A composite subunit vaccine confers full protection against Buruli ulcer disease in the mouse footpad model ofMycobacterium ulceransinfection

Buruli ulcer (BU) disease, a neglected necrotizing tropical skin infection caused by Mycobacterium ulcerans , is the third most common mycobacterial disease after tuberculosis and leprosy. Infections mostly occur in remote, rural areas of Central and West Africa, but also in Australia, Japan and Papua New Guinea. There is currently no vaccine against Buruli ulcer disease and all previous attempts using closely related bacteria and subunit proteins have been partially successful only. Here, we tested in mice a composite subunit formulation incorporating the Mycobacterium ulcerans toxin mycolactone as the immunomodulator, and the antigens Ag85A and Polyketide Synthase Enzyme Ketoreductase A (KRA), formulated with Quil-A adjuvant (‘Burulivac’). Burulivac induced Ag85A and KRA antigen-specific antibodies, T cells and a mixed pro- and anti-inflammatory cytokine responses, which conferred absolute protection against Buruli ulcer disease in the mouse footpad model over a 14-week period of observation. This was superior to both live attenuated mycobacterial vaccines, that is, BCG and an avirulent M. ulcerans strain that lacks the mycolactone toxin ( MuΔ ). Interleukin 10 was found to be strongly associated with protection. We suggest that Burulivac is a promising vaccine candidate against Buruli ulcer disease that warrants further exploration. Author summary Buruli ulcer is a neglected tropical disease caused by skin infections by Mycobacterium ulcerans , an organism related to causative pathogens of tuberculosis and leprosy. The disease is endemic to parts of Central and West Africa but is also found in Australia, Japan and some other countries. While mortality is low, morbidity caused by extensive and unsightly ulceration of the skin is high. There currently is no vaccine against Buruli ulcer and all previous attempts to develop one have been unsuccessful. Here we developed a vaccine formulation termed ‘Burulivac’ that incorporates three M. ulcerans antigens, two of which are proteins and the third the mycolactone toxin, much responsible for the pathology of the BU disease. Our rationale was that in a vaccine setting and using a controlled dose of the toxin, we could calibrate the immune responses to selected antigens, so that they mimic those induced during natural infection. Using an experimental mouse footpad model of infection, we demonstrate that immunisation with Burulivac completely prevented ulceration in the mouse footpad over an extended 14-weeks period of observation, and that this correlated with elevated levels of anti-inflammatory cytokine Interleukin-10. We propose that Burulivac is a promising vaccine candidate that merits further testing and development.