RTG Vaccine

MI72CH13_Laurens ARI 1 August 2018 18:13
Annual Review of Microbiology
The Promise of a Malaria

Vaccine—Are We Closer?
Matthew B. Laurens1,2,3
Access provided by University of Western Ontario on 09/10/18. For personal use only.
Annu. Rev. Microbiol. 2018.72:273-292. Downloaded from www.annualreviews.org
1
Department of Pediatrics, University of Maryland School of Medicine, Baltimore 21201,
Maryland, USA; email: mlaurens@som.umaryland.edu
2
Department of Medicine, University of Maryland School of Medicine, Baltimore,
Maryland 21201, USA
3
Malaria Research Program, Center for Vaccine Development and Global Health, University of
Maryland School of Medicine, Baltimore 21201, Maryland, USA
Annu. Rev. Microbiol. 2018. 72:273–92 Keywords

The Annual Review of Microbiology is online at malaria, Plasmodium, vaccine delivery systems, vaccines, adjuvants,
micro.annualreviews.org
elimination
https://doi.org/10.1146/annurev-micro-090817-
062427 Abstract
Copyright c 2018 by Annual Reviews. Malaria vaccine development has rapidly advanced in the past decade. The
All rights reserved
very first phase 3 clinical trial of the RTS,S vaccine was completed with
over 15,000 African infants and children, and pilot implementation stud-
ies are underway. Next-generation candidate vaccines using novel antigens,
platforms, or approaches targeting different and/or multiple stages of the
Plasmodium life cycle are being tested. Many candidates, in various stages of
development, promise enhanced efficacy of long duration and broad protec-
tion against genetically diverse malaria strains, with a few studies under way
in target populations in endemic areas. Malaria vaccines together with other
interventions promise interruption and eventual elimination of malaria in
endemic areas.
273
Contents
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
2. ADVANCES IN MALARIA VACCINE DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . 275
3. THE MALARIA LIFE CYCLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
4. PATHOGENESIS AND DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
5. EPIDEMIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
6. IMMUNE RESPONSE TO MALARIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
7. OBSTACLES TO MALARIA VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
8. PRE-ERYTHROCYTIC VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
9. BLOOD STAGE VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
10. TRANSMISSION-BLOCKING VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
11. VACCINES AGAINST PREGNANCY-ASSOCIATED MALARIA . . . . . . . . . . . . 285

12. MULTISTAGE, MULTIANTIGEN VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

13. WHOLE-ORGANISM VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
14. CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
1. INTRODUCTION
Malaria remains a significant public health threat, with approximately half of the world’s population
at risk of infection. The disease is caused by parasites transmitted to humans by the bites of infected
mosquitoes. People residing in the poorest countries are particularly vulnerable to death from
malaria illness, especially children under 5 years of age in sub-Saharan African. Eighty percent of
the global malaria burden is borne by only 15 countries, all but one in sub-Saharan Africa (101).
From 2010 to 2015, global malaria incidence dropped by 21%, in part due to expanded funding
for malaria control interventions, including long-lasting insecticidal nets, indoor residual spraying
programs, rapid diagnostic testing, and access to artemisinin combination therapy. During this
same period, malaria mortality rates fell by 29%. This significant public health achievement has
alarmingly reversed direction. In 2016, an estimated 216 million cases of malaria were reported, an
increase of 5 million cases from the previous year. Fourteen countries in West Africa registered an
increase in malaria cases in 2016 compared to 2015 (101). This disturbing trend suggests that recent
advances in malaria control may have moved backward, possibly related to decreased funding per
capita in high-burden countries. Given the reduced capital to treat and prevent malaria and stalled
advances in malaria control using current methods, highly cost-effective tools are desperately
needed to achieve the 2030 target of the World Health Organization (WHO) Global Malaria
Strategy to reduce global malaria burden by at least 90% (46, 100).
Vaccines are among the most highly successful tools in promoting both individual and public
health. After provision of clean water and sanitation, vaccination against infectious diseases has
made the greatest contribution to global public health compared to all other human interventions.
Smallpox eradication was achieved in 1977 only after a successful vaccination program was estab-
lished in endemic areas, and it has saved approximately 5 million lives annually. Polio could be the
next infectious disease eliminated through programs that rely on vaccination. Public health offi-
cials, governments, and donor organizations recognize the extraordinary benefits of vaccination
programs, and groups including UNICEF and Gavi, the Vaccine Alliance have successfully im-
proved access to vaccines for children living in the world’s poorest countries, significantly reducing
childhood mortality (39).
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Currently, no licensed vaccine exists for malaria. Some experts view a malaria vaccine as neces-
sary to eliminate malaria. The WHO published strategic goals to license malaria vaccines targeting
Plasmodium falciparum and Plasmodium vivax with at least 75% protective efficacy against clinical
malaria and reducing transmission to enable elimination (46). The most advanced candidate vac-
cine to date, RTS,S/AS01, completed phase 3 testing in seven sub-Saharan African countries and
demonstrated four-dose efficacy against clinical malaria of 27% over a median 38 months in chil-
dren aged 6–12 weeks, and 39% efficacy over a median 48 months in those aged 5–17 months (71).
Based on the RTS,S phase 3 efficacy and safety data, the vaccine received a favorable opinion from
the European Medicines Agency. At the recommendation of the WHO Strategic Advisory Group
of Experts (SAGE) on immunization and the Malaria Policy Advisory Group (MPAC), the vaccine
is currently being piloted in children 5–17 months of age in three sub-Saharan African countries
with moderate-to-high transmission. Efforts to improve on the modest efficacy of RTS,S/AS01
include modified dosing regimens of RTS,S and over 20 other malaria vaccine strategies currently
in clinical testing, using candidate antigens in monovalent and multivalent formulations either
alone or with other agents, viral vectors, and/or vaccine adjuvants. This article reviews recent
advances in malaria vaccine development and then explains the malaria life cycle as a framework
to describe the challenges, approaches, and focus of current malaria vaccine development efforts.
2. ADVANCES IN MALARIA VACCINE DEVELOPMENT

Early attempts to develop an effective malaria vaccine date from the 1930s, with a focus on inacti-
vated or killed parasites that failed to immunize. The addition of adjuvant systems demonstrated
immunogenicity of malaria vaccine candidates in animal models, including a study by Jules Freund
that demonstrated partial protection in ducklings immunized with formalin-inactivated parasites
with what is now known as Freund’s complete adjuvant, composed of heat-killed Mycobacterium
tuberculosis suspended in a water-in-oil emulsion (24). Subsequent vaccine development efforts em-
ployed rodent malaria models and led to the first human malaria vaccine trial with demonstrated
efficacy, a study that delivered irradiated P. falciparum sporozoites to vaccinees by mosquito bite.
At the time, researchers planned this whole-organism malaria vaccine approach to be a proof of
concept, as mass vaccination campaigns were considered impractical. Despite the initial success
of this approach, malaria vaccine researchers have only recently revived the technique to achieve
high-level efficacy against malaria infection.
Beginning in the 1980s, animal models were used to identify parasite antigens responsible for
protective immunity and to develop synthetic peptide vaccines based on immunogenic parasite
proteins. Challenges to this approach that appear to have been underestimated at that time include
the specificity of antigenic components that are present during only one of multiple developmental
stages of the malaria parasite, and the complex role of antigenic diversity of the parasite in areas
of natural transmission.
Because malaria lacks a biological correlate of protection, continued efforts in vaccine develop-
ment were painstakingly time consuming. A series of steps, including initial development of a can-
didate vaccine antigenic product in the laboratory, testing for safety and proof of concept in animal
models, age de-escalation phase 1 testing in adults and then in children for safety and reactogenic-
ity, needed to take place before phase 2 field testing in the target population of children in malaria-
endemic areas could finally be done to determine vaccine efficacy. These multiple steps are an ardu-
ous process and require significant funding support for a somewhat lengthy product development
timeline, and the process carries the risk of a negative end-result. To abrogate this risk, controlled
human malaria infection (CHMI), where participants are inoculated with sporozoites via the bite
of infected female Anopheles mosquitoes or injection of sporozoites or parasitized erythrocytes in
www.annualreviews.org • Malaria Vaccine—Are We Closer? 275

well-controlled settings, is employed to obtain data on vaccine and drug efficacy to support or refute
further clinical testing in malaria-endemic areas. The first malaria immunization trials using exper-
imental challenge by infected mosquitoes were conducted in the mid-1970s. Since that time, ad-
vances in the ability to maintain P. falciparum parasites in culture (91) and to infect mosquitoes with
P. falciparum parasites using membrane feeding techniques led to the first modern use of CHMI,
in the 1980s (9). The CHMI methodology has helped to advance candidate vaccines, including
testing of the RTS,S vaccine using CHMI to anticipate field efficacy and to refine the adjuvant
choice and support reformulation to a lyophilized form. The CHMI model continues to be highly
efficient and informative for malaria vaccine development pipelines.
3. THE MALARIA LIFE CYCLE

Malaria infection is caused by a unicellular eukaryotic parasite of the genus Plasmodium, with
five species causing human disease: P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi.
Sporozoite stage parasites are transmitted to humans by female anopheline mosquitoes during
a blood meal. These sporozoites invade hepatocytes and over 6 days produce 30,000–40,000
progeny. The sporozoite and liver stages are collectively referred to as pre-erythrocytic parasites
and do not cause physical signs or symptoms in the human host. When infected hepatocytes
rupture and release progeny merozoites into the venous circulation, each merozoite will potentially
invade a red blood cell, then propagate within 48–72 h to produce 6–24 merozoites. When the
infected erythrocyte ruptures, clinical symptoms present, including fever, headache, chills, sweats,
vomiting, myalgias, and malaise. The severity of these symptoms has been correlated with parasite
load (21). In the early stage of clinical manifestation, the fever attacks are periodic (24 h for
P. knowlesi, 48 h for P. vivax, P. ovale, and P. falciparum, and 72 h for P. malariae) and correspond
to release of a new generation of merozoites in the bloodstream (Figure 1). This periodicity
is regulated by human melatonin through a calcium-dependent pathway by increasing inositol-
polyphosphate production in intraerythrocytic parasites. Merozoites released during erythrocyte
rupture will each potentially invade a new erythrocyte to continue the cycle; this is also known as the
blood stage of parasite development. During this blood stage, parasitized erythrocytes will develop
either (a) progeny merozoites that are released to invade other erythrocytes or (b) male or female
gametocytes that may be ingested by a mosquito during a blood meal. In the mosquito midgut, the
male and female gametocyte fuse to form the zygote, at which time the parasite becomes diploid
and homologous recombination can lead to significant genetic variability of progeny.
Malaria vaccines can be divided into six groups based on the parasite developmental stage or the
clinical disease targeted: pre-erythrocytic vaccines; blood stage vaccines; transmission-blocking
vaccines; vaccines against pregnancy-associated malaria; multistage, multiantigen vaccines; and
whole-organism-based vaccines.
4. PATHOGENESIS AND DISEASE

Factors that affect the severity of human malaria infection include host immune status, the general
health and nutritional condition of the infected individual, and the infecting Plasmodium species
(52). Uncomplicated malaria is generally observed in adolescents and adults in high-transmission
areas, whereas severe (complicated) malaria is seen in young children, primigravidae, and malaria-
naive patients traveling to areas of malaria transmission. Severe and lethal malaria are primarily
seen in infections due to P. falciparum. Other species are less commonly fatal, although the
importance of P. vivax as a cause of significant mortality may be underestimated (2). The ability of
P. falciparum to produce high parasite loads, invade all stages of red blood cells, and adhere to
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Figure 1
Life cycle of the malaria parasite. Malaria infection begins when an infected female Anopheles mosquito bites a person, injecting
Plasmodium parasites, in the form of sporozoites, into the dermis, where they migrate via gliding motility into the bloodstream. The
sporozoites pass quickly into the human liver sinusoids, where they interact with liver extracellular matrix proteoglycans and traverse
Kupffer cells inside a vacuole to infect a hepatocyte. The sporozoites multiply asexually in the liver cells over the next 7–10 days,
causing no symptoms. The parasites are released in large “merosomes” that ultimately burst from the liver cells to release
merozoites that enter the bloodstream. In the bloodstream, the merozoites invade red blood cells (erythrocytes) and multiply again
until the cells burst. Then, they invade more erythrocytes. This cycle is repeated, causing fever each time parasites break free and
invade blood cells. Some of the infected blood cells leave the cycle of asexual multiplication. Instead of replicating, the merozoites in
these cells develop into sexual forms of the parasite, called gametocytes, that circulate in the bloodstream. When a mosquito bites an
infected human, it ingests the gametocytes, which develop further into mature sexual stages called gametes. The gametes develop
into actively moving ookinetes that burrow into the mosquito’s midgut wall and form oocysts on the exterior surface. Inside the
oocyst, thousands of active sporozoites develop. The oocyst eventually bursts, releasing sporozoites that travel to and invade the
mosquito’s salivary glands, likely via receptor-ligand interactions. The cycle of human infection begins again when the mosquito
bites another person. Reproduced from Reference 64 with permission of PATH Malaria Vaccine Initiative.

endothelium in end organ vasculature helps to explain this extensive morbidity and mortality.
Cytoadherence plays an important role in the pathogenesis of severe malaria due to P. falciparum
(45) in that parasitized erythrocytes express surface cellular adhesion molecules that localize to
end organs where pathologic effects manifest. Sequestration of infected red blood cells in the
brain may result in cerebral malaria with convulsions, potentially followed by prostration, coma,
and death. When sequestration occurs in the placenta during pregnancy, the resulting disruption
of placental blood flow and inflammatory response can lead to miscarriage, preterm delivery,
intrauterine growth restriction, fetal anemia, perinatal mortality, and maternal mortality (37, 93).
Sequestration in the kidney results in acute tubular injury that may progress to renal failure (59).
5. EPIDEMIOLOGY
Approximately half of the world’s population is at risk of malaria infection, and most cases of clinical
malaria and malaria deaths occur in sub-Saharan Africa. In 2016, 91 countries reported ongoing
transmission of malaria, including regions of Africa, Southeast Asia, the Eastern Mediterranean,
the Western Pacific, and the Americas. Populations at highest risk for developing malaria illness
and severe disease include infants, children <5 years of age, pregnant women, persons with HIV
infection, and nonimmune travelers to endemic areas. Children <5 years of age are particularly
vulnerable to malaria; because of their lack of exposure and the waning presence of maternal
antibodies, they have not yet developed immunity to malaria infection. Micronutrient deficiencies
in these young children after they stop breastfeeding may impair immune function, increasing
malaria risk. According to the WHO, 90% of malaria infections and 91% of malaria deaths occur
in sub-Saharan Africa. Of 445,000 malaria deaths that occurred in 2016, 70% afflicted children
<5 years of age (101).
Malaria is transmitted by the bites of female Anopheles mosquitoes that are most active at dusk
and dawn. Factors that influence malaria transmission intensity are related to the host, parasite,
vector, and environment. For instance, a strong host immune response to malaria infection that
would ideally be inducible by a successful vaccine could potentially inhibit malaria infection and
thus halt transmission. The host immune response must also be stealth, able to identify the mul-
titude of variant surface antigens that the parasite displays on infected erythrocytes as a means
to evade host immune recognition (6). Vector species on the African continent have a relatively
longer lifespan that facilitates parasite development in the vector and human transmission. The
longevity of African Anopheles species and their strong preference for biting humans give reason
for the disproportionate number of malaria illnesses and deaths on the continent. Environmental
factors that can enhance transmission include circumstances that favor the vector, including rain-
fall, temperature, and humidity. Patterns of malaria transmission in endemic areas are classified
as either perennial or seasonal, and this relates to rainfall patterns, as rain generally dictates the
availability of the Anopheles vector for transmission.
The intensity of malaria transmission can be described for a geographic area in terms of cross-
sectional parasite prevalence; how infectious mosquitoes are to humans; the number of infectious
bites a person receives per year, also known as the entomologic inoculation rate (EIR); the se-
roconversion rate; or the number of new infections and/or clinical episodes per person per year.
Such measures permit comparison of malaria risk among different areas and help to characterize
the effectiveness of interventions such as vaccines that may differ based on malaria risk (70).
Manifestations of severe malaria in children reflect local malaria epidemiology patterns. In areas
of high-intensity transmission, increased numbers of infants and very young children experience
severe malarial anemia. This contrasts with the situation in areas of moderate and highly seasonal
transmission, where cerebral malaria is seen in older children (29). Studies of malaria epidemiology
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in different settings demonstrate that as transmission intensity increases, the age of highest risk
for severe malarial anemia and cerebral malaria decreases (35, 68, 69).
6. IMMUNE RESPONSE TO MALARIA

The immune response to malaria is poorly understood overall, and identification of a correlate
of protection against malaria continues to elude malaria immunologists and hinders advances in
malaria vaccine development. Malaria infection incites the human immune system to produce both
“good” immune responses that protect against disease manifestations and “bad” responses that are
misdirected or even pathogenic. Teasing apart the seemingly complex immune hyperstimulation
from a more efficient, directed immune response has potential public health implications for
malaria prevention strategies, especially for malaria vaccines (42). For instance, the high malaria
mortality rates documented in sub-Saharan Africa may result from immune hyperstimulation,
inability to generate an organized immune response to infection, or a combination of the two

(34). Although the epidemiology of each form of malaria illness has been well characterized for
children living in highly endemic areas, very little is known about the harmful mechanisms that
Plasmodium infections stimulate to cause clinical illness, or the components of an effective immune
response that protect against disease manifestations.
A successful immune response to malaria infection manifests as the ability to control disease
and parasite density in the host. As parasite density increases, so does the likelihood that clinical
manifestations will develop in the host. Protection from malaria clinical illness is likely driven by
effector mechanisms that act directly to limit parasite replication, but other factors such as anti-
inflammatory effects may play a critical role. Children living in areas of high transmission rapidly
acquire this protective response against clinical manifestations, but complete protection against
malaria infection is never fully achieved by natural exposure. Adults in areas of high transmission
continue to be infected with malaria parasites, yet infrequently present with clinical disease and
serve as reservoirs for continued community transmission (27).
Pregnancy presents a unique circumstance where women who achieved effective immunity dur-
ing childhood again become susceptible to malaria, especially during first and second pregnancies
(48). This renewed susceptibility is likely related to pregnancy-related immunosuppression, and
to parasitized erythrocytes that accumulate in the placenta via cytoadherence. Acquisition of im-
munity to placental malaria with subsequent pregnancies provides evidence that vaccine-induced
immunity to pregnancy-associated malaria is achievable.
In addition to providing an efficient testing platform for malaria vaccines and therapeutics in
a controlled setting, CHMI has provided insight into early immune activation in malaria-naive
individuals, immune regulation during acute infection, and maintenance of immunologic memory
(74). In summary, CHMI studies demonstrate that both T cell memory and B cell memory are
induced after a single infection, and that malaria-infected erythrocytes can modulate inflammation
in initial and subsequent infections. CHMI studies are now being conducted in malaria-endemic
countries (Kenya, Gabon) where initial research has revealed long-lasting changes to human
innate-like lymphocytes after a single infection (57).
7. OBSTACLES TO MALARIA VACCINES

In 2013, a review process facilitated by the WHO led to revision of the Malaria Technology
Roadmap, a strategic framework for the global malaria vaccine research and development com-
munity (46). This process set a goal to develop and license a first-generation malaria vaccine with
at least 50% efficacy against severe disease that would last for longer than one year. Additional

goals include development of additional vaccines that target P. falciparum and P. vivax by 2030,
with 75% efficacy against clinical malaria illness, and that drive down malaria transmission to the
point where fewer human infections occur.
Obstacles to achieving these goals for malaria vaccines include the complex life cycle of the
parasite both within and outside of the human host, the high level of genetic diversity in Plasmod-
ium populations that allows them to evade the human immune response and potentially a malaria
vaccine-induced response. Vaccine-induced responses need to be broadly protective against dif-
ferent polymorphic variants to prevent vaccine escape (63). Other challenges include the limited
and transient immunity that adults living in high-transmission areas demonstrate against the par-
asite and the fact that some immune responses may be harmful to the human host, contributing
to severe forms of malaria. An additional challenge is the inability to maintain human Plasmodium
species in culture, with the exception of P. falciparum (31).
Perhaps the most significant challenge for malaria vaccine development is the lack of an im-
munologic correlate of protection against malaria infection and disease. Studies of RTS,S and
immunologic data from these clinical trials demonstrate that higher anti-CSP (circumsporozoite
protein) titers are associated with protection (30), although no threshold can be defined. Addi-
tional studies of RTS,S vaccination demonstrate that the combination of a strong CD4 T cell
response together with high-level anti-CSP antibody titers are important to protection against
malaria illness (62, 85), but again the critical levels of these readouts that would serve as a surro-
gate of protection in early clinical development programs have not been established. Studies of
acquired antimalarial immunity in endemic areas have also failed to produce a reliable surrogate
measure of protection. Establishment of a correlate using newly developed methods of systems
biology and modeling would propel malaria vaccine development efforts by helping to prioritize
vaccine antigens and constructs, and it would facilitate dose and regimen optimization for highly
promising candidate vaccines.
8. PRE-ERYTHROCYTIC VACCINES
A highly effective pre-erythrocytic vaccine against P. falciparum would be successful in halting
invasion of hepatocytes by infectious sporozoites. Vaccine-induced immunity would need to act
quickly and efficiently to thwart sporozoites just after injection into the dermis during blood
feeding of female Anopheles mosquitoes and before the seconds-to-minutes-long transit from ve-
nous capillary beds to the liver. Prevention of hepatocyte invasion is complex and not completely
understood, but it might be accomplished via antibodies that opsonize sporozoites (77) or in-
hibit sporozoite motility (95). Alternatively, effective pre-erythrocytic activity can be achieved via
Plasmodium-specific CD8 T cells that target liver stage antigens and provide sterile immunity (10,
18, 32).
The major pre-erythrocytic surface antigen and vaccine target is the circumsporozoite pro-
tein (CSP). This immunogen coats the sporozoite surface, and is composed of 412 amino acids
(38) with 37 tetrapeptide repeats and a conserved central domain (14). Anti-CSP antibodies in-
hibit sporozoite invasion in vitro, likely via inhibition of cell traversal activity (53), and anti-CSP
monoclonal antibodies block experimental infection in animals (23, 66).
Based on the CSP antigen, RTS,S is the leading pre-erythrocytic malaria vaccine. Components
include hepatitis B surface antigen (HBsAg) particles fused to P. falciparum CSP central repeat and
thrombospondin domains formulated in the adjuvant ASO1, a liposome formulation containing
immunostimulants 3-O-desacyl-4 -monophosphoryl lipid A and saponin QS-21 from Quillaja
saponaria extract. The recombinant vaccine antigen contains conserved P. falciparum sequences
from the 3D7 laboratory strain, including the R (repeat) portion, a single polypeptide chain of a
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highly conserved tandem repeat tetrapeptide sequence from CSP (NANP amino acid sequence
repeats); and the T (T cell epitope) portion, T lymphocyte epitopes separated by immunodominant
CD4+ and CD8+ epitopes (Th2R and Th3R). This combined repeat portion and T cell epitope
portion is fused to the N terminus of HBsAg, the S (surface) portion. A second S portion is an
unfused HBsAg, hence the name RTS,S. In the first phase 3 clinical trial of a malaria vaccine,
in 15,449 infants and children at 11 sites in 7 sub-Saharan African countries, the RTS,S vaccine
showed modest results. The three-dose regimen provided 26% efficacy against clinical malaria
over a median of 4 years in young children. When a fourth booster dose was given 18 months
after the primary series, vaccine efficacy increased to 37% over 4 years. Efficacy against clinical
malaria waned over time, was higher in older children than in infants, improved with a fourth
booster dose, and showed the highest impact in areas with the greatest malaria prevalence (71).
Acceptable safety and tolerability were demonstrated in this study, although increased fever and
febrile seizures were documented in recipients of RTS,S compared to controls. While the cases
were few, increased meningitis and severe malaria were also documented in RTS,S recipients.
Results of the phase 3 trial were evaluated by the European Medicines Agency, which adopted a
positive scientific opinion for the vaccine. Based on subsequent recommendations from the WHO,
pilot implementation studies of RTS,S began in 2018 in children 5–17 months of age in moderate-
to high-transmission areas in Ghana, Kenya, and Malawi. These implementation studies aim to
assess the feasibility and impact on mortality of a four-dose series in children aged 5–17 months
as well as the potential for meningitis and cerebral malaria in RTS,S recipients. Results will guide
future deployment of RTS,S in malaria-endemic areas.
In parallel with RTS,S testing in areas of natural transmission, efforts to improve on the
modest efficacy of RTS,S demonstrated that delayed fractional third and fourth doses provided
improved efficacy when compared to the standard dosing regimen using the CHMI model (67,
84), potentially via CSP antibody avidity and somatic hypermutation frequency in CSP-specific
B cells and an enhanced IgG4 response (7). Based on these findings, three additional studies of this
fractional dose regimen are ongoing, including the largest CHMI study to date in 150 malaria-
naive adults in Silver Spring, Maryland, USA (NCT03162614); a safety and immunogenicity study
in adults in Bangkok, Thailand (NCT02992119); and an efficacy study in children 5–17 months
of age in Kumasi, Ghana (NCT03281291). The outcomes of these trials will help to guide clinical
development of the RTS,S fractional dosing regimen.
A challenge to the RTS,S vaccine that is likely for any malaria vaccine is diminished efficacy
against parasites in nature carrying a different CSP allele compared to the vaccine (58). Similar
to the rapid evolution of P. falciparum resistance to chloroquine and sulfadoxine-pyrimethamine
with drug pressure in endemic areas, vaccine pressure could potentially select for CSP alleles that
escape RTS,S-derived immunity, leading to increased circulation of parasites resistant to RTS,S in
endemic areas where RTS,S vaccination programs are deployed. Such potential for development
of vaccine-resistant malaria will need close monitoring and may merit careful selection of variant
CSP antigens to be included in a next-generation, multivalent RTS,S vaccine.
Other candidate pre-erythrocytic vaccines are being developed and are based on the sporo-
zoite liver stage antigens CSP, liver stage antigen 1 (LSA-1), malaria exported protein 1 (Exp1),
cell-traversal protein for Plasmodium ookinetes and sporozoites (CelTOS), and sporozoite sur-
face protein 2/thrombospondin-related adhesion protein (SSP2/TRAP). Table 1 lists ongoing
projects. Some strategies based on the P. falciparum CSP protein seek to employ alternate vaccine
delivery platforms, including virus-like particles that have shown promise for other pathogens
and in animal models (94). Of the vaccine delivery systems that are under development for pre-
erythrocytic vaccine candidates, the most promising to date uses protein-in-adjuvant such as
RTS,S/ASO1. Alternate approaches include DNA vaccines expressed within host cells, but results

Table 1 Current malaria vaccine projects targeting pre-erythrocytic stagesa

Antigen Vaccine mechanism Most advanced status
Plasmodium falciparum
RTS,S (CSP fused to HBsAg) Inhibits sporozoite motility, prevents Pilot implementation, phase 4
hepatocyte invasion pharmacovigilance baseline
RTS,S fractional dose (CSP fused Inhibits sporozoite motility, prevents Phase 2b clinical testing in endemic areas
to HBsAg) hepatocyte invasion
ChAd63/MVA, ME-TRAP Inhibits sporozoite motility, prevents Phase 2b clinical testing in endemic areas
hepatocyte invasion
PfSPZ (radiation-attenuated Inhibits sporozoite motility, prevents Phase 2b clinical testing in endemic areas
whole-organism sporozoites) hepatocyte invasion
PfCelTOS Inhibits sporozoite motility, prevents Phase 1 clinical testing
hepatocyte invasion
R21 (CSP-HBsAg fusion protein) Inhibits sporozoite motility, prevents Phase 1 clinical testing
hepatocyte invasion
Recombinant CSP Inhibits sporozoite mobility, prevents Preclinical testing
hepatocyte invasion
EBA175 Targets merozoite ligand that mediates Phase 1 clinical testing
erythrocyte invasion
Genetically attenuated Inhibits sporozoite motility, prevents Phase 1 clinical testing
whole-organism sporozoites hepatocyte invasion
Plasmodium vivax
DBP Inhibits sporozoite attachment to erythrocyte Phase 1 clinical testing
CSP Inhibits sporozoite motility, prevents Preclinical testing
hepatocyte invasion
Abbreviations: ChAd63, chimpanzee adenovirus 63; CSP, circumsporozoite protein; DBP, Duffy-binding protein; EBA, erythrocyte-binding antigen;
HBsAg, hepatitis B surface antigen; MVA, modified vaccinia ankara; PfCelTOS, P. falciparum cell-traversal protein for ookinetes and sporozoites.
a
Data source: Reference 102.
have been suboptimal (43, 99). Viral vectors are another potential delivery system, and the use of
poxviruses that elicit strong CD4 responses (47, 97) and adenoviruses that induce high-antibody
and elevated interferon-gamma responses (33). Researchers continue to employ advanced tech-
nologies to identify novel pre-erythrocytic vaccine candidates that could be combined with CSP
to enhance efficacy, including transcriptome- and proteome-based approaches (22, 41, 51, 82) as
well as genome-based antibody screening (75).
9. BLOOD STAGE VACCINES

Vaccines based on the blood stage antigens expressed by infected erythrocytes seek to induce
immune responses that limit parasite replication after liver exit, so as to control parasitemia that
would otherwise lead to clinical malaria, including potentially fatal cases. Most blood stage vaccines
target proteins expressed on the surface of parasitized red blood cells that target end organs and
evade splenic clearance. Naturally acquired immunity to blood stage parasites has been demon-
strated by passive antibody transfer from semi-immune adults residing in high-transmission areas
to relatively naive individuals with clinical malaria who then experienced significant declines in
blood stage parasitemia (12, 72). In fact, most of the human immune response to repeated malaria
infection over time seems to target the blood stage parasites (15).
282 Laurens
Table 2 Current malaria vaccine projects targeting blood stagesa

Antigen Antigen description Vaccine mechanism Most advanced status
AMA1 P. falciparum apical membrane Targets the merozoite’s invasion apparatus to Phase 2 clinical testing in
antigen 1 prevent erythrocyte infection endemic areas
GMZ2 P. falciparum glutamate-rich protein Targets merozoite surface to inhibit Phase 2 clinical testing in
and merozoite surface protein 3 erythrocyte invasion endemic areas
P27A P. falciparum malaria protein Targets merozoite surface to inhibit Phase 1 clinical testing
PFF0165c erythrocyte invasion
MSP3 P. falciparum merozoite surface Targets merozoite surface to inhibit Phase 2 clinical testing in
protein 3 erythrocyte invasion endemic areas
SE36 P. falciparum serine repeat antigen 5 Targets merozoite surface to inhibit Phase 1 clinical testing in
erythrocyte invasion endemic areas
PfPEBS P. falciparum pre-erythrocytic and Inhibits sporozoite motility, prevents Phase 2 clinical testing
blood stage hepatocyte invasion, targets merozoite

surface to inhibit erythrocyte invasion
Rh5 P. falciparum reticulocyte-binding Targets merozoite ligand that mediates Phase 1 clinical testing
protein homolog 5 erythrocyte invasion
Pfs25 P. falciparum surface protein 25 Inhibits ookinete development in the Phase 1 clinical testing
mosquito midgut
PvDBP P. vivax Duffy-binding protein Inhibits parasite ligand that binds to placental Phase 1 clinical testing
matrix
MSP1 P. falciparum malaria surface protein 1 Targets merozoite surface to inhibit Preclinical testing
erythrocyte invasion
PfEBA175 P. falciparum erythrocyte-binding Targets merozoite ligand that mediates Preclinical testing
antigen 175 erythrocyte invasion
a
Antigens expressed on the surface of the merozoites and infected red blood cells are consid-
ered blood stage malaria vaccine candidates and include reticulocyte-binding protein homolog 5
(RH5); part of a trophozoite-exported protein, P27A; merozoite surface proteins 1, 2, and 3
(MSP1, MSP2, and MSP3); serine-repeat antigen (SERA); erythrocyte-binding antigen (EBA);
ring-infected erythrocyte surface antigen (RESA), glutamate-rich protein (GLURP); and apical
membrane antigen 1 (AMA1). Table 2 lists current candidates in development.
Phase 2 efficacy studies of blood stage antigens tested in malaria-endemic areas have yielded
disappointing results. With the exception of a post hoc analysis of an MSP3 vaccine in Burkinabe
children that demonstrated short-term protection (78), none of the candidate blood stage antigens
tested as a single-antigen formulation have demonstrated efficacy against clinical malaria illness
(26, 60, 90). Of these, an AMA1-based vaccine tested in Mali demonstrated significant efficacy
against clinical malaria infections that shared identical genetic sequence with the vaccine strain at
key immunologically relevant amino acid positions (90). The strain-specific efficacy and genetic
diversity analysis of these malaria vaccine candidates demonstrate that identification of specific
amino acid residues and clusters of residues that generate a protective immune response against
clinical disease is feasible, narrowing the diversity that must be considered for multivalent vaccine
formulations (63). A next-generation AMA1-based vaccine that includes three AMA1 variants
recently demonstrated high immunogenicity that was sustained for 2 years in malaria-exposed
adults (79) and will likely advance in clinical testing.

RH5 appears to be one of the most highly conserved blood stage candidate antigens, with
studies of growth inhibition supporting significant cross protection against heterologous strains
(17). A recently tested two-dose prime-boost strategy of RH5 that used chimpanzee adenovirus
63 as prime followed by modified vaccinia ankara (MVA) as boost was highly immunogenic in
vaccinees and demonstrated functional inhibition of eight heterologous laboratory malaria strains
in vitro, suggesting that this candidate may be broadly cross protective as a single variant, blood
stage antigen (65).
10. TRANSMISSION-BLOCKING VACCINES

The updated Malaria Vaccine Technology Roadmap highlights a vision of safe and effective
vaccines against P. falciparum and P. vivax that would prevent malaria transmission in communities.
This reflects a heightened interest in transmission-reducing interventions that would target sexual,
sporogenic, and mosquito stage antigens and help to eliminate malaria in defined geographic
settings. These candidates are largely viewed as altruistic vaccines, as they provide no direct benefit
to the individual but would lead to a reduced prevalence of malaria infection in communities.
Naturally acquired antibodies that bind male and female gametocytes and halt further parasite
development have been demonstrated in malaria-experienced populations (25, 36, 83). Vaccines
that mimic this immune response with increased efficiency and effect could have significant impact
on parasite transmission in a community. In addition, vaccines could stimulate an immune response
to zygote and ookinete antigens that are then bound by antibody in the mosquito midgut to halt
parasite life cycle progression and infectivity.
Transmission-blocking vaccine candidate antigens for P. falciparum include the prefertilization
proteins Pfs48/45 and Pfs230 expressed on the surface of parasite gametocyte stages in humans
and the postfertilization proteins Pfs25 and Pfs28 expressed in the mosquito midgut in zygotes and
ookinetes. In addition, the P. vivax ortholog Pvs25 has been developed as the only transmission-
blocking vaccine tested to date in clinical trials. Table 3 lists transmission-blocking vaccines
currently in development.
The candidate Pfs48/45 antigen was initially difficult to manufacture and purify to yield suffi-
cient product in a proper conformation, but use of a chimeric antigen expressed in Lactococcus lactis
has overcome this hurdle (89) and may soon be tested in clinical trials (88). A Pfs230 candidate
vaccine was recently produced in a plant-based expression system in fresh whole-leaf tissue and
induces high antibody titers in animal models that reduce oocyst counts in a standard membrane
feeding assay (SMFA) (20). A clinical trial of Pfs25 conjugated to a detoxified exoprotein A from
Pseudomonas aeruginosa to produce sustained high immunogenicity in malaria-naive adults. This
study documented dose-dependent transmission-blocking activity in vitro using a SMFA that cor-
related with both antibody titer and antibody avidity (86) and was also recently tested in adults
in Mali (NCT01867463, results pending). Other strategies to increase Pfs25 immunogenicity
include a viral-vectored prime boost approach (NCT02013687). A study of bivalent transmission-
blocking vaccines containing Pfs25 and either Pfs28 or Pfs230 did not lead to additional reductions
in transmission-blocking activity when compared to monovalent strategies (49).
Testing the ability of transmission-blocking vaccines to reduce spread of parasites in clinical
trials has relied on both immunology readouts of antibody responses and the SMFA to validate
and prioritize the most promising vaccine candidates. The SMFA employs in vitro cultured game-
tocytes that are mixed with serum or purified antibody from vaccinated individuals. The mixture is
then fed to Anopheles mosquitoes that are subsequently dissected to determine the prevalence and
density of oocysts in the mosquito midgut (54). The CHMI model has also been recently piloted
as a method to assess transmission-blocking vaccines and other interventions (13).
284 Laurens
Table 3 Current malaria vaccine projects targeting other stages and whole-organism approachesa
Antigen Antigen description Vaccine mechanism Most advanced status
Pfs25 P. falciparum surface protein 25 Inhibits ookinete development Phase 1 clinical testing in
in the mosquito midgut endemic areas
Pfs230 P. falciparum surface protein 230 Inhibits ookinete development Phase 1 clinical testing in
in the mosquito midgut endemic areas
Pfs48 P. falciparum surface protein 48 Inhibits ookinete development Preclinical testing
in the mosquito midgut
Pfs45 P. falciparum surface protein 45 Inhibits ookinete development Preclinical testing
in the mosquito midgut
Var2CSA P. falciparum variant 2 chondroitin sulfate A Inhibits parasite ligand that Phase 1 clinical testing in
binds to placental matrix endemic areas
Multistage P. falciparum R21, multiple epitope string Multistage, multiantigen Preclinical testing
with thrombospondin-related adhesion

protein for P. falciparum, P. falciparum RH5,
and P. falciparum surface protein 25
PfSPZ P. falciparum sporozoite Inhibits sporozoite motility, Phase 2 clinical testing in
prevents hepatocyte invasion endemic areas
PfSPZ-CVac P. falciparum sporozoite under Inhibits sporozoite motility, Phase 2 clinical testing in
chemoprophylaxis prevents hepatocyte invasion endemic areas
GAP 3KO P. falciparum genetically attenuated parasite Inhibits sporozoite motility, Phase 1 clinical testing
knockout prevents hepatocyte invasion
PfSPZ GM1 P. falciparum genetically modified 1 Inhibits sporozoite motility, Preclinical testing
prevents hepatocyte invasion
a
11. VACCINES AGAINST PREGNANCY-ASSOCIATED MALARIA

During pregnancy-associated malaria, P. falciparum–infected erythrocytes sequester to placen-
tal endothelial cells via interactions between the P. falciparum erythrocyte membrane protein 1
(PfEMP1) on the surface of infected erythrocytes and chondroitin sulfate A (CSA) receptors on
the placental matrix (3). Expression of parasite VAR2CSA results in PfEMP1 expression. High
maternal titers of anti-PfEMP1 antibody are associated with a lower risk of low birth weight in
malaria-endemic areas (73), and immunologic memory is induced in primigravidae with expansion
in multigravidae (1). The durability of this immune response without reexposure lays the foun-
dation for a vaccine-induced immune response that targets placental malaria. Two VAR2CSA
candidate vaccines are in clinical trials (Table 3), and each includes different antigenic regions
and sequences that could potentially complement each other in terms of immunogenicity and
efficacy (8). However, VAR2CSA is highly polymorphic, and a multivalent vaccine targeting the
most conserved regions may be needed to achieve field efficacy (96).
12. MULTISTAGE, MULTIANTIGEN VACCINES

The concept of a multivalent malaria vaccine that targets different parasite proteins and potentially
different life cycle stages has long been contemplated (16). The benefit of such a vaccine is that
immune responses to different stages would be active to ensure that parasites that are not halted
completely at any stage of development would be targeted at a subsequent stage (92). Some

candidate malaria vaccines in development have combined two antigens from the same life cycle
stage, but few have attempted to target multiple stages in a single formulation.
A candidate vaccine known as GMZ2 is constructed as a fusion protein of two blood stage
candidate vaccine antigens, MSP3 and GLURP, and demonstrated an acceptable safety profile
and significant immunogenicity in malaria-exposed adults and children (4, 56). A large, multicenter
trial of GMZ2 in African children 1–5 years of age demonstrated an adjusted 14% efficacy, with
higher efficacy in older children (80). This promise of a combination blood stage vaccine using a
formulation similar to GMZ2 may lead to a next-generation vaccine designed to provide a more
immunogenic response. Other vaccine strategies in development include the multiple epitope
(ME) thrombospondin-related adhesion protein (TRAP). ME-TRAP consists of fused B cell and
CD4 and CD8 T cell epitopes of P. falciparum liver stage antigens. This vaccine failed to show
consistent protection in phase 2b trials conducted in endemic areas (50, 61), although other variants
are being developed (19).
13. WHOLE-ORGANISM VACCINES

Vaccines based on whole-organism approaches employ attenuated versions of the sporozoite stage
and include radiation-attenuated sporozoites, genetically attenuated parasites, and sporozoites ad-
ministered under chemoprophylaxis. These methods follow ideas that led to the very first successful
human vaccine trials of radiation-attenuated sporozoites delivered by mosquito bites (11). Many
advances in whole-organism vaccine approaches have increased enthusiasm for these candidate
malaria vaccines.
After an unprecedented demonstration of 100% efficacy against CHMI (76), the PfSPZ vaccine,
consisting of live, nonreplicating P. falciparum sporozoites irradiated and cryopreserved in liquid
nitrogen and delivered via direct venous injection with needle and syringe, has rapidly advanced to
testing in endemic areas. An initial study in Malian adults demonstrated sterile protection against
P. falciparum infection (81), a first for any malaria vaccine. Studies of heterologous challenge
using the CHMI model demonstrated significant and durable protection lasting over 6 months
after last vaccination, inducing immunity that may be mediated by vaccine-activated T cells (44).
Additional studies are ongoing at several African sites, including one in Kenyan infants living in
a highly endemic area (NCT02687373). In parallel, many complementary studies are ongoing in
both malaria-endemic and -nonendemic settings. While the PfSPZ vaccine induces significantly
high levels of antibody to the CSP antigen, no known immunology readouts in human clinical
trials correlate with demonstrated protection (44). Careful genomic analyses of naturally acquired
infections in vaccinees will help to guide the development plan for this strategy in endemic areas.
In parallel with the live, radiation-attenuated, whole-organism approach, both chemo-
attenuated sporozoites and genetically attenuated sporozoites studies have shown promise. Clinical
trials of sporozoites delivered via mosquito bite to participants taking P. falciparum prophylaxis
with chloroquine demonstrated induction of polyfunctional T cells and a robust antibody re-
sponse that provided durable protection against homologous parasites (87). Subsequent studies
using cryopreserved sporozoites administered under chemoprophylaxis also demonstrated highly
sterilizing immunity against homologous CHMI in malaria-naive individuals (55), while heterol-
ogous protection was modest (98). Genetically attenuated P. falciparum sporozoites that carry a
triple gene deletion to arrest parasite growth in hepatocytes showed promise in preclinical testing
and a favorable safety profile in initial clinical trials (40). Further testing of this product is planned
in parallel with a second-generation genetically attenuated vaccine that allows infected hepato-
cyte development to later liver stages and induces enhanced cell-mediated and humoral immune
responses (5).
286 Laurens
14. CONCLUSION AND FUTURE DIRECTIONS

The ambitious call to renew scientific, political, and donor commitment to malaria eradication
in 2007 has led to multiple advances in malaria vaccine development over the last ten years.
Multiple new candidate vaccine antigens have been identified, and promising candidates have
advanced quickly to clinical testing in endemic areas. The very first phase 3 malaria vaccine
trial was successful in 15,449 infants and children at 11 sites in 7 sub-Saharan African countries,
providing critical evidence for efficacy, and for regulatory and donor support for pilot imple-
mentation testing. Blood stage vaccines have demonstrated limited efficacy against clinical dis-
ease, and transmission-blocking vaccines are being tested in endemic areas. The first vaccine
targeting pregnancy-associated malaria was developed and is under study in sub-Saharan Africa.
Next-generation malaria vaccines hold high promise for improved efficacy that provides sterile
protection against infection, including the PfSPZ vaccine and fractional dose RTS,S regimens.
Future testing of malaria vaccines will continue to progress along four major avenues: pre-
clinical testing, evaluation of preliminary efficacy using CHMI studies, large field studies to test
candidate vaccines in areas where malaria is naturally transmitted, and head-to-head evaluation
of malaria vaccine efficacy against other malaria control measures. Preclinical testing to refine
mono- and polyvalent vaccines will continue to be informed by studies of genomic, transcrip-
tomic, and proteomic data. The CHMI model will continue to be exploited to inform critical
go–no go criteria that are central to clinical development plans for pre-erythrocytic, blood stage,
transmission-blocking, and whole-organism candidate vaccines. As the very first malaria vaccine
enters pilot implementation studies in three sub-Saharan African countries, studies that com-
pare malaria prevention using seasonal malaria chemoprophylaxis with antimalarial medication
versus seasonal RTS,S vaccination versus a combination of both methods are being planned or
conducted (28). These periodic interventions can take advantage of the high efficacy provided
immediately after administration of RTS,S and pharmacotherapy and hold promise to interrupt
malaria transmission in communities with highly seasonal endemicity.
In tandem with testing candidate vaccines in CHMI and endemic areas, systems biology will
play an important role to evaluate the vaccine-induced immune responses that contribute to
protection. Identification of an immune signature of vaccine-induced protection would serve to
accelerate clinical development of candidate vaccines. Advances in vaccine platform constructs such
as virus-like particles and novel adjuvant formulations will increase efficacy of existing vaccines.
Use of monoclonal antibodies to interrogate protection against CHMI and naturally occurring
malaria may help to inform proteins and/or peptides important to sterile protection.
Ultimately, an integrated approach will likely be necessary to eliminate malaria transmission,
as most tools currently used for malaria control are imperfect. Such approaches would continue
to employ proven methods, including insecticide-treated bed nets, seasonal malaria chemopro-
phylaxis, indoor residual spraying, rapid diagnostic testing, and access to artemisinin combination
therapy. A highly effective malaria vaccine would complement these interventions and provide the
durable protection required to interrupt and eventually eliminate malaria.
DISCLOSURE STATEMENT
The author has received the following funding: NIH U01 grant to assess safety, immunogenicity
and efficacy of PfSPZ vaccine in Burkinabe adults; NIH contract to assess safety, immunogenicity
and efficacy of PfSPZ-CVac in Malian adults; NIH contract to assess safety, immunogenicity and
efficacy of a full-length rCSP vaccine; and Maryland Industrial Partnerships (MIPS) Program to
advance a virus-like particle vaccine in collaboration with VLP Therapeutics.

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Microbiology
Volume 72, 2018 Contents
The Outer Membrane Took Center Stage

Volkmar Braun p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Control of Specialized Metabolism by Signaling and Transcriptional
Regulation: Opportunities for New Platforms for Drug Discovery?
M. Daniel-Ivad, S. Pimentel-Elardo, and J.R. Nodwell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p25

Above and Beyond Watson and Crick: Guanine Quadruplex Structures
and Microbes
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The Clash of Macromolecular Titans: Replication-Transcription
Conflicts in Bacteria
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Eco-evolutionary Dynamics Linked to Horizontal Gene Transfer
in Vibrios
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The Complex Rcs Regulatory Cascade
Erin Wall, Nadim Majdalani, and Susan Gottesman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 111
Broadening the Definition of Bacterial Small RNAs: Characteristics
and Mechanisms of Action
Marie-Claude Carrier, David Lalaouna, and Eric Massé p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 141
Transcriptional Responses to ppGpp and DksA
Richard L. Gourse, Albert Y. Chen, Saumya Gopalkrishnan,
Patricia Sanchez-Vazquez, Angela Myers, and Wilma Ross p p p p p p p p p p p p p p p p p p p p p p p p p p 163
Context-Specific Action of Ribosomal Antibiotics
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Antibiotic-Induced Genetic Variation: How It Arises and How
It Can Be Prevented
Jesús Blázquez, Jerónimo Rodrı́guez-Beltrán, and Ivan Matic p p p p p p p p p p p p p p p p p p p p p p p p p p p 209
Using Cryo-EM to Investigate Bacterial Secretion Systems
Chiara Rapisarda, Matteo Tassinari, Francesca Gubellini, and Rémi Fronzes p p p p p p p p p p 231
A New Lens for RNA Localization: Liquid-Liquid Phase Separation
Erin M. Langdon and Amy S. Gladfelter p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 255
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The Promise of a Malaria Vaccine—Are We Closer?

Matthew B. Laurens p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 273
Spo11-Independent Meiosis in Social Amoebae
Gareth Bloomfield p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 293
The Glyoxylate Shunt, 60 Years On
Stephen K. Dolan and Martin Welch p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 309
Electron Bifurcation: A Long-Hidden Energy-Coupling Mechanism
Volker Müller, Nilanjan Pal Chowdhury, and Mirko Basen p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 331
Epigenetic Variation and Regulation in Malaria Parasites
Manoj T. Duraisingh and Kristen M. Skillman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 355
Interspecific Gene Exchange as a Driver of Adaptive Evolution

in Fungi
Alice Feurtey and Eva H. Stukenbrock p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 377
Communication Between the Microbiota and Mammalian Immunity
Kyla S. Ost and June L. Round p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 399
Ebola: Lessons on Vaccine Development
Heinz Feldmann, Friederike Feldmann, and Andrea Marzi p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 423
Detection of Microbial Infections Through Innate Immune Sensing
of Nucleic Acids
Xiaojun Tan, Lijun Sun, Jueqi Chen, and Zhijian J. Chen p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 447
The Epigenome, Cell Cycle, and Development in Toxoplasma
Kami Kim p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 479
Regulation of Sexual Commitment and Gametocytogenesis
in Malaria Parasites
Gabrielle A. Josling, Kim C. Williamson, and Manuel Llinás p p p p p p p p p p p p p p p p p p p p p p p p p p p 501
Pneumococcal Vaccines: Host Interactions, Population Dynamics,
and Design Principles
Nicholas J. Croucher, Alessandra Løchen, and Stephen D. Bentley p p p p p p p p p p p p p p p p p p p p p p p 521
Indexes
Cumulative Index of Contributing Authors, Volumes 68–72 p p p p p p p p p p p p p p p p p p p p p p p p p p p 551
Errata
An online log of corrections to Annual Review of Microbiology articles may be found at

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MI72CH13_Laurens ARI 1 August 2018 18:13

Annual Review of Microbiology

The Promise of a Malaria

Annu. Rev. Microbiol. 2018. 72:273–92 Keywords

11. VACCINES AGAINST PREGNANCY-ASSOCIATED MALARIA . . . . . . . . . . . . 285

12. MULTISTAGE, MULTIANTIGEN VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

2. ADVANCES IN MALARIA VACCINE DEVELOPMENT

www.annualreviews.org • Malaria Vaccine—Are We Closer? 275

3. THE MALARIA LIFE CYCLE

4. PATHOGENESIS AND DISEASE

www.annualreviews.org • Malaria Vaccine—Are We Closer? 277

6. IMMUNE RESPONSE TO MALARIA

inability to generate an organized immune response to infection, or a combination of the two

7. OBSTACLES TO MALARIA VACCINES

www.annualreviews.org • Malaria Vaccine—Are We Closer? 279

www.annualreviews.org • Malaria Vaccine—Are We Closer? 281

Table 1 Current malaria vaccine projects targeting pre-erythrocytic stagesa

9. BLOOD STAGE VACCINES

Table 2 Current malaria vaccine projects targeting blood stagesa

blood stage hepatocyte invasion, targets merozoite

www.annualreviews.org • Malaria Vaccine—Are We Closer? 283

10. TRANSMISSION-BLOCKING VACCINES

with thrombospondin-related adhesion

11. VACCINES AGAINST PREGNANCY-ASSOCIATED MALARIA

12. MULTISTAGE, MULTIANTIGEN VACCINES

www.annualreviews.org • Malaria Vaccine—Are We Closer? 285

13. WHOLE-ORGANISM VACCINES

14. CONCLUSION AND FUTURE DIRECTIONS

www.annualreviews.org • Malaria Vaccine—Are We Closer? 287

www.annualreviews.org • Malaria Vaccine—Are We Closer? 289

African sites. PLOS Med. 11:e1001685

www.annualreviews.org • Malaria Vaccine—Are We Closer? 291

blood-stage malaria vaccine. N. Engl. J. Med. 365:1004–13

Volume 72, 2018 Contents

The Outer Membrane Took Center Stage

M. Daniel-Ivad, S. Pimentel-Elardo, and J.R. Nodwell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p25

The Promise of a Malaria Vaccine—Are We Closer?

Interspecific Gene Exchange as a Driver of Adaptive Evolution

Cumulative Index of Contributing Authors, Volumes 68–72 p p p p p p p p p p p p p p p p p p p p p p p p p p p 551

An online log of corrections to Annual Review of Microbiology articles may be found at

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