Background
Malaria is a deadly infectious disease caused by a protozoan of the
Plasmodium species. The disease is initiated by the bite of an infected female
Anopheles mosquito and inoculation of sporozoites in skin, which rapidly migrate through the bloodstream to infect hepatocytes. Mature liver stage parasites are then released to the bloodstream to invade the red blood cells and to initiate the asexual erythrocytic cycles responsible for the clinical manifestations of malaria [
1]. Among the five species of
Plasmodium that infect humans,
Plasmodium falciparum is the most virulent with 212 million new cases worldwide, and 429,000 deaths reported in the year of 2016 mainly infants, children, and pregnant women living in sub-Saharan Africa [
2].
Rodents, New World monkeys, and chimpanzees have been used for decades as pre-clinical models of malaria. While rodents have been critically important to study the biology of malaria parasites, it is now clear that rodent malaria parasites do not represent the complexity of
P. falciparum. First, the duration of liver stage infection is 2–3 days for rodent malaria parasites, but 7 days for
P. falciparum [
3]. Secondly, rodent malaria parasites lack orthologues for many proteins expressed by
P. falciparum such as the liver stage antigen 1 (LSA1) [
4] and
var, rif, stevor, and
Pfmc-
2TM, which are responsible for immune evasion [
1]. Thirdly, proteins shared by
P. falciparum and rodent malaria parasites differ in their biological function [
5]. New World monkeys can be experimentally infected with monkey-adapted
P. falciparum blood stage parasites, and splenectomy is required for long-term blood infections [
6]. Except for one Aotus subspecies (
Aotus lemurinus griseimembra), New World monkeys do not sustain reproducible
P. falciparum liver stage infection [
6]. Great apes can be experimentally infected with
P. falciparum sporozoites or with blood stage parasites, but the use of great apes for research is under moratorium [
7]. Consequently, the lack of convenient animal models for
P. falciparum has urged the need of testing the protective efficacy of human malaria vaccine candidates directly in human trials.
HLA class II-expressing DRAG (HLA-DR4.RagKO.IL2RγcKO.NOD) mice infused with HLA-matched human haematopoietic stem cells (HSC) efficiently repopulate the mouse thymus with human T cell precursors, and reconstitute peripheral lymphoid organs with functional human T cells and with human B cells that undergo immunoglobulin class switching and secrete human IgG [
8‐
12]. The DRAG mice, by virtue of reconstituting human cell compartments, sustain infection with human pathogens, such as
P. falciparum, HIV-1, Zika, and influenza A viruses [
9‐
13]. Since DRAG mice do not express transgenically human HLA class-I molecules, and expression of HLA class-I molecules is required for reconstitution of HLA class-I restricted human CD8 T cells, HLA class I/II-expressing DRAGA (HLA-A2.HLA-DR4.RagKO.IL2RγcKO.NOD) mice were generated and upon vaccination they showed to elicit human CD8 T cells that are HLA class I-restricted and cytotoxic [
14].
Immunization of humans with
P. falciparum sporozoites under chloroquine prophylaxis (CPS-CQ) elicits pre-erythrocytic immunity [
15‐
19], since the immunized volunteers were protected against challenge with
P. falciparum sporozoites (Pfspz), but not against challenge with
P. falciparum infected-red blood cells (iRBCs) [
19]. To determine whether the human immune system of DRAGA mice is competent enough to elicit protective immune responses against malaria parasites, DRAGA mice were immunized with
P. falciparum CPS-CQ. The immunized DRAGA mice elicited human T cell and antibody responses to the Pfspz and to the iRBCs, and they were protected against challenge with Pfspz, but not against challenge with iRBCs. The results indicate the potential of DRAGA mice to investigate the immunogenicity and protective efficacy of
P. falciparum malaria vaccine candidates.
Discussion
This study showed that DRAGA mice immunized with
P. falciparum CPS-CQ elicited human T cell and antibody responses and they were protected against malaria. Protective immunity was pre-erythrocytic as evidenced by the fact that the CPS-CQ immunized DRAGA mice were protected against challenge with Pfspz but they were not protected against challenge with iRBCs. The results in humanized DRAGA mice are in agreement with clinical trials demonstrating that human volunteers immunized with CPS-CQ elicited pre-erythrocytic immunity, since they were protected against challenge with infectious Pfspz [
15‐
19], but were unprotected against challenge with iRBCs [
19]. In contrast, studies in rodent malaria models have not reached a consensus on the immunity conferred by CPS-CQ. While BALB/c and C57BL/6 mice immunized with
Plasmodium yoelii CPS-CQ elicited both pre-erythrocytic and erythrocytic immunity, since they were protected either against challenge with sporozoites or with blood stage parasites [
26‐
28], rats immunized with
P. yoelii CPS-CQ elicited only pre-erythrocytic immunity [
29]. On the other hand, C57BL/6 mice immunized with
Plasmodium berghei CPS-CQ elicit pre-erythrocytic immunity [
30], while C57BL/6 mice immunized with
Plasmodium chabaudi elicit erythrocytic immunity [
31]. The differential ability of CPS-CQ immunization to confer pre-erythrocytic and/or erythrocytic immunity in animals and humans may be explained by intrinsic differences among the many rodent malaria parasites (
P. yoelii,
P. berghei,
P. chabaudi) and
P. falciparum, as well as differences between the mouse and human immune systems. The results indicating that DRAGA mice immunized with
P. falciparum CPS-CQ elicited pre-erythrocytic immunity, as found in clinical trials, show the potential of DRAGA mice as a new pre-clinical model to investigate the immunogenicity and protective efficacy of
P. falciparum malaria vaccine candidates.
This study further revealed that CPS-CQ immunization (i) altered the numbers of human T and B cells in spleen and in the liver, (ii) elicited specific humoral and cellular responses to the Pfspz and to the iRBCs, and (iii) a role of Tregs in regulating humoral responses to Pfspz antigens, but not to the iRBCs antigens.
CPS-CQ immunization in DRAGA mice significantly decreased the numbers of human CD4 and CD8 T cells in spleen and liver with a concomitant increase in the numbers of human B cells. This was most likely related to CQ treatment, rather than to the sporozoite injection, since the same was true for DRAGA mice treated with CQ alone though the small sample size (n = 2 mice treated with CQ alone) is a limitation of the study. However, the reduction in the number of human T cells after CPS-CQ immunization or CQ treatment, as found in this study, is in agreement with data from humans living in malaria endemic areas that were treated with CQ to prevent malaria [
32], and with data from patients treated with CQ to ameliorate lupus erythematosus [
33], which showed a decreased in the number of human T cells in the peripheral blood. CPS-CQ immunization or CQ treatment also increased the numbers of human B cells in DRAGA mice, though there are no reports from human studies indicating that CQ treatment increases the numbers of human B cells in blood. Of note, this study examined the spleen where the ratio of human T cells as compared to human B cells averages some 1:1, while the human studies examined peripheral blood where the T cells outnumber the B cells (70–85% T cells, 5–20% B cells) [
34], which could have masked an effect of CQ for increasing the numbers of human B cells. A safety CPS-CQ clinical trial also reported a reduction on the numbers of human leukocytes in peripheral blood of some of the immunized volunteers, though this human study did not specifically examine the numbers of human T and B cells [
18]. Besides the anti-malarial effect of CQ, which is mediated by preventing detoxification of host haemoglobin in the parasite vacuole [
35], CQ is also known to induce apoptosis in memory T cells (CD45RA
− CD45RO
+) [
36] and to inhibit T cell proliferation in vitro [
37,
38]. However, the T cells from CPS-CQ immunized DRAGA were as proficient at secreting human cytokines (IL-2, IFNγ, and TNFα) as the T cells from control (untreated) DRAGA mice, indicating that CPS-CQ immunization did not alter the functional ability of human T cells to secrete cytokines.
Secondly, this study indicated that DRAGA mice immunized with CPS-CQ elicited Pfspz-specific CD4 and CD8 T cells in the liver and spleen, whereas iRBC-specific CD4 and CD8 T cells were mainly localized in the liver. Though this study did not use liver stage parasites for in vitro T cell stimulation due to the difficulty of isolating liver stage parasites [
39], it is known that iRBCs express many proteins that are also shared by late liver stage parasites [
40]. As such, the iRBCs-reactive T cells found localized in the liver of immunized DRAGA mice might be indeed specific for late liver stage antigens, which would account for the presence of iRBC-specific T cells in the liver. In support of this, it was found that most immunized DRAGA mice had liver-resident human CD8 T cells specific for AMA1, which is a protein expressed by sporozoites, by the late liver stage parasites (schizonts), and by the blood stage parasites [
40]. As a note, the DRAGA mice used for this study were well reconstituted with human T cells (Additional file
1: Table S1) and they were proficient at secreting cytokines (Fig.
1c). Though the variability on the malaria-specific human T cell responses developed by each DRAGA mouse immunized with CPS-CQ cannot be explained, humans immunized with CPS-CQ also showed high variability on malaria-specific T cell responses [
15‐
19].
DRAGA mice immunized with CPS-CQ also elicited antibodies against the Pfpsz and to the iRBCs, though the Pfspz antibody titers were significantly higher than those to the iRBCs. This is agreement with data from CPS-CQ clinical trials indicating that while the immunized volunteers elicited antibodies against pre-erythrocytic and erythrocytic antigens, the magnitude of the antibody response was skewed toward the pre-erythrocytic antigens [
15,
41]. Furthermore the human B cells of CPS-CQ immunized DRAGA mice secreted IgM and IgG antibodies to the Pfspz but only IgM antibodies to the iRBCs. These results suggest that antibodies to the Pfspz could be T-cell dependent and that antibodies to the iRBCs could be T-cell independent, since helper CD4 T cells are required to support B cell immunoglobulin class switching from IgM to IgG [
42], and T-cell independent antibodies are predominantly of IgM isotype [
43]. The hypothesis was further supported by the negative correlation between the Pfspz antibody titers and the frequency of splenic human CD4
+FOXP3
+ Tregs, whereas there was no negative correlation between the antibodies to iRBCs and the frequency of splenic Tregs. The Tregs are known to regulate antibody responses either (i) by inhibiting helper CD4 T cell function through secretion of suppressive cytokines or direct cell–cell contact interactions [reviewed in
44] or (ii) by direct inhibition on the B cells [
25,
45,
46].
This study also suggested that antibodies to the Pfspz or iRBCs (as measured by IFA) may not be sufficient for protection, since the only immunized and unprotected DRAGA mouse had similar Pfspz and iRBCs antibody titers as the protected mice. Studies in rodents that were immunized with
P. yoelii CPS-CQ indicated that protection is not mediated by antibodies, since transfer of sera from immunized mice into naïve mice did not protect against malaria [
26]. In a CPS-CQ human trial in which 2 out 5 immunized volunteers were unprotected, antibodies to CSP and LSA-1 did not significantly differ between protected and unprotected subjects [
18]. Furthermore, monoclonal antibodies against the C-terminus of
P. falciparum CS protein that were generated using B cells of CPS-CQ immunized and protected subjects, showed to be ineffective against malaria infection when tested in mice challenged rodent malaria parasites that express
P. falciparum CS protein [
47].
In aggregate, this study demonstrated that the human immune system of DRAGA mice is robust enough to elicit protective immunity against P. falciparum. DRAGA mice thus represent a new humanized mouse model with potential for testing the immunogenicity and protective efficacy of P. falciparum malaria vaccine candidates and anti-malarial drugs.
Authors’ contributions
SC, WW, and SM conceived the study. SM, WW, and SS performed the experiments. WW, SM, TDB and SC analysed and interpreted data. SC wrote the manuscript with contributions from all authors. All authors read and approved the final manuscript.