A review of the global epidemiology of scrub typhus.

Scrub typhus is a serious public health problem in the Asia-Pacific area. It threatens one billion people globally, and causes illness in one million people each year. Caused by Orientia tsutsugamushi, scrub typhus can result in severe multiorgan failure with a case fatality rate up to 70% without appropriate treatment. The antigenic heterogeneity of O. tsutsugamushi precludes generic immunity and allows reinfection. As a neglected disease, there is still a large gap in our knowledge of the disease, as evidenced by the sporadic epidemiologic data and other related public health information regarding scrub typhus in its endemic areas. Our objective is to provide a systematic analysis of current epidemiology, prevention and control of scrub typhus in its long-standing endemic areas and recently recognized foci of infection

Characteristics of scrub typhus in main endemic areas.

<p>Characteristics of scrub typhus in main endemic areas.</p

Global outbreaks of scrub typhus.

<p>Global outbreaks of scrub typhus.</p

Global seroprevalence of scrub typhus by Region/Country.

<p>Global seroprevalence of scrub typhus by Region/Country.</p

Protection by and maintenance of CD4 effector memory and effector T cell subsets in persistent malaria infection

<div><p>Protection at the peak of <i>Plasmodium chabaudi</i> blood-stage malaria infection is provided by CD4 T cells. We have shown that an increase in Th1 cells also correlates with protection during the persistent phase of malaria; however, it is unclear how these T cells are maintained. Persistent malaria infection promotes protection and generates both effector T cells (Teff), and effector memory T cells (Tem). We have previously defined new CD4 Teff (IL-7Rα^-) subsets from Early (Teff^Early, CD62L^hiCD27⁺) to Late (Teff^Late, CD62L^loCD27^-) activation states. Here, we tested these effector and memory T cell subsets for their ability to survive and protect <i>in vivo</i>. We found that both polyclonal and <i>P</i>. <i>chabaudi</i> Merozoite Surface Protein-1 (MSP-1)-specific B5 TCR transgenic Tem survive better than Teff. Surprisingly, as Tem are associated with antigen persistence, Tem survive well even after clearance of infection. As previously shown during T cell contraction, Teff^Early, which can generate Tem, also survive better than other Teff subsets in uninfected recipients. Two other Tem survival mechanisms identified here are that low-level chronic infection promotes Tem both by driving their proliferation, and by programming production of Tem from Tcm. Protective CD4 T cell phenotypes have not been precisely determined in malaria, or other persistent infections. Therefore, we tested purified memory (Tmem) and Teff subsets in protection from peak pathology and parasitemia in immunocompromised recipient mice. Strikingly, among Tmem (IL-7Rα^hi) subsets, only Tem^Late (CD62L^loCD27^-) reduced peak parasitemia (19%), though the dominant memory subset is Tem^Early, which is not protective. In contrast, all Teff subsets reduced peak parasitemia by more than half, and mature Teff can generate Tem, though less. In summary, we have elucidated four mechanisms of Tem maintenance, and identified two long-lived T cell subsets (Tem^Late, Teff^Early) that may represent correlates of protection or a target for longer-lived vaccine-induced protection against malaria blood-stages.</p></div

Mature effector T cells decay faster than effector memory T cells in <i>P</i>. <i>chabaudi</i>.

<p>Decay of malaria-specific polyclonal cells was detected by infecting C57Bl/6 mice with <i>P</i>. <i>chabaudi</i> and administration of BrdU either (<b>A-E</b>) during the memory phase (days 24–30), or (<b>F-K</b>) the peak of infection (days 4–10) to label Teff. The day after the end of BrdU administration, the infection was terminated with mefloquine (MQ), and decay of CD4⁺ memory (CD44^hi CD127^hi CD11a⁺, BrdU^+/-) and effector (CD127^<b>-</b>, (CD11a, BrdU)^+/-) T cells in the spleen was determined by flow cytometry. <b>A)</b> Schematic representation of the experimental design for memory phase. <b>B)</b> Plots show the gating strategy for Tmem, including BrdU. Graphs showing <b>C)</b> number of Tmem (CD4⁺ CD11a⁺ CD44^hi CD127^hi) and <b>D)</b> survival of memory T cell subsets in the spleen after parasite clearance. <b>E)</b> Graphs showing percentage (left) and number (right) of cells in each Tmem subset that survive after proliferating days 24–30 (BrdU⁺). <b>F)</b> Schematic representation of the experimental design to study decay of effector T cells, where BrdU was given days 4–10 p.i., and infection was terminated with MQ days 10–14 p.i. Flow cytometric gating and graphs showing <b>G)</b> number of Teff (CD4⁺ CD127^<b>-</b>) and <b>H)</b> survival of Teff subset populations in the spleen after parasite clearance. <b>I)</b> Plots showing the gating strategy for Teff from CD11a+ to Teff (CD4⁺ CD11a⁺ CD44^hi CD127^lo). Graphs showing <b>J)</b> the number of divided Teff (CD4⁺ CD11a⁺ CD127^- BrdU⁺), as they decay after labelling days 4–10 p.i, and subsequent parasite clearance, and <b>K)</b> the percentage (left) and number (right) of cells in each of the divided Teff subsets as they decay. Data represent 3 mice per group. Data was analyzed by Student’s <i>t</i> test and error bars represent SEM. * represents a significant difference between subsets at one timepoint. † represents a significant difference between timepoints d10-d30, or d30-50, # from d20-30 only; one symbol p<0.05, two symbols p<0.01, n.s.–not significant with color coding of symbols to indicate which subset changes.</p

Teff^Early survive like Tmem cells, while highly activated Teff subsets decay.

<p><b>A)</b> Schematic representation of the experimental design. T cell subsets were sorted from spleens of infected B5 TCR Tg animals (Effector on d8 p.i. (top) and Memory on d60 p.i. (bottom)) and the same number of T cells of each subset (5 x 10⁴) were transferred into uninfected congenic recipients (Thy1.1) for 60 days. <b>B)</b> Graph showing numbers of B5 TCR Tg (CD4⁺ Thy1.2⁺) T cells recovered from spleens of recipients of each T cell subset on d60 post-transfer. Data represent 4–9 mice per group from two experiments. Data were analyzed using Student’s <i>t</i> test, **p<0.01, *p<0.05. n.s.–not significant. <b>C)</b> Concatenated contour plot of B5 T cells recovered from Teff^Early recipients day 60 post-transfer showing memory (CD44, CD127) and memory T cell subset (CD62L, CD27) phenotype, and summary graph of Tmem phenotype of recovered T cells from the groups of mice that received each Teff subset. Error bars represent SEM.</p

Persistent infection promotes Tem survival.

<p><b>A)</b> Schematic representation of the experimental design. Memory T cell subsets were sorted from infected B5 TCR Tg mice (d60 p.i.) and the same number of each subset (2.5 x 10⁵) were transferred into either infection-matched (d60 p.i., top) or uninfected (bottom) Thy1.1 hosts for 60 days after transfer. <b>B)</b> Graph shows numbers of recovered B5 T cells (CD4⁺ Thy1.2⁺) in recipients of Tem^Early. <b>C)</b> Concatenated contour plots show division (CFSE-), and levels of CD127, and phenotypes (CD62L, CD27) of cells recovered from Tem^Early recipients. Summary bar graphs show average of divided cells or fraction in each Tmem subset gate on recovery. <b>D)</b> Graph shows numbers of recovered B5 T cells in recipients of Tem^Late. <b>E)</b> Concatenated contour plots show levels of CFSE, and CD127, and phenotypes (CD62L, CD27) of cells recovered from Tem^Late recipients. Summary bar graphs show average of divided cells or fraction in each Tmem subset gate on recovery. Data are representative of 2–4 mice per group from 2 similar experiments. Data was analyzed by Student’s <i>t</i> test, and error bar represents SEM, *p<0.05, n.s.–not significant. On summary bar graphs symbols refer to differences between fractions of recovered cells in each Tmem subset in a given stacked bar, one symbol = p<0.05; two symbols, **p<0.01 comparing Tcm to TemL; three symbols, ***p<0.001 comparing Tem^Early to Tem^Late, ^{<b><i>#</i></b>} comparing Tcm (very few) to Tem^Early, ^<b>+</b> comparing Tem^Early to Tem^Late.</p