an envelope glycoprotein)
and AS02; and cancer vaccine, comprising melanoma-associated antigen 3 (MAGE-A3) and
AS02 have elicited potent immune responses in preclinical and clinical studies [119]. An AS03
emulsion composed of biodegradable oils (squalene and a-tocopherol) and a surfactant
(polysorbate 80) in phosphate-buffered saline (PBS) also showed some efficacy. Even though
this adjuvant system did not show encouraging results with malaria and HIV vaccines, it
demonstrated strong immunostimulatory activity and surrogate protection against H5N1
and H1N1 pandemic influenza in both children and adults [120].The AS04 emulsion contains
MPLA with a particulate form of aluminum salt. CervarixTM and FENDrixTM are two licensed
vaccines containing AS04 against HPV and HBV [121] and others, such as herpes simplex virus
(HSV), respiratory syncytial virus (RSV), and Epstein–Barr virus (EBV) are under clinical evalua-
tion [119]. This system is also exploited in other infectious diseases [122].

Water-in-Oil Emulsion
In W/O emulsions, the antigen is present in aqueous droplets entrapped in the continuous phase of
oil and, therefore, has a tendency to remain at the site of injection. This accumulation can induce
granulomas at the injection site and also causes sharp pain [123–125]. However, this type of
emulsion generates high immunogenicity especially due to the sustained release of antigen from
the oily phase. Nevertheless, W/O emulsion are of limited use in humans. However, many
veterinary vaccines are based on W/O emulsions and some are in clinical trials for the treatment
of certain cancers, such as melanoma [126]. Freund's adjuvant, a classical W/O emulsion system
with nonmetabolizable oils, produced high antibody responses against many antigens with a Th1-
biased cytokine response, although it is not authorized for human use. Other W/O emulsions that
have gained interest as adjuvant delivery systems include Montanide ISATM 51 and Montanide
ISATM 720. These emulsions comprise mineral oil (Drakeol1 6VR) (Montanide ISATM 51) and
nonmineral oil (squalene) (Montanide ISATM 720) with a surfactant from the mannide monooleate
family (Table 1) [127]. Both formulations have been used in preclinical and clinical vaccine trials
against HIV infection, malaria, and breast cancer [117].

788 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


Multiple or Double Emulsions Outstanding Questions
In W/O/W emulsions, antigen may be entrapped in the inner aqueous phase, which is How can we formulate vaccines so
surrounded by large oil droplets dispersed in an outer aqueous phase, or can be dispersed that their kinetics and biodistribution
ensure optimal immune responses
in the outer aqueous phase. This type of emulsion is more acceptable compared with W/O and safety?
emulsions because it does not induce granulomas at the injection site. However, their physical
instability remains a limiting factor to their use in vaccine formulations. Miyahara and colleagues Can adjuvants deliver a sufficiently pro-
licensed a W/O/W emulsion comprising polyethylene glycol as the outer aqueous phase [128]. longed potent immune stimulus as a
rapid response in the face of a pan-
This type of emulsion, which includes W/O/W-type delivery systems with or without antigens [e.g.,
demic threat?
Actinobacillus pleuropneumoniae NG-22 strain (serotype 2), Japanese encephalitis virus (JEV),
Newcastle disease virus, and bovine ephemeral fever (BEF) virus] demonstrated high adjuvant Will currently available adjuvants be
activity and stability with minimum adverse effects. Although promising, more work is needed to suitable for use via non-invasive routes
ascertain the efficacy and safety of this original preparation. of vaccine delivery?

Can novel adjuvants help design vac-


Of all the emulsion types, mineral oil-based W/O emulsions show superior efficacy. However,
cines that elicit long-term memory
O/W emulsions have a greater safety profile. Therefore, a novel emulsion type with good responses and exhibit a broad spec-
adjuvanticity and safety profile is eagerly awaited [129]. Researchers have focused on formu- trum of action against constantly
lating a submicronized, highly stable, and relatively weakly viscous novel emulsion vaccine mutating pathogens and emerging
infectious agents, such as HIV, influ-
delivery system. This was designed to increase the sustainability of antigen release and to
enza, hemorrhagic fevers, and
efficiently activate the innate and adaptive immune systems. To this end, an oleic acid-based dengue?
nanoemulsion (O/W) was developed for mucosal vaccine delivery (Figure 8B). Mice immunized
intranasally with this emulsion containing standard adjuvant (MPLA) and a model antigen (i.e., Can we design smart adjuvants that
OVA) produced significantly higher antibody levels (sixfold higher in terms of IgG titers) than contribute to the development of pro-
tective responses in hosts who are
control mice immunized with the same adjuvant without emulsion. The emulsion was also found immunocompromised as a result of,
to activate APCs, antigen uptake, and B cell proliferation [130]. These results clearly demon- for example, HIV infection, cancer,
strated that an antibody class switch (IgG and IgA) occurred and that high-affinity antibodies and organ and stem cell transplanta-
were produced following mucosal immunization (Figure 8B). Interestingly, this delivery system tion, or various diseases, such as
asplenia, congenital immune deficien-
could be used to significantly reduce the antigen and adjuvant doses required without cies, chronic inflammatory/autoim-
impacting the induced cellular and humoral immunity [130]. mune conditions, or cerebrospinal
fluid leaks?
Concluding Remarks and Future Directions
Protein subunit or inactivated vaccines are usually less immunogenic than traditional vaccines.
Therefore, to improve their immunogenicity, co-administration with an adjuvant is required.
Adjuvants act via activation of the innate immune system and provide key signals that modulate
the adaptive immune response. This results in the priming of antigen-specific Th cells that
exhibit signature cytokine profiles (Th1, Th2, and Th17) associated with protection.

Basic research on adjuvants has come a long way in identifying and or synthesizing novel
molecules that exhibit potent immunostimulatory properties with minimal adverse effects.
These included autoimmune diseases (rabies vaccine), disseminated encephalomyelitis (small
pox vaccine), and paralysis of children (polio vaccine). New vaccine adjuvants currently in
clinical use, such as MF59 and AS03, minimize the number of injections, and exhibit fewer
adverse effects and improved vaccine efficacy.

Many preclinical and clinical studies have demonstrated the use of purified TLR agonists as
adjuvants. Ligands of TLR4 are currently used in human licensed vaccines for the prevention of
HPV and HBV infections [9,10]. With the increased understanding of TLR4 receptor–ligand
interactions, chemists have synthesized new compounds that exhibit immunostimulatory
properties with minimal adverse effects. Such work has led to the development of novel
Pam3CSK4 analogs [12], such as carbohydrate di- and tri-lipidated cysteine-based 1,2,3-
triazoles that exhibit adjuvant properties in vaccine formulations against bacterial, viral, and
protozoan infections, and against cancer [27].

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 789


By making changes to the carbohydrate and lipid scaffolds (e.g., with the introduction of a linker),
saponin mimics have been developed that enhance the immune response. However, despite
intensive research on a-GalCer components, which resulted in numerous analogs and mimics,
disappointing data have been reported in the literature. The new analogs that we have briefly
described in this review show potential because they elicit strong Th cell responses. However, at
this stage, more work is needed for further exploring the immunomodulatory responses of these
novel molecules in the context of various antigens, and notably against tumors.

Non-invasive vaccine delivery remains a primary focus of research that could impact mass
vaccination campaigns worldwide [131–133]. In this context, developing vaccine formulations
that are safe, effective, and available at low cost is a priority (see Outstanding Questions).
Stringent strategies should be followed for the development of vaccine formulations that
include adjuvants, that result in the desired immune responses, that have immunopotentiating
activity that result in long-term immunity and protection. Extensive research has already led to
the development of several novel adjuvants that are currently being evaluated in clinical trials or
have been licensed. Along this line, research efforts have focused on developing novel lipid-
containing adjuvants that are safe and improve the efficacy of vaccine, notably for non-invasive
delivery. However, detailed information regarding the interactions between cell surface recep-
tors after stimulation by adjuvant molecules and the compatibility of these novel adjuvants with
existing or novel formulations is required. As our understanding of the molecular mechanisms
involved in immune protection improves, and with the advent of new methods in synthetic
chemistry, considerable breakthroughs in vaccine development, along the lines of those
summarized here, are anticipated in the near future. Novel technologies, such as new glyco-
conjugation methods, reverse vaccinology, and next-generation sequencing techniques,
should lead to novel vaccine strategies including, but not limited to, HBV, pertussis toxin,
Lyme borreliosis, and HPV. Such vaccines could be developed with or without adjuvants [134].
Thus, the goal of the research community is to ensure a high level of broad protection by
building new concepts that are no longer based on structural vaccinology (given the variability of
target epitopes and the constant emergence of new pathogens and tumor antigens), but on
introducing new immunostimulants and novel delivery systems that combine efficacy (with
longlasting memory immune responsiveness) and safety.

Author Contributions
All the authors listed made substantial direct and intellectual contributions to this article and approved it for publication.

Acknowledgments
We thank Dennis Klinman for insightful comments. Some figures were made from the material provided by Servier Medical
Art (www.servier.fr) under the CC 3.0 FR license. Research in S.M.’s laboratory is funded by the French Centre National de
la Recherche Scientifique (CNRS), the Laboratory of Excellence Medalis (ANR-10-LABX-0034), and the EquipEx program
I2MC (ANR-11-EQPX-022), Initiative of Excellence (IdEx), Strasbourg University, France. Research in H.M.S.K.’s labora-
tory is funded by the Council of Scientific and Industrial Research (CSIR), Government of India for the founding of the 12th
five-year plan CSC0205 (Development of Novel Vaccine Adjuvant, DENOVA). S.R.B. thanks the Department of Science
and Technology (DST), Government of India, and the Centre Franco-Indien pour la Promotion de la Recherche Avancée
(CEFIPRA) for the award of a Raman-Charpak fellowship.

References
1. Kaushik, D. and Sehgal, D. (2008) Developing antibacterial 4. Chan, Y.K. and Gack, M.U. (2016) Viral evasion of intracellular
vaccines in genomics and proteomics era. Scand. J. Immunol. DNA and RNA sensing. Nat. Rev. Microbiol. 14, 360–373
67, 544–552 5. Marciani, D.J. (2003) Vaccine adjuvants: role and mechanisms
2. Leclerc, C. and Ronco, J. (1998) New approaches in vaccine of action in vaccine immunogenicity. Drug Discov. Today 8,
development. Immunol. Today 19, 300–302 934–943
3. Nascimento, I. and Leite, L. (2012) Recombinant vaccines and 6. Akira, S. et al. (2006) Pathogen recognition and innate immunity.
the development of new vaccine strategies. Braz. J. Med. Biol. Cell 124, 783–801
Res. 45, 1102–1111 7. Hoebe, K. et al. (2004) The interface between innate and adap-
tive immunity. Nat. Immunol. 5, 971–974

790 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


8. Thompson, A.G. and Thomas, R. (2002) Induction of immune 31. Klinman, D.M. (2004) Immunotherapeutic uses of CpG oligo-
tolerance by dendritic cells: implications for preventative and deoxynucleotides. Nat. Rev. Immunol. 4, 249–259
therapeutic immunotherapy of autoimmune disease. Immunol. 32. Bode, C. et al. (2011) CpG DNA as a vaccine adjuvant. Expert
Cell Biol. 80, 509–519 Rev. Vaccines 10, 499–511
9. Giannini, S.L. et al. (2006) Enhanced humoral and memory B 33. Shirota, H. et al. (2015) CpG oligonucleotides as cancer vaccine
cellular immunity using HPV16/18 L1 VLP vaccine formulated adjuvants. Vaccines 3, 390–407
with the MPL/aluminium salt combination (AS04) compared to
34. Davis, H.L. et al. (1998) CpG DNA is a potent enhancer of
aluminium salt only. Vaccine 24, 5937–5949
specific immunity in mice immunized with recombinant hepatitis
10. Tong, N.K.C. et al. (2005) Immunogenicity and safety of an B surface antigen. J. Immunol. 160, 870–876
adjuvanted hepatitis B vaccine in pre-hemodialysis and hemo-
35. Muraoka, D. et al. (2010) Peptide vaccine induces enhanced
dialysis patients. Kidney Int. 68, 2298–2303
tumor growth associated with apoptosis induction in CD8+ T
11. Leroux-Roels, G. (2010) Unmet needs in modern vaccinology: cells. J. Immunol. 185, 3768–3776
adjuvants to improve the immune response. Vaccine 28,
36. Stern, B.V. et al. (2002) Vaccination with tumor peptide in CpG
C25–C36
adjuvant protects via IFN-g-dependent CD4 cell immunity. J.
12. Allison, A.C. and Byars, N.E. (1991) Immunological adjuvants: Immunol. 168, 6099–6105
desirable properties and side-effects. Mol. Immunol. 28,
37. Bianco, A. et al. (2005) Cationic carbon nanotubes bind to CpG
279–284
oligodeoxynucleotides and enhance their immunostimulatory
13. Petrovsky, N. and Aguilar, J.C. (2004) Vaccine adjuvants: cur- properties. J. Am. Chem. Soc. 127, 58–59
rent state and future trends. Immunol. Cell Biol. 82, 488–496
38. Partidos, C.D. et al. (2009) Immunomodulatory consequences
14. Nalla, N. et al. (2015) Design, synthesis and immunological of ODN CpG-polycation complexes. Methods 49, 328–333
evaluation of 1, 2, 3-triazole-tethered carbohydrate-Pam 3
39. Fogg, C.N. et al. (2007) Adjuvant-enhanced antibody responses
Cys conjugates as TLR2 agonists. Bioorg. Med. Chem. 23,
to recombinant proteins correlates with protection of mice and
5846–5855
monkeys to orthopoxvirus challenges. Vaccine 25, 2787–2799
15. Kumar, S. et al. (2017) Carbon nanotubes: a novel material for
40. Sun, S. et al. (1998) Type I interferon-mediated stimulation of T
multifaceted applications in human healthcare. Chem. Soc. Rev.
cells by CpG DNA. J. Exp. Med. 188, 2335–2342
46, 158–196
41. McCluskie, M.J. and Davis, H.L. (1998) Cutting edge: CpG DNA
16. Klinman, D.M. et al. (2015) Use of nanoparticles to deliver
is a potent enhancer of systemic and mucosal immune
immunomodulatory oligonucleotides. Wiley Interdiscip. Rev.
responses against hepatitis B surface antigen with intranasal
Nanomed. Nanobiotechnol. 8, 631–637
administration to mice. J. Immunol. 161, 4463–4466
17. Knudsen, N.P.H. et al. (2016) Different human vaccine adjuvants
42. Chu, R.S. et al. (1997) CpG oligodeoxynucleotides act as adju-
promote distinct antigen-independent immunological signa-
vants that switch on T helper 1 (Th1) immunity. J. Exp. Med. 186,
tures tailored to different pathogens. Sci. Rep. 6, 19570
1623–1631
18. Buwitt-Beckmann, U. et al. (2005) Toll-like receptor 6-indepen-
43. Beignon, A.S. et al. (2002) Immunization onto bare skin with
dent signaling by diacylated lipopeptides. Eur. J. Immunol. 35,
synthetic peptides: immunomodulation with a CpG-containing
282–289
oligodeoxynucleotide and effective priming of influenza virus-
19. Bessler, W.G. et al. (1985) Synthetic lipopeptide analogs of specific CD4+ T cells. Immunology 105, 204–212
bacterial lipoprotein are potent polyclonal activators for murine
44. Mullen, G.E. et al. (2008) Phase 1 trial of AMA1-C1/Alhydrogel
B lymphocytes. J. Immunol. 135, 1900–1905
plus CPG 7909: an asexual blood-stage vaccine for Plasmo-
20. Takeuchi, O. et al. (2001) Discrimination of bacterial lipoproteins dium falciparum malaria. PLoS One 3, e2940
by Toll-like receptor 6. Int. Immunol. 13, 933–940
45. Cooper, C.L. et al. (2005) CPG 7909 adjuvant improves hepatitis
21. Takeuchi, O. et al. (2002) Cutting edge: role of Toll-like receptor B virus vaccine seroprotection in antiretroviral-treated HIV-
1 in mediating immune response to microbial lipoproteins. J. infected adults. AIDS 19, 1473–1479
Immunol. 169, 10–14
46. Speiser, D.E. et al. (2005) Rapid and strong human CD8+ T cell
22. Kang, J.Y. et al. (2009) Recognition of lipopeptide patterns by responses to vaccination with peptide, IFA, and CpG oligodeox-
Toll-like receptor 2-Toll-like receptor 6 heterodimer. Immunity ynucleotide 7909. J. Clin. Invest. 115, 739–746
31, 873–884
47. Valmori, D. et al. (2007) Vaccination with NY-ESO-1 protein and
23. Jin, M.S. et al. (2007) Crystal structure of the TLR1-TLR2 het- CpG in Montanide induces integrated antibody/Th1 responses
erodimer induced by binding of a tri-acylated lipopeptide. Cell and CD8 T cells through cross-priming.
130, 1071–1082 Proc. Natl. Acad. Sci. U. S. A. 104, 8947–8952
24. Borsutzky, S. et al. (2006) Efficient systemic and mucosal 48. Tross, D. and Klinman, D.M. (2008) Effect of CpG oligonucleo-
responses against the HIV-1 Tat protein by prime/boost vacci- tides on vaccine-induced B cell memory. J. Immunol. 181,
nation using the lipopeptide MALP-2 as adjuvant. Vaccine 24, 5785–5790
2049–2056
49. Minang, J.T. et al. (2014) Enhanced early innate and T cell-
25. Steinhagen, F. et al. (2011) TLR-based immune adjuvants. mediated responses in subjects immunized with Anthrax Vac-
Vaccine 29, 3341–3355 cine Adsorbed Plus CPG 7909 (AV7909). Vaccine 32,
26. Halliday, A. et al. (2016) The TLR2/6 ligand PAM2CSK4 is a Th2 6847–6854
polarizing adjuvant in Leishmania major and Brugia malayi 50. Lin, A.Y. et al. (2013) Gold nanoparticle delivery of modified CpG
murine vaccine models. Parasit. Vectors 9, 96 stimulates macrophages and inhibits tumor growth for
27. Cheng, C. et al. (2011) A TLR2 agonist is a more effective enhanced immunotherapy. PLoS One 8, e63550
adjuvant for a Chlamydia major outer membrane protein vaccine 51. De Titta, A. et al. (2013) Nanoparticle conjugation of CpG
than ligands to other TLR and NOD receptors. Vaccine 29, enhances adjuvancy for cellular immunity and memory recall
6641–6649 at low dose. Proc. Natl. Acad. Sci. U. S. A. 110, 19902–19907
28. Zom, G.G. et al. (2014) Efficient induction of antitumor immunity 52. Cho, H.J. et al. (2000) Immunostimulatory DNA-based vaccines
by synthetic toll-like receptor ligand–peptide conjugates. Can- induce cytotoxic lymphocyte activity by a T-helper cell-indepen-
cer Immunol. Res. 2, 756–764 dent mechanism. Nat. Biotechnol. 18, 509–514
29. Sampathkumar, H.M. et al. Council of Scientific and Industrial 53. Den Brok, M.H. et al. (2016) Saponin-based adjuvants induce
Research. 1,2,3-triazole-tethered carbohydrate-di and tri lipi- cross-presentation in dendritic cells by intracellular lipid body
dated cysteine conjugates useful as vaccine adjuvants and formation. Nat. Commun. 7, 13324
process for preparation thereof, 20160200758
54. Richou, R. et al. (1964) Research on saponin, an adjuvant
30. Bayik, D. et al. (2016) Structure, mechanism and therapeutic substance which stimulates immunity: I. Rev Immunol Ther
utility of immunosuppressive oligonucleotides. Pharmacol. Res. Antimicrob 28, 49–62 (in French)
105, 216–225

Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9 791


55. Bomford, R. (1982) Studies on the cellular site of action of the 77. Koch, M. et al. (2005) The crystal structure of human CD1d with
adjuvant activity of saponin for sheep erythrocytes. Int. Arch. and without a-galactosylceramide. Nat. Immunol. 6, 819–826
Allergy Appl. Immunol. 67, 127–131 78. Zajonc, D.M. et al. (2005) Structure and function of a potent
56. Dalsgaard, K. (1974) Saponin adjuvants. Archiv fuer die gesamte agonist for the semi-invariant natural killer T cell receptor. Nat.
Virusforschung 44, 243–254 Immunol. 6, 810–818
57. Soltysik, S. et al. (1993) Adjuvant activity of QS-21 Isomers. 79. Banchet-Cadeddu, A. et al. (2011) The stimulating adventure of
Ann. N. Y. Acad. Sci. 690, 392–395 KRN 7000. Org. Biomol. Chem. 9, 3080–3104
58. Jacobsen, N.E. et al. (1996) Structure of the saponin adjuvant 80. Borg, N.A. et al. (2007) CD1d–lipid-antigen recognition by the
QS-21 and its base-catalyzed isomerization product by 1H and semi-invariant NKT T-cell receptor. Nature 448, 44–49
natural abundance 13C NMR spectroscopy. Carbohydr. Res. 81. Yoshimoto, T. and Paul, W.E. (1994) CD4pos, NK1.1pos T cells
280, 1–14 promptly produce interleukin 4 in response to in vivo challenge
59. Ragupathi, G. et al. (2011) Natural and synthetic saponin adju- with anti-CD3. J. Exp. Med. 179, 1285–1295
vant QS-21 for vaccines against cancer. Expert Rev. Vaccines 82. Carnaud, C. et al. (1999) Cutting edge: cross-talk between cells
10, 463–470 of the innate immune system: NKT cells rapidly activate NK cells.
60. Eggermont, A.M. et al. (2013) Adjuvant ganglioside GM2-KLH/ J. Immunol. 163, 4647–4650
QS-21 vaccination versus observation after resection of primary 83. Li, X. et al. (2017) Co-localization of a CD1d-binding glycolipid
tumor> 1.5 mm in patients with stage II melanoma: results of the with an adenovirus-based malaria vaccine for a potent adjuvant
EORTC 18961 randomized phase III trial. J. Clin. Oncol. 31, effect. Vaccine 5, 3171–3177
3831–3837
84. Verma, Y.K. et al. (2015) Design, synthesis, and immunological
61. Mahmoudi, S. and Keshavarz, H. (2017) Efficacy of phase 3 trial evaluation of benzyloxyalkyl-substituted 1, 2, 3-triazolyl
of RTS, S/AS 01 malaria vaccine in infants: a systematic review a-GalCer analogues. ACS Med. Chem. Lett. 7, 172–176
and meta-analysis. Hum. Vaccin. Immunother. Published online
85. Hammond, K. and Godfrey, D. (2002) NKT cells: potential tar-
January 6, 2017. http://dx.doi.org/10.1080/
gets for autoimmune disease therapy? Tissue Antigens 59,
21645515.2016.1271686
353–363
62. Rts, S. et al. (2012) A phase 3 trial of RTS, S/AS01 malaria
86. Kobashi, K. et al. (2000) Down-regulation of IL-18 receptor in
vaccine in African infants. N. Engl. J. Med. 367, 2284–2295
cancer patients: its clinical significance. Anticancer Res. 21,
63. Kennedy, J.S. et al. (2008) The safety and tolerability of an HIV-1 3285–3293
DNA prime–protein boost vaccine (DP6-001) in healthy adult
87. Smyth, M.J. et al. (2000) Differential tumor surveillance by natu-
volunteers. Vaccine 26, 4420–4424
ral killer (NK) and NKT cells. J. Exp. Med. 191, 661–668
64. Vandepapelière, P. et al. (2008) Vaccine adjuvant systems con-
88. Biron, C.A. and Brossay, L. (2001) NK cells and NKT cells in
taining monophosphoryl lipid A and QS21 induce strong and
innate defense against viral infections. Curr. Opin. Immunol. 13,
persistent humoral and T cell responses against hepatitis B
458–464
surface antigen in healthy adult volunteers. Vaccine 26,
1375–1386 89. Miyamoto, K. et al. (2001) A synthetic glycolipid prevents auto-
immune encephalomyelitis by inducing TH2 bias of natural killer
65. Leroux-Roels, G. et al. (2015) Vaccine Adjuvant Systems con-
T cells. Nature 413, 531–534
taining monophosphoryl lipid A and QS-21 induce strong
humoral and cellular immune responses against hepatitis B 90. Fujii, S.I. et al. (2003) Activation of natural killer T cells by
surface antigen which persist for at least 4 years after vaccina- a-galactosylceramide rapidly induces the full maturation of den-
tion. Vaccine 33, 1084–1091 dritic cells in vivo and thereby acts as an adjuvant for combined
CD4 and CD8 T cell immunity to a coadministered protein.
66. Von Eschen, K. et al. (2009) The candidate tuberculosis vaccine
J. Exp. Med. 198, 267–279
Mtb72F/AS02A: tolerability and immunogenicity in humans.
Hum. Vaccin. 5, 475–482 91. Kopecky-Bromberg, S.A. et al. (2009) Alpha-C-galactosylcer-
amide as an adjuvant for a live attenuated influenza virus vac-
67. Vellas, B. et al. (1792) 2009) Long-term follow-up of patients
cine. Vaccine 27, 3766–3774
immunized with AN: reduced functional decline in antibody
responders. Curr. Alzheimer Res. 6, 144–151 92. Gonzalez-Aseguinolaza, G. et al. (2002) Natural killer T cell
ligand a-galactosylceramide enhances protective immunity
68. Fernández-Tejada, A. et al. (2014) Development of a minimal
induced by malaria vaccines. J. Exp. Med. 195, 617–624
saponin vaccine adjuvant based on QS-21. Nat. Chem. 6,
635–643 93. Huang, Y. et al. (2008) Enhancement of HIV DNA vaccine
immunogenicity by the NKT cell ligand, a-galactosylceramide.
69. Slovin, S.F. et al. (2005) Carbohydrate vaccines as immunother-
Vaccine 26, 1807–1816
apy for cancer. Immunol. Cell Biol. 83, 418–428
94. Ko, S.-Y. et al. (2005) a-Galactosylceramide can act as a nasal
70. Bhunia, D. et al. (2015) Design, synthesis, and evaluation of
vaccine adjuvant inducing protective immune responses against
novel 1, 2, 3-triazole-tethered glycolipids as vaccine adjuvants.
viral infection and tumor. J. Immunol. 175, 3309–3317
Archiv der Pharmazie 348, 689–703
95. Artiaga, B.L. et al. (2016) a-Galactosylceramide protects swine
71. Murphy, N. et al. (2010) R-Galactosylceramides and analogues
against influenza infection when administered as a vaccine
 Important immunomodulators for use as vaccine adjuvants.
adjuvant. Sci. Rep. 6, 23593
Carbohydr. Chem. 36, 64–100
96. Guichard, G. et al. (1994) Antigenic mimicry of natural L-pep-
72. Fowlkes, B. et al. (1987) A novel population of T-cell receptor
tides with retro-inverso-peptidomimetics. Proc. Natl. Acad. Sci.
ab-bearing thymocytes which predominantly expresses a single
U. S. A. 91, 9765–9769
Vb gene family. Nature 329, 251–254
97. Boeckler, C. et al. (1996) Immunogenicity of new heterobifunc-
73. Bonifaz, L.C. et al. (2004) In vivo targeting of antigens to matur-
tional cross-linking reagents used in the conjugation of synthetic
ing dendritic cells via the DEC-205 receptor improves T cell
peptides to liposomes. J. Immunol. Methods 191, 1–10
vaccination. J. Exp. Med. 199, 815–824
98. Tandrup Schmidt, S. et al. (2016) Liposome-based adjuvants for
74. Silk, J.D. et al. (2004) Utilizing the adjuvant properties of CD1d-
subunit vaccines: formulation strategies for subunit antigens and
dependent NK T cells in T cell–mediated immunotherapy.
immunostimulators. Pharmaceutics 8, 7
J. Clin. Invest. 114, 1800–1811
99. Milicic, A. et al. (2012) Small cationic DDA: TDB liposomes as
75. Kim, S. et al. (2008) Glycolipid ligands of invariant natural killer T
protein vaccine adjuvants obviate the need for TLR agonists in
cells as vaccine adjuvants. Expert Rev. Vaccines 7, 1519–1532
inducing cellular and humoral responses. PLoS One 7, e34255
76. Laurent, X. et al. (2014) Switching invariant natural killer T (iNKT)
100. Reed, S.G. et al. (2013) Key roles of adjuvants in modern
cell response from anticancerous to anti-inflammatory effect:
vaccines. Nat. Med. 19, 1597–1608
molecular bases: miniperspective. J. Med. Chem. 57, 5489–
5508 101. Saroja, C. et al. (2011) Recent trends in vaccine delivery sys-
tems: a review. Int. J. Pharm. Investig. 1, 64

792 Trends in Pharmacological Sciences, September 2017, Vol. 38, No. 9


102. Beck, Z. et al. (2015) Detection of liposomal cholesterol and 122. Baldwin, S.L. et al. (2012) The importance of adjuvant formula-
monophosphoryl lipid A by QS-21 saponin and Limulus poly- tion in the development of a tuberculosis vaccine. J. Immunol.
phemus amebocyte lysate. Biochim. Biophys. Acta 1848, 188, 2189–2197
775–780 123. Gregoriadis, G. et al. (2012) Vaccines: New Generation Immu-
103. Billeskov, R. et al. (2016) Testing the H56 vaccine delivered in 4 nological Adjuvants, Springer Science & Business Media
different adjuvants as a BCG-booster in a non-human primate 124. Sivakumar, S. et al. (2011) Vaccine adjuvants–current status and
model of tuberculosis. PLoS One 11, e0161217 prospects on controlled release adjuvancity. Saudi Pharm. J.
104. Yan, D. et al. (2015) The application of virus-like particles as 19, 197–206
vaccines and biological vehicles. Appl. Microbiol. Biotechnol. 125. Petrovsky, N. (2015) Comparative safety of vaccine adjuvants: a
99, 10415–10432 summary of current evidence and future needs. Drug Saf. 38,
105. Wang, J.W. and Roden, R.B. (2013) Virus-like particles for the 1059–1074
prevention of human papillomavirus-associated malignancies. 126. Slingluff, Jr et al. (2003) Clinical and immunologic results of a
Expert Rev. Vaccines 12, 129–141 randomized phase II trial of vaccination using four melanoma
106. Metz, S.W. et al. (2013) Chikungunya virus-like particles are peptides either administered in granulocyte-macrophage col-
more immunogenic in a lethal AG129 mouse model compared ony-stimulating factor in adjuvant or pulsed on dendritic cells. J.
to glycoprotein E1 or E2 subunits. Vaccine 31, 6092–6096 Clin. Oncol. 21, 4016–4026
107. Akahata, W. et al. (2010) A virus-like particle vaccine for epi- 127. Aucouturier, J. et al. (2002) Montanide ISA 720 and 51: a new
demic Chikungunya virus protects nonhuman primates against generation of water in oil emulsions as adjuvants for human
infection. Nat. Med. 16, 334–338 vaccines. Expert Rev. Vaccines 1, 111–118
108. Spohn, G. et al. (2010) A VLP-based vaccine targeting domain III 128. Miyahara, T. et al. Juridical Foundation, The Chemo-Sero-Ther-
of the West Nile virus E protein protects from lethal infection in apeutic Research Institute. Oil adjuvant vaccine and method for
mice. Virol. J. 7, 146 preparing same, EP 0781559 A2
109. Schnurr, M. et al. (2009) ISCOMATRIX adjuvant induces efficient 129. Pérez, O. et al. (2012) Human prophylactic vaccine adjuvants
cross-presentation of tumor antigen by dendritic cells via rapid and their determinant role in new vaccine formulations. Braz. J.
cytosolic antigen delivery and processing via tripeptidyl pepti- Med. Biol. Res. 45, 681–692
dase II. J. Immunol. 182, 1253–1259 130. Sravanthi, V. et al. (2015) Oleic acid nanoemulsion for nasal
110. Drane, D. et al. (2009) Priming of CD4+ and CD8+ T cell vaccination: Impact on adjuvanticity based immune response. J.
responses using a HCV core ISCOMATRIXTM vaccine: A phase Drug Deliv. Sci. Technol. 28, 56–63
I study in healthy volunteers. Hum. Vaccin. 5, 151–157 131. Holmgren, J. and Czerkinsky, C. (2005) Mucosal immunity and
111. Lövgren Bengtsson, K. et al. (2011) ISCOM technology-based vaccines. Nat. Med. 11, S45–S53
Matrix MTM adjuvant: success in future vaccines relies on for- 132. Vajdy, M. et al. (2004) Mucosal adjuvants and delivery systems
mulation. Expert Rev. Vaccines 10, 401–403 for protein-, DNA-and RNA-based vaccines. Immunol. Cell Biol.
112. Jacobs, C. et al. (2011) An ISCOM vaccine combined with a 82, 617–627
TLR9 agonist breaks immune evasion mediated by regulatory T 133. Azegami, T. et al. (2014) Challenges in mucosal vaccines for the
cells in an orthotopic model of pancreatic carcinoma. Int. J. control of infectious diseases. Int. Immunol. 26, 517–528
Cancer 128, 897–907
134. Rappuoli, R. et al. (2011) Vaccine discovery and translation of
113. Lycke, N. (2004) From toxin to adjuvant: the rational design of a new vaccine technology. Lancet 378, 360–368
vaccine adjuvant vector, CTA1-DD/ISCOM. Cell Microbiol. 6,
135. Calabro, S. et al. (2013) The adjuvant effect of MF59 is due to the
23–32
oil-in-water emulsion formulation, none of the individual com-
114. Fox, C.B. et al. (2013) Technology transfer of oil-in-water emul- ponents induce a comparable adjuvant effect. Vaccine 31,
sion adjuvant manufacturing for pandemic influenza vaccine 3363–3369
production in Romania. Vaccine 31, 1633–1640
136. Mosca, F. et al. (2008) Molecular and cellular signatures of
115. Stavaru, C. et al. (2016) Technology transfer of oil-in-water human vaccine adjuvants. Proc. Natl. Acad. Sci. U. S. A.
emulsion adjuvant manufacturing for pandemic influenza vac- 105, 10501–10506
cine production in Romania: preclinical evaluation of split virion
137. Didierlaurent, A.M. et al. (2014) Enhancement of adaptive immu-
inactivated H5N1 vaccine with adjuvant. Hum. Vaccin. Immun-
nity by the human vaccine adjuvant AS01 depends on activated
other. 12, 1009–1026
dendritic cells. J. Immunol. 193, 1920–1930
116. Banzhoff, A. et al. (2008) MF591-adjuvanted vaccines for sea-
138. Garçon, N. and Van Mechelen, M. (2011) Recent clinical expe-
sonal and pandemic influenza prophylaxis. Influenza Other
rience with vaccines using MPL-and QS-21-containing adjuvant
Respir. Viruses 2, 243–249
systems. Expert Rev. Vaccines 10, 471–486
117. Mohan, T. et al. (2013) Novel adjuvants & delivery vehicles for
139. Morel, S. et al. (2011) Adjuvant System AS03 containing
vaccines development: a road ahead. Indian J. Med. Res. 138, 779
a-tocopherol modulates innate immune response and leads
118. Bojang, K.A. et al. (2001) Efficacy of RTS, S/AS02 malaria to improved adaptive immunity. Vaccine 29, 2461–2473
vaccine against Plasmodium falciparum infection in semi-
140. Künzi, V. et al. (2009) Immunogenicity and safety of low dose
immune adult men in The Gambia: a randomised trial. Lancet
virosomal adjuvanted influenza vaccine administered intrader-
358, 1927–1934
mally compared to intramuscular full dose administration. Vac-
119. Garçon, N. et al. (2007) GlaxoSmithKline Adjuvant Systems in cine 27, 3561–3567
vaccines: concepts, achievements and perspectives. Expert
141. Miles, A.P. et al. (2005) Montanide1 ISA 720 vaccines: quality
Rev. Vaccines 6, 723–739
control of emulsions, stability of formulated antigens, and com-
120. Garçon, N. et al. (2012) Development and evaluation of AS03, an parative immunogenicity of vaccine formulations. Vaccine 23,
Adjuvant System containing a-tocopherol and squalene in an 2530–2539
oil-in-water emulsion. Expert Rev. Vaccines 11, 349–366
142. Sidiq, T. et al. (2011) A novel sarsasapogenin glycoside from
121. Didierlaurent, A.M. et al. (2009) AS04, an aluminum salt-and Asparagus racemosus elicits protective immune responses
TLR4 agonist-based adjuvant system, induces a transient local- against HBsAg. Immunol. Lett. 135, 129–135
ized innate immune response leading to enhanced adaptive
143. Colovai, A.I. et al. (2004) Flow cytometric analysis of normal and
immunity. J. Immunol. 183, 6186–6197
reactive spleen. Mod. Pathol. 17, 918–927

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