A brief Summary of Carbohydrates as

Adjuvants
Background:
Vaccination requires adjuvants for optimal immune response. Currently, the FDA-approved adjuvant,
aluminum hydroxide, primarily stimulates a robust Th2 immune response but demonstrates limited
efficacy in inducing cellular (Th1) response, thereby restricting its applications. A number of
carbohydrate polymers from plants,microbes, and synthetic sources have been studied to possess
immunomodulating activities, as well as the performance of high biocompatibility and low toxicity .
These characteristics of carbohydrates,especially polysaccharides, have drawn the attention of many
experts to explore the possibility to develop polysaccharides as successful vaccine adjuvants.

Polysaccharide-based adjuvants:
Inulin-based adjuvants:
Inulin, which is made up of a linear -D-(21)polyfructofuranosyl -Dglucoses with up to 100 fructose
moieties connected to a single terminal glucose, is found in the roots of Compositae (9). Alpha, beta,
gamma, and delta are the four solubility-distinguished forms of inulin; gamma and delta forms have
been shown to display adjuvanticity with increase of both cellular and humoral immunity, while
exhibiting no toxicity. Numerous vaccines have been developed using delta inulin, also known as
Advax, which has been widely studied for its ability to increase both cellular and humoral immunity.
Studies have demonstrated its effectiveness in boosting the immune response against pathogens
such the influenza virus, the Japanese encephalitis virus (JEV), and hepatitis B virus. Advax appears
to work by attaching to antigen-presenting cells, increasing antigen presentation, and then activating
T- and B-cells that are specific for the antigen. This results in the generation of both Th1 and Th2
cytokines and antibody responses. Notably, because it does not cause substantial inflammatory
reactions in individuals, it has been found to be safer and more tolerable than conventional
adjuvants like aluminium.

Chitosan-based adjuvant:
Chitosan is a linear β-(1→4)-linked copolymer of D-glucosamine and N-acetyl-D-glucosamine
(GlcNAc), prepared by alkaline partial deacetylation of chitin. Chitosan possesses good biological
characteristics in vivo, such as favorable biocompatibility and biodegradability, no toxicity and no
reactogenicity. In addition to activating macrophages and dendritic cells and upregulating the
production of activation markers and proinflammatory cytokines, chitosan-based powders and
micro/nanoparticles show improved antigen-presenting abilities. Furthermore, influenza virus, CpG
ODN, and QS-encapsulated chitosan nanospheres exhibit a noteworthy capacity to elicit both local
and systemic immune responses, making them effective adjuvant delivery methods for influenza
vaccination. Likewise, it has been demonstrated that chitosan's trimethylated derivative (TMC)
causes significant antibody responses in the nasal and serum compartments. Additionally, preclinical
research and Phase I/IIa clinical trials have shown that hydrogel formulations like ViscoGel, made of
soluble chitosan, have considerable adjuvant action, inducing higher humoral and cellular responses
when paired with vaccinations. As chitosan-based DC vaccines encourage cytotoxic T lymphocyte
(CTL) activity against tumours, suggesting their potential value in cancer therapy, the use of chitosan
in anti-tumor adjuvants has also demonstrated promise. Notably, water-soluble chitosan (WSC)
treatment has been linked to an increase in immune cell populations and cytokine levels in
radiotherapy patients, suggesting the possibility of using chitosan as an immunological adjuvant in
anti-tumor therapy.

Glucan-based adjuvant:
Glucans are polysaccharides from plants and microorganisms made up of repeating D-glucose units
linked by glycosidic bonds, and can be divided into α- and β-glucans according to conformations (7).
β-Glucans are one of the most abundant polysaccharides in bacteria, fungi, and plants, such as
zymosan, lentinan, and algal glucan. They have been reported to possess immunological, anti-tumor,
anti-infection activities, and also enhance the immune response of vaccines. The innate immune
system recognises -glucans as pathogen-associated molecular patterns (PAMPs) by attaching to
receptors on different immune cells. Studies show that they can improve both innate and adaptive
immune responses by increasing the generation of antibodies and upregulating the transcription of
immunomodulatory molecules. Notably, -glucans have been found to exhibit adjuvant and
protective effects in a variety of vaccination models, including those for fish and fowl, demonstrating
their broad potential for improving vaccine effectiveness. Additionally, research on the
immunomodulating properties of several glucans, including curdlan sulphate and -glucan particles,
has demonstrated their capacity to promote cell proliferation, activate immune cells, and trigger
cytokine production. These findings imply that glucans have the capacity to modify immunological
responses, create a shift towards a Th1-biased response, and function as efficient antigen delivery
systems. Additionally, several -glucans, including Nano-11 and Ac-DEX microparticles, show promise
adjuvant effects by promoting immune cell stimulation and antigen absorption, making them ideal
candidates for efficient vaccine delivery methods.

Other polysaccharide adjuvants:

Mannose-containing polysaccharides have the property of adjuvanticity because they bind to
mannose-binding lectin (MBL) and other C-type lectins on macrophages and dendritic cells,
activating complement and triggering phagocytosis, both of which are essential for innate immunity.
Mice exposed to systemic aspergillosis have showed protective benefits from mannan and mannan-
BSA conjugates. Studies on oxidised and reduced mannan-MUC1 in mice demonstrate that they
induce Th1 and Th2 responses, respectively, as well as the generation of particular antibodies,
highlighting their potential in immunotherapy. Additionally, oligomannose-coated liposomes show
the capacity to transport antigens, activating cytotoxic T cells and specific Th1 immune responses.
The MBL receptor has also been shown to be recognised by fructooligosaccharide (FOS), and FOS
supplementation has been shown to increase the generation of particular antibodies in hens given
the infectious bronchitis vaccination. Notably, AS04, a compound made of monophosphoryl lipid A
(MPL) and aluminium phosphate, has been successfully licenced for use in HBV and HPV vaccines
and has demonstrated strong immunomodulatory effects. MPL is an LPS derivative that functions as
an immunologically active adjuvant by binding to the TLR4 complex.
The carbohydrate-based drugs launched during 2000-2021

No. Generic Name Indications Year Country Chemical Category

1 Remedesivir Antiviral 2020 USA Nucleoside
2 Molnupiravir Antiviral 2021 UK Nucleoside
3 Azvudine Antiviral 2021 China Nucleoside
4 Givosiran siRNA for AHP 2019 USA Glycoconjugate
5 Typhim Vi Typhim prevention 2014 USA Glycoconjugate
vaccine

Conclusions:
The potent immune adjuvants derived from polysaccharides have been the hot topic in the pathway
to a successful vaccine adjuvant, due to the advantages of non-toxic, biodegradation, good
biocompatibility, strong immune enhancement and low reactogenicity. Polysaccharide-based
compounds and formulations are promising candidates for vaccine adjuvants in prevention and
treatment of infectious pathogen diseases or cancers. Although a large number of studies on novel
adjuvants have been carried out, further efforts are needed to select one adjuvant to challenge the
monopoly of aluminum adjuvants in human vaccine adjuvant usage.