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Monkey Models of Tuberculosis: Lessons Learned

Juliet C. Pea,b* Wen-Zhe Hoa,b
Animal Biosafety Level III Laboratory at the Center for Animal Experiment, State Key Laboratory of Virology, Wuhan University, Wuhan, Chinaa; Department of Pathology
and Laboratory Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USAb

bout one-third of the population worldwide is infected with

Mycobacterium tuberculosis, while nearly 9 million cases of
active tuberculosis (TB) are reported annually (1). Hence, the
need for improved preventative and treatment strategies against
TB is ever-increasing. In an attempt to globally control TB, researchers have employed multiple animal models (mice, guinea
pigs, rabbits, cows, nonhuman primates, and others) for testing
novel experimental vaccines and therapies for TB (2, 3). The use of
nonhuman primates (NHP), especially cynomolgus macaques
(CM; Macaca fascicularis, also called long-tailed macaques, a species of Old World monkeys native to Southeast Asia) and rhesus
macaques (RM; Macaca mulatta, a species of Old World monkeys
native to Asia; most experimental models are from India or
China), has led to significant advances in TB research due to their
inherent commonalities with humans, as illustrated in previous
reviews in this subject area (46). By using the macaque model of
TB, we can gain even greater insights into ways to prevent M.
tuberculosis infection and disease progression.
JUSTIFICATION FOR MACAQUES IN TB RESEARCH

Macaques exhibit remarkable similarities to humans in virtually

every aspect of their anatomy and physiology (79). As such, macaques respond similarly to many human immunological, pathological, and drug agents, providing a tremendous advantage over
other animal models (6, 10). The literature shows that macaques
and humans share extensive clinical manifestations of TB, including pulmonary and extrapulmonary signs and symptoms (6, 10).
Clinicians and researchers can monitor the disease course in macaques by measuring nearly identical parameters tested in humans, ranging from skin and blood tests to radiographic imaging
and body fluid samples (Table 1). In addition, multidrug chemotherapy for TB provides effective treatment in both humans and
macaques (11, 12). Furthermore, as in humans, Mycobacterium
bovis bacillus Calmette-Gurin (BCG) vaccination exhibits variable efficacy in macaques of even the same species (1315). Table
1 highlights the similarities and differences in M. tuberculosis infection between humans and the rhesus macaques and cynomolgus macaques.
HISTORICAL OUTLOOK ON MACAQUE MODELS

The use of NHP models to study M. tuberculosis infection traces

back to published literature from the 1960s. This Golden Age of
TB research using NHP, performed through the 1970s, generated

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valuable data on the evolving BCG vaccine (16), as well as one

report on the TB drug efficacies of ethambutol and isoniazid (12).
The majority of the studies focused on the BCG-induced immune
reactions and vaccine efficacy (1723). All pertinent studies published during this era used Indian RM models, which underwent
intrabronchial (i.b.), intratracheal (i.t.), or aerosol infection with
M. tuberculosis. The estimated mycobacterial retention rate in
mammalian lungs after aerosol exposure was derived from prior
animal models, including macaques exposed to anthrax spores, as
well as guinea pigs and mice infected with M. tuberculosis (24).
Figure 1 recaps the major published articles of NHP models with
experimental M. tuberculosis infection during this time period (12,
1723).
Not until about 20 years after the Golden Age was another
study using experimentally infected macaques with M. tuberculosis published (25). This large research gap may be attributed
to several factors, including the high maintenance costs and necessary space/equipment for biocontainment to properly conduct
such experiments (6). Additionally, the limited animal availability, handling difficulties, and adverse public opinions discouraged
TB research with NHP. However, with greater research funding
and the emergence of compatible reagents for macaques, further
investigations into M. tuberculosis infection using NHP models
regained momentum (10). Especially amid the expansion of the
National Primate Research Centers (NPRCs), TB investigators revisited the macaque model of experimental M. tuberculosis inoculation with renewed enthusiasm. A series of subsequent investigations were dedicated to macaque research to assess novel TB
vaccines and drugs, as well as to gain an understanding of the
pathogenesis of M. tuberculosis infection and reactivation. Figures

Accepted manuscript posted online 29 December 2014

Citation Pea JC, Ho W-Z. 2015. Monkey models of tuberculosis: lessons learned.
Infect Immun 83:852862. doi:10.1128/IAI.02850-14.
Editor: A. T. Maurelli
Address correspondence to Wen-Zhe Ho, wenzheho@temple.edu.
* Present address: Juliet C. Pea, Office of Disease Prevention and Health
Promotion, U.S. Department of Health and Human Services, Rockville, Maryland,
USA.
Copyright 2015, American Society for Microbiology. All Rights Reserved.
doi:10.1128/IAI.02850-14

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The use of animal models has been invaluable for studying the pathogenesis of Mycobacterium tuberculosis infection, as well as
for testing the efficacy of vaccines and drug regimens for tuberculosis. Among the applied animal models, nonhuman primates,
particularly macaques, share the greatest anatomical and physiological similarities with humans. As such, macaque models have
been used for investigating tuberculosis pathogenesis and preclinical testing of drugs and vaccines. This review focuses on published major studies which illustrate how the rhesus and cynomolgus macaques have enriched and may continue to advance the
field of global tuberculosis research.

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TABLE 1 Comparison of TB in humans versus rhesus and cynomolgus macaquesa

Parameter
Clinical manifestations
Rate of disease progressionb
Presence of active/chronic infection symptom
Cough
Bloody sputum
Increased body temp
Wt loss
Presence of latent infection symptoms
No clinical signs
Activated by coinfection (HIV or SIV)

Pathology
Caseous granulomas
Calcification
Fibrous capsule
Pulmonary cavities
Disseminated lesions

Rhesus macaques

Cynomolgus macaques

Acute latent (10% vs 90%)

Acute latent (90% vs 10%)

Acute latent (60% vs 40%)

/
/

/
/

/
/

a
The majority of macaques, particularly the rhesus species, develop acute or active TB after artificial infection, whereas 90% of infected humans have latent TB. Chronic infection is
defined as persistent signs of active disease, radiographic involvement, or culture positivity. Although the PPD and old tuberculin skin tests are used in both humans and macaques,
these diagnostic exams are less reliable in macaques than in humans (69). Also, macaques exhibit a more random than apical distribution of pulmonary cavities. Abbreviations:
BAL, bronchoalveolar lavage; CBC, complete blood count; CRP, C-reactive protein; LT, lymphocyte transformation; rBCG, recombinant bacillus Calmette-Gurin, , positive for
the indicated finding or functional modality; , absent finding or unused modality; /, a variable finding.
b
Acute disease lasts weeks to months, and latent disease lasts months to years. Percentages (in parentheses) indicate the global percentage of the species infected with M.
tuberculosis.

2 and 3 abridge the RM (13, 2643) and CM (10, 15, 25, 4259)
models of experimental M. tuberculosis infection after the Golden
Age, from 2001 to 2014.
The majority of NHP models of M. tuberculosis infection have
involved either CM or Indian RM, except for at least five reported
research projects which used Chinese RM in Wuhan, China (34,
35), Solna, Sweden (28, 29), and Rijswijk, the Netherlands (30). So
far within the scientific literature illustrating macaque models of
M. tuberculosis infection, the routes of inoculation have included
i.b. instillation as well as i.t., aerosol, and intranasal (i.n.) infection. Although zoonotic TB outbreaks have revealed horizontal
transmission of M. tuberculosis, an experimental macaque model
of natural M. tuberculosis infection has not been reported. Tables 2
to 4 summarize by route the dose and M. tuberculosis strain of
infection in each study design, along with the major findings of the
listed papers.
RHESUS VERSUS CYNOMOLGUS MACAQUE MODELS OF TB

Both RM and CM models have served to evaluate the efficacy of

TB vaccines/drugs, as well as improve our understanding of the
immunopathogenesis of M. tuberculosis infection and reactivation. However, there are differences between the two species. For
example, one investigation revealed that BCG provides greater

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protective efficacy in CM than in RM against M. tuberculosis infection (42). Later investigations exploring stereological techniques for measuring the bacterial burden showed that RM are
more susceptible to M. tuberculosis infection than are CM (60). As
a result, RM are more often used for the study of active TB,
whereas CM provide better models of latent or chronic TB (10).
Depending on the route and dose of infection, as well as the strain
for the inoculum, either CM or RM can develop acute, chronic, or
latent TB. Therefore, several research endeavors have employed
both species for developing and determining the efficacy of TB
screening immunoassays (6164) (Table 2).
RHESUS MACAQUES

RM have been used extensively to study TB (Table 3). The early

investigations during the Golden Age (1721) specifically showed
that M. tuberculosis infection in RM progresses rapidly, within 8 to
9 weeks after aerosol inhalation of the H37Rv strain administered
at low doses of up to 62 CFU. In 2004, the Tulane NPRC established a model of asymptomatic, or latent, M. tuberculosis infection of RM (26). The investigators there revealed that RM are a
good model for not only active TB but also asymptomatic TB
when the investigators used lower doses (30 CFU) of the H37Rv
strain. In addition to RM of Indian origin, Chinese RM can also be

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Clinical tests
Skin tests
PPD
Old tuberculin test
Blood tests
ELISA, ELISpot
Quantiferon-TB Gold
Primagram
CBC, ESR, CRP, LT
Imaging (chest X-Ray, MRI, PET/CT)
Fluid sampling (BAL, gastric aspirate)

Humans

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used as a viable model of acute TB (34). Chinese RM are highly

susceptible to M. tuberculosis infection and develop active TB regardless of the dose of strain H37Rv used (34). In an attempt to
improve the methods to monitor the progression of TB disease,
Helke et al. (27) from the Oregon NPRC showed that use of highresolution radiographic and fine immunologic studies helped define the disease status in RM as in humans. Namely, computed
tomography (CT) evaluation and M. tuberculosis-specific T cell
frequencies measured by enzyme-linked immunosorbent spot
(ELISPOT) assays correlated well with the bacterial burden and
severity of disease (27).
CYNOMOLGUS MACAQUES

In addition to RM, CM have aided researchers similarly in the

study of TB (Table 4), particularly after the so-called Golden Age
(16). The first published CM investigation of controlled M. tuberculosis infection stemmed from Walsh et al.s (25) work in the
Philippines (Fig. 3), in collaboration with the University of California Los Angeles School of Medicine. In this project, the Philippine CM were found to make an excellent model of not only acute
TB but also chronic TB. This research pioneered the intratracheal
infection of Philippine CM in a TB model. Within 7 years,
Capuano et al. (10) from The University of Pittsburgh developed
a CM model representing the full spectrum of human M. tuberculosis infection by infecting the macaques after intrabronchial inoculation with a low dose (25 CFU) of the Erdman strain. Interestingly, this low dose of inoculum precipitated various reactions
in the CM, ranging from latent TB to active-chronic and even
rapidly progressive TB. The CMs pulmonary and even extrapulmonary manifestations of disease within the different stages of TB
infection closely resembled the pathological and clinical findings
in human TB, as confirmed by laboratory assessments, including
purified protein derivative (PPD) tests and erythrocyte sedimentation rate (ESR) profiling (10) (Table 1). A substantial number of
the proceeding publications on CM models of M. tuberculosis infection were similarly published by researchers at The University
of Pittsburgh (4750, 52, 56, 57). Therefore, CM models have now
been used for evaluating TB drugs and vaccines (42, 46, 52).

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SPECIFIC MACAQUE MODELS OF TB

Macaque models for TB vaccine evaluation. Using the RM

model, researchers from the Swedish Institute of Infectious Disease Control strived to augment, broaden, and prolong immune
protection against M. tuberculosis. They showed that a recombinant BCG (AFRO-1) could induce strong antigen-specific T cell
responses when combined with the TB vaccine vector rAD35 (28,
29). Two other investigations using RM models of M. tuberculosis
infection also focused on evaluating TB vaccines (30, 31). The
Biomedical Primate Research Center in Rijswijk, the Netherlands,
aimed to develop a model to test TB vaccines before progressing to
human clinical trials (30). By using an RM model employing intratracheal inoculation with the Erdman strain of M. tuberculosis,
the study revealed that prior immunization with the MVA.85boosted BCG and an attenuated, phoP-deficient TB vaccine provided effective protection against M. tuberculosis infection. A
novel aerosol challenge model effected by Sharpe et al. (31) helped
to assess the endpoints for testing the BCG/MVA.85 vaccine. This
NHP model used a three-jet collision nebulizer in addition to a
modified Henderson apparatus (a device for studying the infectivity and virulence of microorganisms in small air droplets; the 3
components include a continuous aerosol-generating unit (collision spray), exposure unit, and sampling unit), as described by
Barclay et al. (18), in a head-out plethysmography chamber. The
results of these studies indicated that the gamma interferon
(IFN-) indicesfrom ELISPOT assays and enzyme-linked immunosorbent assays (ELISAs) do not relate to protection
against TB; only the magnetic resonance imaging (MRI) readouts
offered a reliable correlate, using ex vivo lung samples removed at
necropsy (18, 31). Another way to objectively measure the efficacy
of TB vaccines and drugs was later developed by Luciw et al. (37)
at the California NPRC. The research findings from these studies
determined that stereological analysis (i.e., three-dimensional interpretation of planar sections of materials or tissues) from MRI
could provide quantitative data, showing a significant correlation
between bacterial load and lung granulomas.
Researchers did not use CM for testing TB vaccines until much

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FIG 1 The Golden Age of TB research using rhesus macaques. The timeline illustrates major studies of experimental M. tuberculosis infection in Indian rhesus
macaques during the so-called Golden Age from the 1960s to 1970s (12, 1723). Events are organized chronologically by year of publication. Thus, the 10-year
study by Good (17) actually began before the first reported investigation in 1966. Locations of the experiments (red) and the corresponding author (blue) are
indicated. Abbreviations: ic, intracutaneous; im, intramuscular; iv, intravenous; sc, subcutaneous; M.tb, M. tuberculosis; NBL, Naval Biological Laboratories; UC,
University of California.

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macaques during the 21st century, from 2001 to 2014 (13, 2634, 3643). Events are organized chronologically by year of publication. Locations of the
experiments (red) and the corresponding author (blue) are specified accordingly. Boxed events refer to comparative TB studies using both cynomolgus and
rhesus macaques. All studies, except for those reported in references 28 to 30 and 34, used Indian rhesus macaques. Abbreviations: BPRC, Biomedical Primate
Research Center; rBCG, recombinant BCG.

later than for the early RM models of TB. Between 2005 and 2012,
three reported studies using CM models evaluated the efficacy of
TB vaccines that had been tested previously with smaller animal
models, including guinea pigs and mice (44, 45). The first project
evaluated the efficacy of the 72f recombinant BCG vaccine and
HASP65 plus interleukin-12 (IL-12)/HVJ vaccine (44), which another team of investigators also tested later in Osaka, Japan (45).
Both research investigations showed that the recombinant BCG
vaccines were more effective than BCG alone. In subsequent years,
the multistage vaccine H56 was found to boost the effects of BCG
to protect CM against active TB and the reactivation of latent TB
(52). Ultimately, the macaque models have exhibited the potential
to help evaluate preventative methods and interventions before
reaching human clinical trials, particularly for TB vaccines.
Macaque models for TB drug evaluation. Finally, another recently reported investigation of experimental M. tuberculosis infection in a CM model was also published from the University of
Pittsburgh School of Medicine (56, 57). The purpose of this research endeavor was to determine potential alternative markers
for evaluating the efficacy of TB drugs. Specifically, the studies
compared the overall metabolic and radiographic changes, as well

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as the alterations within individual granulomas, in CM infected

with M. tuberculosis. Of note, the results revealed that TB granulomas evolve and resolve independently within a single host and
that individual lesions respond variably to different drugs (56).
Furthermore, the clinical findings concluded that the overall positron emission tomography (PET) and CT signals could be used as
prognostic markers to predict successful TB drug therapies. However, the overall metabolic and radiographic changes reported by
this study were nonspecific indicators of metabolic activity, measured from [18F]FDG-radiolabeled glucose in PET/CT imaging
data (56).
Macaque models for the study of TB pathogenesis. By gaining
a better understanding of the pathogenesis of M. tuberculosis infection and reactivation of latent TB, researchers can further develop and improve treatment strategies. As such, investigators at
the Tulane NPRC profiled the TB granuloma transcriptome in an
RM model to identify key immune signaling pathways that are
activated during M. tuberculosis infection (32). Previously, scientists from the Chicago Center for Biomedical Research characterized gene networks in RM after only BCG vaccination/infection
(65). Mechanistic studies of M. tuberculosis delineated more spe-

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FIG 2 Twenty-first century TB research using rhesus macaques. The timeline shows important studies of experimental M. tuberculosis infection in rhesus

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FIG 3 TB research using cynomolgus macaques. The timeline includes significant studies on cynomolgus macaques experimentally infected with M. tuberculosis
from 1996 to 2014 (10, 15, 25, 4259). Events are organized chronologically by year of publication. Locations of experiments (red) and the corresponding author
(blue) are listed. Boxed events refer to comparative TB studies using both cynomolgus and rhesus macaques, as shown in Fig. 2. Abbreviations: BPRC, Biomedical
Primate Research Center; IFN-, gamma interferon; TNF-, tumor necrosis factor alpha; Treg, regulatory T cells; U Pitt, University of Pittsburgh.

cific factors employed by M. tuberculosis to successfully infect and

persist in mammalian lungs (33). The identification of a potential
therapeutic target sparked from the discovery of the M. tuberculosis stress response factor SigH as an important player in the
growth/replication of M. tuberculosis (38, 39).
Lin et al. (47) characterized the clinical manifestations of TB
disease within the three stages: latent, active-chronic, and rapidly
progressive TB. The results of these studies showed that at necropsy, CM with active TB had more CD4 and CD8 T cells in the

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lungs and more gamma interferon from peripheral blood mononuclear cells, bronchoalveolar lavage fluid, and mediastinal lymph
nodes than CM with latent TB (47). Investigators from the same
group also showed that tumor necrosis factor neutralization resulted in disseminated disease in both acute and latent TB with
normal granulomatous structures (48). Another CM study examined the role of CD4 regulatory T cells in active TB; these cells
occurred in response to increased inflammation rather than acting
as a causative factor in the progression to active disease (49).

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TABLE 2 TB studies using both rhesus and cynomolgus macaquesa

Exptl design
Major findings

Reference

6 RM, 6 CM

Erdman (i.t.), 3,000

BCG provides greater protective efficacy against TB in CM than in RM

42c

8 RM, 15 CM

Erdman (i.t.), 1,0003,000

In vitro IFN- assays provide reproducible, reliable results while

causing less stress than the PPD skin test

61

5 RM, 4 CM

Erdman (i.t.), 100

Synthetic peptides may be used in lieu of full-length ESAT-6 protein in

TB diagnostic antibody detection assays

62d

26 RM
4 RM
3 RM
16 CM

Erdman (i.t.), 301,000

H37Rv (i.t.), 210
Beijing (i.t.), 1,000
Erdman (i.t.), 1001,000

Highest rate of TB detection achieved when skin test is combined with

PrimaTB STAT-PAK immunoassay

63e

4 RM
6 CM

H37Rv (i.b.), 1,000

Erdman (i.b.), 25

The multiplex microbead immunoassay profiles M. tuberculosis

antibodies at multiple stages of infection/disease

64

9 RM, 21 CM

Erdman K01 (aerosol), 30500

MRI and stereology provides most accurate, quantifiable

measurements of TB disease burden; RM exhibit higher
susceptibility to M. tuberculosis than CM

60

6 RM
4 RM
14 CM

Erdman (i.b.), 500

H37Rv (i.b.), 1,000
Erdman (i.b.), 25

M. tuberculosis antibody profiles depend on the NHP species and

infecting M. tuberculosis strain but do not significantly change with
TB disease progression

43

All studies used Indian RM models.

The Erdman strain is a virulent set of M. tuberculosis isolates existing in two forms, including the laboratory ATCC 35801 isolate and the clinically isolated K01; this strain is most
commonly used to study acute tuberculosis. Here, Erdman strain ATCC 35801 was used unless K01 is indicated. H37RV is an attenuated laboratory strain of M. tuberculosis
typically used to study latent infection.
c
A TB vaccine-related study (42).
d
The study reported in reference 62 also used African green monkeys.
e
In the study reported in reference 63, additional RM, CM, and African green monkey groups were inoculated with the mycobacteria M. kansaii and M. avium.
b

In light of the discovery that TB granulomas change uniquely

within a host (56), the latest published investigation by Lin et al.
(57) aimed to define how these structures vary between CM with
latent and active TB. Interestingly, the sterilization of the granulomas occurred in both stages of TB, regardless of the differential
killing of bacteria within a single host (57). Moreover, TB vaccinerelated studies have elucidated possible genetic mechanisms of
host resistance to M. tuberculosis after immunization (58), as well
as immunosuppressant mechanisms of M. tuberculosis virulence
(59). While adding insight into the molecular and pathological
pathways of TB progression, these findings may also help to evaluate the disease status as well as spur the development of novel
therapeutic targets.
Macaque models of TB/HIV coinfection. Macaques also serve
as an excellent model of TB/HIV coinfection, which is of importance to understand TB latency and reactivation (36). Upon inoculation with high-dose BCG (36, 66, 67) or low-dose Erdman
strain (25 CFU, i.b.) (50), latently infected RM and CM, respectively, had reactivated TB when coinfected with the simian immunodeficiency virus (SIV). Pathogenic SIV-BCG interactions facilitated
the development of TB-like disease (67), while antiretroviral
agents restored M. tuberculosis-specific T cell immune responses
(36). The reactivation of latent TB in CM infected with SIV was
associated with early T cell depletion and not the virus load (50).
Another particularly innovative RM model of TB was established
at the Southwest NPRC (40). The purpose of that study was to
institute an NHP model for pediatric TB/HIV coinfection. New-

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born macaques were infected with M. tuberculosis Erdman strain

intrabronchially or via the aerosol route, using an ultrasonic nebulizer specifically adapted for the newborn macaque nose. Investigators confirmed M. tuberculosis infection by various methods,
including chest X-rays, ELISPOT, bronchoalveolar and gastric lavages, and necropsy. Because people with HIV/AIDS carry a high
risk of M. tuberculosis infection and disease severity, it is clinically
significant to have a model that mimics coinfection.
KEY LESSONS AND FUTURE DIRECTIONS

Collectively, the literature on macaque models of TB has shared

four important lessons and opportunities for improvement. First,
we recognize that the biosafety requirements, cost of equipment
and maintenance, and animal availability have impeded scientists
from using NHP models in TB research. To address these issues,
researchers may experiment with smaller genera and species of NHPs
that still recapitulate human TB, such as the common marmoset
(Callithrix jacchus) model (68). Second, we found that different
animal species, individually and as a whole, respond differently
when exposed to M. tuberculosis in terms of immunopathogenesis
of the disease (43, 64) (Table 2). Therefore, investigators must
consider the purpose of the study for the appropriate selection of
NHP species. Third, the strain of M. tuberculosis used for inoculation can significantly impact the disease outcome. Instead of
employing merely the laboratory-adopted Erdman and H37Rv
strains, study designs should include clinical isolates of M. tuberculosis. Although this approach may introduce more variability

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No. of animals

M. tuberculosis strainb (inoculation route),

dose(s) (CFU)

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TABLE 3 TB studies using rhesus macaquesa

Exptl design
M. tuberculosis strainb (inoculation route),
dose(s) (CFU)

Major findings

Reference(s)

8
12

Erdman (i.b.), 10150

H37Rv (i.b.), 306,000,000

RM are a good model for latent TB, with use of low doses of H37Rv

26

H37Rv (i.b.), 1,000

High-resolution radiographic and fine immunologic studies provide definition of

TB disease progression

27

18

Erdman (i.t.), 500

Recombinant BCG (AFRO-1) induces strong antigen-specific T cell responses

with TB vaccine vector (rAD35)

28, 29c

24

Erdman (i.t.), 1,000

MVA.85 boosting of BCG and an attenuated, phoP-deficient TB vaccine show

protective efficacy against TB

30c

16

Erdman K01 (aerosol), 4065

RM may be used as models of M. tuberculosis aerosol challenge; IFN- (ELISpot,

ELISA) does not correlate with protection against TB; only MRI offers a
reliable correlate

31

NP

NP

Early TB lesions have a highly proinflammatory environment, expressing IFN-,

TNF-, JAK, STAT, and C-C/C-X-C chemokines; in contrast, late TB lesions
have a silenced inflammatory response

32

12

326 CDC1551 Himar 1 mutants (i.n.),

100,000

Virulence mechanisms of M. tuberculosis include transport of lipid virulence

factors, biosynthesis of cell wall arabinan and peptidoglycan, DNA repair,
sterol metabolism, and lung cell entry

33

9
24

H37Rv (i.b.), 503,000

Erdman (i.b.), 25500

Chinese RM are highly susceptible to M. tuberculosis infection and develop active

TB regardless of the dose of strain H37Rv or Erdman used

34, 35

16

CDC1551 (i.n.), 50

RM are an excellent model of TB/HIV coinfection and can be used to study TB

latency and reactivation

36

Erdman K01 (i.b.), 500

Stereological analysis quantitative data show a strong correlation between

bacterial load and lung granulomas

37

13

CDC1551 (i.n.), 5,000

The M. tuberculosis stress response factor sigH is required for M. tuberculosis

growth and replication in mammalian lungs

38

Erdman (i.b./i.n.), 550

Newborn macaques infected with aerosolized M. tuberculosis develop human-like

immunologic responses and are a good model for pediatric TB/HIV

40

32

Erdman K01 (i.b.), 275

RM aerosol vaccination with AERAS-402 elicits transient cellular immune

responses in blood and robust, sustained immune responses in BAL fluid but
does not protect against high-dose M. tuberculosis infection

13c

17

CDC1551 (aerosol), 100

Clinical profiles vary considerably among RM infected with M. tuberculosis but

can help identify predictive biomarkers for TB susceptibility along with gene
expression profiles

41

All studies, except for those reported in references 28 to 30 and 33, used Indian rhesus macaques. Abbreviations: i.d., intradermal; i.n., intranasal; NP, not provided.
The Erdman strain is most commonly used to study acute TB. It is a virulent subset of M. tuberculosis and exists in two forms, the laboratory isolate ATCC 35801 and the clinical
isolate, K01; the Erdman ATCC 35801 strain was used in most studies, except those for which the K01 strain is indicated. H37RV is an attenuated laboratory strain of M. tuberculosis
typically used to study latent TB infection. CDC1551 is a clinical isolate of M. tuberculosis and exhibits a similar degree of virulence as the Erdman strain.
c
TB vaccine-related study.
b

into the NHP studies of TB while making studies performed at

different sites more difficult to compare, the findings would likely
further mimic human TB disease and add valuable knowledge to
the field. Lastly, most of the macaque studies so far have shown
only acute TB, which is much less prevalent than latent TB in
humans. Hence, it is necessary to establish more clinically relevant
NHP models that resemble human passive airway transmission.
By creating an NHP model of natural M. tuberculosis infection

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under experimental conditions, researchers would be able to test

new and existing TB vaccines/drugs for protection against M. tuberculosis infection.
CONCLUDING REMARKS

Evidently, the macaque models have served as a valuable tool in

TB research over the past several decades. As demonstrated in the
literature, the CM and RM TB models have revealed clinically

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No. of
RM

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TABLE 4 TB studies using cynomolgus macaquesa

Exptl design
M. tuberculosis strain (inoculation),
dose(s) (CFU)

Major findings

Reference(s)

28

Erdman (i.t.), 10100,000

Philippine CM provide an excellent model of chronic TB

25

17

Erdman (i.b.), 25

Low-dose infection of CM represents the full spectrum of human M. tuberculosis infection and
provides a model to study latent as well as active-chronic and rapidly progressive TB

10

16

Erdman (i.t.), 500

CM vaccination with the 72f rBCG vaccine provides better protective efficacy than with BCG

44b

44

Erdman (i.t.), 500

CM vaccination with the HSP65 plus IL-12/HVJ vaccine provides better protective efficacy
than BCG

44, 45b

15

Erdman (i.t.), dose not reported

CM vaccination with Mtb72F/AS02A provides greater protective efficacy than BCG alone

46b

24

Erdman (i.b.), 1,000

CM vaccination with mc26020 or mc26030 provides less protection than with BCG

15b

25

Erdman (i.b.), 25

At necropsy, CM with active TB have more lung T cells and more IFN- from PBMC, BAL
fluid, and mediastinal lymph nodes than CM with latent TB

47

24

Erdman (i.b.), 25

Neutralization of TNF results in disseminated disease in acute and latent TB infection with
normal granuloma structure in a CM model

48

41

Erdman (i.b.), 25

Increased regulatory T cells in active TB occur in response to increased inflammation, not as a

causal factor of disease progression

49

15

Erdman (i.b.), 25

Reactivation of latent TB with SIV is associated with early T cell depletion and not virus load

50

7
5

Erdman (i.b.), 25
Erdman (i.b.), 200

M. tuberculosis-specific multifunctional T cells are better correlates of antigen load and disease
status than of protection

51c

33

Erdman (i.t.), 25500

The multistage vaccine H56 boosts effects of BCG to protect CM against active TB and
reactivation of latent TB

52

14

Erdman (i.b.), 25200

The CM model of M. tuberculosis infection mimics human TB, particularly in granuloma type
and structure

53

Erdman (i.t.), 250

M. tuberculosis may modulate protective immune responses via the use of indoleamine 2,3dioxygenase (an immunosuppressant) found in nonlymphocytic regions of TB granulomas

14b

Erdman (i.b.), 25

Experimental and epidemiologic estimates of the M. tuberculosis mutation rate are comparable

54

27

Erdman (i.b.), 500

Early expansion/differentiation of V2V2 T effector cells during M. tuberculosis infection

increases resistance to TB

55

26

Erdman (i.b.), 25400

TB granulomas evolve and resolve independently within a single host; individual lesions
respond differently to different drugs; overall PET and CT signals can predict successful TB
drug treatment

56

12

Erdman (i.b.), 1,000

Compared to nonvaccinated CM, BCG-vaccinated CM exhibit higher expression levels of

TNF-, IL-10, IL-1b, TLR4, IL-17, IL-6, IL-12, and iNOS in lungs

58b

39
2

Erdman (i.b.), 25
SNP strains (i.b.), 34

Sterilization of TB granulomas occurs in both active and latent TB amid the differential killing
of M. tuberculosis within a single host

57

Erdman (i.b.), 240500

CM vaccination with BCG transiently increases levels of macrophages and lymphocytes in

blood, with later recruitment in the lungs; however, M. tuberculosis continues to replicate in
lungs

59b

Downloaded from http://iai.asm.org/ on December 11, 2016 by guest

No. of
CM

a
Abbreviations: SNP strains, strains with a single-nucleotide polymorphism mutation; rBCG, recombinant BCG; BAL, bronchoalveolar lavage; PBMC, peripheral blood
mononuclear cells; iNOS, inducible nitric oxygen synthase.
b
TB vaccine-related study.
c
Animals were coinfected with M. tuberculosis and SIV.

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14.

15.

16.
17.
18.

ACKNOWLEDGMENTS
J.C.P. and W.H. were the sole contributors to the literature analysis and
written work. Graphic illustrations were developed by J.C.P. and W.H.
and enhanced by Patrick Lane at ScEYEnce Studios.
We received no additional support in the preparation of the manuscript.

19.

20.

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similar manifestations of TB disease or latency through multiple

diagnostic and prognostic parameters. Even the variabilities in
immune responses to M. tuberculosis infection imitate the diverse
human host reactions to the pathogen (41). Although a number of
studies on TB vaccine evaluation have been conducted using experimentally infected macaques, the majority of these studies
merely showed the reduction of TB disease progression by BCGbased vaccines. Therefore, an urgent need still exists in order to
establish macaque models that can demonstrate protection
against M. tuberculosis infection besides TB disease progression.
Fortunately, some investigators and funding institutions have revamped an interest in further developing NHP models for TB
research. Undoubtedly, given the reemerging TB epidemic, many
people worldwide should benefit from more advanced treatment
and prevention strategies against M. tuberculosis infection and disease progression. Hence, the use of NHP models should be considered a highly effective means of reaching these common goals.
In essence, from a global health standpoint, there is truth in the
words of the literary science author Chris Roberson: Everything
is improved by the judicious application of primates.

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Juliet C. Pea, M.D., M.P.H., dedicated 1 year

(2013 to 2014) as a postdoctoral fellow in WenZhe Hos laboratory at the Temple University
School of Medicine in Philadelphia, PA, where
she focused her studies on the immunopathogenesis of tuberculosis and HIV. Her interest in
tuberculosis research stemmed from her medical and public health background, as well as her
collaborations with Wen-Zhe Hos laboratory
using monkey models of tuberculosis. She
earned her M.D. (2012) and M.P.H. (2014)
from The University of Arizona College of Medicine and the Mel and Enid
Zuckerman College of Public Health. Currently, Dr. Pea is completing a
health policy fellowship at the Office of Disease Prevention and Health Promotion within the U.S. Department of Health and Human Services.

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http://dx.doi.org/10.1093/ilar.49.2.170.

Wen-Zhe Ho has 30 years of research experience in understanding the interactions between

host innate immunity and the pathogens HIV,
hepatitis C virus, and M. tuberculosis. He received his M.D. and clinical training as a pediatrician in infectious diseases at Wuhan University, China in the 1980s. He was a postdoctoral
fellow in infectious diseases at the Childrens
Hospital of Philadelphia and the Wistar Institute of the University of Pennsylvania, where he
became a full professor (2005). He also received
his M.P.H. at the University of Pennsylvania (2006), through which he
gained a greater interest in public health issues of M. tuberculosis and HIV
coinfection. In 2009, Dr. Ho moved to Temple University, where he now
serves as a tenured professor in the Departments of Pathology and Cell Biology. Additionally, as Director/Professor at the Center for Animal Experiment/ABSL-III Laboratory of Wuhan University (2010 to present), he continues his research on M. tuberculosis infection using monkey models.

Infection and Immunity

March 2015 Volume 83 Number 3

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