Clinical and Vaccine Immunology, July 2008, p. 1035-1041, Vol. 15, No. 7
1071-412X/08/$08.00+0 doi:10.1128/CVI.00030-08
Copyright © 2008, American Society for Microbiology. All Rights Reserved.

Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115
Received 23 January 2008/ Returned for modification 9 April 2008/ Accepted 28 April 2008
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IgA) provided protection against a serotype III strain and a serotype Ia strain bearing beta C protein. High-titered anti-rAlp3 rabbit serum opsonized Alp3-containing strains of two GBS serotypes (types V and VIII) and invasive type III strains bearing the cross-reactive Rib protein for in vitro killing by human peripheral blood leukocytes. Thus, the potential exists for the inclusion of rAlp3 in a GBS vaccine formulated to provide multiserotype coverage. |
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14% to 30%) and type III (
50% to 68%). Serotype V has emerged as the most common serotype (
30%) isolated from nonpregnant adults (14, 19), and serotypes VI and VIII are prevalent colonizers of pregnant women in Japan (25). Early vaccine trials with purified, uncoupled type Ia, II, and III capsule polysaccharides (CPSs) showed that these antigens evoked low and variable type-specific antibody responses in healthy adults (2, 4). Later vaccine trials of conjugate vaccines created by the covalent attachment of the CPS to an immunogenic carrier protein, such as tetanus toxoid (TT), enhanced the immune response to the CPS and resulted in high levels of type-specific, functionally active antibody predominantly of the immunoglobulin G (IgG) class (1, 40). Thus far, only a few protein carriers have been used for the preparation of licensed conjugate vaccines (15). Three protein carriers, including diphtheria mutant protein cross-reactive material (CRM197), TT, and diphtheria toxoid have been used in Haemophilus influenzae type b conjugate vaccines, whereas CRM197, TT, and diphtheria toxoid have been used in Neisseria meningitidis conjugate vaccines (15, 39). Seven pneumococcal CPSs have each been coupled to CRM197 to create the multivalent conjugate vaccine against Streptococcus pneumoniae infections (13). While all of these carrier proteins improved the immune response to the CPS antigens, there was concern regarding their overuse. Indeed, studies have shown that healthy adults and children vaccinated with the protein carrier subsequently have suppressed antibody responses to the CPS epitopes (6, 10), and apparent epitopic suppression was observed when multiple vaccines sharing common protein epitopes were administered simultaneously (12). The use of alternative carrier proteins may reduce the potential for immune suppression in primed individuals as more conjugate vaccines are added to the routine vaccination program. Therefore, the development of alternative protein carriers that are immunogenic, protective, and easy to produce and ideally expand coverage is desired.
To date, several GBS protein carriers that confer protection in animals have been described, including the alpha C protein (ACP) (17, 29), beta C protein (BCP) (32), Rib (29, 45), Sip (9), C5a peptidase (11), and surface-exposed antigens GBS67, GBS80, and GBS104 (36). The majority of GBS isolates express one or more of a family of surface-anchored proteins that form ladder-like patterns on Western blot due to a large number of repeat units. These proteins include ACP, Rib, alpha-like protein 2 (Alp2), and alpha-like protein 3 (Alp3) (31). The Rib protein is present in most type III strains, and Alp3 is present on most type V and type VIII strains (22, 31). The Alp3 protein has N-terminal regions that are highly similar to those of the ACP and BCP, and its tandem repeats are essentially identical to the repeat region of the Rib protein (24). This tandem repeat region in Alp3 might constitute the antigenic site that was also present in the Rib protein (34, 33). Except for the number of repeats, the sequence of Alp3 is 98% identical to the sequence of R28 from S. pyogenes, and antibodies against R28 confer protective immunity against S. pyogenes disease in mice (44). Rabbit antiserum to a GBS purified alpha-like protein, later named Alp2, conferred protection against an alpha-like protein-expressing GBS type V strain in a neonatal mouse model of GBS disease (26). The ability of an alpha-like protein to elicit antibody-mediated protection in experimental animals provided the rationale to investigate whether Alp3 could be used as an immunogen and/or as a protein carrier for CPS antigens in the development of GBS vaccines.
We have recently demonstrated that a recombinant BCP and a recombinant BCP modified to eliminate its human IgA-binding site (rBCP
IgA) were not only effective immunogens but also strong carriers for the type III CPS, creating vaccines with greater serotype coverage than a conjugated vaccine prepared with a non-GBS protein carrier (47). In this report, we describe the expression and purification of a recombinant Alp3 (rAlp3) and demonstrate its immunogenicity in mice and its ability to be a good carrier protein for GBS type III CPS. Type III CPS conjugate vaccines prepared with rAlp3 (III-rAlp3) elicited IgG in adult female mice, which provided protection against lethal GBS challenges to their newborn pups. In addition, rabbit serum to rAlp3 opsonized GBS for in vitro killing by human peripheral blood leukocytes, further confirming the potential of this protein as a viable vaccine antigen.
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IgA was produced from GBS serotype Ia strain H36B, cloned into pTrcHisA, and expressed by Escherichia coli strain BL21(DE3) (47); soluble rAlp3 was produced from GBS serotype VIII strain H4A0158, cloned into pTrcHisA, and expressed by E. coli strain BL21(DE3) as described previously (7). Six GBS type III strains (KMP103, KMP105, KMP114, KMP115, KMP120, and KMP121) were isolated from newborns with invasive GBS disease (41). All strains contained rib, with the exception of strain KMP114, which contained alp3 (41).
Protein expression and purification. To prepare each recombinant protein, a 1-liter culture of each E. coli transformant was incubated at 37°C in Luria-Bertani medium (Difco, Sparks, MD) supplemented with 100 µg/ml of ampicillin (Sigma, St. Louis, MO) with shaking at 200 rpm to an optical density at 600 nm of 0.6. Protein expression was induced with 1 mM isopropyl-β-D-thiogalactopyranoside (IPTG) (Invitrogen, Carlsbad, CA) for 3 h at 37°C. Histidine-tagged recombinant proteins were purified by His-bind Fractogel chromatography (Novagen) as described previously (47).
Generation of GBS conjugate vaccines. GBS type III CPS was purified from GBS strain M781 as previously described (46). To create aldehydes on the sialic acid moieties of type III CPS, 15.2 mg of pure type III CPS was combined with 4 µM freshly prepared sodium m-periodate (Sigma) in 1 ml of distilled water. The resulting oxidized CPS was purified, and the degree of sialic acid oxidation was determined by pulsed amperometric detection as described previously (47).
A III-rAlp3 conjugate was created by combining 5 mg of oxidized type III CPS with 5 mg of rAlp3 in 1 ml of phosphate-buffered saline (PBS) (Gibco, Grand Island, NY). A tricomponent conjugate vaccine consisting of III-rAlp3-rBCP
IgA was generated by combining 5 mg of oxidized type III CPS with 2.5 mg of rAlp3 and 2.5 mg of rBCP
IgA in 1 ml PBS. Sodium cyanoborohydride (Matreya, Pleasant Gap, PA) was added to each mixture to promote the covalent attachment of the protein(s) to the oxidized CPS. The conjugation procedure, column purification of the conjugates, and biochemical analyses of the vaccines were performed as described previously (47).
Immunogenicity and efficacy of rAlp3-containing vaccines in mice.
Eight-week-old female outbred CD-1 mice (Charles River Laboratories, Wilmington, MA) were vaccinated intraperitoneally with either rAlp3, III-rAlp3, III-rAlp3-BCP
IgA, or type III CPS plus rAlp3 plus BCP
IgA (III+rAlp3+BCP
IgA) (10 µg of protein content) mixed with equal amounts of alum (1.3% alhydrogel; Brenntag Biosector, Frederikssund, Denmark) in a total volume of 0.5 ml. Booster doses with alum were administered on days 21 and 42 after the primary dose, and serum was collected before each booster dose. Control dams received saline with alum by the same route and schedule. Mice were then bred on day 56, and their litters were challenged with viable GBS. Neonatal mouse pups (<24 h of age) were challenged with GBS at
8.5 x 103 CFU/pup (
100-fold 50% lethal dose [LD50]) for strain M781,
5 x 104 CFU/pup (
100-fold LD50) for strain A909,
9 x 105 CFU/pup (
200-fold LD50) for strain CJB111,
7.0 x 106 CFU/pup (
7-fold LD50) for strain HIA00001, and
9.0 x 105 CFU/ml (
10-fold LD50) for strain JM9130013. The challenge dose was administered intraperitoneally in a total volume of 50 µl of Todd-Hewitt broth (Difco) supplemented with 0.5% yeast extract (Difco). The number of pups that survived the GBS challenge was assessed 48 h after challenge.
ELISAs.
Specific IgG levels elicited by each vaccine component (type III CPS, rAlp3, and rBCP
IgA) were measured by enzyme-linked immunosorbent assay (ELISA) as described previously (47). Briefly, microtiter plates were coated with the following concentration of primary antigen: 0.2 µg/ml rAlp3, 0.2 µg/ml rBCP
IgA, or 1.0 µg/ml type III CPS-human serum albumin in 0.1 M sodium carbonate buffer (pH 9.8). Mouse sera from each vaccine group were pooled and serially twofold diluted across wells of the coated microtiter plates. Phosphatase-labeled goat anti-mouse IgG (diluted 1:3,000) was used as the secondary antibody. ELISA titers were reported as the reciprocal of the highest dilution corresponding to an optical density at 405 nm of
0.2 after 30 min of development at 37°C with 1 mg/ml phosphatase substrate (Sigma) dissolved in substrate buffer (1 M Tris, 0.3 mM MgCl2 [pH 9.8]).
Antigenicity of coupled and uncoupled rAlp3.
Competitive inhibition of the binding of mouse antiserum (diluted 1:10,000) to rAlp3-coated microtiter plates was assessed by using rAlp3, II-rAlp3, and III-rAlp3-rBCP
IgA as inhibitors at concentrations ranging from 1 to 1,000 ng/ml; competitive inhibition in rBCP
IgA-coated microtiter plates was assessed by using rBCP
IgA and III-rAlp3-rBCP
IgA as inhibitors. Percent inhibition was calculated as [(absorbance at 405 nm without inhibitor – absorbance at 405 nm with inhibitor)/absorbance at 405 nm without inhibitor] x 100; the percentage was plotted against the log10 of the inhibitor concentration to generate inhibition curves.
Rabbit antiserum to rAlp3. A New Zealand White rabbit was given three 200-µg doses of rAlp3 mixed with incomplete Freund's adjuvant at 21-day intervals. The rAlp3-specific IgG titer was determined with the use of the rAlp3 ELISA described above and goat anti-rabbit IgG-alkaline phosphatase conjugate as the secondary antibody.
Whole-cell GBS Western blot analysis. A 1-ml culture of GBS grown overnight was pelleted by centrifugation, washed with 1 ml PBS (Gibco, Grand Island, NY), and resuspended in 200 µl PBS. A 10-µl aliquot of resuspended cells was mixed with 15 µl loading buffer (NuPAGE LDS sample buffer and NuPAGE sample reducing agent; Invitrogen) and heated at 70°C for 10 min, and proteins were separated on NuPAGE Novex Bis-Tris gels (Invitrogen) according to the manufacturer's protocol. Western blot analysis of separated GBS proteins was performed with mouse anti-rAlp3 serum followed by phosphatase-labeled goat anti-mouse IgG.
PCR analysis. GBS was treated with protoplast buffer (20% sucrose, 10 mM MgCl2, 10 mM Tris, 0.05% Triton X-100, and 0.5 U/µl mutanolysin [pH 7.0]) at 37°C for 1 h. Supernatant recovered from the protoplast-treated sample was used directly for PCR amplification. The alp3 gene was amplified with alp3-2F (5'-GTGGAGTGATGGGAGTCGTG-3') and alp3-2R (5'-TCTGTTGCTCTGGAGTGACG-3') (42) at an annealing temperature of 66°C.
Functionality of rAlp3 antiserum. The functionality of rabbit antiserum to rAlp3 was evaluated using an in vitro opsonophagocytosis assay as described previously (5). Briefly, 2.5 µl of rabbit serum collected on day 57 following vaccination with rAlp3 was diluted in 47.5 µl of minimum essential medium (Invitrogen) to yield a final assay dilution of 1:100 when combined with 25 µl of baby rabbit complement (Cedarlane, Burlington, NC), 150 µl of human peripheral blood leukocytes, and 25 µl of GBS. Pooled rabbit antiserum to GBS type V CPS-CRM197 was used as a positive control. Viable GBS cells were enumerated by quantitative plate counts at time zero and after a 60-min incubation at 37°C with mixing. The difference in the number of GBS CFU was calculated and expressed as the average of two determinations per GBS strain.
Statistics. Fisher's exact test was used to compare the efficacies of GBS vaccines (Instat, version 3.0a; Graphpad Software, San Diego, CA) at a significance level of 0.05.
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IgA. Purified III-rAlp3 conjugate was composed of 32% (wt/wt) protein and 63% (wt/wt) carbohydrate, while the III-rAlp3-rBCP
IgA conjugate was composed of 32% (wt/wt) protein and 59% carbohydrate. The presence of rAlp3 in purified conjugate vaccines was confirmed by Western blot analysis (Fig. 1).
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FIG. 1. Confirmation of the presence of rAlp3 in test vaccines by Western blot analysis. The blot containing uncoupled rAlp3 (lane 1), III-rAlp3 conjugate vaccine (lane 2), III-rAlp3-rBCP IgA conjugate vaccine (lane 3), and the uncoupled mixture III+rAlp3+rBCP IgA (lane 4) was probed with mouse antisera to rAlp3. Bound antibodies were identified following incubation with labeled goat anti-mouse IgG antiserum. Each lane contained 0.4 µg rAlp3. The formation of high-molecular-weight polymers following conjugation is evident in lanes 2 and 3.
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IgA serum (Fig. 2A). Similarly, the antigenicity of rBCP
IgA was also retained following coupling to type III CPS in the presence of rAlp3 (Fig. 2B). These data imply that the conjugation procedure did not destroy antigenic epitopes of rAlp3 when used alone or in combination with rBCP
IgA.
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FIG. 2. Antigenicity of recombinant proteins and conjugates with the use of an inhibition ELISA with microtiter plates coated with rAlp3 (A) or rBCP IgA (B). The inhibition of mouse antibody to rAlp3 was achieved with increasing concentrations of rAlp3 (closed circles), III-rAlp3 (open circles), and III-rAlp3-rBCP IgA (closed squares); the inhibition of mouse antibody to rBCP IgA was achieved with increasing concentrations of rBCP IgA (open squares) and III-rAlp3-rBCP IgA (closed squares). Each point represents the mean of duplicate measurement.
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IgA) in mice was evaluated. An uncoupled mixture (III+rAlp3+rBCP
IgA) served as a control vaccine. Conjugate vaccines containing rAlp3 either as a single carrier protein or as one of two carrier proteins induced high levels of type III CPS-specific IgG in outbred mice following a single dose (Table 1). A second dose of conjugate vaccines at day 21 served to improve these titers 30- to 60-fold, with no additional increases in titer following the third dose. As expected, uncoupled rAlp3, either alone or admixed with rBCP
IgA, did not induce type III CPS-specific antibody. |
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TABLE 1. GBS type III CPS-specific IgG response in mice elicited by immunization with rAlp3, III-rAlp3, III-rAlp3-BCP IgA, tIII+rAlp3+BCP IgA, and saline
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IgA was also elicited in mice that received vaccines containing this protein either coupled to type III CPS or admixed with type III CPS and rAlp3 (Table 2). Similarly, rAlp3 was highly immunogenic in mice following a single dose, with subsequent increases in specific IgG titers after each of two booster doses (Table 3). The immunogenicity of rAlp3 remained high whether coupled to type III CPS alone or in combination with type III CPS and rBCP
IgA. |
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TABLE 2. Antibody response to rBCP IgA in mice elicited by immunization with III-rAlp3-BCP IgA, III+rAlp3+BCP IgA, and saline
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TABLE 3. Antibody response to rAlp3 in mice elicited by immunization with rAlp3, III-rAlp3, III-rAlp3-BCP IgA, III+rAlp3+BCP IgA, and saline
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IgA vaccine survived challenge with an ordinarily lethal dose of GBS type III strain M781 (Table 4). Interestingly, 44% survival and 43% survival were observed among pups born to dams that received uncoupled rAlp3 (rAlp3 or III+rAlp3+rBCP
IgA, respectively) and challenged with strain M781, a rate significantly greater (P < 0.001) than those for pups born to dams that received saline. |
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TABLE 4. Efficacy of rAlp3, III-rAlp3, III-rAlp3-BCP IgA, and III+rAlp3+BCP IgA vaccines in neonatal mouse pups born to vaccinated dams
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IgA vaccine was immunogenic in female mice, and antibody to this vaccine provided protection to 69% (25 survived of 36 challenged) of their pups against challenge with GBS type Ia strain A909 bearing BCP (Table 4). Significant (P < 0.005) reduction in survival was observed among pups born to dams that received an uncoupled tricomponent mixture (III+rAlp3+BCP
IgA). None of the vaccines tested were highly efficacious against challenge with GBS strain CJB111, with the highest survival rate of 39% afforded by III-rAlp3 (Table 4). This surprising finding led us to analyze whole GBS cell extracts for the expression of Alp3 among these GBS strains. Despite possessing the alp3 gene, GBS strain CJB111 did not express Alp3 as revealed by a lack of whole-cell reactivity with rAlp3 antisera (Fig. 3). The lack of Alp3 expression provided a possible explanation for the poor efficacy of the rAlp3-containing vaccines against challenge with CJB111, a type V strain that also does not express the Rib protein or BCP.
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FIG. 3. Reactivity of rAlp3 antiserum with GBS. Whole-cell extracts of GBS type III strain M781 (lane 1), type V strain H1A00001 (lane 2), and type VIII strain JM9130013 (lane 3) but not type V strain CJB111 (lane 4) and type Ia strain A909 (lane 5) reacted with rAlp3 antiserum. The alp3 gene was PCR amplified with use of specific primers (42). As expected, strain M781, which contains rib but not alp3, expressed Rib that cross-reacted with rAlp3 antiserum. Surprisingly, strain CJB111 did not express Alp3 despite possessing the gene for this protein, and as expected, strain A909 neither possessed alp3 nor expressed the protein.
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IgA, and III+rAlp3+BCP
IgA) had high rAlp3-specific IgG titers (>1,000,000), the survival among litters was poor: from 0% to 3% for H1A00001 challenge and from 0% to 26% with JM9130013 challenge. These sera were also not functionally active against these GBS strains in the opsonophagocytosis assay (data not shown). Rabbit antiserum to rAlp3. To explore the functional activity of rAlp3 antiserum further, a rabbit was vaccinated with rAlp3 admixed with incomplete Freund's adjuvant. The titer of rAlp3-specific IgG rose from <100 before vaccination to 656,100 on days 42 and 50 and to 1,968,300 on day 57.
Opsonophagocytosis of GBS strains by rabbit serum raised to rAlp3. The in vitro opsonophagocytosis assay was used to further explore the number of GBS serotypes that would be susceptible to the antibody-mediated killing of GBS in vivo. GBS type V strain H1A00001, which possesses alp3 and expresses Alp3 (Fig. 3), was opsonized for killing by human peripheral blood leukocytes in the presence of complement (Table 5). GBS type VIII strain JM9130013, which bears Alp3, was also killed in this assay, in sharp contrast to the lack of opsonization and killing of type V strain CJB111 and type Ia strain A909, both which lack Alp3 (Fig. 3 and Table 5). Interestingly, cells of GBS type III strain M781, which lacks alp3 but possesses the anti-rAlp3 cross-reactive Rib protein (Fig. 3), were opsonized and killed in this assay (Table 5).
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TABLE 5. Functional activity of rabbit serum to group B streptococcal rAlp3 as measured by an in vitro opsonophagocytosis assaya
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0.6 log10 CFU (Fig. 4). Western blot analysis of whole-cell proteins from these strains showed that all but strain KMP114, which was not opsonized and killed, expressed cross-reactive proteins, presumably Rib (Fig. 4); the nonopsonized strain possessed alp3 but did not express Alp3. Rabbit serum to rAlp3 (diluted 1:10,000) reacted with colony blots of all GBS strains used in this study, with the exception of CJB111, A909, and KMP114.
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FIG. 4. In vitro opsonophagocytic killing of GBS type III strains. Opsonophagocytosis of a prototype type III strain, M781, and six type III clinical isolates by rabbit rAlp3 antiserum (diluted 1:100), complement, and human peripheral blood leukocytes was measured (bottom). The means and standard deviations from three separate experiments of the log10 reduction in GBS CFU after 1 h of incubation are shown. All strains except KMP114 were opsonized and killed by this antiserum. Growth (i.e., increases in GBS CFU) is represented as 0-log10 reduction in GBS CFU. Expression of cross-reactive proteins with rabbit rAlp3 antiserum (diluted 1:3,000) on these GBS strains was determined by Western blot analysis of whole-cell extracts (top). Extracts from five strains showed high levels of cross-reactivity, presumably to the Rib protein; strain KMP103 possessed two bands of minor reactivity; and strain KMP114, which was not opsonized and killed in this assay, expressed a single low-molecular-weight band that reacted weakly.
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Because of the preclinical and clinical successes with GBS CPS-protein conjugate vaccines (20), we chose to examine the role of the Alp3 protein not as a stand-alone vaccine per se but as a carrier protein for CPSs. As it was shown to be a strong immunogen in animals, rAlp3, like other GBS proteins (31), was a good carrier for type III CPS, as revealed by efficacy in mice. Surprisingly, in this animal model, uncoupled rAlp3 conferred partial protection against a GBS type III strain lacking Alp3. GBS Alp3 possessed at least two antigenic determinants: Alp2/Alp3 and Alp3/Rib common sites (34). Repeat regions of Alp3 and of Rib match by 99% and are likely sites for the Alp3/Rib serological cross-reactivity (24). This cross-reactivity was also reflected in the ability of rAlp3 rabbit serum to opsonize Rib protein-expressing type III strain M781 for killing in vitro, a result that explains the >40% protection against challenge with strain M781 in newborn mouse pups born to dams that received rAlp3. Indeed, the degree of opsonically mediated killing of GBS strains with this antiserum correlated with the expression of Alp3-cross-reactive proteins, as measured among a panel of invasive GBS isolates.
Active immunization of mice with rAlp3 or rAlp3-containing vaccines did not provide protection against challenge with Alp3-expressing GBS strains H1A00001 and JM9130013, nor did antisera to these vaccines mediate opsonic killing. However, high-titered rabbit rAlp3 antisera mediated the opsonization and killing of these strains, a finding that raises the possibility that the Alp3/Rib common site may, under certain conditions, be partially concealed by other surface antigens such as the CPS.
As both Alp3 and Rib proteins occur with high frequency in GBS, usually in strains of different capsular antigen types (8, 22), the Alp3/Rib common site will be expressed more often than either of the two proteins alone. Indeed, expression of the Alp3/Rib common site occurs frequently in GBS, notably in pathogenic serotype III, V, and VIII strains (22, 35), and in group A streptococci that express the Alp3-like protein R28 (43, 44), suggesting that the inclusion of the Alp3/Rib common region in a vaccine might provide at least partial protection against a broader range of streptococci. The ability of rAlp3 antisera to opsonize invasive GBS type III strains bearing the cross-reactive proteins, presumably Rib, is of particular importance given the correlation of low maternal levels of Rib antibody with neonatal GBS disease (28).
BCP, encoded by the bac gene, is found on nearly all strains of GBS serotype Ib as well as on some isolates of types Ia, II, and V (31), and approximately 23% of GBS strains contained the bac gene according to bac-specific PCR analysis (21). Our recently developed rBCP
IgA demonstrated a higher degree of efficacy against a BCP-positive GBS type Ia strain when coupled to type III CPS and rAlp3 than as a component of an uncoupled mixture, despite evoking similar levels of maternal IgG. Mechanisms for this enhanced efficacy are currently unknown but may include an effect of size, given the generation of large polymers due to conjugation or the exposure of protective epitopes by conjugation.
In summary, our data suggest that rAlp3 is a good carrier for GBS CPS, and antiserum to this protein is functionally active against GBS strains bearing Alp3 or the cross-reactive Rib protein. In theory, a conjugate vaccine containing type Ia CPS, rBCP
IgA, and rAlp3 could provide coverage against multiple GBS serotypes, serotypes Ia (from the CPS), Ib (from BCP), III (from the cross-reactivity of rAlp3 with Rib), and V and VIII (from rAlp3) or most serotypes causing early- and late-onset neonatal GBS disease in the United States (14, 19).
This work was supported by PHS grants U01AI-060603, R01AI053191 (L.C.P.), and R01AI38424 (L.C.M.) from the National Institute of Allergy and Infectious Diseases.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Allergy and Infectious Diseases or the National Institutes of Health.
Published ahead of print on 7 May 2008. ![]()
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