MINI REVIEW

published: 05 March 2021

doi: 10.3389/fimmu.2021.640916

Local Pulmonary Immunological

Biomarkers in Tuberculosis
Hazel Morrison* and Helen McShane

The Jenner Institute, University of Oxford, Oxford, United Kingdom

Regardless of the eventual site of disease, the point of entry for Mycobacterium
tuberculosis (M.tb) is via the respiratory tract and tuberculosis (TB) remains primarily
a disease of the lungs. Immunological biomarkers detected from the respiratory
compartment may be of particular interest in understanding the complex immune
response to M.tb infection and may more accurately reflect disease activity than those
seen in peripheral samples. Studies in humans and a variety of animal models have
shown that biomarkers detected in response to mycobacterial challenge are highly
localized, with signals seen in respiratory samples that are absent from the peripheral
blood. Increased understanding of the role of pulmonary specific biomarkers may prove
particularly valuable in the field of TB vaccines. Here, development of vaccine candidates
is hampered by the lack of defined correlates of protection (COPs). Assessing vaccine
immunogenicity in humans has primarily focussed on detecting these potential markers
of protection in peripheral blood. However, further understanding of the importance of
local pulmonary immune responses suggests alternative approaches may be necessary.
Edited by: For example, non-circulating tissue resident memory T cells (TRM ) play a key role in
Adam Penn-Nicholson,
Foundation for Innovative New
host mycobacterial defenses and detecting their associated biomarkers can only be
Diagnostics, Switzerland achieved by interrogating respiratory samples such as bronchoalveolar lavage fluid or
Reviewed by: tissue biopsies. Here, we review what is known about pulmonary specific immunological
Warwick Britton,
biomarkers and discuss potential applications and further research needs.
The University of Sydney, Australia
Björn Corleis, Keywords: tuberculosis, biomarkers, pulmonary, mucosal, vaccines
Friedrich-Loeffler-Institute, Germany

*Correspondence:
Hazel Morrison INTRODUCTION
[email protected]
Tuberculosis (TB) remains one of the top ten causes of death worldwide. Around a quarter of the
Specialty section: world’s population are estimated to be infected with Mycobacterium tuberculosis (M.tb) (1). The
This article was submitted to World Health Organization’s (WHO) End TB Strategy has set the goals of reducing TB incidence
Microbial Immunology,
by 90% and TB deaths by 95% globally by 2035. If there is any chance of meeting these ambitious
a section of the journal
targets, new tools to combat this devastating disease will be needed. These include an urgent need
Frontiers in Immunology
for improved diagnostic tests, shorter treatment regimens and more effective vaccines (2).
Received: 12 December 2020
The range of clinical phenotypes following M.tb exposure spans complete elimination of the
Accepted: 10 February 2021
pathogen through immunologically contained latent infection to active TB disease (3). This
Published: 05 March 2021
spectrum is governed by complex and incompletely understood interactions between the pathogen
Citation:
and host innate and adaptive immune responses. Innate immune mechanisms within the lung
Morrison H and McShane H (2021)
Local Pulmonary Immunological
mucosa may be responsible for early clearance of M.tb bacilli prior to T-cell sensitization in exposed
Biomarkers in Tuberculosis. individuals who appear to be resistant to M.tb infection (4). Of those who do have presumed latent
Front. Immunol. 12:640916. M.tb infection (LTBI), 5–10% of immunocompetent individuals go on to develop TB disease in
doi: 10.3389/fimmu.2021.640916 their lifetime (5), with the remaining majority achieving immunological equipoise.

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Morrison and McShane Pulmonary Immunological Biomarkers in Tuberculosis

Incomplete knowledge of the desired immune responses Alveolar Macrophages

needed to prevent either active disease or initial infection is one In CD4/CD8 T-cell knock out mice, subcutaneous BCG
of the key barriers to effective vaccine development (6). It is vaccination induces lasting protective immunity within 7 days,
well-characterized that a T-helper 1 (Th1) cell-mediated adaptive prior to any adaptive immune mechanisms (18). Cells from the
immune response is required, but insufficient, for protection (7, lungs of vaccinated mice show a higher proportion of tissue
8). Likewise, whilst antigen-specific interferon gamma (IFN-γ) resident macrophages (CD11b+ F4/80+ ) compared to circulating
plays a key role, the level of vaccine-induced IFN-γ in the blood monocytes. Following an infection, or in this case immunization,
does not correlate with protection (9, 10). Understanding the host monocytes may differentiate into interstitial lung macrophages,
immune responses that are needed to confer adequate protection which then self-perpetuate within the pulmonary compartment.
against M.tb would dramatically help in the development and This may represent a mechanism via which BCG induces innate
prioritization of vaccines that induce these putative responses. immune memory within the lung (18).
An immunological biomarker is a measurable characteristic Respiratory viral infection has been found to induce immune
of the immune system that can be assessed as an indicator memory in lung resident mouse alveolar macrophages (AMs),
of normal immune function, disease process, or response to a which go on to produce accelerated levels of detectable neutrophil
therapeutic intervention (11). Biomarkers of disease can be used chemokines, such as CXCL1 and CXCL2 upon restimulation.
in diagnosis and disease monitoring. Vaccines aim to induce an These trained AMs protect against secondary bacterial infection,
immunological response to prevent infection or reduce disease with a memory response that is not reliant on circulating
severity, termed protection. Biomarkers that are believed to monocytes (19).
correspond with this effect are termed immune correlates of In a recent model using T-cell depleted mice, mucosal, but not
protection (COP) (12) and form the main focus of biomarkers intramuscular, vaccination with an adenoviral-vectored vaccine
discussed in this review. expressing the M.tb antigen 85A resulted in upregulation of
The majority of TB studies looking at biomarkers of activation markers, such as MHC II, on alveolar and pulmonary
protection, both from disease and from infection, have focussed interstitial macrophages. This corresponded with reduced M.tb
on the peripheral blood compartment in humans and blood and burden after challenge and suggests that activated airway
lymphoid organs in animal models. Regardless of the site of macrophages may play an important role in early M.tb control
active disease, the predominant route via which M.tb bacilli enter (20). Debate is ongoing about the precise role AM play in
the body is via aerosol droplets that are deposited onto alveolar M.tb control. AMs do not readily express pro-inflammatory
surfaces of the lungs (4). Systemic immunity does not necessarily genes until 10 days after host M.tb infection, which may
reflect pulmonary immune responses in the bronchoalveolar allow early mycobacterial replication (21). AM-depleted mice
spaces at this site of entry for M.tb in humans. Cells of both show defective granuloma formation, but increased recruitment
the innate (such as alveolar macrophages) and adaptive (such of other phagocytic and cytotoxic cells to the lungs, with
as tissue resident memory cells) components of the pulmonary corresponding improved M.tb clearance (22).
immune system play an increasing recognized role that may be AM have been shown to leave the alveolar space and transport
interrogated in the search for markers of protection. M.tb to the lung interstitium in an IL-1 dependent manner,
proliferating within the lung to form aggregates (23). Whether
this represents the initiation of effective immunological control
INNATE IMMUNITY WITHIN THE LUNG or the first step in M.tb dissemination is not clear. Systemic BCG
immunization in mice has been shown to hasten this egress of
Trained Immunity M.tb-infected AM from the alveoli into the lung interstititum,
Trained immunity refers to immunological memory within the increase attraction of monocyte-derived macrophages to the site
innate immune system, leading to an augmented response to of infection and promote the early transfer of M.tb from AM to
subsequent, often heterologous insults (13). Innate immune other phagocytic cells (24). In humans, infant AM are less able
memory is induced in animals after vaccination with BCG (14, to control M.tb replication in vitro than adult AM, which may
15) although the precise mechanisms via which this occurs are partly explain their susceptibility to more severe, disseminated
still being studied. Studies of TB contacts show that despite high forms of TB disease. Infant AM were found to express lower
levels of exposure, up to 30–50% of individuals do not become levels of chemotactic cytokines including chemokine (C-X-C
infected with M.tb, as evidenced by non-reactive tuberculin motif) ligand 9 (CXCL9), suggesting that failure of AM to recruit
skin tests and negative IFN-γ release assay (IGRA) testing additional mononuclear cells to the site of infection may result in
(16). BCG vaccination correlates with this state of immune failure of initial M.tb control (25).
protection, suggesting that BCG-potentiated innate immunity
may contribute to early M.tb clearance (17). Innate Lymphoid Cells
Given this, it is unclear why, in mice, BCG does not protect Innate lymphoid cells (ILCS) mediate protective immunity in a
against M.tb in the first 14 days post-challenge (18). The kinetics variety of tissues, including the lungs. Activated ILCs proliferate
and role of the innate immune response need further study. in the lungs of mice following mucosal BCG vaccination and lead
Controlled human infection models with serial mucosal and to increased levels of IFN-γ production (26).
systemic sampling allow us to define the kinetics of innate and Group 3 ILCs (ILC3s) have similar functionality to Th-
adaptive immunity and may help us understand this further. 17 cells, including production of Il-17 and Il-22. In a human

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Morrison and McShane Pulmonary Immunological Biomarkers in Tuberculosis

lung tissue explant model, ILC3s upregulate IL-22 and GM- killing of M.tb infected macrophages (38). Following bacterial
CSF following ex vivo M.tb infection (27) and IL-22 producing infection, lung γδ T-cells in mice exhibit increased expression of
ILCs have been shown to enhance phagolysosomal fusion activation markers such as CD69 and CD25, and proliferate by
leading to mycobacterial growth inhibition (28). Inhibition of local expansion rather than recruitment from the periphery (39).
phagolysosomal fusion is one of the key immune mechanisms In NHPs, expansion of lung γδ T-cells by selective vaccination
whereby M.tb evades host immunity. reduces disease pathology and dissemination following M.tb
ILC3s proliferate in the lungs of M.tb infected mice, leading challenge (40).
to early alveolar macrophage accumulation. ILC knockout mice
showed loss of early AM-mediated M.tb control, which could ADAPTIVE PULMONARY IMMUNITY
be rescued by adoptive cell transfer (ACT) of lung ILCs from
M.tb-infected control mice (29). ACT of ILC3s also prolonged Lung Tissue Resident Memory Cells
the survival of diabetic M.tb-infected mice, with increased IL-22 Tissue resident memory cells (TRM ) represent a distinct subset
production resulting in reduced lung epithelial damage (30). Loss of lymphocytes. They share functional similarities with central
of ILCs, in particular ILC3, leads to a decrease in AM recruitment and effector memory T-cells, but remain situated within localized
within the lung and subsequent higher mycobacterial burden tissue compartments and do not recirculate into the blood
during M.tb infection (29). stream. They have been demonstrated at sites including the
Distinct populations of CD103-expressing ILC2 and ILC3s skin, intestines, urogenital tract, and lung mucosa (41–44). This
and CXCR5-expressing ILC3s have been identified in human positioning at key anatomical barrier sites means that TRM can
M.tb-infected lung tissue (29). CXCR5 signaling is essential in respond rapidly to potential infective stimuli and lung TRM may
the formation of inducible bronchus associated lymphoid tissue signify the first line of adaptive cellular defense against specific
(iBALT). iBALT is seen surrounding granuloma formation in respiratory pathogens, including M.tb.
non-human primate (NHP) and humans with LTBI, but not TB Due to the highly vascular nature of the lungs, distinguishing
disease (31). iBALT proliferation in the lungs of mice lacking genuine TRM , truly resident in the lung mucosa, from blood
lymph nodes and spleen may be sufficient to control M.tb lymphocytes that egress from the vasculature following a
infection (32). stimulus such as infection, is difficult. Mouse models, using
These studies suggest that ILC3s in particular may have a techniques such as parabiosis and in vivo intravascular staining,
protective role in early M.tb control, via CXCR5-dependant have confirmed that true lung TRM cells are identifiable and
iBALT formation and the production of IL-22 and IL-17. Mouse do not re-enter the peripheral circulation, in comparison to
models of intranasal BCG vaccination have shown a correlation lymphoid memory T cells.
between protection and levels of IL-17 producing cells within the Many of the techniques employed in animal models to
lungs following M.tb challenge (33). delineate TRM from pulmonary vascular lymphocytes are not
feasible in humans but have been crucial in confirming that
biomarkers seen in humans correspond to TRM specific markers
Mucosal-Associated Invariant and γδ T identified in animals. Upregulation of CD69 is a key marker
Cells of TRM activation at a variety of sites including the lung
Mucosal-associated invariant T (MAIT) cells preferentially and results in inhibition of sphingosine 1-phosphate-meditated
reside in mucosal tissues, including the pulmonary mucosa. lymphocyte migration (45). Additionally, CD8+ TRM cells
They express pattern recognition receptors, conferring express the αEβ7 integrin heterodimer, identified by CD103
innate immune function, and secrete IFN-γ following marker staining (46). Other significant markers of lung TRM in
stimulation. In humans and NHPs, MAIT cells are enriched both human and animal models include PD-1, CD44, CXCR3,
in the lungs and BAL fluid following M.tb infection and and integrins including CD49a, CD11a, and VLA-4 (45), with
NHP MAITs express activation markers such as CD69 KLRG-1 and CD62L downregulated (47). CD4+ TRM form a
following both M.tb challenge and intradermal (ID) BCG heterogeneous group, with some displaying an effector profile (T-
vaccination (34, 35). In rhesus macaques, intravenous (IV) bet+ ) and others appearing more regulatory (Foxp3hi IL-10hi ]. In
BCG vaccination induces pulmonary MAIT expansion, contrast, pulmonary CD8+ TRM cells appear more homogenous,
which corresponds with subsequent protection against expressing predominantly Th1 cytokines (48).
M.tb challenge (36). Following M.bovis infection, MAIT The key importance of these cells in animal models of
cell deficient mice show higher bacterial colony forming respiratory infection has been shown in several studies. In murine
units (CFUs) at early time points compared to wild-type adoptive transfer studies, CXCR3hi CD4+ T-cells preferentially
mice (37), highlighting a potential role for MAITs in early localize to the lung parenchyma and are better at controlling
mycobacterial clearance. M.tb infection than their CX3CR1h iKLRG1hi equivalents which
γδ T-cells are defined by heterodimeric T-cell receptors remain within the vasculature (47). Intranasal immunization
(TCRs) composed of γ and δ chains and are enriched in epithelial of mice with a recombinant influenza A vaccine expressing
and mucosal tissues, including lung alveoli. The majority the PR8.p25 Ag85B epitope led to the development CD4+
are activated in an MHC-independent manner and produce TRM throughout the lung parenchyma. Persistence of these
cytotoxic granules and canonical pro-inflammatory cytokines, cells following FTY720-induced intravascular lymphopaenia
including IFN-γ, TNF-α, and IL-17. Their activation results in indicates true tissue-resident memory status, without reliance

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Morrison and McShane Pulmonary Immunological Biomarkers in Tuberculosis

on circulating cells, and was sufficient for protection against model, IgA deficient mice are more susceptible to infection than
subsequent M.tb challenge (49). wild-type (58).
Route of vaccination may alter the magnitude and character of
the adaptive pulmonary immune response, but it is unclear if this
LINKING THE INNATE AND ADAPTIVE
will necessarily lead to improved overall protective efficacy. For
example, airway mucosal boosting following parental priming IMMUNE SYSTEM
with the subunit vaccine candidate H56:CAF01 results in a
A functional mycobacterial growth inhibition assay (MGIA),
significant increase in pulmonary TRM and early local T-cell
which measures the sum of the parts of the innate and adaptive
responses, without conferring any additional protection against
immune response, may be a useful tool to facilitate vaccine
M.tb challenge (50). Intramuscular vaccination of mice with
development. Such a tool could also allow the interrogation of
the adjuvanted subunit TB vaccine candidate ID-93 results
potential COP by depletion studies using serum, peripheral blood
in a systemic, TH1-dominated immune response. In contrast,
mononuclear cells (PBMCs) or other specific cell types. To date
following ID-93 intranasal immunization, a predominantly IL-
such an assay has been optimized for use in whole blood and
17A-producing, TH-17 response is seen; with an increase in
PBMC (59, 60). Using mucosal samples in such an assay may
antigen specific CD4+ TRM in the lung and BAL fluid. Despite
further identify lung specific protective mechanisms in future.
these differences, the level of protection conferred was equal
across the different delivery methods (51). In a recent study,
protection conferred by intra-tracheal administration of the INTERROGATING PULMONARY MUCOSAL
fusion protein TB vaccine candidate, CysVac2, was associated IMMUNITY
with the induction of higher levels of antigen-specific CD4+ lung
TRM , expressing IL-17, and RORγT (52). Animal and human studies that focus on sampling the lung
While intradermal BCG vaccination is able to generate mucosal compartment will improve our understanding of lung
antigen-specific pulmonary TRM in mice, mucosal BCG mucosal immunity to M.tb. Parallel animal and human studies
vaccination produces increased numbers of both CD4+ and would allow more detailed interrogation of these processes.
CD8+ TRM and this corresponds with subsequent enhanced Delivery of vaccine candidates via aerosol routes has been shown
protection against M.tb challenge (48, 53). Mucosal transfer to induce specific mucosal immune components that can be
of sorted airway resident T-cells, in particular CD8+ TRM , compared across species, with BAL samples from macaques
from mucosally BCG-vaccinated mice provided increased and humans following aerosol MVA85A showing increased
protection against M.tb challenge in recipient mice (48). levels of antigen-specific cellular immune responses compared
Non-human primates immunized with intravenous BCG to peripheral blood (61–63). Further detailed mechanistic
were found to have significantly higher levels of CD69+ interrogation of lung-specific immunity is possible in the more
(with a subset of CD103+ ) lung parenchymal CD4+ T- tractable murine model (64, 65).
cells than intradermal or aerosol immunized animals and
this was associated with sterilizing immunity against M.tb Specific Challenges of Human Studies
challenge (36). The study of human lung immunity gives the opportunity to
These findings suggest that vaccination routes and strategies interrogate the interaction between the host and M.tb bacilli at
which induce pulmonary CD4+ and CD8+ TRM may result the site of natural infection. However, significant barriers exist.
in superior levels of protection. This may be one reason why Obtaining high quality respiratory samples for immunological
levels of peripheral circulating antigen-specific T-cells do not analysis generally requires invasive sampling (see Figure 1).
adequately correlate with protection. Biomarkers of TRM may The scarcity of these resources in areas with the highest
be useful as correlates of vaccine induced protection, but would burdens of TB disease, coupled with the costs and ethical
require a significant change in sampling methods to assess considerations of invasive sampling, may explain the relative lack
vaccine efficacy. of immunological studies focussing on the human pulmonary
microenvironment (4).
Lung Mucosal Antibodies IgA How best to sample the human pulmonary compartment
The role of the humoral immune system in TB control is remains the subject of debate. Sputum (induced or spontaneous)
uncertain. In humans, M.tb infection induces M.tb-specific IgA, is often too contaminated, for example with upper airway
as well as IgG, antibodies in BAL fluid, but their precise role epithelial cells and microbes, to provide detailed immunological
and level of interaction with M.tb at the mucosal level remains analysis of the lower respiratory tract. Bronchoalveolar lavage
unknown (54, 55). (BAL) can be used to obtain bronchoalveolar cells (66). Studies
Secretory Immunoglobulin A (sIgA) is the predominant comparing BAL cells to lung tissue biopsies in healthy controls
isotype in mucosal secretions and may contribute to protection. and TB patients suggest that BAL cells are a reasonable
Intranasal administration of purified human sIgA to mice leads representation of lung cellular composition (67). However, this
to increased M.tb clearance and improved disease control (56). assumption may not hold true for HIV infected individuals,
Knockout mice lacking the polymeric IgR receptor necessary for where significant depletion of lung interstial CD4+ T cells
IgA transport to the respiratory mucosa are more susceptible may occur despite relatively normal CD4+ T cells levels in
to M.tb infection than wild-type mice (57). In a BCG challenge bronchoalveolar cells (68).

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Morrison and McShane Pulmonary Immunological Biomarkers in Tuberculosis

FIGURE 1 | (A) Samples that can be obtained from the human pulmonary compartment from immunological interrogation. (B) Selected components of the
pulmonary mucosal immune system that may be involved in protection against Mycobacterium tuberculosis (M.tb). AM, alveolar macrophages; CD, cluster of
differentiation; CXCR, C-X-C chemokine receptor; FBC, follicular dendritic cell; GM-CSF, granulocyte-macrophage colony-stimulating factor; iBALT, inducible
bronchus-associated lymphoid tissue; IFN, interferon; ILC, innate lymphoid cells; IM, interstitial macrophages; IL, interleukin; KLRG, killer-cell lectin like receptor G;
MAIT, mucosal-associated invariant T-cells; PD, programmed cell death protein; sIgA, secretory immunoglobulin A; TCR, T-cell receptor; TNF, tumor necrosis factor;
TRM, tissue-resident memory T-cell. Created with BioRender.com.

Where comparative data does exist, it suggest there is a disease. Suppressive cytokines, including IL-4, TGF-β and IL-
significant difference in immunological activity and therefore 10, are increased in bronchoalveolar cell samples of active
possible biomarkers of disease and protection in the lungs TB compared with healthy controls (71) and may represent
compared to the peripheral blood. Schwander et al. found distinct local immunosuppressive mechanisms that interfere with
compartmentalized markers of active TB disease, with Th1-mediated effectors in the bronchoalveolar environment.
significantly increased levels of activated T lymphocytes One difficulty in studying the respiratory mucosal immune
(CD69+ HLA DR +) seen in bronchoalveolar cells of patients response to M.tb infection in humans is the inability to
with active TB compared to healthy controls, whereas in PBMCs define precisely the time of infection. Due to the varying
there was no difference across groups (69). PBMC in TB patients clinical course and potential for latency, active disease may
are hyporesponsive, with respect to both frequency of IFN-γ only be diagnosed months or years after the point of
producing cells and DNA synthesis, to both mycobacterial infection. In other diseases, such as influenza, malaria and
and non-mycobacterial antigens compared to healthy subjects. typhoid, controlled human infection models (CHIMs) have
Conversely, bronchoalveolar cells from affected lung segments been used to interrogate the immune response and can also
in TB patients show increased responses to mycobacterial be used to evaluate vaccine efficacy. Treatment for active TB
antigens, suggesting significant localization of antigen–specific disease requires a lengthy combination of potentially toxic
cells within the affected lungs during active pulmonary medications, and proof of definitive cure may not be possible.
TB (70). For these reasons, a CHIM with M.tb would not be ethical.
Pulmonary TB disease is characterized by an enhancement of However, use of alternative mycobacterial models to mimic
local Th1-mediated immunity, with increased IL-12 and IFN- M.tb infection are being explored. For example, BCG may be
γ production within affected lung segments (70). Despite this used as a surrogate, as it does not cause active disease in
apparently functional local Th1-mediated immune response, immunocompetent humans but is a live replicating mycobacteria
there is clearly failure to control M.tb in those with active that stimulates an immune response. Interrogation of the

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Morrison and McShane Pulmonary Immunological Biomarkers in Tuberculosis

pulmonary mucosal immune response following a defined time immunity (COP) at the site of initial host contact with M.tb.
point infection with BCG may lead to greater understanding of Logistical and ethical difficulties in obtaining invasive human
key immunological mechanisms, in particular in the early stages pulmonary sample in these circumstances mean that more novel
of infection. investigative strategies may be needed.
Bronchoscopic instillation of BCG into lung segments of Vaccine development in TB faces a paradox—a vaccine-
healthy, HIV-negative participants in South Africa with a induced COP can only be validated in large field trials of an
range of TB phenotypes was shown to be safe and resulted effective vaccine. However, selection of which candidate vaccines
in changes to differentially expressed genes and proteomics to take forward for such costly trials requires some level of
in the BAL fluid which were not detectable in the blood, discrimination. As evidenced by the compartmentalized nature
suggesting a highly localized response (72). Studies in our of immunological biomarkers in both human and animal models,
group are ongoing to define the human innate and adaptive peripheral blood biomarkers, whilst easier to obtain, may not be
immune response to a defined time point challenge with the best choice of read-out for rational vaccine selection.
aerosol BCG, and specifically comparing the peripheral and CHIMs in healthy volunteers, either with BCG or potentially
pulmonary compartment (Clinical trials.gov/NCT03912207). in future with rationally attenuated M.tb strains, may prove an
Parallel ongoing studies in non-human primates will add value to alternative strategy to delineate human immunological response
this work. to a defined time point infection (73). Davids et al. human lung
challenge model showed that responses to in-vitro and in-vivo
DISCUSSION PPD and BCG stimulation were significantly different, raising the
prospect that the study of vaccine-induced immune biomarkers
Growing evidence shows that immunological responses are of protection may need to focus more on lung mycobacterial
compartmentalized and biomarkers present in the peripheral challenges and sampling, rather than peripheral blood (72).
blood may be poorly representative of important, local effects Given the considerable technical obstacles this approach faces,
within the lungs. Innate, trained and adaptive components it could prove more likely that if pulmonary correlates of
of the pulmonary immune system are likely to play an protection (or disease) are identified, systemic surrogate markers
interconnected role in protection, with distinct features of lung may be identifiable that can then be more easily appraised in
mucosal immunity such as alveolar macrophages, BALT and future studies.
TRM all warranting further investigation. The characterization
of these immunological responses at the natural site of M.tb AUTHOR CONTRIBUTIONS
infection is of paramount importance, both in to increase our
understanding of pathogenesis and more specifically to aid HMo wrote the first draft of the manuscript. HMo and HMc
rational vaccine development. contributed to manuscript revision and read and approved the
Pre-clinical animal models play a key role in defining submitted version.
the pulmonary immune response to both M.tb and systemic
and mucosally-delivered TB vaccines. Carefully designed small FUNDING
studies in humans can complement and add to these pre-
clinical studies. Interrogating the initial stages of M.tb immunity HMc is a Wellcome Trust Investigator (WT 206331/Z/17/Z). The
in human lungs, for example in healthy household contacts, views expressed are those of the author(s) and not necessarily
would have the potential to distinguish biomarkers of protective those of the Wellcome Trust.

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not secondary vaccination with Mycobacterium bovis BCG. Clin Vaccine potential conflict of interest.
Immunol. (2013) 20:1683–9. doi: 10.1128/CVI.00427-13
60. Tanner R, O’Shea MK, White AD, Müller J, Harrington-Kandt R, Matsumiya Copyright © 2021 Morrison and McShane. This is an open-access article distributed
M, et al. The influence of haemoglobin and iron on in vitro mycobacterial under the terms of the Creative Commons Attribution License (CC BY). The use,
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43478 author(s) and the copyright owner(s) are credited and that the original publication
61. Satti I, Meyer J, Harris SA, Manjaly Thomas ZR, Griffiths K, Antrobus in this journal is cited, in accordance with accepted academic practice. No use,
RD, et al. Safety and immunogenicity of a candidate tuberculosis vaccine distribution or reproduction is permitted which does not comply with these terms.

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