Sensitivity to ivermectin and pyrantel of Ancylostoma ceylanicum and Necator americanus

Antiparasitic activity of ivermectin: Four decades of research into a "wonder drug"

Parasitic diseases still pose a serious threat to human and animal health, particularly for millions of people and their livelihoods in low-income countries. Therefore, research into the development of effective antiparasitic drugs remains a priority. Ivermectin, a sixteen-membered macrocyclic lactone, exhibits a broad spectrum of antiparasitic activities, which, combined with its low toxicity, has allowed the drug to be widely used in the treatment of parasitic diseases affecting humans and animals. In addition to its licensed use against river blindness and strongyloidiasis in humans, and against roundworm and arthropod infestations in animals, ivermectin is also used "off-label" to treat many other worm-related parasitic diseases, particularly in domestic animals. In addition, several experimental studies indicate that ivermectin displays also potent activity against viruses, bacteria, protozoans, trematodes, and insects. This review article summarizes the last 40 years of research on the antiparasitic effects of ivermectin, and the use of the drug in the treatment of parasitic diseases in humans and animals.

Recombinant Paraprobiotics as a New Paradigm for Treating Gastrointestinal Nematode Parasites of Humans

Gastrointestinal nematodes (GINs) of humans, e.g., hookworms, negatively impact childhood growth, cognition, nutrition, educational attainment, income, productivity, and pregnancy. Hundreds of millions of people are targeted with mass drug administration (MDA) of donated benzimidazole anthelmintics.

Gastrointestinal nematodes (GINs) of humans, e.g., hookworms, negatively impact childhood growth, cognition, nutrition, educational attainment, income, productivity, and pregnancy. Hundreds of millions of people are targeted with mass drug administration (MDA) of donated benzimidazole anthelmintics. However, benzimidazole efficacy against GINs is suboptimal, and reduced/low efficacy has been seen. Developing an anthelmintic for human MDA is daunting: it must be safe, effective, inexpensive, stable without a cold chain, and massively scalable. Bacillus thuringiensis crystal protein 5B (Cry5B) has anthelmintic properties that could fill this void. Here, we developed an active pharmaceutical ingredient (API) containing B. thuringiensis Cry5B compatible with MDA. We expressed Cry5B in asporogenous B. thuringiensis during vegetative phase, forming cytosolic crystals. These bacteria with cytosolic crystals (BaCC) were rendered inviable (inactivated BaCC [IBaCC]) with food-grade essential oils. IBaCC potency was validated in vitro against nematodes. IBaCC was also potent in vivo against human hookworm infections in hamsters. IBaCC production was successfully scaled to 350 liters at a contract manufacturing facility. A simple fit-for-purpose formulation to protect against stomach digestion and powdered IBaCC were successfully made and used against GINs in hamsters and mice. A pilot histopathology study and blood chemistry workup showed that five daily consecutive doses of 200 mg/kg body weight Cry5B IBaCC (the curative single dose is 40 mg/kg) was nontoxic to hamsters and completely safe. IBaCC is a safe, inexpensive, highly effective, easy-to-manufacture, and scalable anthelmintic that is practical for MDA and represents a new paradigm for treating human GINs.

A Functional Comparison of Homopentameric Nicotinic Acetylcholine Receptors (ACR-16) Receptors From Necator americanus and Ancylostoma ceylanicum

Effective control of hookworm infections in humans and animals relies on using a small group of anthelmintics. Many of these drugs target cholinergic ligand-gated ion channels, yet the direct activity of anthelmintics has only been studied in a subset of these receptors, primarily in the non-parasitic nematode, Caenorhabditis elegans. Here we report the characterization of a homopentameric ionotropic acetylcholine receptor (AChR), ACR-16, from Necator americanus and Ancylostoma ceylanicum, the first known characterization of human hookworm ion channels. We used two-electrode voltage clamp electrophysiology in Xenopus laevis oocytes to determine the pharmacodynamics of cholinergics and anthelmintics on ACR-16 from both species of hookworm. The A. ceylanicum receptor (Ace-ACR-16) was more sensitive to acetylcholine (EC50 = 20.64 ± 0.32 μM) and nicotine (EC50 = 24.37 ± 2.89 μM) than the N. americanus receptor (Nam-ACR-16) (acetylcholine EC50 = 170.1 ± 19.23 μM; nicotine EC50 = 597.9 ± 59.12 μM), at which nicotine was a weak partial agonist (% maximal acetylcholine response = 30.4 ± 7.4%). Both receptors were inhibited by 500 μM levamisole (Ace-ACR-16 = 65.1 ± 14.3% inhibition, Nam-ACR-16 = 79.5 ± 7.7% inhibition), and responded to pyrantel, but only Ace-ACR-16 responded to oxantel. We used in silico homology modeling to investigate potential structural differences that account for the differences in agonist binding and identified a loop E isoleucine 130 of Nam-ACR-16 as possibly playing a role in oxantel insensitivity. These data indicate that key functional differences exist among ACR-16 receptors from closely related species and suggest mechanisms for differential drug sensitivity.

Ivermectin: An Anthelmintic, an Insecticide, and Much More

Here we tell the story of ivermectin, describing its anthelmintic and insecticidal actions and recent studies that have sought to reposition ivermectin for the treatment of other diseases that are not caused by helminth and insect parasites. The standard theory of its anthelmintic and insecticidal mode of action is that it is a selective positive allosteric modulator of glutamate-gated chloride channels found in nematodes and insects. At higher concentrations, ivermectin also acts as an allosteric modulator of ion channels found in host central nervous systems. In addition, in tissue culture, at concentrations higher than anthelmintic concentrations, ivermectin shows antiviral, antimalarial, antimetabolic, and anticancer effects. Caution is required before extrapolating from these preliminary repositioning experiments to clinical use, particularly for Covid-19 treatment, because of the high concentrations of ivermectin used in tissue-culture experiments.

Bacillus thuringiensis Cry5B protein as a new pan-hookworm cure

Hookworms are intestinal nematode parasites that infect nearly half a billion people and are globally one of the most important contributors to iron-deficiency anemia. These parasites have significant impacts in developing children, pregnant women and working adults. Of all the soil-transmitted helminths or nematodes (STNs), hookworms are by far the most important, with disease burdens conservatively estimated at four million DALYs (Disability-Adjusted Life Years) and with productivity losses of up to US$139 billion annually. To date, mainly one drug, albendazole is used for hookworm therapy in mass drug administration, which has on average ∼80% cure rate that is lower (<40%) in some places. Given the massive numbers of people needing treatment, the threat of parasite resistance, and the inadequacy of current treatments, new and better cures against hookworms are urgently needed. Cry5B, a pore-forming protein produced by the soil bacterium Bacillus thuringiensis (Bt) has demonstrated good efficacy against Ancylostoma ceylanicum hookworm infections in hamsters. Here we broaden studies of Cry5B to include tests against infections of Ancylostoma caninum hookworms in dogs and against infections of the dominant human hookworm, Necator americanus, in hamsters. We show that Cry5B is highly effective against all hookworm parasites tested in all models. Neutralization of stomach acid improves Cry5B efficacy, which will aid in practical application of Cry5B significantly. Importantly, we also demonstrate that the anti-nematode therapeutic efficacy of Cry5B is independent of the host immune system and is not itself negated by repeated dosing. This study indicates that Bt Cry5B is a pan-hookworm anthelmintic with excellent properties for use in humans and other animals.

Ivermectin - Old Drug, New Tricks?

Ivermectin is one of the most important drugs in veterinary and human medicine for the control of parasitic infection and was the joint focus of the 2015 Nobel Prize in Physiology or Medicine, some 35 years after its remarkable discovery. Although best described for its activity on glutamate-gated chloride channels in parasitic nematodes, understanding of its mode of action remains incomplete. In the field of veterinary medicine, resistance to ivermectin is now widespread, but the mechanisms underlying resistance are unresolved. Here we discuss the history of this versatile drug and its use in global health. Based on recent studies in a variety of systems, we question whether ivermectin could have additional modes of action on parasitic nematodes.

Ligand-gated ion channels, particularly glutamate-gated chloride channels, are well characterised as the targets of IVM in nematodes and insects.

Nematode genomes are helping to cast light on the diversity of ion-channel subunits in different parasite species of human and veterinary importance.

Resistance to IVM is an increasing problem in the control of parasitic nematodes, and resolving the mechanisms is an important research priority.

Recent studies in other biological systems suggest that IVM can affect a number of additional pathways.

IVM may have novel applications in the treatment and control of important human diseases.

Microfluidic platform for electrophysiological recordings from host-stage hookworm and Ascaris suum larvae: A new tool for anthelmintic research

The screening of candidate compounds and natural products for anthelmintic activity is important for discovering new drugs against human and animal parasites. We previously validated in Caenorhabditis elegans a microfluidic device (‘chip’) that records non-invasively the tiny electrophysiological signals generated by rhythmic contraction (pumping) of the worm's pharynx. These electropharyngeograms (EPGs) are recorded simultaneously from multiple worms per chip, providing a medium-throughput readout of muscular and neural activity that is especially useful for compounds targeting neurotransmitter receptors and ion channels. Microfluidic technologies have transformed C. elegans research and the goal of the current study was to validate hookworm and Ascaris suum host-stage larvae in the microfluidic EPG platform. Ancylostoma ceylanicum and A. caninum infective L3s (iL3s) that had been activated in vitro generally produced erratic EPG activity under the conditions tested. In contrast, A. ceylanicum L4s recovered from hamsters exhibited robust, sustained EPG activity, consisting of three waveforms: (1) conventional pumps as seen in other nematodes; (2) rapid voltage deflections, associated with irregular contractions of the esophagus and openings of the esophogeal-intestinal valve (termed a ‘flutter’); and (3) hybrid waveforms, which we classified as pumps. For data analysis, pumps and flutters were combined and termed EPG ‘events.’ EPG waveform identification and analysis were performed semi-automatically using custom-designed software. The neuromodulator serotonin (5-hydroxytryptamine; 5HT) increased EPG event frequency in A. ceylanicum L4s at an optimal concentration of 0.5 mM. The anthelmintic drug ivermectin (IVM) inhibited EPG activity in a concentration-dependent manner. EPGs from A. suum L3s recovered from pig lungs exhibited robust pharyngeal pumping in 1 mM 5HT, which was inhibited by IVM. These experiments validate the use of A. ceylanicum L4s and A. suum L3s with the microfluidic EPG platform, providing a new tool for screening anthelmintic candidates or investigating parasitic nematode feeding behavior.

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Pharyngeal pumping in nematodes generates an electropharyngeogram (EPG).

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The EPG provides a readout of the electrical activity of neurons and muscles.

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A microfluidic platform for recording EPGs was validated in parasitic nematodes.

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EPG activity and drug responses were characterized in host-stage larvae.

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Microfluidic EPG recordings provide a powerful new tool for anthelmintic research.

In vitro screening of compounds against laboratory and field isolates of human hookworm reveals quantitative differences in anthelmintic susceptibility

A panel of 80 compounds was screened for anthelmintic activity against a laboratory strain of Ancylostoma ceylanicum and field isolates of hookworm obtained from school children in the Kintampo North District of the Brong Ahafo Region of Ghana. Although the laboratory strain of A. ceylanicum was more susceptible to the compounds tested than the field isolates of hookworm, a twofold increase in compound concentration resulted in comparable egg hatch percent inhibition for select compounds. These data provide evidence that the efficacy of anthelmintic compounds may be species-dependent and that field and laboratory strains of hookworm differ in their sensitivities to the anthelmintics tested. These data also suggest that both compound concentration and hookworm species must be considered when screening to identify novel anthelmintic compounds.

Discrimination of gastrointestinal nematode eggs from crude fecal egg preparations by inhibitor-resistant conventional and real-time PCR

Diagnosis of gastrointestinal nematodes relies predominantly on coproscopic methods such as flotation, Kato-Katz, McMaster or FLOTAC. Although FLOTAC allows accurate quantification, many nematode eggs can only be differentiated to genus or family level. Several molecular diagnostic tools discriminating closely related species suffer from high costs for DNA isolation from feces and limited sensitivity since most kits use only small amounts of feces (<1 g). A direct PCR from crude egg preparations was designed for full compatibility with FLOTAC to accurately quantify eggs per gram feces (epg) and determine species composition. Eggs were recovered from the flotation solution and concentrated by sieving. Lysis was achieved by repeated boiling and freezing cycles – only Trichuris eggs required additional mechanic disruption. Egg lysates were directly used as template for PCR with Phusion DNA polymerase which is particularly resistant to PCR inhibitors. Qualitative results were obtained with feces of goats, cattle, horses, swine, cats, dogs and mice. The finally established protocol was also compatible with quantitative real-time PCR in the presence of EvaGreen and no PCR inhibition was detectable when extracts were diluted at least fourfold. Sensitivity was comparable to DNA isolation protocols and spiked samples with five epg were reliably detected. For Toxocara cati a detection limit below one epg was demonstrated. It was possible to distinguish T. cati and Toxocara canis using high resolution melt (HRM) analysis, a rapid tool for species identification. In human samples, restriction fragment length polymorphism (RFLP) and HRM analysis were used to discriminate Necator americanus and Ancylostoma duodenale. The method is able to significantly improve molecular diagnosis of gastrointestinal nematodes by increasing speed and sensitivity while decreasing overall costs. For identification of species or resistance alleles, analysis of PCR products with many different post PCR methods can be used such as RFLP, reverse-line-blot, Sanger sequencing and HRM.

In vitro and in vivo efficacy of tribendimidine and its metabolites alone and in combination against the hookworms Heligmosomoides bakeri and Ancylostoma ceylanicum

Worldwide, 3 billion people are at risk of hookworm infection, particularly in resource-poor countries. While control of soil-transmitted helminthiases relies mostly on chemotherapy, only few drugs are available and concern about potential emergence of drug resistance is rising. In the present study, tribendimidine, a derivative of amidantel, and its metabolites deacylated amidantel (dADT) and acetylated deacylated amidantel (AdADT) were tested in vitro and in vivo against Heligmosomoides bakeri and Ancylostoma ceylanicum, two hookworm rodent models, alone or in combination with standard drugs. Tribendimidine achieved IC(50)s ≤ 5 μg/ml against both H. bakeri third-stage larvae and adults in vitro and a single 2 mg/kg oral dose resulted in complete worm elimination in vivo. Comparable results were obtained with dADT, whereas AdADT displayed no effect in vitro and gave a moderate worm burden reduction of 42.9% in H. bakeri-infected mice. Tribendimidine combined with albendazole, levamisole or ivermectin revealed antagonistic interactions against H. bakeri in vitro and no significant killing effect in vivo. Tribendimidine and dADT exerted high efficacies against A. ceylanicum third-stage larvae (IC(50)s < 0.5 μg/ml) whereas adults were moderately affected in vitro (IC(50)s > 88 μg/ml). In vivo at single oral doses of 10 mg/kg, dADT showed a slightly higher efficacy than tribendimidine, achieving worm burden reductions of 87.4% and 74.8%, respectively. At the same dose, AdADT reduced the worm burden by 57.9%. Synergistic interactions were observed with tribendimidine-levamisole combinations against A. ceylanicum in vitro (combination index at IC(50)=0.5), and in vivo (combination index at ED(90)=0.19). In conclusion, tribendimidine and dADT show potent anti-hookworm properties. The potential of the promising tribendimidine-levamisole combination should be investigated in greater detail.

In vitro and in vivo efficacy of Monepantel (AAD 1566) against laboratory models of human intestinal nematode infections

Background

Few effective drugs are available for soil-transmitted helminthiases and drug resistance is of concern. In the present work, we tested the efficacy of the veterinary drug monepantel, a potential drug development candidate compared to standard drugs in vitro and in parasite-rodent models of relevance to human soil-transmitted helminthiases.

Methodology

A motility assay was used to assess the efficacy of monepantel, albendazole, levamisole, and pyrantel pamoate in vitro on third-stage larvae (L3) and adult worms of Ancylostoma ceylanicum, Necator americanus and Trichuris muris. Ancylostoma ceylanicum- or N. americanus-infected hamsters, T. muris- or Ascaris suum-infected mice, and Strongyloides ratti-infected rats were treated with single oral doses of monepantel or with one of the reference drugs.

Principal Findings

Monepantel showed excellent activity on A. ceylanicum adults (IC₅₀ = 1.7 µg/ml), a moderate effect on T. muris L3 (IC₅₀ = 78.7 µg/ml), whereas no effect was observed on A. ceylanicum L3, T. muris adults, and both stages of N. americanus. Of the standard drugs, levamisole showed the highest potency in vitro (IC₅₀ = 1.6 and 33.1 µg/ml on A. ceylanicum and T. muris L3, respectively). Complete elimination of worms was observed with monepantel (10 mg/kg) and albendazole (2.5 mg/kg) in A. ceylanicum-infected hamsters. In the N. americanus hamster model single 10 mg/kg oral doses of monepantel and albendazole resulted in worm burden reductions of 58.3% and 100%, respectively. Trichuris muris, S. ratti and A. suum were not affected by treatment with monepantel in vivo (following doses of 600 mg/kg, 32 mg/kg and 600 mg/kg, respectively). In contrast, worm burden reductions of 95.9% and 76.6% were observed following treatment of T. muris- and A. suum infected mice with levamisole (200 mg/kg) and albendazole (600 mg/kg), respectively.

Conclusions/Significance

Monepantel reveals low or no activities against N. americanus, T. muris, S. ratti and A. suum in vivo, hence does not qualify as drug development candidate for human soil-transmitted helminthiases.

Soil-transmitted helminthiases affect more than one billion people among the most vulnerable populations in developing countries. Currently, control of these infections primarily relies on chemotherapy. Only five drugs are available, all of which have been in use for decades. None of the drugs are efficacious using single doses against all soil-transmitted helminths (STH) species and show low efficacy observed against Trichuris trichiura. In addition, the limited availability of current drug treatments poses a precarious situation should drug resistance occur. Therefore, there is great interest to develop novel drugs against infections with STH. Monepantel, which belongs to a new class of veterinary anthelmintics, the amino-acetonitrile derivatives, might be a potential drug candidate in humans. It has been extensively tested against livestock nematodes, and was found highly efficacious and safe for animals. Here we describe the in vitro and in vivo effect of monepantel, on Ancylostoma ceylanicum, Necator americanus, Trichuris muris, Strongyloides ratti, and Ascaris suum, five parasite-rodent models of relevance to human STH. Since we observed that monepantel showed only high activity on one of the hookworm species and lacked activity on the other parasites tested we cannot recommend the drug as a development candidate for human soil-transmitted helminthiases.

An ivermectin-sensitive glutamate-gated chloride channel from the parasitic nematode Haemonchus contortus

Nematode glutamate-gated chloride channels are targets of the macrocyclic lactones, the most important group of anthelmintics available. In Xenopus laevis oocytes, channels formed by the GluClalpha3B subunit from the parasite Haemonchus contortus were more sensitive to l-glutamate (EC(50) = 27.6 +/- 2.7 microM) than those formed by the homologous subunit from Caenorhabditis elegans (EC(50) = 2.2 +/- 0.12 mM). Ibotenate was a partial agonist (EC(50) = 87.7 +/- 3.5 microM). The H. contortus channels responded to low concentrations of ivermectin (estimated EC(50) = approximately 0.1 +/- 1.0 nM), opening slowly and irreversibly in a highly cooperative manner: the rate of channel opening was concentration-dependent. Responses to glutamate and ivermectin were inhibited by picrotoxinin and fipronil. Mutating an N-terminal domain amino acid, leucine 256, to phenylalanine increased the EC(50) for l-glutamate to 92.2 +/- 3.5 microM, and reduced the Hill number from 1.89 +/- 0.35 to 1.09 +/- 0.16. It increased the K(d) for radiolabeled ivermectin binding from 0.35 +/- 0.1 to 2.26 +/- 0.78 nM. Two other mutations (E114G and V235A) had no effect on l-glutamate activation or ivermectin binding: one (T300S) produced no detectable channel activity, but ivermectin binding was similar to wild-type. The substitution of any aromatic amino acid for Leu256 had similar effects in the radioligand binding assay. Molecular modeling studies suggested that the GluCl subunits have a fold similar to that of other Cys-loop ligand-gated ion channels and that amino acid 256 was unlikely to play a direct role in ligand binding but may be involved in mediating the allosteric properties of the receptor.

Necatoriasis: treatment and developmental therapeutics

Two hookworm parasites, Necator americanus and Ancylostoma duodenale, infect approximately one billion people worldwide. These hookworms are one of the leading causes of iron-deficiency anaemia especially in children, resulting directly from intestinal capillary blood loss following the feeding activities of fourth-stage (L(4)) larva and adult worms. If ignored, human hookworm infections can retard growth and the intellectual development of children. Another clinical manifestation often associated with hookworm infections is cutaneous larva migrans (CLM). It is a well recognised, usually self-limiting condition caused by the infectious larvae of nematodes, especially Ancylostoma spp. CLM is characterised by skin eruption and represents a clinical description rather than a definitive diagnosis. Of the hookworm parasites, the dog and cat worm A. braziliense and A. caninum are the most common nematodes causing CLM, although many other species have also been implicated. The major subject of this review article will be discussion of the evolution of therapies and treatment of human necatoriasis and the development of experimental infections with N. americanus. Difference in the clinical efficacy of mebendazole and albendazole will be discussed along with drug resistance of N. americanus.

The epidemiology of human hookworm infections in the southern region of Mali

Two surveys of hookworm (Necator americanus) infections, conducted three years apart (December 1994 and January 1998) in a village in the Sikasso region of Mali, revealed that overall prevalence of infection was 68.7% and 53%, respectively. In both years there was a highly significant difference between the sexes in the prevalence and abundance of infection, with male subjects carrying heavier infections than females. Both prevalence and abundance of infection increased with age, although in 1998 there was a strong interaction between sex and age, arising from the declining egg counts among 16-20-year-old females and the continuing increase among males, reinforced by the subsequent reduction among the older males (> or = 61 years) and concomitant increase among females. After controlling for the effects of age, sex and their interaction, a highly significant positive relationship was detected between faecal egg counts of individuals who were examined in both 1994 and 1998 (n = 134), indicating predisposition to infection. This relationship remained significant in each of 4 age classes spanning 7-79 years. The members of some family compounds were shown to carry heavier infections than expected whilst others were less infected, suggesting compound-related clustering of hookworm infections. The use of footwear increased with age but there was no significant relationship between the extent of use of footwear and the abundance of hookworm infection. Eyesight deteriorated with age and impaired vision was particularly prominent among the older sectors of the community, a legacy from the time when onchocerciasis was widely prevalent in the region. Although men with partially damaged eyes carried lower infections than expected for their age, no overall significant relationship was found between quality of vision and hookworm infections. These results are discussed in relation to hookworm epidemiology in general and in Mali in particular.

Comparison of the efficacy of mebendazole, albendazole and pyrantel in treatment of human hookworm infections in the southern region of Mali, West Africa

A randomized, placebo-controlled trial of the efficacy of pyrantel (single dose 12.5 mg/kg bodyweight), mebendazole (single 500 mg dose) and albendazole (single 400 mg dose) in the treatment of hookworm infections (Necator americanus) was carried out in January 1998 in the Southern Region of Mali, West Africa, during the period of Ramadan (Islamic fast). Statistical analysis of the pre-intervention faecal egg counts showed that there was a significant pre-treatment chance bias, despite randomization of subjects into treatment groups, arising from the main effect of sex (heavier infections among males) and a sex x treatment interaction (the sex bias was not evident in the pyrantel-treatment group). The participants were re-examined 10 days after treatment, and after controlling for the drift in faecal egg counts in the placebo-treated subset, age, sex, fasting and intensity of infection, albendazole was clearly the most effective drug showing consistently efficacies in the range 92.1 to 99.7%, depending on the method of evaluation and the particular subset of the treatment group. Neither mebendazole nor pyrantel was as effective, with efficacies ranging from 60.9 to 89.8% and 4.8 to 89.7%, respectively. Fasting made no difference to drug efficacy. On the basis of our results the single 400 mg dose of albendazole is the treatment of choice for hookworm infections in this region of Mali. We emphasize the need for standardization of the methods used for trial designs, for calculation of summary data relating to drug efficacies and the accompanying statistical tests.

In vitro studies on the relative sensitivity to ivermectin of Necator americanus and Ancylostoma ceylanicum

Experiments were carried out to compare the sensitivity of Ancylostoma ceylanicum and Necator americanus to ivermectin (IVM) and pyrantel in vitro. Loss of motility and inhibition of ingestion by IVM were compared and A. ceylanicum was found to be approximately 40-50 times more sensitive to IVM than N. americanus. Both species showed a similar sensitivity to pyrantel. Uptake of [3H]IVM across the cuticle was compared and shown to be unlikely to account for the differences in sensitivity to IVM between the two species.

Effect of ivermectin on infection with gastro-intestinal nematodes in Sierra Leone

Levels of intestinal nematode infections were assessed six months after a two year trial of ivermectin for efficacy against onchocerciasis had ended. In the trial the inhabitants of six villages in Sierra Leone were offered treatment with ivermectin or placebo at six monthly intervals for four rounds in total. Quantitative faecal egg counts were carried out on stool samples provided by 202 subjects, all of whom had received all four rounds of treatment, in two of the villages (Dodo and Mogibisi). These data were analysed by a novel procedure in which a 3-way ANOVA with negative binomial errors enabled village and host gender influences on the outcome of treatment to be identified. Necator americanus was the most common species showing an overall prevalence of 90% but a higher intensity in Mogibisi relative to Dodo, particularly among male subjects. Neither prevalence nor intensity of infection were altered in ivermectin-treated compared with placebo-treated subjects. Trichuris trichiura was the least common species with a prevalence of 15%. It was concluded that there was no significant protection from infection with this species among the ivermectin relative to the placebo-treated subjects. Ascaris lumbricoides, with an overall prevalence of 39%, was more common among female (50%) compared with male (27%) villagers. Prevalence was not significantly affected by ivermectin but the intensity of infection declined by 91.3% in Dodo whilst in Mogibisi intensity was only reduced by 14.6%.(ABSTRACT TRUNCATED AT 250 WORDS)