Two variants among Haemophilus influenzae serotype b strains with distinct bcs4, hcsA and hcsB genes display differences in expression of the polysaccharide capsule
© Schouls et al; licensee BioMed Central Ltd. 2008
Received: 27 August 2007
Accepted: 25 February 2008
Published: 25 February 2008
Despite nearly complete vaccine coverage, a small number of fully vaccinated children in the Netherlands have experienced invasive disease caused by Haemophilus influenzae serotype b (Hib). This increase started in 2002, nine years after the introduction of nationwide vaccination in the Netherlands. The capsular polysaccharide of Hib is used as a conjugate vaccine to protect against Hib disease. To evaluate the possible rise of escape variants, explaining the increased number of vaccine failures we analyzed the composition of the capsular genes and the expressed polysaccharide of Dutch Hib strains collected before and after the introduction of Hib vaccination.
The DNA sequences of the complete capsular gene clusters of 9 Dutch Hib strains were assessed and two variants, designated type I and type II were found. The two variants displayed considerable sequence divergence in the hcsA and hcsB genes, involved in transport of capsular polysaccharide to the cell surface. Application of hcsA type specific PCRs on 670 Hib strains collected from Dutch patients with invasive Hib disease showed that 5% of the strains collected before 1996 were type II. No endogenous type II Hib strains were isolated after 1995 and all type II strains were isolated from 0–4 year old, non-vaccinated children only. Analysis of a worldwide collection of Hib strains from the pre-vaccination era revealed considerable geographic differences in the distribution of the type I and type II strains with up to 73% of type II strains in the USA. NMR analysis of type I and type II capsule polysaccharides did not reveal structural differences. However, type I strains were shown to produce twice as much surface bound capsular polysaccharide.
Type II strains were only isolated during the pre-vaccination era from young, non-vaccinated individuals and displayed a lower expression of capsular polysaccharide than type I strains. The higher polysaccharide expression may have provided a selective advantage for type I strains resulting in the rapid elimination of type II from the Dutch Hib population after introduction of nationwide Hib vaccination. However, this phenomenon does not explain the increase in the number of Hib vaccine failures in the Netherlands.
Worldwide the number of cases of invasive disease caused by Haemophilus influenzae serotype b (Hib) has dramatically decreased after the introduction of vaccines composed of the conjugated polysaccharide capsule of the pathogen. In the Netherlands Hib vaccination was introduced in 1993 resulting in a decrease in incidence of invasive Hib disease among children younger than 5 years of age from 28.7 per 100,000 in 1992 to 0.4 in 2001 .
Despite nearly complete vaccine coverage, a small number of fully vaccinated children in the Netherlands have experienced invasive Hib disease. In 2002 the incidence of vaccine failures in Dutch children aged 0–4 years increased from 0.4 per 100,000 in the years 1996 to 2001 to 1.3 per 100,000 in 2002 [2, 1]. In only a few patients underlying conditions were found that might have contributed to vaccine failure. Half of the patients had adequate anti-PRP titers at the onset of disease, which is similar to what is found in the same age group of the healthy population. All vaccine failure patients responded well to revaccination with the Hib vaccine yielding high anti-PRP titers, indicating there was no impairment of the immune system. Since 2002 the annual number of cases of invasive Hib disease among 0–4 year old children in the Netherlands has remained approximately the same .
In the United Kingdom a somewhat more pronounced rise in vaccine failures has been observed particularly in children 1–4 years of age and this was believed to be caused by inadequate antibody titers against Hib due to waning immunity. To compensate for the reduced antibody titers, a catch-up campaign, designed to boost immunity in children aged 6 months to 4 years of age, was implemented in the United Kingdom . Furthermore, an additional Hib booster in the second year of life has now been implemented in the United Kingdom vaccination schedule . A Hib booster vaccination at 11 months of age has been part of the Dutch Hib vaccination schedule since its introduction in 1993. This booster should have prevented waning immunity in children and suggests that reduced antibody titers may not have been the cause of the increased number of vaccine failures observed in the Netherlands. Therefore, changes in the properties, e.g. virulence factors, of circulating Hib strains could not excluded. The major virulence factor of Hib is the polysaccharide capsule, a polymer of ribose ribitol phosphate (PRP), which is also the antigen used for Hib vaccination. The production and export of the polysaccharide capsule of Hib is encoded by 10 genes located in single locus consisting of 3 distinct regions. The first region contains 4 bex genes involved in the export of the capsular polysaccharide, the second region carries 4 bcs genes which are considered to be involved in the actual synthesis of the polysaccharide and the third region carrying 2 hcs genes is now also considered to be involved in the export of the polysaccharide to the surface of the cell [6, 7].
Changes of the genes in the capsular gene cluster locus may lead to an altered capsule of the Hib. If this would be the case in the currently circulating Hib strains the vaccine induced immunity may not provide optimal protection causing an increased incidence of invasive Hib disease among vaccinated children in the Netherlands. This prompted us to analyze the composition of the genes encoding for capsular polysaccharide, the structure of the encoded polysaccharide and of the level of expressed capsular polysaccharide in Hib strains isolated before and after the introduction of nationwide Hib vaccination in the Netherlands.
Sequence analysis of the Hib capsule locus
Strains used for sequencing the capsule gene cluster
Capsule locus type
Hib from pre-vaccination era
Hib from post-vaccination era
Vaccine strain 1482
Comparison with the sequences in the publicly available databases revealed that sequences of the capsule gene clusters from 3 different Hib strains have been published . Although the sequences were not identical, they were highly similar (e.g. 17 bp difference between type II sequences DQ368335 and AF54213) and it was clear that the capsule gene cluster in one of these 3 strains, a Hib minus strain isolated from a patient in the USA, is of type I (acc.no. AF549212). The capsule gene clusters of the other 2 strains, a regular Hib strain and a Hib minus strain, have a type II composition (acc.no. AF549213 and AF549210). Currently, the Sanger Institute, in collaboration with Dr. Derrick Crook and Prof. Richard Moxon, is sequencing the genome of a Hib isolate (strain 10810) from a meningitis patient from the United Kingdom . The nucleotide sequence of the capsular genes in the unfinished genome sequence of this strain 10810 is identical to that of the type I capsular gene cluster found in the Dutch strains.
Distribution of Hib type I and type II strains
Distribution of the type I and type II strains stratified over time and age groups
Capsule locus type
Time period of isolation
No. of strains
≤ 4 years
> 4 years
≤ 4 years
> 4 years
Distribution of capsular genotypes in various geographic regions among Hib strains collected during the pre-vaccination era 1980–1990
Capsule locus type
No. of strains
Europe (Finland & Switzerland)
Africa (The Gambia & South Africa)
Asia (Malaysia & Vietnam)
Sequence variation of the hcsA gene
We found only 2 variants of the capsule gene cluster in the 11 strains from which the complete gene cluster was sequenced, suggesting very limited variation of the capsular genes. To verify this finding we determined the DNA sequence of hcsA PCR products obtained from a large number of type I and type II strains. In total the DNA sequences of the hcsA PCR products obtained from 111 Dutch type I strains collected during the time period 1984 to 2006 were determined. The DNA sequences of 109 of the 111 PCR products were identical. Only two strains, one isolated in 1992 from a 99 year old patient and the other in 1996 from 4 months non-vaccinated old child, had an A→G SNP at position 597 of the type I hcsA gene that did not lead to an amino acid substitution. The DNA sequences of the hcsA PCR products from all 21 type II strains in the strain collection were determined and all products had identical sequences. In addition, the sequences of the hcsA PCR products of 14 type I and 13 type II Hib strains collected during the pre-vaccination era in various other parts of the world were also determined. This revealed very limited variation in the hcsA sequence of type I strains. As, The A→G SNP at position 597 of the type I hcsA gene which was also found in the Dutch Hib strains, appeared to be present in a strain from South-Africa, in one from Malaysia, one from Vietnam and in 2 strains from the USA. Furthermore, 2 strains from Cuba contained 2 SNPs: an A→G SNP at position 736 and a C→A SNP at position 806. Both base pair changes lead to amino acid substitutions. Remarkably, these SNPs correspond to the sequences found in the type II hcsA gene. All PCR products obtained from the 13 type II strains had sequences identical to the previously determined type II hcsA sequence.
Association between capsular type and genotype
Composition of the capsular polysaccharide obtained from type I and type II strains
Level of expression of polysaccharide capsule in type I and type II Hib strains
Reduction in SBA of a high titer serum sample absorbed with type I or type II Hib cells
Type I target cells
Type II target cells
Absorbed with type I cells
Absorbed with type II cells
Electron microscopy of type I and type II strains
In this study, we determined the composition of the genes encoding the components required for the synthesis and transport of the polysaccharide capsule of Hib strains isolated from patients with invasive disease in the Netherlands. We found that two variants of the capsular gene cluster exist and we designated these as type I and type II. Type I strains were found to carry approximately twice as much capsular polysaccharide on the surface of the cells as did type II strains. Of the strains, isolated from patients with invasive Hib disease in the Netherlands during the time period 1983–1995, 5% were type II. After 1995, only 2 years after the introduction of the Hib vaccine in the Dutch national immunization program, type II strains were no longer isolated from Dutch patients with invasive Hib disease.
The variation between the capsular gene cluster sequences of type I and type II strains was predominantly found in the hcsA and hcsB genes. The nucleotide sequences of bex, bcs1 and bcs2 of type I and of type II were identical. Only one SNP was found in bcs3 and a few SNPs in bcs4, some of which are leading to amino acid substitutions. The bcs genes are believed to be involved in the biosynthesis of the polysaccharide and even small alterations in these genes could change the composition of the polysaccharide produced. However, NMR analysis of the polysaccharides isolated from type I and type II strains revealed no structural differences between the two types. Recently, Sukupolvi-Petty and colleagues demonstrated that the products of the hcsA and hcsB genes facilitate transport of capsular polysaccharide across the outer membrane . Inactivation of hcsA alone resulted in accumulation of polysaccharide in the periplasm and a partial decrease in surface-associated polysaccharide, whereas inactivation of hcsB alone or of both hcsA and hcsB resulted in accumulation of polysaccharide in the periplasm and complete loss of surface associated polysaccharide. It is therefore feasible that alterations in the hcsA and hcsB genes would influence the degree of export of the capsular polysaccharide to the surface of the Hib cells or the efficiency of retaining the exported polysaccharide on the surface. We showed that the type I hcsA and hcsB genes and putative encoded proteins differed considerably in composition from those of the type II strains. These differences did not lead to a detectable difference in structure between the two capsular genotypes. However, we provided evidence that, at least in vitro, the amount of capsular polysaccharide retained on the surface of studied type I strains was twice as high as that in type II strains. In an inhibition ELISA, cells obtained from type I cultures caused significantly more inhibition than cells from type II cultures. Similar results were obtained in an SBA where absorption of serum samples with type I cells resulted in a four-fold higher reduction of SBA titer compared to absorption with type II cells. Furthermore, there always was a pronounced pro-zone effect when type I strains were used in the SBA while only a modest pro-zone effect was seen when type II strains were used as target cells in the SBA. The pro-zone effect is thought to reflect a steric hindrance caused by high concentrations of bound antibodies which in turn is caused by high concentrations of antigen . This would confirm the higher density of capsular polysaccharide on the surface of type I cells. Electron microscopy revealed that the capsular layers of type I Hib cells were thinner, yet denser than that of type II cells, that could suggest that in type I strains more polysaccharide may bound per surface area.
Cerquetti and colleagues showed that a significantly greater proportion of strains isolated from vaccine failures in the United Kingdom carried multiple copies of the cap gene cluster . As shown by Noel and colleagues, the presence of multiple copies of the cap locus would result in more polysaccharide production and decreased complement-mediated lysis . Hence, higher antibody levels may be required to protect against Hib disease caused by strains with multiple copies of the cap gene cluster. We have shown that type I strains may produce more capsular polysaccharide and therefore higher antibody titers may be required to eliminate type I Hib compared to type II strains. All Dutch type II strains used in this study were exclusively isolated from non-vaccinated children younger than 5 years of age and consequently, all vaccine failures in the Netherlands were caused by type I strains. This suggests that type II Hib strains may be less well equipped to cause invasive disease in hosts that have been immunized by vaccination or by natural exposure to Hib and may explain why the type II strains seem to have become extinct in the Netherlands after the introduction of the Hib vaccine. The fact that the proportion of type II strains among the Hib population before the introduction of the vaccine was only 5% possibly would have contributed to the rapid elimination.
The type I and type II strains appear to represent two distinct groups within the Hib population. This is particularly obvious from the MLST analysis of the Hib strains. The Hib population displays a relatively low degree of genetic diversity when analyzed by MLST. In the Netherlands 75% of the Hib strains typed by MLST had ST-6. Remarkably, none of the Dutch type II strains were ST-6, suggesting an inverse relationship between capsular genotype II and ST-6. This inverse relationship was confirmed by our finding that none of the type II strains obtained from other countries had ST-6. MLVA analysis of the Dutch Hib collection also revealed a non-random distribution of the type II strains corroborating the distinct nature of the type II strains.
It is unclear what has caused the polymorphism of the two gene clusters in Hib strains, but it is unlikely that this reflects a gradual change in the capsular genes. DNA sequence analysis of the complete capsular gene clusters of 11 Hib strains revealed the presence of only 2 types of sequences. Sequence analysis of a large number of hcsA PCR products obtained from Dutch type I and type II Hib and from strains collected in various other parts of the world confirmed the very limited variability in type I strains and the complete lack thereof in those from type II strains. Possibly Hib strains have acquired the hcsA and hcsB genes from other capsulated H. influenzae or other bacterial species through lateral transfer and recombination. Thus far only the hcsA and hcsB genes of serotype b and serotype f strains have been sequenced . Comparison of the type I and type II hcs gene sequences of the Hib strains with the hcs sequences of the serotype f strain shows that these are similar but distinct sequences and that Hib has not acquired the hcs genes from H. influenzae serotype f.
In summary, this investigation has shown that two variants of Hib strains exist that differ considerably in the DNA sequence of the genes hcsA and hcsB. These genes are involved in the transport of the major virulence factor, the capsular polysaccharide, to the surface of the Hib cell. We show that the type I isolates used in this study carried more surface bound capsular polysaccharide than type II isolates. Type II strains were isolated from 0–4 year old, non-vaccinated patients suggesting type II only causes invasive disease in hosts that have not yet mounted antibodies against the Hib capsule. Before the introduction of the Hib vaccine 5% of the Hib isolates from Dutch patients with invasive Hib disease were type II and after nationwide Hib vaccination this type was no longer found. The lower capsule production in type II strains may have caused a selective disadvantage explaining the rapid disappearance of type II strains from the Dutch Hib population. However, this change in the composition of the Hib population does not explain why the Netherlands has experienced an increase in the number of vaccine failures since 2002 and further investigation is required to explain the observed increase.
Bacterial strains and serum samples
For this study we included 670 Hib strains collected during the years 1983–2006 by the Netherlands Reference Laboratory for Bacterial Meningitis (NRBM) from Dutch patients with invasive disease. Of these strains 409 were isolated from CSF and 245 strains were isolated from blood. The remainder of the strains was isolated from other normally sterile compartments such as joints. Hib strains are sent to the NRBM on a voluntary basis, but it is estimated that this results in coverage of more than 85% of all cases of invasive Hib disease in the Netherlands. The strain collection contained all available 282 Hib strains isolated from 1996–2006 and 388 randomly selected strains from the time period 1983–1996. From each year of latter time period, we included approximately 20 Hib strains isolated from 0–4 year old children and approximately 10 strains from patients older than 4 years, 75% of which were 18 years or older. In addition, we used Hib reference strain Eagan and vaccine strain 1482 kindly provided by Dr. R. Schneerson. Dr. L. van Alphen kindly provided us with 134 Hib strains from different locations in the world collected during the years 1980–1990. However, the nature of these strains, carriage or invasive disease, was unknown. Of the Dutch Hib strains 667 were typed by multiple-locus variable number tandem repeats analysis (MLVA)  and 237 by multi-locus sequence typing (MLST) [10, 9].
Positive serum samples for SBA and ELISA were obtained from 5 volunteers who received a single dose of ActHib vaccine (Aventis Pasteur MSD, Lyon, France) and a negative control serum was obtained from a volunteer who was not immunized (ages ranged from 25 to 57 years). Serum samples were collected 2 months after vaccination, aliquoted and stored at -20°C until use.
DNA sequencing of the capsular gene cluster
For sequencing of the complete Hib capsule gene cluster PCR products creating overlapping fragments of the gene cluster were used. Sequence reactions were performed with the ABI PRISM BigDye Terminator cycle sequencing kit v3.1 (Applied Biosystems, Foster City, Calif.) and analyzed on an AB3700 DNA sequencer. DNA sequences have been submitted to GenBank under acc.no. DQ368334 and acc.no. DQ368335.
Hib capsular genotype specific PCR
For PCR detection of the type I hcsA oligonucleotide primers HiHcsA12667F-I (GTACTTGTCATTGACCAAACTTT) and HiHcsA13116R-I (GGTATATTGAAAGTATGCTGCAT) yielding a 450 bp PCR product were used. To detect type II hcsA primers HiHcsA12668F-II (TGCTTGTCATCGATCAAA) and HiHcsA13484R-II (ACTAAAGAAAGGGGTGCAA) yielding a 817 bp PCR product were used. Two separate PCRs were performed in AB9700 PCR machines using the following protocol: 1 μl of 1:10 diluted heat-treated H. influenzae lysate was added to a 24 μl mixture containing 10 pmol of each primer and 12.5 μl diluted HotStar Taq mastermix (Qiagen, Hilden, Germany). The PCR program used was 15 min at 95°C, followed by 30 cycles of amplification that consisted of 30 sec at 95°C, 1 min at 52°C, and 1 min at 72°C and a final 7 min at 72°C. Strains were screened by type I PCR and all samples that did not yield a PCR product were analyzed again in both the type I and type II PCR. All strains for which the hcsA PCR products were used for sequence analysis were analyzed in both PCRs.
Serum bactericidal activity
Functional antibodies binding to the PRP capsule of Hib and fixing complement onto the bacterial surface were measured by an slightly modified assay for serum bactericidal activity (SBA) described by Romero-Steiner et al. . Ten μl of heat inactivated serum was mixed with 20 μl of the diluted Hib suspension and incubated for 15 min at 35°C at 5% CO2. Thereafter, 25 μl of Hanks buffer (Life Technologies, Grand Island, N.Y., USA) with 2% Fildes (BBL, Becton Dickinson and Co., Sparks, Md., USA) and 25 μl of baby rabbit complement (Pel-Freez, Brown Deer, Wis., USA) was added and the mixture was incubated for 1 h at 35°C at 5% CO2. From the mixture 5 μl aliquots were applied onto 12 × 12 cm square culture plates filled with Brain Hearth Infusion agar, supplemented with Haemophilus test medium supplement (Oxoid, Haarlem, The Netherlands). SBA titers were defined as the serum dilution that resulted in >90% killing of the Hib culture used for the assay.
Inhibition of the serum bactericidal activity
Hib suspensions used for absorption assays were obtained from 100 ml overnight cultures, grown in supplemented Brain Hearth Infusion broth. Fifty ml of culture was centrifuged for 10 min at 3000 g, and the pellet was resuspended in 5 ml 150 Mm NaCl after which the bacteria were killed by a 10 min incubation at 65°C. In the SBA absorption assays 10 μl aliquots of heat inactivated serum samples were pre-absorbed with 10 μl heat killed Hib suspensions. The mixture was incubated for 1 h at 37°C followed by an overnight incubation at 4°C. The mixture was then centrifuged for 10 min at 10,000 g and the supernatant was used for SBA. To ensure the various cultures contained the same number of bacteria, real time quantative PCR and protein quantification were used to assess and adjust the number of bacteria in each culture used for absorption. Cell suspensions and supernatants were aliquoted and stored at -20°C until use.
Type b polysaccharide inhibition ELISA
To assess the level of the capsular polysaccharide expression of the various Hib strains an inhibition ELISA was designed. For this purpose an ELISA, described by Phipps et al.  and used to determine antibody titers against Hib polysaccharide was adapted. In contrast to the original method 1:20,000 diluted horse-radish-peroxidase labeled Protein A/G (Pierce, Rockford, USA) and TMB substrate solution (110 mM NaAc pH 5.5, 166 μg/ml 3,3',5,5' tetramethylbenzidine, 0.006% H2O2) were used. Reactions were stopped after 5 min using 2 M H2SO4, and values were read at 450 nm in a Biotek EL312e ELISA reader. In order to relate the degree of inhibition to the amount polysaccharide, serial dilutions of purified polysaccharide (HBO-HA, National Institute for Biological Standards and Control, Hertfordshire, United kingdom) with known concentration were added to HBO-HA-coated microtiter plates after which a single dilution of a high titer serum sample was added to all wells and incubated for 1 h at room temperature. Subsequently the ELISA was performed as described above.
Hib suspensions used for the inhibition ELISA were obtained from the same overnight grown type I and type II cultures as those used for the absorption of the SBA. Five ml culture was centrifuged as described above and the pellet was reconstituted in 5 ml PBS after which Hib in both supernatant and cellular fraction were heat killed. To ensure the various cultures contained the same number of bacteria, real time quantative PCR and protein quantification were used to assess and adjust the number of bacteria in each culture used for absorption. To assess the polysaccharide content in Hib strains, the above described cells and culture supernatants from type I and type II strains were pre-treated with 0.1% SDS for 30 min at 60°C and used in the inhibition ELISA described above.
Electron microscopy of Hib strains
Fixation and capsular stain were basically performed according to the lysine-acetate-based formaldehyde-glutaraldehyde ruthenium red-osmium fixation procedure (LLR-methode) method . A 30 ml overnight culture of Hib grown in supplemented BHI was centrifuged for 10 min at 1800 g. Half of the supernatant was discarded and the remaining cells were fixed in paraformaldehyde and glutaraldehyde in the presence of ruthenium red after which they were imbedded in agarose by centrifugation, dehydrated using graded series of ethanol, impregnated in the epoxy resin glycidether 100 and finally polymerized in BEEM capsules at 60°C. Ultrathin sections were cut with a diamond knife, contrasted with 2% uranyl acetate, counterstained with lead citrate and examined in a FEI Tecnai12 transmission electron microscope.
Purification of the Hib polysaccharide
The capsular polysaccharide of various Hib strains was isolated and purified from liquid cultures as described before with some modifications . Strains were cultured 22 hours at 35°C in 500 ml supplemented brain heart infusion broth. The culture was centrifuged for 30 min at 3000 g and 0.65% cetyl trimethyl ammonium bromide (CTAB) was added to the culture supernatant. After overnight incubation at 4°C the solution was centrifuged for 30 min. at 3000 g. The pellet was dissolved in 50 ml solution containing 1 M NaCl, 5 mM NaAc pH5.2 and 72% ethanol was added. After overnight incubation the solution was centrifuged for 30 min at 3000 g and the pellet was dissolved in 10 ml PBS (200 mM NaCl, 4.5 mM KCl, 17 mM phosphate buffer pH7.4). The solution was then purified on a Hi Prep 16/60 Sephacryl S300 high resolution column (GE Healthcare, Uppsala, Sweden) using PBS at a flow rate of 0.5 ml/min. The purified polysaccharide was eluted from the column in a 12 ml volume directly after the void volume. The purified polysaccharide was precipitated by adding 1 M NaCl, 5 mM NaAc pH5.2 and 72% ethanol and overnight incubation at 4°C. After centrifugation for 30 min. at 3000 g the pellet was dissolved in water, dialyzed extensively against water in a slide-a-lyzer with a 7000 Da cut-off (Pierce Biotechnology, Rockford, USA) and dried in a SpeedVac. The average yield of this procedure was 5–10 mg of purified PRP.
Nuclear magnetic resonance analysis of Hib polysaccharide
The purified PRP was analyzed by nuclear magnetic resonance (NMR) as described before . Briefly, samples were dissolved in deuterated water (D2O), containing 0.075% (w/w) of trimethylsilyl-[D4]-propanoate sodium salt (Sigma-Aldrich, Zwijndrecht, The Netherlands). NMR-spectra were recorded on a JEOL JNM-ECP400 FT NMR system (JEOL, Tokyo, Japan) at 9.4 T using a pre-saturation pulse to lower the residual water peak.
We are indebted to the Dutch Medical Microbiology laboratories for sending the H. influenzae isolates the Netherlands Reference Laboratory for Bacterial Meningitis. This study would not have possible without their help.
This study was funded by the Dutch Ministry of Health, Welfare and Sport.
- Van der Ende A, Spanjaard L, Dankert J: Bacterial Meningitis in the Netherlands. 31th annual report of the Netherlands Reference Laboratory for Bacterial Meningitis. 2004, 1-58.Google Scholar
- Rijkers GT, Vermeer-de Bondt PE, Spanjaard L, Breukels MA, Sanders EA: Return of Haemophilus influenzae type b infections. Lancet. 2003, 361: 1563-1564. 10.1016/S0140-6736(03)13201-1.View ArticlePubMedGoogle Scholar
- Spanjaard L, Van den Hof S, De Melker HE, Vermeer-de Bondt PE, Van der Ende A, Rijkers GT: Increase in the number of invasive Haemophilus influenzae type b infections. Ned Tijdschr Geneeskd. 2005, 149: 2738-2742.PubMedGoogle Scholar
- Trotter CL, Ramsay ME, Slack MP: Rising incidence of Haemophilus influenzae type b disease in England and Wales indicates a need for a second catch-up vaccination campaign. Commun Dis Public Health. 2003, 6: 55-58.PubMedGoogle Scholar
- Cameron C, Pebody R: Introduction of pneumococcal conjugate vaccine to the UK childhood immunisation programme, and changes to the meningitis C and Hib schedules. Euro Surveill. 2006, 11: E060302-PubMedGoogle Scholar
- Satola SW, Schirmer PL, Farley MM: Complete sequence of the cap locus of Haemophilus influenzae serotype b and nonencapsulated b capsule-negative variants. Infect Immun. 2003, 71: 3639-3644. 10.1128/IAI.71.6.3639-3644.2003.PubMed CentralView ArticlePubMedGoogle Scholar
- Sukupolvi-Petty S, Grass S, Stgeme JW: The Haemophilus influenzae Type b hcsA and hcsB Gene Products Facilitate Transport of Capsular Polysaccharide across the Outer Membrane and Are Essential for Virulence. J Bacteriol. 2006, 188: 3870-3877. 10.1128/JB.01968-05.PubMed CentralView ArticlePubMedGoogle Scholar
- Sanger sequencing projects. [http://www.sanger.ac.uk/Projects/H_influenzae/]
- Schouls LM, van der Ende A, van de Pol I, Schot C, Spanjaard L, Vauterin P, Wilderbeek D, Witteveen S: Increase in genetic diversity of Haemophilus influenzae serotype b (Hib) strains after introduction of Hib vaccination in The Netherlands. J Clin Microbiol. 2005, 43: 2741-2749. 10.1128/JCM.43.6.2741-2749.2005.PubMed CentralView ArticlePubMedGoogle Scholar
- Meats E, Feil EJ, Stringer S, Cody AJ, Goldstein R, Kroll JS, Popovic T, Spratt BG: Characterization of encapsulated and noncapsulated Haemophilus influenzae and determination of phylogenetic relationships by multilocus sequence typing. J Clin Microbiol. 2003, 41: 1623-1636. 10.1128/JCM.41.4.1623-1636.2003.PubMed CentralView ArticlePubMedGoogle Scholar
- Taborda CP, Rivera J, Zaragoza O, Casadevall A: More is not necessarily better: prozone-like effects in passive immunization with IgG. J Immunol. 2003, 170: 3621-3630.View ArticlePubMedGoogle Scholar
- Cerquetti M, Cardines R, Ciofi Degli Atti ML, Giufre M, Bella A, Sofia T, Mastrantonio P, Slack M: Presence of Multiple Copies of the Capsulation b Locus in Invasive Haemophilus influenzae Type b (Hib) Strains Isolated from Children with Hib Conjugate Vaccine Failure. J Infect Dis. 2005, 192: 819-823. 10.1086/432548.View ArticlePubMedGoogle Scholar
- Noel GJ, Brittingham A, Granato AA, Mosser DM: Effect of amplification of the Cap b locus on complement-mediated bacteriolysis and opsonization of type b Haemophilus influenzae. Infect Immun. 1996, 64: 4769-4775.PubMed CentralPubMedGoogle Scholar
- Satola SW, Schirmer PL, Farley MM: Genetic analysis of the capsule locus of Haemophilus influenzae serotype f. Infect Immun. 2003, 71: 7202-7207. 10.1128/IAI.71.12.7202-7207.2003.PubMed CentralView ArticlePubMedGoogle Scholar
- Romero-Steiner S, Fernandez J, Biltoft C, Wohl ME, Sanchez J, Feris J, Balter S, Levine OS, Carlone GM: Functional antibody activity elicited by fractional doses of Haemophilus influenzae type b conjugate vaccine (polyribosylribitol phosphate-tetanus toxoid conjugate). Clin Diagn Lab Immunol. 2001, 8: 1115-1119. 10.1128/CDLI.8.6.1115-1119.2001.PubMed CentralPubMedGoogle Scholar
- Phipps DC, West J, Eby R, Koster M, Madore DV, Quataert SA: An ELISA employing a Haemophilus influenzae type b oligosaccharide-human serum albumin conjugate correlates with the radioantigen binding assay. J Immunol Methods. 1990, 135: 121-128. 10.1016/0022-1759(90)90264-V.View ArticlePubMedGoogle Scholar
- Hammerschmidt S, Wolff S, Hocke A, Rosseau S, Muller E, Rohde M: Illustration of pneumococcal polysaccharide capsule during adherence and invasion of epithelial cells. Infect Immun. 2005, 73: 4653-4667. 10.1128/IAI.73.8.4653-4667.2005.PubMed CentralView ArticlePubMedGoogle Scholar
- Anderson P, Smith DH: Isolation of the capsular polysaccharide from culture supernatant of Haemophilus influenzae type b. Infect Immun. 1977, 15: 472-477.PubMed CentralPubMedGoogle Scholar
- Lemercinier X, Jones C: An NMR spectroscopic identity test for the control of the capsular polysaccharide from Haemophilus influenzae type b. Biologicals. 2000, 28: 175-183. 10.1006/biol.2000.0255.View ArticlePubMedGoogle Scholar
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