Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
www.fems-microbiology.org
Abstract
Shigella flexneri is a gram-negative bacterium which causes the most communicable of bacterial dysenteries, shigellosis. Shigellosis
causes 1.1 million deaths and over 164 million cases each year, with the majority of cases occurring in the children of developing
nations. The pathogenesis of S. flexneri is based on the bacteriaÕs ability to invade and replicate within the colonic epithelium, which
results in severe inflammation and epithelial destruction. The molecular mechanisms used by S. flexneri to cross the epithelial barrier,
evade the hostÕs immune response and enter epithelial cells have been studied extensively in both in vitro and in vivo models. Con-
sequently, numerous virulence factors essential to bacterial invasion, intercellular spread and the induction of inflammation have been
identified in S. flexneri. The inflammation produced by the host has been implicated in both the destruction of the colonic epithelium
and in controlling and containing the Shigella infection. The hostÕs humoral response to S. flexneri also appears to be important in
protecting the host, whilst the role of the cellular immune response remains unclear. The hostÕs immune response to shigellosis is
serotype-specific and protective against reinfection by the same serotype, making vaccination a possibility. Since the 1940s vaccines for
S. flexneri have been developed with little success, however, the growing understanding of S. flexneri’s pathogenesis and the hostÕs
immune response is assisting in the generation of more refined vaccine strategies. Current research encompasses a variety of vaccine
types, which despite disparity in their efficacy and safety in humans represent promising progress in S. flexneri vaccine development.
Ó 2003 Federation of European Microbiological Societies. Published by Elsevier B.V. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2. Pathogenesis of S. flexneri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.1. Crossing the colonic epithelial layer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.2. Macrophage apoptosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.3. Adhesion to the basolateral membrane of colonic epithelial cells . . . . . . . . . . . . . . . 46
2.4. Uptake by the epithelial cell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.5. Replication within the epithelial cell and intracellular and intercellular spread . . . . . 47
3. The hostÕs immune response to S. flexneri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.1. Innate immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.2. Cellular immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.3. Humoral immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4. S. flexneri vaccine development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.1. Subunit vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4.2. Killed oral vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
*
Corresponding author. Tel.: +61-2-6125-2666;
fax: +61-2-6125-0313.
E-mail address: naresh.verma@anu.edu.au (N.K. Verma).
0168-6445/$22.00 Ó 2003 Federation of European Microbiological Societies. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.femsre.2003.07.002
44 A.V. Jennison, N.K. Verma / FEMS Mircobiology Reviews 28 (2004) 43–58
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
45
46 A.V. Jennison, N.K. Verma / FEMS Mircobiology Reviews 28 (2004) 43–58
2.1. Crossing the colonic epithelial layer Ironically, PMN-mediated interruption of the barrier
function of the epithelial layer promotes the local spread
Experiments using polarised cell lines have demon- of Shigella, whilst the same PMN cells appear to be
strated that the majority of S. flexneri epithelial cell responsible for restricting the infection to the submu-
invasion occurs through the basolateral pole of colonic cosa and preventing systemic dissemination [25].
epithelial cells [19]. The epithelial layer acts as a barrier Recent research has revealed that the S. flexneri is
to pathogens found in the gut lumen. S. flexneri is able capable of manipulating the tight-junction associated
to penetrate the epithelial lining through the follicular proteins of human intestinal epithelial cells, allowing
associated epithelium (FAE). This is the epithelial layer bacterial paracellular movement through a model in-
found above the mucosa-associated lymph nodes, which testinal barrier. These results suggest that shigellae are
contains highly endocytic M cells (Membranous epi- also capable of penetrating the colonic epithelium via an
beneath the epithelium [35]. IpaB is also able to bind the tin filaments, organising an entry foci around the bac-
membrane receptor, CD44, which is the major cell surface terium [50,51]. IpgD is injected into the epithelial cell by
receptor for hyaluronic acid and is found on the baso- the S. flexneri type III secretion system, where it acts as
lateral membrane of epithelial cells [36,37]. Both a5b1 a phosphoinositide phosphatase, uncoupling the plasma
integrin and CD44 can act as cytoskeleton linkers, sug- membrane from the actin cytoskeleton, allowing mem-
gesting that upon the binding of Shigella they may con- brane extensions to form [52].
tribute to the cytoskeletal reorganisation seen during VirA has recently been identified as an additional
epithelial invasion [38]. effector molecule of S. flexneri epithelial cell invasion.
More recently, bacterial adherence to epithelial cells in An interaction between VirA and tubulin within the
a polarised model epithelium was shown to be dependant host cytosol destabilises microtubules around the bac-
on the length and presence of the O-antigen [39]. These terial site of entry. It is proposed that this destabilisation
2.4. Uptake by the epithelial cell 2.5. Replication within the epithelial cell and intracellular
and intercellular spread
S. flexneri invades epithelial cells through a macr-
opinocytic process, where S. flexneri-induced rear- The macropinocytic vacuole containing the Shigella
rangements of the host cell cytoskeleton engulf the bacterium is rapidly lysed by the IpaB invasin, which
bacterium into a vacuole (Fig. 1). acts as membranolytic toxin in the phagosome mem-
The virulence plasmid of S. flexneri encodes two loci brane, releasing Shigella into the host cell cytoplasm
crucial to this invasive phenotype, the ipa locus and the [29]. The lysis of the phagosome may also involve IpaC,
mxi-spa locus. The ipa operon encodes the ‘‘invasion which is able to disrupt phospholipid membranes upon
plasmid antigens’’, IpaA, IpaB, IpaC and IpaD, which insertion of its hydrophobic regions [54,55].
are the effectors of bacterial entry into the host cell. The S. flexneri can replicate inside the cytoplasm of epi-
mxi-spa operon encodes the components of a type-III thelial cells in vitro with a doubling time of 40 minutes.
secretion system, which is a flagella-like structure used Epithelial cells are observed undergoing necrotic-like
to deliver proteins, such as the Ipa proteins, from the death during shigellosis (Fig. 1) [56]. Although it was
bacterial cytoplasm to the cytoplasmic membrane or initially proposed that Shigella multiplication within the
even cytosol of the host cell [42]. The mxi-spa operon cytosol was the cause of epithelial cell lysis, it seems
and IpaB, IpaC and IpaD are essential for in vitro epi- more likely that the cells are being destroyed by the
thelial cell invasion [43,44]. hostÕs inflammatory response [26]. In fact, Shigella
The detailed mechanisms by which the Ipa proteins would gain little advantage from killing the epithelial
generate Shigella invasion are not completely under- cell as whilst the bacteria are contained within the epi-
stood. The Ipa proteins are synthesised and stored thelial cell they are protected from immune cells and are
within the bacteria, where they are associated with in a favourable environment for replication [56].
chaperone proteins until secretion is activated by con- mxiE, a gene located within the mxi/spa locus has
tact with a host cell [45,46]. A complex formed by IpaB recently been identified as a transcriptional regulator for
and IpaD may play a role in the regulation of this se- a number of putative virulence factors required for vir-
cretion [34]. Once secretion is activated by contact with ulence in the Sereny test. mxiE is only activated when
an epithelial cell, the N-terminus of IpaC binds IpaB the bacterium is within the epithelial cell cytosol sug-
[47]. Both proteins are hydrophobic allowing this com- gesting that its role is to regulate virulence genes used in
plex to insert into the membrane of the host cell to form the post-invasion steps of infection [57].
a pore [48]. It is presumed that the other effector mole- Shigella is able to exploit the host cells actin assembly
cules, delivered by the type III secreton, are able to ac- machinery to move through the host cell cytoplasm and
cess the host cytoplasm through this pore. into adjacent epithelial cells. This intra and intercellular
The C-terminal domain of IpaC activates host cell spread is a crucial step in the virulence of Shigella and is
Rho GTPases, triggering actin polymerisation and fi- driven by the outer membrane protein, IcsA (VirG)
lopodial extensions in the vicinity of the bacteria [49]. [58–60]. IcsA is expressed in a unipolar fashion on the
IpaA is secreted into the cytosol of the host epithelial bacterial surface, with the greatest concentration local-
cell where it binds the cytoskeleton-associated protein ised to the old pole of the bacterium [61]. Newly syn-
vinculin. The IpaA–vinculin complex depolymerises ac- thesised IcsA appears to be directly targeted to the old
48 A.V. Jennison, N.K. Verma / FEMS Mircobiology Reviews 28 (2004) 43–58
pole by two internal regions, where it is autotransported regulation of a variety of cytokines (IL-1, TNF-a, IL-6,
to the outer membrane [62,63]. The maintenance of IcsAÕs IFN-c, TNF-b, IL-4, IL-10, TGF-b and IL-8) [80]. Al-
unipolar localisation is essential for intracellular move- though some of the clinical symptoms of shigellosis may
ment and appears to be dependant on the structure of the actually be a direct consequence of the cytokines, they
LPS. Mutant S. flexneri strains missing, expressing partial also assist in controlling and containing the infection.
O-antigenÕs or lacking a modal distribution of O-antigen Resident macrophages and infiltrating monocytes are
chain length display non-polar surface localisation of unable to efficiently kill S. flexneri in their phagosomes
IcsA and are unable to spread from cell to cell [64–66]. It is and instead succumb to apoptosis [81,82]. The IL-18
possible that the LPS maintains IcsA polarity by forming released by apoptotic macrophages can target NK cells
interlocking microdomains with its O-antigen side chains and T lymphocytes, inducing production of IFN-c [83].
on the surface of the bacterium, which would prevent IcsA IFN-c deficient mice are five times more susceptible to a
and Th2 lymphocyte responses [94,95]. Additionally, the IgA, especially anti-LPS IgA have been detected in
increased susceptibility of AIDS patients, deficient in humans suffering natural shigellosis in a number of
CD4þ T cells, to shigellosis could suggest that cell- studies and is thought to play an important role in im-
mediated immunity can play a protective role in shig- munity to re-infection [105–109]. Anti-LPS secretory
ellosis [96]. IgA antibodies in the breast milk of mothers exposed to
However, the contribution of T lymphocytes to the shigellosis appear to be responsible for the decreased
hostÕs protective immunity to Shigella was studied in the severity of shigellosis in Shigella-infected infants [110].
mouse pulmonary model where mice deficient in T cells Additionally, the implantation of a serotype-specific
were vaccinated with attenuated S. flexneri. These mice sIgA hybridoma on the back of mice protected them
were suitably protected from challenge with wild type against intranasal challenge with a lethal dose of
bacteria despite their deficiency in T lymphocytes, sug- S. flexneri organisms [111]. This experiment suggests
Since the 1940s a number of candidate vaccines for S. content in ribosomal preparations varies, making a
flexneri have been developed but as yet none have been consistent vaccine difficult to manufacture [129].
successful enough for field release. Early attempts to
develop S. flexneri vaccines consisted of inactivated 4.2. Killed oral vaccines
bacteria delivered parenterally, which failed to induce a
protective immune response, despite inducing a high Early challenge experiments in monkeys revealed that
titre of serum anti-LPS antibody [118–121]. The lack orally administered acetone-killed and dried Shigella
of protection was most likely due to the failure of was unable to protect monkeys from infection [130].
the parenteral vaccine in inducing a mucosal immune More recently however, an oral heat-killed S. flexneri
response. vaccine evaluated in a rabbit model was shown to be
Consequently, many recent vaccine strategies have
Table 1
Live non-invasive oral S. flexneri vaccines which have been assessed in monkeys or humans
Vaccine Description Safety Efficacy Comment References
S. flexneri 2a 2457O Spontaneous Reverts to virulence Monkeys are Reactogenic in [130,146,147]
avirulent mutant, virF in humans protected. Caused humans
inactivated by dysentery in 34% of
insertion human volunteers
S. flexneri streptomy- Spontaneous Reversion to Up to 90% protection Unstable [98,148,149]
cin dependant strains mutants incapable of streptomycin in field trials with phenotype and
growing in the independence in multiple doses. US inconsistent
absence of volunteers. Diarrhoea trials found marginal protective efficacy
streptomycin and vomiting in protection
15–35% of volunteers
(5 1010 CFU)
S. flexneri 2a Istrati Spontaneous deletion Safe in humans, mild Around 80% Protection lasts 6 [132,150]
T32 of ipaBCDA, invA adverse effects in very protection in humans months. Reduces
and icsA (virG) from few volunteers at when administered in attack rate of
the virulence plasmid 2 1011 CFU 5 doses heterologous
Shigella serotypes
A.V. Jennison, N.K. Verma / FEMS Mircobiology Reviews 28 (2004) 43–58 51
egies to construct safe invasive vaccines. Invasive vac- 4.6. Multiple-serotype protection strategies
cine strains are generally attenuated by mutations in
either virulence genes necessary for pathogenesis after Because immunity to S. flexneri is serotype-specific,
cell entry or in metabolic genes which prevent the bac- vaccination against one serotype will only provide pro-
teria from replicating and spreading in the host after tection to infection by the homologous serotype. The
invasion. serotypes of S. flexneri differ in their distribution with up
Mutations in either icsA and/or in a variety of met- to four different serotypes prevalent in an endemic area.
abolic genes have produced attenuated invasive vaccine Thus, the ideal S. flexneri vaccine would provide pro-
strains which are safe and capable of up to 100% pro- tection to all prevalent serotypes of a particular geo-
tection with multiple doses in monkeys (Table 2). A graphical region.
number of auxotrophic vaccine strains, some also car- All S. flexneri serotypes, with the exception of sero-
SFL124 to serotype X by the insertion of the bacterio- Chen, R., Ma, D., Qiang, B., Wen, Y., Hou, Y. and Yu, J. (2002)
phage SfX serotype-conversion gene cluster [145]. This Genome sequence of Shigella flexneri 2a: insights into pathoge-
nicity through comparison with genomes of Escherichia coli K12
approach has been utilised to insert the serotype con- and O157. Nucleic Acids Res. 30, 4432–4441.
version gene cluster of bacteriophage SfV and the glu- [3] Bennish, M.L. (1991) Potentially lethal complications of shigel-
cosyl transferase gene of bacteriophage SfII in tandem losis. Rev. Infect. Dis. 13, S319–S324.
into the SFL124 chromosome. The resulting strain dis- [4] Kotloff, K.L., Winickoff, J.P., Ivanoff, B., Clemens, J.D.,
played the 3,4 group antigen and both the II and V type Swedlow, D.L., Sansonetti, P.J., Adak, G.K. and Levine,
M.M.M. (1999) Global burden of Shigella infections: implica-
antigens as detected by monovalent antiserum and tions for vaccine development and implementation of control
simultaneously induced a serotype-specific immune strategies. Bull. World Health Organ. 77, 651.
response to both serotypes 2a and 5a in the mouse [5] Bennish, M.L. and Wojtyniak, B.J. (1991) Mortality due to
pulmonary model (unpublished data, this lab). This shigellosis: community and hospital data. Rev. Infect. Dis. 13,
[22] Beatty, W.L. and Sansonetti, P.J. (1997) Role of lipopolysac- CD11/CD18 and CD14 share a common lipid A signalling
charide in signaling to subepithelial polymorphonuclear leuko- pathway. J. Immunol. 161, 5413–5420.
cytes. Infect. Immun. 65, 4395–4404. [42] Hueck, C.J. (1998) Type III protein secretion systems in bacterial
[23] Perdomo, J.J., Gounon, P. and Sansonetti, P.J. (1994) Polymor- pathogens of animals and plants. Microbiol. Mol. Biol. Rev. 62,
phonuclear leukocyte transmigration promotes invasion of colonic 379–433.
epithelial monolayer by Shigella flexneri. J. Clin. Invest. 93, 633– [43] Menard, R., Sansonetti, P.J. and Parsot, C. (1993) Non-polar
643. mutagenesis of the ipa genes defines IpaB, IpaC and IpaD as
[24] Sansonetti, P.J., Arondel, J., Cavaillon, J.M. and Huerre, M. effectors of Shigella entry into epithelial cells. J. Bacteriol. 175,
(1995) Role of interleukin-1 in the pathogenesis of experimental 5899–5906.
shigellosis. J. Clin. Invest. 96, 884–892. [44] Sasakawa, C., Kamata, K., Sakai, T., Makino, S., Yamada, M.,
[25] Sansonetti, P.J., Arondel, J., Huerre, M., Harada, A. and Okada, N. and Yoshikawa, M. (1988) Virulence-associated
Matsushima, K. (1999) Interleukin-8 controls bacterial transepi- genetic regions comprising 31 kilobases of the 230-kilobase
thelial translocation at the cost of epithelial destruction in plasmid in Shigella flexneri 2a. J. Bacteriol. 170, 2480–2484.
and intercellular spread through interaction with F-actin. Proc. [76] Rathman, M., de Lanerolle, P., Ohayon, H., Gounon, P. and
Natl. Acad. Sci. USA. 86, 3867–3871. Sansonetti, P.J. (2000) Myosin light chain kinase plays an
[59] Lett, M., Sasakawa, C., Okada, N., Sakai, T., Makino, S., essential role in S. flexneri dissemination. J. Cell Sci. 113, 3375–
Yamada, M., Komatsu, K. and Yoshikawa, M. (1989) irG, a 3386.
plasmid-coded virulence gene of Shigella flexneri: identification [77] Sansonetti, P.J., Mounier, J., Prevost, M.C. and Mege, R.M.
of the virG protein and determination of the complete coding (1994) Cadherin expression is required for the spread of Shigella
sequence. J. Bacteriol. 171, 353–359. flexneri between epithelial cells. Cell 76, 829–839.
[60] Sansonetti, P.J., Arondel, J., Fontaine, A., dÕHauteville, H. and [78] Page, A.L., Ohayon, H., Sansonetti, P.J. and Parsot, C. (1999)
Bernardini, M.L. (1991) OmpB (osmo-regulation) and IcsA (cell– The secreted IpaB and IpaC invasins and their cytoplasmic
cell spread) mutants of Shigella flexneri; vaccine candidates and chaperone IpgC are required for intercellular dissemination of
probes to study the pathogenesis of shigellosis. Vaccine 9, 416– Shigella flexneri. Cell. Microbiol. 1, 183–193.
422. [79] Suzuki, T., Murai, T., Fukuda, T., Tobe, T., Yoshikawa, M. and
[61] Goldberg, M.B., Barzu, O., Parsot, C. and Sansonetti, P.J. Sasakawa, C. (1994) Identification and characterization of a
specific deletions in virG, sen, set and guaBA, is highly attenuated [111] Phalipon, A., Kaufman, M., Michetti, P., Cavaillon, J.M.,
in humans. Infect. Immun. 68, 1034–1039. Huerre, M., Sansonetti, P.J. and Kraehenbuhl, J.P. (1995)
[95] van de Verg, L.L., Mallet, C.P., Collins, H.H., Larsen, T., Monoclonal immunoglobulin A antibody directed against sero-
Hammack, C. and Hale, T.L. (1995) Antibody and cytokine type-specific epitope of Shigella flexneri lipopolysaccharide
responses in a mouse pulmonary model of Shigella flexneri protects against murine experimental shigellosis. J. Exp. Med.
serotype 2a infection. Infect. Immun. 63, 1947–1954. 182, 769–778.
[96] Nelson, M.R., Shanson, D.C., Hawkins, D.A. and Gazzard, [112] Oaks, E.V., Hale, T.L. and Formal, S.B. (1986) Serum immune
B.G. (1992) Salmonella, Campylobacter and Shigella in HIV- response to Shigella protein antigens in Rhesus monkeys and
seropositive patients. AIDS 6, 1495–1498. humans infected with Shigella species. Infect. Immun. 53, 57–
[97] Way, S.S., Borczuk, A.C. and Goldberg, M.B. (1999) Thymic 63.
independance of adaptive immunity to the intracellular pathogen [113] van de Verg, L.L., Herrington, D.A., Boslego, J., Lindberg, A.A.
Shigella flexneri serotype 2a. Infect. Immun. 67, 3970–3979. and Levine, M.M. (1992) Age-specific prevalence of serum
[98] DuPont, H.L., Hornick, R.B., Synder, M.J., Libonati, J.P., antibodies to the invasion plasmid and lipopolysaccharide
conjugate vaccines composed of the O-specific polysaccharides of candidate strain against Shigella flexneri 2a and Shigella sonnei.
Shigella dysenteriae type 1, Shigella flexneri type 2a and Shigella Chin. J. Biotechnol. 12, 89–97.
sonnei (Plesiomonas shigelloides) bound to bacterial toxoids. [142] Klee, S.R., Tzscgaschel, B.D., Singh, M., Falt, I., Lindberg,
Infect. Immun. 61, 3678–3687. A.A., Timmis, K.N. and Guzman, C.A. (1997) Construction and
[127] Turbyfill, K.R., Hartman, A.B. and Oaks, E.V. (2000) Isolation characterization of genetically-marked bivalent anti-Shigella
and characterization of a Shigella flexneri invasin complex dysenteriae and anti-Shigella flexneri Y live vaccine candidates.
subunit vaccine. Infect. Immun. 68, 6624–6632. Microb. Pathogenesis 22, 363–376.
[128] Levenson, V.I., Chernokhvostova, E.V., Lyubinskaya, M.M., [143] Carlin, N.I.A. and Lindberg, A.A. (1987) Monoclonal antibodies
Salamatova, S.A., Dzhikidze, E. and Stasilevitch, Z.K. (1988) specific for Shigella flexneri lipopolysaccharides: clones binding
Parental immunization with Shigella ribosomal vaccine elicits to type IV, V and VI antigens, group 3,4 antigen and an epitope
local IgA response and primes for mucosal memory. Int. Arch. common to all Shigella flexneri and Shigella dysenteriae type 1
Allergy Immunol. 87, 25–31. strains. Infect. Immun. 55, 1412–1420.
[129] Levenson, V.I. and Egorova, T.P. (1990) Polysaccharide nature [144] Noriega, F.R., Liao, F.M., Maneval, D.R., Ren, S., Formal, S.B.
[157] Karnell, A., Sweiha, H. and Lindberg, A.A. (1992) Auxotrophic [161] Karnell, A., Cam, P.D., Verma, N.K. and Lindberg, A.A. (1993)
live oral Shigella flexneri vaccine protects against challenge with AroD deletion attenuates Shigella flexneri strain 2457T and
S. flexneri of different serotypes. Vaccine 10, 167–174. makes it a safe and efficacious oral vaccine in monkeys. Vaccine
[158] Karnell, A., Stocker, B.A., Katakura, S., Reinholt, F.P. and 11, 830–836.
Lindberg, A.A. (1992) Live oral auxotrophic Shigella flexneri [162] Noregia, F., Wang, J., Losonsky, G., Maneval, D., Hone, D. and
SFL124 vaccine with a deleted aroD gene: characterisation and Levine, M. (1994) Construction and characterization of attenu-
monkey protection studies. Vaccine 10, 389–394. ated delta aroA delta virG Shigella flexneri 2a strain CVD 1203, a
[159] Li, A., Cam, P.D., Islam, D., Minh, N.B., Huan, P.T., Rong, prototype live oral vaccine. Infect. Immun. 62, 5168–5172.
Z.C., Karlsson, K., Lindberg, A.A. and Lindberg, G. (1994) [163] Noriega, F.R., Losonsky, G.A., Wang, J.Y., Formal, S.B. and
Immune response in vietnamese children after a single dose of the Levine, M.M. (1996) Further characterisation of aroA virG
auxotrophic, live Shigella flexneri Y vaccine strain SFL124. J. Shigella flexneri 2a strain CVD 1203 as a mucosal Shigella
Infect. 28, 11–23. vaccine and as a live-vector vaccine for delivering antigens of
[160] Li, A., Karnell, A., Huan, P.T., Cam, P.D., Minh, N.B., Tram, enterotoxigenic Escherichia coli. Infect. Immun. 64, 23–27.