Coronavirus (21) COVID-19 vaccine candidates in clinical trials: inactivated vaccines (a)

Inactivated vaccines are also known as whole killed virus vaccines. They are prepared by protein denaturation, which is performed by chemicals such as formalin, formaldehyde, or β-propiolactone, or by heat and radiation. This destroys the pathogen's ability to infect and replicate, but still retains its ability to act as an immunogen because the inactivation process keeps the pathogen intact. The inactivated pathogen triggers the production of antibodies against the pathogen when the vaccine is injected into humans.¹

Inactivated vaccines are among the first vaccines invented to act against viruses. The best known traditional inactivated vaccines include the rabies vaccine which was first introduced in 1885,² the polio vaccine which was first widely used in 1955,³ and the hepatitis A vaccine which was first approved in 1991.⁴ The flu vaccines provided by the NHS to adults aged above 18 are also inactivated vaccines.⁵ The fact that the technique in developing inactivated vaccines has long been established makes them one of the attractive types of vaccines prepared in the market today.

There are now 5 inactivated-vaccine candidates for COVID-19 in clinical trials (as of 20th August),⁶ four developed by biotech companies from China and one from India. Let us have a look at the progress of the testing of these vaccine candidates.

Inactivated vaccines in clinical trials
1. CoronaVac by Sinovac Biotech Co. Ltd.*
CoronaVac was developed by inactivating SARS-CoV-2 using formalin. The vaccine uses aluminium sulfate as an adjuvant to help boost the immune response (alum-adjuvanted); results from clinical trials indicated that two injections, 14 days apart, are needed for best results.

Currently the vaccine candidate is in its phase 3 trials to test the efficacy and safety in Brazil (trials started from 20th July) and Indonesia (trials started from early August). The company is partnered with the Butantan Institute, a public research institute recognized in Brazil for work in vaccines, to recruit 9000 healthcare professionals working in COVID-19 specialized facilities.⁷ In around July, Brazil became the second country with the most COVID-19 confirmed cases, thus providing sufficient volunteers to speed up the vaccine's development. Analysts remarked that under the current emergency circumstances, phase 3 trials in Brazil could last less than a semester. CoronaVac might be ready for regulatory approval early next year if all goes well.⁷ Sinovac also partnered with PT Bio Farma, a state-run pharmaceutical company in Indonesia, to recruit up to 1620 volunteers, age between 15 and 59, to run clinical tests of CoronaVac. Indonesia is a country with the world's fourth biggest population and has a high number of COVID-19 infections. The entire process is expected to complete around the coming new year.⁸

Previous phase 2 clinical trials for CoronaVac demonstrated that the vaccine is well tolerated, with relatively lower incidence rate of fever compared with other COVID-19 vaccine contenders, and without any notable dose-related safety concerns from 743 healthy volunteers aged 18 to 59. The result was published and is currently available as a medRxiv preprint.⁹

Sinovac is a Beijing-based pharmaceutical company established in 2001 by its Chief Executive Officer Mr. Weidong Yin and the team at Tangshan Yian Biological Engineering Co. Ltd. According to the Sinovac's website, the company has developed and commercialized 6 human-used vaccines over the past two decades. All are inactivated vaccines. Healive, a vaccine against hepatitis A, is their first vaccine product which was first launched in 2002 and took 20 years to research and develop. With the advancing of their technique, they only used about 6 months to complete clinical trials and obtained a production license from China SFDA for PANFLU.1®, a vaccine against H1N1, when a H1N1 influenza broke out in Mexico in March 2009. This is a good example to show their core R&D competence. Their latest vaccine product, Inlive, is a vaccine against enterovirus 71, which causes severe hand, foot, and mouth disease among children.

The company has developed a SARS vaccine which went into phase 1 trials. Although the project was discontinued due to the sudden disappearance of the disease, the experience from 17 years ago benefits Sinovac in developing the COVID-19 vaccine, given that SARS-CoV-2 is very similar to the SARS virus. Moreover, the company obtained one billion renmibi (approximately USD140 million) from the Chinese government and contributions from international NGOs.¹⁰

However, if CoronaVac is approved to be used, the accessibility of the vaccine is likely to be a big issue. Almost a decade would be needed to vaccinate every person in China, as at least two doses will be required to immunize each person whereas the company can produce only 300 million doses per year.¹⁰

Moreover, it is noteworthy that the company may not be able to run stably. There has been a dispute between the company and its investors since 2018, and its stock in Nasdaq has been frozen since February 2019 and has not since reopened.¹¹



*Information obtained mostly from Sinovac's own website unless otherwise stated. Sinovac's webpage is www.sinovac.com



References
1. Vaccination strategies to combat novel corona virus SARS-CoV-2. Life Sciences 256 (2020), 117956
2. G.L. Geison. Pasteur's work on rabies: Reexamining the ethical issues. The Hastings Center Report. Vol.8, No.2, (April, 1978), p.26-33.
3. Monto AS. Francis field trial of inactivated poliomyelitis vaccine: background and lessons for today. Epidemiol Rev.,1999;21:7-23.
4. P. Vandana, D. Prajakta, and J. Ratnesh. Nanoparticulate drug delivery perspectives on the transition from laboratory to market. Oxford: Woodhead Pub. p212. ISBN 9781908818195.
5. Flu vaccine overview. NHS. https://www.nhs.uk/conditions/vaccinations/flu-influenza-vaccine/
6. Draft landscape of COVID-19 candidate vaccines. World Health Orgainzation. 20 August 2020. https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines
7. China's Sinovac phase III trials in Brazil could take as little as three months. Sergio Held and Elise Mak. BioWorld, 10 June, 2020. https://www.bioworld.com/articles/436374-chinas-sinovac-phase-iii-trials-in-brazil-could-last-as-little-as-three-months
8. Indonesia joins Sinovac to initiate phase 3 testing of CoronaVac while securing option to purchase 100m doses. Trial Site News, 23 July, 2020. https://www.trialsitenews.com/indonesia-joins-sinovac-to-initiate-phase-3-testing-of-coronavac-while-securing-option-to-purchase-100m-doses/
9. Y.J. Zhang, G. Zeng, H.X. Pan, et al. mmunogenicity and Safety of a SARS-CoV-2 Inactivated Vaccine in Healthy Adults Aged 18-59 years: Report of the randomized, double-blind, and placebo-controlled phase 2 clinical trial. MedRxiv. doi: https://doi.org/10.1101/2020.07.31.20161216
10. "We will share our vaccine with the world." Inside the Chinese biotech firm leading the fight against COVID-19. Charlie Campbell. Time, 27 July, 2020. https://time.com/5872081/sinovac-covid19-coronavirus-vaccine-coronavac/
11. A vaccine with a poison pill. Matt Levine. Bloomberg, 22 May, 2020. https://www.bloomberg.com/opinion/articles/2020-05-22/a-vaccine-with-a-poison-pill

Coronavirus (20) The race to develop COVID-19 vaccines

Five months have passed since the characterization of COVID-19 as a pandemic by the WHO on 11th March. You may wonder how much progress is being made in developing vaccines specifically for COVID-19. Let us have a look at a report by the WHO that provides data on all the COVID-19 candidate vaccines that are being developed in the world.¹

According to the latest data from WHO (20th August), there are 169 candidate vaccines being developed for COVID-19 prevention, of which 139 are in *preclinical evaluation and 30 are in *clinical evaluation. Eleven countries are at the forefront of the race to develop vaccines: among the vaccines in clinical stages, 6 are from China, 4 from the US, 2 from the UK, 2 from India, and one each from Germany, Japan, South Korea, Belgium, Cuba, Singapore, Canada and Russia. The other 8 candidate vaccines which are in the clinical evaluation stages are jointly developed by research institutes and/or pharmaceutical companies from different countries; adding these 8 candidate vaccines causes Italy, France, Australia and Taiwan to be among the contestants in the race to develop a COVID-19 vaccine.

There are some encouraging points to note. Among the 30 candidate vaccines in clinical evaluation, six are already in phase 3, the last phase of clinical trials. China, where COVID-19 first originated, has 3 candidate vaccines already entered into phase 3, plus one vaccine (BNT162b1) which is jointly developed with Pfizer (a worldwide pharmaceutical company with headquarters in the US) is also in phase 3 of clinical trials. The vaccine (AZD1222) co-developed by the University of Oxford and AstraZeneca in the UK, and the mRNA vaccine (mRNA-1273) developed by Moderna in the US, are also in phase 3 of clinical trials.

Although the speed of global vaccine development is already high, the chief medical officer of England, Professor Whitty, said in an interview on 23rd August that he would be "quite surprised if we had a highly effective vaccine ready for mass use in a large percentage of the population before the end of winter, certainly [not] this side of Christmas".² We should not anticipate that the vaccine for COVID-19 will be available this year. This reflects the fact that phase 3 of clinical trials usually takes a much longer time, than the other initial phases, and usually lasts for several years as more volunteers are needed and the safety requirements are more stringent.

An interesting point to note is that a tobacco company, Kentucky Bioprocessing, Inc., in the US is one of the leading contestants in developing a COVID-19 vaccine. The vaccine candidate they developed has already finished phase 1 and is now in phase 1/2 of clinical trials. In fact, when we look at their website, we can understand that this is not a pure tobacco selling company. It plants tobacco to express, extract and purify proteins for use in vaccines and other pharmaceuticals.³

The traditional vaccines developed in the early 20th century are virus-based and are either live-attenuated or inactivated. However, in the race for COVID-19 vaccine development, we can see a much greater variety of vaccine platforms being used. Other than the traditional platform, different viral vectors, nucleic acid-based vaccines, and antigen-presenting cells are also among the vaccine candidates in the clinical stages. I am going to introduce you the 30 candidate vaccines for COVID-19 which are in clinical evaluation, based on their vaccine platforms, in the next blog posts.



*Preclinical evaluation is the analytical results from testing of the toxicity and efficacy of a medication, vaccine in this case, using human cell cultures or animal models in the laboratory.

Clinical evaluation is the assessment and analysis of clinical data collected from clinical trials. Clinical trials are performed, if the result from preclinical research is promising, to see how well the vaccine works in humans. Clinical trials happen in 3 phases, each phase building on the results of previous phases and recruiting more volunteer participants. Clinical studies to demonstrate the safety and efficacy of vaccines must be conducted in humans before a vaccine can be released for widespread use.



References
1. Draft landscape of COVID-19 candidate vaccines. World Health Orgainzation. 20 August 2020. https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines
2. Coronavirus: Missing school is worse than virus for children - Whitty. BBC news, UK. 23 August, 2020. https://www.bbc.co.uk/news/uk-53875410
3. Home page of Kentucky Bioprocessing, Inc. (KBP). https://kentuckybioprocessing.com/

Western diet triggers trained immunity and causes chronic inflammatory diseases

My last blog post reviewed evidence of the involvement of trained immunity in several chronic inflammatory diseases. You may wonder what are the persistent stimuli that can trigger the innate immunity memory and cause the chronic inflammation that can result in inflammatory-related diseases. The answer is not the live attenuated vaccines, nor any invading pathogens, but the Western style of living. As Prof Netea and others wrote in a review paper, "there is increasing evidence that *sterile inflammation (a pathogen-free inflammation) in response to lifestyle changes in Western societies forms the basis on which chronic inflammatory diseases develop."¹ Let us see the research studies that may give us an idea of how to prevent such chronic inflammatory diseases.

Western diet can induce trained immunity
According to the definition by scientists in the immunity field, the Western style of living includes consumption of a Western-type diet and sedentary behaviour. The Western-type diet, particularly the American diet, contains high calories and is rich in sugars, trans and saturated fats, salt and food additives, but low in complex carbohydrates, fibre, vitamins and minerals.²

In a study aimed at finding out if the Western-type diet can induce trained immunity, mice which were genetically modified so that they are prone to atherosclerosis, had high expression of genes related to inflammation and ^#epigenetic reprogramming in their circulating monocytes and their bone marrow myeloid progenitor cells, after being constantly fed with Western-type diet for 4 weeks. This shows that the Western-type diet induces systemic inflammation and long-lasting innate immune cell reprogramming, which amplifies responses to a secondary immune challenge.³

Even after the mice had been switched to a standard normal diet for another 4 weeks, and the serum cholesterol levels and systemic inflammatory markers returned back to normal, the functional reprogramming in myeloid cells still remained.³ The induction in innate immunity response remaining high indicates that the long-lasting reprogramming of the innate cells triggered by the previous Western-type diet could potentially contribute to chronic inflammatory diseases.

Key substances in a Western-type diet that induce trained immunity
Thus far, research studies have identified several ^@endogenous triggers of innate immunity. These include ^$lipoprotein(a) and ^%oxidized low-density lipoprotein.^4,5 These studies found that oxidized low-density lipoprotein induces long-term cytokine production which promotes inflammation, and foam cell formation which is associated with atherosclerosis. The long-term cytokine production and foam cell formation are induced via epigenetic reprogramming of monocytes.

When ^&oxidized cholesterol in the diet is absorbed, it contributes to the pool of oxidized lipoprotein in human serum.⁶ The high fat Western-type diet thus provides a rich source of endogenous stimulation in form of oxidized low-density lipoprotein that can cause chronic inflammation by triggering a long-lasting innate immunity response via cellular reprogramming.

How does the Western-type diet cause the innate immunity to "memorize"?
The same research study which used mice models to demonstrate the triggering of long-lasting innate immunity by a chronic Western-type diet found that such a diet activates NLRP3 inflammasome, a key innate immune sensor for many environmental danger signals such as uric acid and cholesterol crystals, to induce system inflammation and reprogramming of innate immunity. Therefore, the Western-type diet appears to be mistakenly recognized by the immune system as a threat to the organism.³

What we can learn from these findings?
It is well established that diet high in fat and cholesterol is a risk factor for the development of atherosclerosis, and also for the development of other chronic inflammatory diseases, such as type 2 diabetes, obesity, and chronic liver disease. However, the above studies provide clear evidence that such a diet is mistakenly recognized by innate immunity as a danger signal. The persistent uptake of such a diet could contribute to chronic inflammatory reaction by triggering a long-lasting innate immunity.

Moreover, the fact that studies have shown the reprogramming of innate immune cells occurs via a change in the DNA chromatin level, has caused the emerging concept that ancestral environments and abnormal changes in body functions which are the causes, consequences, or concomitants of disease processes, can be transferred down through generations.

Are the findings from these studies powerful enough to make you determined to make changes to your diet?



*Sterile inflammation: A form of pathogen-free inflammation. This can be caused by mechanical trauma, stress, or environmental conditions. The sterile inflammation referred to in this post is caused by a Western-type diet. These damage-related stimuli induce the secretion of molecular agents, collectively termed danger-associated molecular patterns.

^#Epigenetic reprogramming: A process that involves changing of methylation status of histones on the DNA's chromatin level. This results in a change of chromatin structure and hence of gene expression. Epigenetic reprogramming in innate immune cells usually results in the changing of expression of different inflammatory related genes. The change is reversible but usually can last for a few years. Therefore the epigenetic reprogramming in innate immune cells enables the cells to remember the stimulation and react more quickly next time. However, this can also cause chronic inflammation if the innate immune cells are persistently stimulated.

^@Endogenous triggers: Stimuli from substances inside the body. In this post, these include lipoprotein(a) and oxidized low-density lipoprotein.

^$Lipoprotein(a): This is a plasma lipoprotein composed of apolipoprotein(a) and apolipoprotein B-100 of a low-density lipoproteins-like particle. Lipoproteins are macromolecular complexes of lipid (cholesterol) and proteins that originate mainly from the liver and intestine, and are involved in the transport and redistribution of lipids (cholesterol) in the body.⁷ In other words, cholesterol travels through the blood on lipoproteins.

^%Oxidized low-density lipoprotein: This is a product of chemical reactions between normal low-density lipoproteins and free radicals. It is potentially harmful, because a high level of low-density lipoprotein can lead to a build-up of cholesterol in arteries, which can cause blockages.

^&Oxidized cholesterols: They are mainly generated by frying, heating, and processing of a high cholesterol, fat-rich diet.



References
1. M.G. Netea, J. Dominguez-Andres, L.B. Barreiro, et al. Defining trained immunity and its role in health and disease. Nat. Rev. Immunol., 2020, Jun;20(6): 375-388.
2. A. Christ, & E. Latz. The Western lifestyle has lasting effects on metaflammation. Nat. Rev. Immunol., 2019, 19, 267-268.
3. A. Christ, P. Gunther, M.A.R. Lauterbach, et al. Western diet triggers NLRP3-dependent innate immune reprogramming. Cell, 2018, 172, 162-175.
4. S. Bekkering, J. Quintin, L.A.B. Joosten. et al. Oxidized low-density lipoprotein induces long-term proinflammatory cytokine production and foam cell formation via epigenetic reprogramming of monocytes. Arterioscler. Thromb. Vasc. Biol., 2014, 34, 1731–1738.
5. F.M. van der Valk, S. Bekkering, J. Kroon, et al. Oxidized phospholipids on lipoprotein(a) elicit arterial wall inflammation and an inflammatory monocyte response in humans. Circulation, 2016, 134, 611–624.
6. I. Staprans, X.M. Pan, J.H. Rapp, et al. Oxidized cholesterol in the diet is a source of oxidized lipoproteins in human serum. Journal of Lipid Research, 2003, 44, 705-715.
7. Nutrition in the prevention and treatment of disease. Jose.M. Ordovas, 2001, p157-182.

Trained immunity: a double-edged sword

My last blog post explained that trained immunity, or innate immune memory, provides non-specific protection from secondary infections. The induction of cellular reprogramming in innate immune cells confers an innate immunity with memory characteristics. So far, the only trigger of innate immune memory that we have discussed is microbial triggering, such as triggering from a live attenuated vaccine. But actually the same mechanism of recognition and memory function can also recognize other substances which are not pathogens. In other words, the memory characteristic of the innate immunity mechanism can also be induced by exogenous and endogenous stimuli which are not pathogenic. The fact that trained innate immunity evolved this way, however, does result in harmful effects. Let us have a look at the most recent review paper jointly written by Prof Mihai Netea, who discovered the trained immunity, and the other experts in the field.¹

Netea et al suggested that the reprogramming of the innate immunity and the concomitant increased inflammatory responses to exogenous or endogenous stimuli may have harmful consequences. The induction of trained innate immunity can turn a transient inflammation into a long-lasting effect. Prolonged inflammation is associated with several inflammatory diseases, such as atherosclerosis, and neurodegenerative diseases such as Alzheimer's and dementia, and can also lead to tumour growth and metastasis. The review paper provides evidence from research studies for the association between the innate immunity and the above-mentioned diseases.

Atherosclerosis
Atherosclerosis can lead to heart attack and stroke. Persistent inflammation of vessel wall is characteristic of atherosclerosis. Foam cells, which derived from macrophage*, form a plaque which plays a central role in inflammation during all phases of the atherosclerosis.

A study from Prof Netea found that when *monocytes, an innate immune cell, are stimulated by various micro-organisms, they can develop into *macrophages with persistent ability to promote inflammation, to produce cytokine production and form into foam cells which could lead to atherosclerosis. The stimulated monocytes in the experiment were found to have change at the DNA chromatin level, an indication of the trained immunity process.² The above study indicates that trained immunity stimulated by infections can lead to atherosclerosis.

Alzheimer's disease
Alzheimer's disease is a type of dementia caused by the degeneration of brain cells that process, store and retrieve information, to the point of a loss of function. The disease is characterized by plaques composed of a neurotoxin called β-amyloid. It is hypothesised that the aggregation of the β-amyloid disrupts cell-to-cell communication and activates innate immune cells such as microglia, macrophages which reside in the brain. These immune cells trigger inflammation and ultimately destroy the brain cells.³

In a research study cited by the review, scientists found that peripheral application of inflammatory stimuli in a 3-month old mouse model of Alzheimer's disease, and the second stimulation from β-amyloid plaques at 6-month old leads to a higher β-amyloid plaque load. This indicates a long-lasting training result of microglia.⁴ Moreover, the scientists also found that the functional changes of microglia are accompanied by reprogramming of the cells. This is evidenced by chromatin changes at HIF1α, a gene which usually responds to peripheral trained immunity.^4,5

Cerebral small vessel disease
Cerebral small vessel disease links to systemic inflammation and is a major cause of dementia. According to a research finding cited by the review, in patients with cerebral small vessel disease, peripheral blood-derived monocytes (one type of innate immune cells) have enhanced IL-6 and IL-8 production after **ex vivo stimulation of monocytes with Pam3Cys. Enhanced IL-6 production in the subsequent stimulation is an indication of trained immunity. This shows that the trained immunity contributes to the progression of the disease.⁶ However, a causal link to the pathophysiology of the small vessels in the brain remains to be determined.

Alzheimer's disease and cerebral small vessel disease associated dementia are neurodegenerative diseases occurring generally in older people. In fact, more evidence suggests that there is a link between trained immunity and the inflammatory condition related to an ageing immune system. Therefore, the review suggested that a better understanding of the dark side of trained immunity in ageing populations might help to fight chronic inflammatory diseases such as dementia in elderly patients.

Tumour growth and metastasis
According to the review, chronic inflammation can provide fuels to sustain disease progression and neoplastic transformation, in particular tumour entities. Studies found that trained immunity and the metabolic processes in cancer cells are both reliant on glycolytic metabolism and the up-regulation of the expression and activity of transcription factors such as HIF1α. These findings provide the basis for the interplay between trained immunity and the tumour cells.

Moreover, the review mentioned that innate immune cells infiltrating the tumours' microenvironments can undergo a reprogramming process that leads to the development of maintained inflammatory responses that can boost up the infection-associated proliferation of lymphocytes, impair apoptosis, promote mitochondrial dysfunction and increase oxidative stress. This ultimately promotes the progression of the tumour. Trained cells produce cytokines such as IL-6 and tumour necrosis factor (TNF) that are associated with increased tumorigenicity and the spread of metastases in specific types of tumours. These include oral squamous cell carcinoma and lung, kidney and breast cancer.^7,8

On the other hand, the review mentioned that innate immune cells can be reprogrammed by tumour cells to acquire a more anti-inflammatory situation. This can be exemplified by the low levels of cytokine production in monocytes from chronic lymphocytic leukaemia patients.⁹ Cancer cells also produce a series of soluble mediators that can induce direct epigenetic and metabolic reprogramming in immune cells and can in turn contribute to the progression of the tumour.¹⁰

Conclusion
The reprogramming of the innate immune cells is beneficial when trained immunity results in a fast response to the heterologous pathogen with similar molecular characteristics as the first stimuli. However, from the above examples, we can see that innate immune cells can also be harmful. The resulting prolonged inflammation may also lead to various chronic inflammatory related diseases.



* Monocytes and macrophages are mononuclear cells composing innate immunity. Monocytes are bone-marrow derived leukocytes that circulate in the blood and spleen. Once recruited to tissues, monocytes can differentiate into macrophages and dendritic cells. Macrophages are generally considered terminally-differentiated cells that "engulf" pathogens or toxins and secrete chemokines to recruit other immune cells. The engulfed pathogen is processed by the macrophage and presented to the adaptive immune cells such as B lymphocytes. ** Ex vivo refers to experiments done in cells or tissue from an organism in an external environment with minimal alteration of natural conditions. In the experiment mentioned, the ex vivo stimulation of monocytes were achieved by first isolation of monocytes from blood samples.



References
1. M.G. Netea, J. Dominguez-Andres, L.B. Barreiro, et al. Defining trained immunity and its role in health and disease. Nat. Rev. Immunol., 2020, Jun;20(6): 375-388.
2. J. Leentjens, S. Bekkering, L.A.B. Joosten, et al. Trained innate immunity as a novel mechanism linking infection and the development of atherosclerosis. Circ. Res., 2018,122, 664-669.
3. Beta-amyloid and the amyloid hypothesis. Alzheimer's Association. https://www.alz.org/national/documents/topicsheet_betaamyloid.pdf
4. A.C. Wendeln, K. Degenhardt, L. Kaurani, et al. Innate immune memory in the brain shapes neurological disease hallmarks. Nature, 2018, 556, 332-338.
5. S.C. Cheng, J. Quintin, R.A. Cramer, et al. mTOR- and HIF-1-mediated aerobic glycolysis as metabolic basis for trained immunity. Science, 2014, 345, 1250684-1250684.
6. M.P. Noz, A. tel Telgte, K. Wiegertjes, et al. Trained immunity characteristics are associated with progressive cerebral small vessel disease. Stroke, 2018, 49, 2910-2917.
7. S.H. Lee, H.S. Hong, Z.X. Liu, et al. TNFα enhances cancer stem cell-like phenotype via Notch-Hes1 activation in oral squamous cell carcinoma cells. Biochem. Biophys. Res. Commun., 2012, 424, 58-64.
8. D.R. Hodge, E.M. Hurt, & W.L. Farrar. The role of IL-6 and STAT3 in inflammation and cancer. Eur. J. Cancer, 2005, 41, 2502-2512. 9. T. Jurado-Camino, R. Cordoba, L. Esteban-Burgos, et al. Chronic lymphocytic leukemia: a paradigm of innate immune cross-tolerance. J. Immunol., 2015, 194, 719-727.
10. K. Rabold, M.G. Netea, G.J. Adema, et al. Cellular metabolism of tumor-associated macrophages-functional impact and consequences. FEBS Lett., 2017, 591, 3022-3041.