Malaria: even more chronic in nature than previously thought; evidence for subpatent parasitaemia detectable by the polymerase chain reaction

Influence of CD4+CD25+ T cells on Plasmodium berghei NK65 infection in BALB/c mice

CD4(+) T cells co-expressing CD25 (CD4(+)CD25(+) T cells) have been identified as immunoregulatory suppressors modulating autoimmune response. Beside that, autoimmune response was supposed to be associated with malaria infection. Based on these data, we hypothesised that CD4(+)CD25(+) T cells may influence protective immunity to malaria parasites, while suppressing autoimmune response arising throughout the course of malarial infection. To test this possibility, we evaluated the kinetics of CD4(+)CD25(+) T cells during malaria infection and investigated the influence of CD25 depletion by anti-mouse CD25 monoclonal antibody (PC61) on the infection, using a mouse model of premunition to Plasmodium berghei NK65 malaria. The results showed that, during exacerbation of P. berghei NK65 infection, the proportion of CD4(+)CD25(+) T cells among CD4(+) T cells decreased, although that of CD4(+) T cells increased. CD25 depletion clearly delayed the growth of parasitaemia during parasite challenge, particularly in immunised mice. These findings demonstrated that CD4(+)CD25(+) T cells are able to influence protective immunity underlying premunition to P. berghei NK65 parasites.

The molecular epidemiology of malaria

This review discusses how the use of molecular genetic techniques such as the polymerase chain reaction are helping in the management and prevention of malaria.

New strategies for the diagnosis and screening of malaria

Thin and thick blood film microscopy are the "gold standard" for malaria diagnosis. In recent years, there have been important developments in malaria diagnostic tests including fluorescence microscopy of malaria parasites stained with acridine orange, dipstick immunoassays that detect species-specific parasite antigens, and more recently, detection of parasite nucleic acids after amplification by PCR. With some of these methods, sensitivities and specificities approaching and even exceeding those of the thin and thick film can be attained. In particular, PCR-based tests for plasmodium DNA or RNA are more sensitive and specific than other tests for malarial parasites. A specific application for PCR diagnosis of malaria could be blood donor screening. Clinical trials of blood donor sreening for malarial parasites by PCR are being conducted, in which pooled donor samples are screened to increase efficiency and reduce costs. Some of the new diagnostic methods may have specific applications in particular settings, depending on the purpose and location of testing, and other factors such as cost, desired sensitivity and specificity, speed and ease of use.

Plasmodium falciparum: PCR detection and genotyping of isolates from peripheral, placental, and cord blood of pregnant Malawian women and their infants

Polymerase chain reaction (PCR) is both a sensitive means of detecting malaria parasitaemia, and a simple tool for identifying genetic differences in parasites infecting human subjects. We compared PCR to microscopy in detection of Plasmodium falciparum infection in peripheral, placental and cord blood samples collected from 131 pregnant Malawian women and their infants in 1997-99. Infections detected by species-specific PCR were genotyped at the merozoite surface protein 1 and 2 loci, and minimum numbers of infecting genotypes determined. PCR was of similar sensitivity to microscopy in detecting peripheral and placental infection, and placental blood PCR was 100% specific compared to placental histology. Cord blood parasitaemia was more frequently detected by PCR than microscopy, 20% versus 6%. Genotype numbers in peripheral blood (mean 2.36; range 1-5), placental blood (mean 2.41; range 1-6) and cord (mean 2.14; range 1-4) were similar. The frequency of detection of each allelic family did not differ between sites. Genotypes from different sites in each patient were compared. In 69% of women, genotypes were detected in peripheral blood and not placenta, or vice versa, suggesting possible differential sequestration of different parasite populations. Cord blood genotypes were usually a subset of those in peripheral and placental blood, but, in some cases, genotypes were found in cord blood that were absent from the mother. Transplacental infection before term, and clearance of maternal infection, is postulated.

Evaluation of the OptiMAL rapid antigen test and species-specific PCR to detect placental Plasmodium falciparum infection at delivery

During pregnancy, Plasmodium falciparum infection of the placenta frequently occurs in the absence of parasites in peripheral blood. We investigated the abilities of the OptiMAL rapid immunochromatographic strip test for P. falciparum lactate dehydrogenase and species-specific PCR performed on peripheral blood to detect placental infection or malaria-associated low birth weight. Of 509 Malawian women screened by microscopy, 76 had malaria infection. Among these 509 women, the frequency of peripheral blood parasitemia was low. The OptiMAL test gave positive results in 37 of 171 women tested (one of whom had placental but not peripheral blood parasitemia) and had sensitivities of 71% for peripheral parasitemia and 38% for placental parasitemia compared to the microscopy values. The specificity for peripheral parasitemia was 94%. In 135 women, PCR had sensitivities of 94% for peripheral blood malaria detected by microscopy and 72% for placental infection. In samples examined by PCR, the prevalence of malaria in peripheral blood increased from 26.7% by microscopy to 51.9%. Women with placental malaria and women with malaria in peripheral blood samples by microscopy or OptiMAL testing, but not women with malaria detected only by PCR, had lower-birth-weight babies than did women without malaria by these criteria. Positive results by PCR in the absence of microscopic parasitemia were not associated with low birth weight. Neither OptiMAL nor PCR testing of peripheral blood is adequately sensitive to detect all placental malaria infection, but a positive result by OptiMAL testing identifies women with a high proportion of low-birth-weight babies.

Malaria in pregnancy in rural Mozambique: the role of parity, submicroscopic and multiple Plasmodium falciparum infections

BACKGROUND

Falciparum malaria affects pregnant women, especially primigravidae, but before malaria control programmes targeted to them can be designed, a description of the frequency and parity pattern of the infection is needed. There is little information on the frequency and effect of submicroscopic malaria infection, as well as on multiplicity of Plasmodium falciparum genotypes in pregnancy. This study aimed to describe the prevalence of malaria parasitaemia and anaemia and their relation to parity and age in pregnant women, during two malaria transmission seasons in a rural area of southern Mozambique. It also tried to assess the frequency and effect on anaemia of submicroscopic and multiple falciparum infections.

METHODS

A total of 686 pregnant women were enrolled in three cross-sectional community-based surveys during different transmission seasons in rural southern Mozambique. In each survey a questionnaire was administered on previous parity history, the gestational age was assessed, the axillary temperature recorded and both haematocrit and malaria parasitaemia were determined. We used polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analysis to determine submicroscopic and multiple P. falciparum infections in a subsample of women.

FINDINGS

A total of 156 women (23%) had microscopic parasitaemia, of which 144 (92%) were asexual forms of P. falciparum. The prevalence of clinical malaria was 18 of 534 (3%), that of anaemia, 382 of 649 (59%). In a multivariate analysis age but not parity was associated with an increased risk of microscopic parasitaemia. Anaemia was associated with microscopic P. falciparum parasitaemia. Both malaria parasitaemia and anaemia were more frequent during the rainy season. Although not statistically significant, submicroscopic infections tended to be more frequent among grand-multiparous pregnant women. Subpatent infections were not associated with increased anaemia. Multiplicity of infection was not associated with either parity, age or anaemia. Likewise, there was no correlation between P. falciparum density and multiplicity of infection.

INTERPRETATION

We did not observe a clear parity pattern of malaria and anaemia in our study. It is possible although unlikely that selection bias may have influenced these findings; but in which direction is unclear. The importance of locally based research before implementation of public health measures needs to be highlighted. According to our findings, a more cost-effective malaria control approach in this area would be targeting all pregnant women regardless of their parity. This would be also more feasible logistically as it would not rely on accurate ascertainment of parity, something that is not always easy in busy antenatal clinics.

AIDS possibly caused by HIV and latent malaria coinfection

The presented hypothesis suggests that chronic latent malaria infection prepares the niche where the otherwise feeble HIV coinfection can thrive and cause AIDS. It is suggested that the roots of the HIV outbreak and AIDS pandemic lay in the urbanization processes in Africa that resulted in the eradication of the Anopheles vector from previously endemic areas, which changed the immunological status of the inhabitants there as they lost their natural immunity to malaria. Since malarial parasites may persist in the lymphatic network for a lifetime and reduce T cell proliferation while adhering to immature dendritic cells, the loss of this natural immunity made the African population, which was chronically affected with scanty parasitemia, vulnerable to opportunistic infections, HIV among them. The specific transmission modes of latent malaria infection elucidate why AIDS flares up in Africa and spreads there evenly in the population, while in the West it expands rather slowly and is restricted mainly to homosexuals and blood recipients.

The detection of Plasmodium falciparum and P. vivax in DNA-extracted blood samples using polymerase chain reaction

Seventeen pairs of published primer sets were compared for their relative sensitivity to detect malaria DNA extracted from blood samples, which were obtained from Pakistani patients suffering from malaria. The primer sets investigated consisted of: (i) 9 pairs of direct primers and 3 sets of nested primers for detecting Plasmodium falciparum, (ii) 2 pairs of direct primers and 2 sets of nested primers for detecting P. vivax, and (iii) 1 set of multiplex primers for detecting both P. falciparum and P. vivax, simultaneously. After a miniscreen of 9 DNA-extracted blood samples using the 17 primer sets stated above, 5 primer sets were short-listed (based on their superior sensitivity) and used for a maxi-screen of DNA extracted from 126 microscopy-positive blood samples from Pakistan, with the following results. (i) For the detection of P. falciparum, the direct primer pair 'PF1 + PF2' gave a sensitivity of 95% and the nested primer set 'RIT405 + RIT406/RIT371 + RIT372' gave a sensitivity of 97%. (ii) For the detection of P. vivax, the direct primer pair 'Forward + Reverse' and the nested primer set 'PLF + UNR/PLF + VIR' both gave a sensitivity of 94%. (iii) The nested multiplex primer set 'rPLU5 + rPLU6/rFAL1 + rFAL2 + rVIV1 + rVIV2' gave a sensitivity of 97% and 96% for P. falciparum and P. vivax, respectively. It was concluded that the nested multiplex primer set was the most optimal primer set to use for the detection of malaria DNA extracted from blood samples. Furthermore, the nested multiplex primer set has the advantage of simultaneously detecting and differentiating between P. vivax and P. falciparum.

Subacute clinical forms of Plasmodium falciparum malaria in travelers receiving chloroquine-proguanil prophylaxis

We have observed 4 French travelers, returning from African countries, who were not immune to malaria and were receiving chloroquine-proguanil prophylaxis, in whom the diagnosis of malaria could easily have been missed because the clinical signs were uncommon. These cases suggest that chloroquine-proguanil prophylaxis is not always effective and that travelers with unexplained symptoms should be monitored closely for malaria.

Malaria in São Tomé and Príncipe: parasite prevalences and vector densities

A cross-sectional survey was carried out in 16 localities on the island of São Tomé and three on the island of Príncipe, at the end of the rainy season of 1997, to determine malaria prevalence and vector densities. Blood samples from 664 inhabitants of all ages were examined by optical microscopy (OM) and PCR. Mosquito collections were made by outdoor landing captures from 21:00-23:00 h. Great differences were found between OM and PCR readings. OM had a sensitivity of 66%, a specificity of 79% and failed to reveal any mixed-infections. Overall prevalence, determined by PCR, was higher in São Tomé (53%) than in Príncipe (35%). It was highest in children below 16 years-old. All four human Plasmodium species occurred in São Tomé but P. ovale was not detected in Príncipe. The human population was largely asymptomatic. Bednet users had lower prevalence than did non-users. The FOREST form of Anopheles gambiae s.s., identified by PCR and cytogenetics, was the only vector on the islands. The sporozoite rate in São Tomé, assessed by ELISA, was 0.5%. Parasite prevalence and vector densities were positively correlated in São Tomé, where malaria transmission must occur predominantly in the more populated coastal areas.

Modelling a predictable disaster: the rise and spread of drug-resistantmalaria

The evolution of drug-resistant malaria is one of the most important factors thwarting the development of effective malaria disease control. Several mathematical models have been developed to try and understand the dynamics of this process and how it can be slowed or even avoided. Much of the mathematics describing the evolution of drug resistance in malaria focuses on the derivation and mechanics of the calculations, which can make it inaccessible to experimentalists and field workers. In this article, Ian Hastings and Umberto D'Alessandro describe general model results without recourse to mathematical details, identify the factors that should be considered in the design of drug control programmes, and discuss the crucial parameters that remain unknown and need to be measured in the field or laboratory.

Apoptosis modulation in mononuclear cells recovered from individuals exposed to Plasmodium falciparum infection

In endemic areas, asymptomatic infection by the malaria parasite Plasmodium falciparum was found associated with elevated percentages of human host's mononuclear cell spontaneous in-vitro apoptosis. In Dielmo, a village where malaria is holoendemic, apoptosis was age-and parasite-dependent. In-vitro exposure of peripheral blood mononuclear cells (PBMC) to the parasite extract induced a marked increase in the mononuclear cell membrane expression of functional CD95 antigen: a 3-h exposure of the mononuclear cells to anti-CD95 antibodies led to a detectable increase in the mean percentage of apoptotic nuclei found in the cultures carried out in the presence of P. falciparum extracts compared to control cultures. IL-2, IL-4, IL-6 and IL-10 promoted the viability of PBMC in cultures while IL-1alpha or IFN-gamma had no obvious impact and TNFalpha gave conflicting results. IL-2 was the most efficient cytokine at rescuing PBMC from cell death and this effect was associated with a strong increase in T cell activation. In contrast, IL-4 and IL-10 had no such effect on T cell activation, hence they acted as survival factors and not through their mitogenic activity. Taken together, these different observations suggested that the levels of in-vitro apoptosis observed were not only associated with parasite infection, but also potentially modulated by the human host through different pathways.

Submicroscopic Plasmodium falciparum infections in pregnancy in Ghana

Malarial parasitaemia below the threshold of microscopy but detectable by polymerase chain reaction (PCR) assays is common in endemic regions. This study was conducted to examine prevalence, predictors, and effects of submicroscopic Plasmodium falciparum infections in pregnancy. In a cross-sectional study among 530 pregnant women in Ghana, plasmodial infections were assessed by microscopy and PCR assays. Concentrations of haemoglobin and C-reactive protein (CRP) were measured and antimalarial drugs (chloroquine, pyrimethamine) in urine were demonstrated by ELISA dipsticks. By microscopy, 32% of the women were found to harbour malaria parasites. This rate increased to 63% adding the results of the parasite-specific PCR. P. falciparum was present in all but one infection. With increasing gravidity, infection rates and parasite densities decreased and the proportions of submicroscopic parasitaemia among infected women grew. Correspondingly, anaemia, fever and evidence of inflammation (CRP > 0.6 mg/dl) were more frequent in primigravidae than in multigravidae. Antimalarial drugs were detected in 65% of the women and were associated with a reduced prevalence of P. falciparum infections and a raised proportion of submicroscopic parasitaemia. Both gravidity and antimalarial drug use were independent predictors of submicroscopic P. falciparum infections. These infections caused a slight reduction of Hb levels and considerably increased serum concentrations of CRP. Conventional microscopy underestimates the actual extent of malarial infections in pregnancy in endemic regions. Submicroscopic P. falciparum infections are frequent and may contribute to mild anaemia and inflammation in seemingly aparasitaemic pregnant women.

Biased distribution of msp1 and msp2 allelic variants in Plasmodium falciparum populations in Thailand

Plasmodium falciparum isolates were obtained from Thai patients attending a malaria clinic on the Thai-Kampuchean border over 4 cross-sectional surveys carried out at 3-monthly intervals. The genetic structure of the parasite populations was determined by nested polymerase chain reaction (PCR) amplification of polymorphic regions of 3 P. falciparum antigen genes: msp1, msp2 and glurp. Although a high degree of diversity characterized these isolates, the overall population structure of the parasites associated with patent malaria infections was observed to remain relatively stable over time. The highest degree of polymorphism was observed with msp2, and the mean number of lines per infection (multiplicity of infection) calculated with this marker was higher than that obtained using msp1 or glurp alone, or combined. Infections with > or = 2 parasite lines were seen in 76% of the samples, and were proportionally more numerous at the start and end of the rainy season. Two interesting exceptions to the random distribution were observed and involved 2 allelic variants which in one case were found dissociated (msp1 MAD20-family) and in the other were associated (msp2 FC27-family). The epidemiological significance of these types of data is discussed.

The blood-stage dynamics of mixed Plasmodium malariae-Plasmodium falciparum infections

We present the first mathematical model of the within-host dynamics of a mixed-species malaria infection in a human: the blood-stage population dynamics of a dual infection with Plasmodium malariae and Plasmodium falciparum. Our results reproduce several important features of such infections in nature, including the asymmetry of species asexual-form densities, inter-specific suppression through interactions with the human immune system, and seasonal alternations in species prevalence. Most importantly, our results suggest that an existing P. malariae infection can reduce the peak parasitemia of a subsequent P. falciparum superinfection by as much as 50%. This result integrates numerous empirical observations and supports the hypothesis that clinical outcomes of P. falciparum infections may be influenced by the presence of a congener.

Development of a Plasmodium PCR for monitoring efficacy of antimalarial treatment

We report in this work a highly sensitive and nonradioactive PCR method for the detection of the four species of parasite causing human malaria. Plasmodium-specific primers corresponding to the small-subunit rRNA genes of the malaria parasite were used, and a 291-bp fragment was amplified. Our results showed a high specificity for the four human Plasmodium species, and we were able to detect one parasite in 50 microl of whole blood. The responses of 12 patients infected with Plasmodium falciparum to antimalarial therapy were monitored by PCR diagnosis and examination of thick blood film for at least 20 min by an experienced microscopist. For one patient this study allowed early diagnosis of therapeutic failure, confirmed 7 days later by examination of the thick blood film. A total of 134 samples were examined; 94 were positive by PCR, and among these 68 were positive by thick blood film examination. The sensitivity of the thick blood film was 72.3% compared to PCR and 60.7% compared to dot blot hybridization.

Unstable malaria in Sudan: the influence of the dry season. Clone multiplicity of Plasmodium falciparum infections in individuals exposed to variable levels of disease transmission

Studies of infection and immunity to malaria often take little account of the fact that the amount of infectious challenge individuals receive is very variable. Classic studies in areas of holoendemic transmission showed that clinical immunity develops quite rapidly during childhood, although the processes through which increasing levels of resistance to infection are acquired are still not understood. However, holoendemic transmission is one end of the spectrum of malaria epidemiology and the development of clinical immunity is also affected by factors such as the infection rate and the local parasite species composition. An exceptionally simple type of malaria transmission occurs during the short, autumnal malaria outbreaks of the Sudanese sahel-savannah belt, where a sparse 200-500 mm of rain falls in 2-3 summer months, Plasmodium falciparum causes > 95% of malaria cases in most areas, and the entomological inoculation rate (EIR) is very low by African standards; thus the population dynamics of malaria parasites are less affected by super-infection. A comparison of certain features of parasite genetic diversity, particularly the average number of parasite clones present in infections in the Sudanese sahel and in malaria study sites with different levels of transmission, is presented. It is proposed that increasing EIRs are associated with progressively smaller increases in the average number of malaria parasite clones per host and the implications of this relationship for studies on malaria infection and immunity are discussed.

Sequence variation in the small-subunit rRNA gene of Plasmodium malariae and prevalence of isolates with the variant sequence in Sichuan, China

By two PCR-based diagnostic methods, Plasmodium malariae infections have been rediscovered at two foci in the Sichuan province of China, a region where no cases of P. malariae have been officially reported for the last 2 decades. In addition, a variant form of P. malariae which has a deletion of 19 bp and seven substitutions of base pairs in the target sequence of the small-subunit (SSU) rRNA gene was detected with high frequency. Alignment analysis of Plasmodium sp. SSU rRNA gene sequences revealed that the 5' region of the variant sequence is identical to that of P. vivax or P. knowlesi and its 3' region is identical to that of P. malariae. The same sequence variations were also found in P. malariae isolates collected along the Thai-Myanmar border, suggesting a wide distribution of this variant form from southern China to Southeast Asia.

Unstable malaria in Sudan: the influence of the dry season. Plasmodium falciparum population in the unstable malaria area of eastern Sudan is stable and genetically complex

This paper reviews surveys carried out, over a period of 6 years between 1989 and 1995, to examine Plasmodium falciparum population structure in Asar village in eastern Sudan, an area of unstable malaria, the incidence of which is confined to a few weeks following the short rainy season (June-October). The first phase of the study involved regular cross sectional surveys, between 1989 and 1993 during the seasons of malaria incidence, while the second involved surveys during the malaria-free months of the dry seasons. The parasites were examined for 20 polymorphic loci, including enzyme electrophoretic variants, proteins detected by 2 dimensional polyacrylamide gel electrophoresis, antigens detected by monoclonal antibodies, and in vitro responses to antimalarial drugs. In addition, alleles of the polymorphic genes for merozoite surface proteins 1 and 2 (MSP-1, MSP-2) were examined using the polymerase chain reaction and oligonucleotide probes. Great genetic complexity was observed among the parasites which appeared during the short transmission seasons. A large proportion of the patients who were infected during the transmission season maintained asymptomatic, subpatent parasitaemias throughout the subsequent dry season, often as genetically complex infections.

Only viable parasites are detected by PCR following clearance of rodent malarial infections by drug treatment or immune responses

Detection and analysis of pathogens by PCR plays an important role in infectious disease research. The value of these studies would be diminished if nuclear material from dead parasites were found to remain in circulation for extended periods and thus result in positive amplification. This possibility was tested in experimental rodent malaria infections. Blood samples were obtained from infected mice during and following drug or immune clearance of Plasmodium chabaudi chabaudi parasitemias. Detection of parasite DNA by a sensitive Plasmodium-specific PCR amplification assay was associated with the presence of viable parasites, as detected by subinoculation. No parasite DNA could be detected by PCR 48 h after the injection of killed parasites into mice. Nuclear material from parasites removed by drug or immune responses is rapidly cleared from the circulation and does not contribute significantly to amplification. Thus, results from PCR analysis of malaria-infected blood accurately reflect the presence of live parasites.

Comparison of a rapid dipstick test and thick blood films for detecting parasites of plasmodium falciparum used under typical conditions at a semi-rural hospital in Cote d'Ivoire

This prospective study compares a rapid dipstick test (ParaSight-F) with thick blood films for the detection of parasites of P falciparum, under 'typical' conditions and constraints to be found in a semi-rural hospital in a tropical developing country in Africa. Eighty-two samples were tested using the two techniques and found to concur in 95.1% of cases. However, in four of the samples the results differed. The thick blood films of 60 samples were later re-read by a local reference laboratory. Of these 98.3% were in agreement with the reading performed at the hospital. Only one of the 60 slides differed. The rapid dipstick test proved to be both easy to use and free from many of the usual constraints such as a need for formally trained or experienced laboratory staff, laboratory equipment, and reliable water and electricity supplies. In an holoendemic area for P falciparum transmission, it would appear to be eminently suitable, in technical terms and ease of handling as well as on the basis of rapid results, for wider distribution within this region. Its main drawback remains financial.

Multiparasite communities in animals and humans: frequency, structure and pathogenic significance

Individual humans and animals are subject to infection by a variety of parasites (broadly defined to include viruses, bacteria and other non-protozoan microparasites) at any one time. Multiple parasite infections occur frequently in populations of wild animals as well as in humans from developing countries. In some species and regions, hosts with multiple infections are more common than hosts with either no infection or a single infection. Studies, predominantly on animals, show that a wide variety of environmental and host-dependent factors can influence the structure and dynamics of the communities of parasites that make up these multiple infections. In addition, synergistic and competitive interactions can occur between parasite species, which can influence the likelihood of their successful transmission to other hosts and increase or decrease their overall pathogenic impact. This review summarises aspects of our current knowledge on the frequency of multiparasite infections, the factors which influence them, and their pathogenic significance.

The glutamate-rich protein (GLURP) of Plasmodium falciparum is a target for antibody-dependent monocyte-mediated inhibition of parasite growth in vitro

Monocyte-dependent as well as direct inhibitory effects of antimalarial antibodies point toward antigens accessible at the time of merozoite release as targets for biologically active antibodies capable of mediating protection against Plasmodium falciparum. The glutamate-rich protein (GLURP), being an antigen associated with mature schizont-infected erythrocytes, was therefore the object of the present investigation, in which we analyzed whether anti-GLURP antibodies can either interfere directly with merozoite invasion or act indirectly by promoting a monocyte-dependent growth inhibition, antibody-dependent cellular inhibition. GLURP-specific human immunoglobulin G (IgG) antibodies, from pooled IgG of healthy Liberian adults who were clinically immune to malaria, were purified by affinity chromatography on columns containing R0 (N-terminal nonrepetitive region of GLURP) or R2 (C-terminal repetitive region of GLURP) recombinant protein or synthetic peptides as ligands. Analysis of the pattern of reactivity of highly purified anti-GLURP antibodies led to the definition of at least four B-cell epitopes. One epitope was specific for R0, two were specific for R2, and the fourth displayed cross-reactivity between R0 and R2. None of the purified IgG antibodies had direct invasion-inhibitory effects, even at high concentrations. In contrast, when allowed to cooperate with monocytes, all anti-GLURP IgG preparations mediated a strong monocyte-dependent parasite growth inhibition in a dose-dependent manner.

Discrete-Event Simulation Models of Plasmodium falciparum Malaria

We develop discrete-event simulation models using a single "timeline" variable to represent the Plasmodium falciparum lifecycle in individual hosts and vectors within interacting host and vector populations. Where they are comparable our conclusions regarding the relative importance of vector mortality and the durations of host immunity and parasite development are congruent with those of classic differential-equation models of malaria, epidemiology. However, our results also imply that in regions with intense perennial transmission, the influence of mosquito mortality on malaria prevalence in humans may be rivaled by that of the duration of host infectivity.

T-cell immunity to peptide epitopes of liver-stage antigen 1 in an area of Papua New Guinea in which malaria is holoendemic

Liver-stage antigen 1 (LSA1) is one of several pre-erythrocytic antigens considered for inclusion in a multiantigen, multistage subunit vaccine against falciparum malaria. We examined T-cell proliferation and cytokine responses to peptides corresponding to amino acids 84 to 107, 1813 to 1835, and 1888 to 1909 of LSA1 in asymptomatic adults living in an area of Papua New Guinea where malaria is holoendemic. Whereas T cells from North Americans never exposed to malaria did not respond to any of the peptides, those from 52 of 55 adults from the area where malaria is endemic had vigorous proliferation responses to one or more of the LSA1 peptides (mean stimulation indices of 6.8 to 7.2). Gamma interferon (IFN-gamma) production driven by LSA1 peptides ranged from 34 to more than 3,500 pg/2 x 10(6) cells, was derived primarily from CD8+ cells, and was dissociated from T-cell proliferation. The frequencies of IFN-gamma response to the amino acid 1819 to 1835 and 1888 to 1909 peptides were significantly greater than that to the amino acid 84 to 107 peptide (87 and 88% versus 33% of subjects; P < 0.0001). In contrast to proliferation and IFN-gamma, interleukin 4 (IL-4) and/or IL-5 responses to LSA1 peptides were detected in only 18% of the subjects. These data show that T-cell immunity to epitopes in the N- and C-terminal regions of LSA1 are common in persons living in this area of Papua New Guinea where malaria is endemic. The dominance of type 1 CD8 cell IFN-gamma responses is consistent with a role for this T-cell population in immunity to liver-stage Plasmodium falciparum in humans.

A hypothesis about the chronicity of malaria infection

It is generally accepted that malaria evolves as a chronic blood infection by escaping the immune responses directed against a series of antigens that express variable epitopes and/or by selecting parasite populations with distinct polymorphic antigens. However, exacting in vitro studies, performed with clinically well-defined biological material, have correlated the state of protection of African adults (in whom low-grade infection persists) with an indirect defence mechanism where the antibodies are effective owing to their ability to cooperate with blood monocytes. Further studies showed that the antibody bridges the parasite (at the merozoite stage) with a monocyte and triggers the release of mediators which have a parasitistatic, reversible and non-antigen-specific effect. The fact that the parasite directly triggers the antiparasite effect leads Pierre Druilhe and Jean-Louis Pérignon to formulate here an alternative hypothesis for the chronicity of malaria infection, which would rely on conserved antigenic targets and, in contrast with direct mechanisms, would not select emerging mutated parasites. The above two mechanisms are discussed in the context of their fitness with clinical and parasitological observations. It is proposed that they are not mutually exclusive but, rather, may come into play successively as patients gradually evolve from high-grade symptomatic to low-grade asymptomatic parasitic infection.

Incidence of clinical malaria in pregnant women exposed to intense perennial transmission

The interaction between pregnancy and malaria attacks was investigated from 1990 to 1994 among women in the village of Dielmo, a holoendemic area in Senegal where malaria transmission is intense and perennial. Clinical and parasitological data collected during the daily follow-up of 48 pregnancies among 31 women were compared with those collected from the same women using the same methods during the year which preceded or followed their pregnancy. The parasite prevalence, mean and maximum parasite density in Plasmodium falciparum infections were significantly higher during pregnancy. The incidence rate of malaria attacks was, on average, 4.2 times higher during pregnancy than during the control period. Although most pregnancies were not associated with a malaria attack and the incidence of malaria attacks decreased as the number of previous pregnancies increased, a significant increase in risk of malaria attacks among multigravidae was noted until the fifth pregnancy.

Humoral immune responses of Solomon Islanders to the merozoite surface antigen 2 of Plasmodium falciparum show pronounced skewing towards antibodies of the immunoglobulin G3 subclass

The immunoglobulin G (IgG) subclass distribution of antibodies to merozoite surface antigen 2 of Plasmodium falciparum in Solomon Islanders showed marked skewing towards the IgG3 subclass. This was not observed with crude P. falciparum schizont antigen. IgG3 responses may be short-lived and require repeated restimulation for their maintenance. This may be provided by persistent infection (premunition) or new infections.