Thus, the primary hypothesis of the study, i.e., that at least 50% of the subjects in any of the vaccine groups should mount a mucosal immune response to at least four of the five primary vaccine antigens, was strongly supported and the results clearly exceeded the expectations. The comparatively BYL719 cell line high and frequent mucosal immune responses recorded against CS6 are particularly important since the first-generation formalin-inactivated

ETEC vaccine did not induce any immune responses to this prevalent CF in humans [5]. Hence, our approach to use CS6 expressing bacteria inactivated with phenol, which preserves CS6 immunogenicity [13], rather than formalin has find more been successful. Increased preimmunization antibody levels, i.e. titers above background levels, were detected in some of the subjects, particularly against the CS3 antigen (data not shown), suggesting previous exposure to ETEC or other microorganisms expressing immunologically related proteins. Previous exposure to such antigens, as well as different host genetic factors, may partially explain the variation in magnitude and breadth of immune responses observed in different vaccinees. Thus, it was recently shown that ETEC

infection may induce memory B cells to ETEC CFs and LT that may mediate an anamnestic response to reexposure to ETEC [20] and probably also to corresponding antigens in MEV. Furthermore, we have previously shown that Astemizole individuals with certain blood groups are more susceptible to infection with ETEC expressing certain

CFs, and then most likely respond more strongly to corresponding vaccine antigens [21]. The influence of immunological memory and host genetics on immune responses to MEV will be addressed in follow-up studies. Our finding of a positive effect of the lower dose of dmLT adjuvant on immune responses to antigens expressed in lower amounts supports the rationale to evaluate this adjuvant further. Of particular interest would be to assess the adjuvant effect in malnourished children in developing countries who are known to respond less well to oral vaccines [22]. Furthermore, previous studies with the first-generation ETEC vaccine have suggested that lower doses of vaccine might be needed to improve tolerability in younger age groups [8]. The observed lack of an effect of the higher dose of dmLT on the anti-LTB and anti-CF responses indicates the need to determine the optimal dosage of dmLT when given together with different vaccines in future clinical trials. The reason for the lack of an immune-enhancing effect of the higher dose of dmLT in this study is unclear. However, a related phenomenon was observed when a single, oral dose of dmLT was given to human volunteers where 100 μg was found to be less immunogenic than 50 μg doses [23].