CD8+ T cells and Humoral Immunity Influence the Development of Antibody-Dependent Enhancement: Implications for Vaccine Design.

Dengue virus (DENV) infection is a major and growing global health threat. The development of a safe and effective vaccine regardless of prior dengue immunity remains an unmet need. Virus-specific antibodies typically limit viral replication. In contrast, low-to-intermediate dengue-specific antibody titers can enhance viral replication and increase disease severity-a phenomenon known as antibody-dependent enhancement (ADE). ADE complicates dengue vaccine development; signals of ADE were observed in the CYD-TDV (Dengvaxia) vaccine trials but have not yet been reported for trials of TAK-003 (Qdenga). To better understand how prior immunity influences dengue infection outcomes, we developed a mechanistic within-host model of acute dengue infection dynamics that incorporates both humoral immunity and CD8+ T cells. Model simulations predict that severe disease is most likely when dengue-specific antibody titers are intermediate and dengue-specific CD8+ T-cell immunity is low at the time of infection. In our simulations, increasing pre-infection levels of CD8+ T-cell immunity reduces disease severity in a dose-dependent manner and can mitigate ADE. Our results suggest a mechanistic interaction between antibody levels and CD8+ T-cell immunity that may influence whether enhanced viral replication leads to severe disease. The model provides a possible explanation for why ADE is frequently observed in infections of nonhuman primates following passive antibody transfer, yet is less common during secondary infections in humans with memory CD8+ T cells. These findings may help interpret differences in reported clinical outcomes of dengue vaccine trials and highlight the importance of considering CD8+ T-cell responses in the design of future dengue vaccines.