Susceptibility of Schistosoma japonicum to praziquantel in China

Praziquantel resistance in schistosomes: a brief report

Schistosomiasis is a group of both acute and chronic parasitic trematode infections of the genus Schistosoma. Research into schistosomiasis has been minimal, leading to its classification as a neglected tropical disease, yet more than 140 million people are infected with schistosomes globally. There are no treatments available for early-stage infections, schistosomal dermatitis, or Katayama syndrome, other than symptomatic control with steroids and antihistamines, as the maturing organisms seem to be mostly resistant to typical antiparasitics. However, praziquantel (PZQ) has been the drug of choice for schistosomiasis for decades in the latter stages of the disease. Though it is effective against all three clinically relevant species, heavy reliance on PZQ has led to concerns of schistosome resistance, especially in areas that have implemented this drug in mass drug administration (MDA) programs. This article summarizes the available literature concerning the available evidence for and against a warranted concern for PZQ resistance, genomic studies in schistosomes, proposed mechanisms of resistance, and future research in alternative methods of schistosomiasis treatment.

Expression profile analysis of the transient receptor potential (TRPM) channel, a possible target of praziquantel in Schistosoma japonicum

The WHO considers schistosomiasis, which is controlled by the mass administration of the drug praziquantel (PZQ), to be a neglected tropical disease. Despite its clinical use for over four decades, PZQ remains the only choice of chemotherapy against this disease. Regarding the previous studies that demonstrated that PZQ activates the transient receptor potential (TRP) channel in Schistosoma mansoni (Sm.TRPMPZQ), the expression profile of the ortholog of this channel gene (Smp_246790.5) in S. japonicum (EWB00_008853) (Sj.TRPMPZQ) was analyzed. The relative expression of this gene in various stages of the parasite lifecycle was analyzed by quantitative real-time reverse transcription-PCR (qRT-PCR), and the expression of Sj.TRPMPZQ was observed by immunohistochemical staining using anti-serum against the recombinant Sj.TRPMPZQ protein. qRT-PCR revealed the significantly lower mRNA expression in the snail stage in comparison to other stages (p < 0.01). The relative quantity of the Sj.TRPMPZQ expression for paired females, unpaired males, and eggs was 60%, 56%, and 68%, respectively, in comparison to paired males that showed the highest expression (p < 0.05). Interestingly, immunostaining demonstrated that Sj.TRPMPZQ is expressed in the parenchyma which contains muscle cells, neuronal cells and tegument cells in adult worms. This may support the two major effects of PZQ-worm paralysis and tegument disruption-induced by channel activation. Moreover, the channel was expressed in both the eggshell and the miracidia inside, but could not be observed in sporocyst. These results suggest that the expression of Sj.TRPMPQZ corresponds to the known sensitivity of S. japonicum to PZQ.

Anti-schistosomal activities of quinoxaline-containing compounds: From hit identification to lead optimisation

Schistosomiasis is a neglected disease of poverty that is caused by infection with blood fluke species contained within the genus Schistosoma. For the last 40 years, control of schistosomiasis in endemic regions has predominantly been facilitated by administration of a single drug, praziquantel. Due to limitations in this mono-chemotherapeutic approach for sustaining schistosomiasis control into the future, alternative anti-schistosomal compounds are increasingly being sought by the drug discovery community. Herein, we describe a multi-pronged, integrated strategy that led to the identification and further exploration of the quinoxaline core as a promising anti-schistosomal scaffold.

Firstly, phenotypic screening of commercially available small molecules resulted in the identification of a moderately active hit compound against Schistosoma mansoni (1, EC₅₀ = 4.59 μM on schistosomula). Secondary exploration of the chemical space around compound 1 led to the identification of a quinoxaline-core containing, non-genotoxic lead (compound 22). Compound 22 demonstrated substantially improved activities on both intra-mammalian (EC₅₀ = 0.44 μM, 0.20 μM and 84.7 nM, on schistosomula, juvenile and adult worms, respectively) and intra-molluscan (sporocyst) S. mansoni lifecycle stages. Further medicinal chemistry optimisation of compound 22, resulting in the generation of 20 additional analogues, improved our understanding of the structure-activity relationship and resulted in considerable improvements in both anti-schistosome potency and selectivity (e.g. compound 30; EC₅₀ = 2.59 nM on adult worms; selectivity index compared to the HepG2 cell line = 348). Some derivatives of compound 22 (e.g. 31 and 33) also demonstrated significant activity against the two other medically important species, Schistosoma haematobium and Schistosoma japonicum. Further optimisation of this class of anti-schistosomal is ongoing and could lead to the development of an urgently needed alternative to praziquantel for assisting in schistosomiasis elimination strategies.

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Lead compound 22 was identified with EC₅₀ of 0.44 µM and 84.7 nM for schistosomula and adult worms.

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20 analogues of the lead compound 22 were synthesised.

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Compounds 25, 30 and 32 showed the best selectivity profile.

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Compounds 31 and 33 are the most active on three medically important schistosome species.

Pharmacological and immunological effects of praziquantel against Schistosoma japonicum: a scoping review of experimental studies

BACKGROUND

Chemotherapy for schistosomiasis has been around for 100 years. During the past century, great efforts have been made to develop new antischistosomal drugs from antimonials to nonantimonials, and some of these have been used extensively in clinical treatment. With the exception of a few drugs, such as oxamniquine and metrifonate, most of the antischistosomals developed in the pre-praziquantel period have variable limitations with respect to safety and efficacy. Although oxamniquine and metrifonate have been used for schistosomiasis control, they are only effective against Schistosoma mansoni and S. haematobium, respectively. Currently, praziquantel is the only drug used for treatment of all five species of human schistosomes. In this review, the pharmacological and immunological effects of praziquantel against S. japonicum are summarized and discussed.

MAIN TEXT

From the end of the 1970s until the 2000s, scientists have conducted a series of experimental studies on the effects of praziquantel against S. japonicum. These have included examining its unique pharmacological action on schistosomes, the characteristics in susceptibility of the different developmental stages of schistosomes to the drug, the relationship between plasma concentration of the drug and efficacy, the impact of host factors on cidal action of the drug, prevention and early treatment of schistosomal infection, as well as praziquantel-resistant schistosomiasis.

CONCLUSION

The effects of praziquantel against S. japonicum, as elucidated by the experimental studies that are reviewed in this paper, may have some reference significance for the development of new antischistosomals.

Efficacy of artemether and artesunate in mice infected with praziquantel non-susceptible isolate of Schistosoma japonicum

Praziquantel is currently the only drug of choice for the treatment of human Schistosoma japonicum infections, and praziquantel-based chemotherapy has been proved to be generally effective to control the morbidity and reduce the prevalence and intensity of S. japonicum infections. However, the potential emergence of praziquantel resistance in S. japonicum seriously threatens the elimination of this neglected tropical disease in China. The purpose of this study was designed, in mouse animals, to evaluate the in vivo efficacy of artemether and artesunate against praziquantel non-susceptible S. japonicum. Mice infected with a praziquantel non-susceptible isolate and a praziquantel-susceptible isolate of S. japonicum were treated with artemether and artesunate at a single oral dose of 300 mg/kg given once on each of days 7-8 and 35-36 post-infection to assess the efficacy against juvenile and adult worms. Administration with artemether and artesunate at a single oral dose of 300 mg/kg on each of days 7-8 post-infection resulted in total worm burden reductions of 72.8 and 73.5% in mice infected with praziquantel-susceptible S. japonicum, and 77.9 and 74.1% in mice infected with the non-susceptible isolate (both P values >0.05), while the same treatments given on days 35-36 post-infection reduced total worm burdens by 71.4 and 69.6% in mice infected with the susceptible isolate, and 75.3 and 69.6% in mice infected with the non-susceptible parasite (both P values >0.05). It is concluded that there is no evidence for reduced susceptibility of artemether and artesunate in praziquantel non-susceptible S. japonicum.

Application of praziquantel in schistosomiasis japonica control strategies in China

Schistosomiasis remains a major public health problem with an estimated 200 million people infected in the world, and in China, schistosomiasis japonica is endemic in the south part of the country. In 1960s, before praziquantel was developed, there were about seven million patients. Praziquantel has a high efficacy against Schistosoma, few and transient side effects, simple administration and competitive cost, and is equally suited for both individual and large-scale treatment. Praziquantel has been widely used in the morbidity control, transmission control, and prevention of schistosomiasis japonica in China since 1980s. The schemes of praziquantel chemotherapy include the diagnostic selective chemotherapy, extensive chemotherapy, mass chemotherapy, stratified chemotherapy, phased chemotherapy, etc. Chemotherapy alone or combined with other control measure, such as Oncomelania snail control, health education, safety water supply, and so on, has achieved a great success, and there are only 0.33 million infected people now. This paper reviews the application of praziquantel in the schistosomiasis japonica control strategies in China so as to provide the rich experiences for reference of health workers of other countries where schistosomiasis is endemic.

Susceptibility or resistance of praziquantel in human schistosomiasis: a review

Since praziquantel was developed in 1970s, it has replaced other antischistosomal drugs to become the only drug of choice for treatment of human schistosomiases, due to high efficacy, excellent tolerability, few and transient side effects, simple administration, and competitive cost. Praziquantel-based chemotherapy has been involved in the global control strategy of the disease and led to the control strategy shifting from disease control to morbidity control, which has greatly reduced the prevalence and intensity of infections. Given that the drug has been widely used for morbidity control in endemic areas for more than three decades, the emergence of resistance of Schistosoma to praziquantel under drug selection pressure has been paid much attention. It is possible to induce resistance of Schistosoma mansoni and Schistosoma japonicum to praziquantel in mice under laboratorial conditions, and a reduced susceptibility to praziquantel in the field isolates of S. mansoni has been found in many foci. In addition, there are several schistosomiasis cases caused by Schistosoma haematobium infections in which repeated standard treatment fails to clear the infection. However, in the absence of exact mechanisms of action of praziquantel, the mechanisms of drug resistance in schistosomes remain unclear. The present review mainly demonstrates the evidence of drug resistance in the laboratory and field and the mechanism of praziquantel resistance and proposes some strategies for control of praziquantel resistance in schistosomes.

The sensitivity of Schistosoma japonicum to praziquantel: a field evaluation in areas with low endemicity of China

The purpose of the current study was to investigate the susceptibility of Schistosoma japonicum to praziquantel in low endemic foci of China. During the non-transmission period of schistosomiasis, a total of 43 of 1,242 subjects were identified as being infected with the parasite using parasitological stool examinations in two low-endemicity areas of China, with a prevalence rate of 3.46%. All stool-egg-positive subjects were treated with praziquantel in a single oral dose of 40 mg/kg or 30 mg/kg for two successive days. Six weeks post-treatment, no S. japonicum eggs were detected in the 43 treated villagers. The results indicate that the current efficacy of praziquantel against S. japonicum seems satisfactory and has not changed over the past three decades in the low endemic areas of China. It is also suggested that no evidence of tolerance or resistance to praziquantel in S. japonicum is detected in areas with low endemicity in China.

Five-year longitudinal assessment of the downstream impact on schistosomiasis transmission following closure of the Three Gorges Dam

BACKGROUND

Schistosoma japonicum is a major public health concern in the Peoples' Republic of China (PRC), with about 800,000 people infected and another 50 million living in areas at risk of infection. Based on ecological, environmental, population genetic and molecular factors, schistosomiasis transmission in PRC can be categorised into four discrete ecosystems or transmission modes. It is predicted that, long-term, the Three Gorges Dam (TGD) will impact upon the transmission of schistosomiasis in the PRC, with varying degree across the four transmission modes.

METHODOLOGY/PRINCIPAL FINDINGS

We undertook longitudinal surveillance from 2002 to 2006 in sentinel villages of the three transmission modes below the TGD across four provinces (Hunan, Jiangxi, Hubei and Anhui) to determine whether there was any immediate impact of the TGD on schistosomiasis transmission. Eight sentinel villages were selected to represent both province and transmission mode. The primary end point measured was human incidence. Here we present the results of this five-year longitudinal cohort study. Results showed that the incidence of human S. japonicum infection declined considerably within individual villages and overall mode over the course of the study. This is also reflected in the yearly odds ratios (adjusted) for infection risk that showed significant (P<0.01) downward trends in all modes over the follow-up period.

CONCLUSIONS/SIGNIFICANCE

The decrease in human S. japonicum incidence observed across all transmission modes in this study can probably be attributed to the annual human and bovine PZQ chemotherapy. If an increase in schistosome transmission had occurred as a result of the TGD, it would be of negligible size compared to the treatment induced decline seen here. It appears therefore that there has been virtually no immediate impact of the TGD on schistosomiasis transmission downstream of the dam.

New insight into praziquantel against various developmental stages of schistosomes

Praziquantel, due to high efficacy, excellent tolerability, few and transient side effects, simple administration, and competitive cost, is virtually the only drug of choice for treatment of human schistosomiasis. Treatment of schistosomiasis has shown great advances with the introduction of the drug into the therapeutic arsenal in areas that are endemic for the parasite. However, the drug presents various efficacies against different developmental stages of schistosomes, appearing an oddity intermitted mode. The present review article reviews the effects and mechanism of action of praziquantel against schistosomes briefly and suggests the research on this oddity phenomenon.

Human schistosomiasis resistance to praziquantel in China: should we be worried?

The efficacy of praziquantel for the treatment of Schistosoma japonicum in humans is reported from a cross-sectional survey conducted in 33 villages in Sichuan Province. Infection prevalence was found to be 5.7% (185 infected of 3,269 tested) in a region where 44–73% prevalence was found 9 years before. Collected miracidia were subjected to an in vitro test of praziquantel susceptibility. An effective concentration of praziquantel associated with 50% of miracidia changing shape was found between 10⁻⁸ and 10⁻⁷ M and 10⁻⁷ and 10⁻⁶ M for 10 and 5 minutes of exposure, respectively. After treating infected persons two times with 40-mg/kg doses of praziquantel, only one remained infected. Findings are reported from a 60-household questionnaire on attitudes and behaviors that may be associated with development of drug resistance. The low number of treatment failures and good compliance with treatment despite side effects and repeated annual treatments suggest that, in the near term, praziquantel remains effective in treating human S. japonicum infection in China.

Expression, characterization and therapeutic efficacy of chimeric Fab of anti-idiotypic antibody NP30 against Schistosoma japonicum

The murine monoclonal anti-idiotypic antibody NP30 is a promising therapeutic antibody against Schistosoma japonicum. However, the immunogenicity of murine NP30 limits its further study and application in humans. Here the chimeric Fab of NP30 (chFab-NP30) comprising the variable regions of murine NP30 and constant regions of human antibody was assembled. chFab-NP30 was expressed and purified as a soluble and functional protein. Administration of chFab-NP30 in vivo increased the survival rate, reduced egg burdens and ameliorated organ pathology of mice with acute schistosomiasis. Our study indicated that chFab-NP30 is a promising candidate to be used as a specific and efficient recombinant antibody against acute schistosomiasis japonica. Further studies on function mechanism of chFab-NP30 needs to be carried out in the future.

A 5-year longitudinal study of schistosomiasis transmission in Shian village, the Anning River Valley, Sichuan Province, the Peoples' Republic of China

Background

Schistosoma japonicum is a major public health concern in the Peoples' Republic of China (PRC), with over one million people infected and another 50 million living in areas at risk of infection. Based on ecological, environmental, population genetic and molecular factors, schistosomiasis transmission in PRC can be categorised into four discrete ecosystems or transmission modes. It is predicted that the Three Gorges Dam (TGD) will impact upon the transmission of schistosomiasis in the PRC, with varying degree across the four transmission modes. We undertook longitudinal surveillance from 2002 to 2006 in sentinel villages both above and below the TGD across five provinces (Hunan, Jiangxi, Hubei, Anhui and Sichuan) to determine whether there was any impact of the TGD on schistosomiasis transmission during its construction. Here we present the results from a schistosomiasis-endemic village located above the dam in Sichuan Province.

Results

Baseline results showed a human S. japonicum prevalence of 42.0% (95% CI: 36.6-47.5). At follow-up, results showed that the incidence of S. japonicum infection in the selected human cohort in Shian decreased by three quarters from 46% in 2003 to 11.3% in 2006. A significant (P < 0.01) downward trend was also evident in the yearly adjusted (for water contact) odds ratios. Over the four years of follow-up, the incidence of S. japonicum infection in bovines declined from 11.8% in the first year to zero in the final year of follow-up.

Conclusions

The substantial decrease in human (75%) and bovine (100%) incidence observed in Shian village can probably be attributed to the annual human and bovine PZQ treatment of positives; as seen in drug (PZQ) intervention studies in other parts of PRC. If an increase in schistosome transmission had occurred as a result of the TGD, it would be of negligible size compared to the treatment induced decline seen here. It appears therefore that the construction of the TGD had virtually no impact on schistosomiasis transmission in Shian village over the period of study. Furthermore, contrary to previous reports from Sichuan downplaying the role of animals in human schistosome transmission, bovines may indeed play a role.

In vitro praziquantel test capable of detecting reduced in vivo efficacy in Schistosoma mansoni human infections

Although great reductions in human schistosomiasis have been observed after praziquantel (PZQ) mass drug administration (MDA), some individuals remain infected after multiple treatments. Many MDA programs now require monitoring for drug efficacy as a key component. No molecular tools for PZQ resistance currently exist and investigations into the dose of PZQ required to kill 50% of adult worms in vivo (ED(50)) present ethical, logistical, and temporal restraints. We, therefore, assessed the feasibility and accuracy of a rapid, inexpensive in vitro PZQ test in the laboratory and directly in the field in Uganda under MDA in conjunction with highly detailed infection intensity, clearance, and reinfection data. This test strongly differentiated between subsequently cleared and uncleared infections as well as differences between parasite populations pre- and post-PZQ treatments, advocating its use for on-the-spot monitoring of PZQ efficacy in natural foci. After only a few treatments, uncleared parasites were identified to be phenotypically different from drug-sensitive parasites, emphasizing the urgent need for monitoring of these repeatedly PZQ-treated populations.

Is there reduced susceptibility to praziquantel in Schistosoma japonicum? Evidence from China

Praziquantel is widely used for the treatment of human schistosomiasis. However, in recent years, there has been increasing concern about the resistance of Schistosoma species to praziquantel. The study described here was designed to evaluate the current susceptibility to praziquantel in S. japonicum in China. During the non-transmission period of schistosomiasis, a random sample of 4760 subjects from the main endemic foci of China were examined using parasitological stool examination. In total, 584 subjects were identified as being infected with S. japonicum, with a prevalence rate of 12.27%. Among them, 565 stool-egg-positive subjects were treated with praziquantel in a single oral dose of 40 mg/kg. Six weeks post-treatment, among the 505 villagers re-examined, 480 (95.05%) had no detectable S. japonicum eggs. Twenty-one subjects still excreting eggs after the first treatment were treated with praziquantel for the second time. All stool samples, including those from those participants with second treatment were re-examined 6 weeks after the second treatment, and no stool-egg-positives were found. The results indicate that the current efficacy of praziquantel against S. japonicum is still high and has not changed after more than 2 decades of repeated, expanded chemotherapy in the main endemic areas of China. It is suggested that no evidence of tolerance or resistance to praziquantel in S. japonicum was detected in China.

Environmental effects on parasitic disease transmission exemplified by schistosomiasis in western China

Environmental effects on the transmission of many parasitic diseases are well recognized, but the role of specific factors like climate and agricultural practices in modulating transmission is seldom characterized quantitatively. Based on studies of Schistosoma japonicum transmission in irrigated agricultural environments in western China, a mathematical model was used to quantify environmental impacts on transmission intensity. The model was calibrated by using field data from intervention studies in three villages and simulated to predict the effects of alternative control options. Both the results of these interventions and earlier epidemiological findings confirm the central role of environmental factors, particularly those relating to snail habitat and agricultural and sanitation practices. Moreover, the findings indicate the inadequacy of current niclosamide-praziquantel strategies alone to achieve sustainable interruption of transmission in some endemic areas. More generally, the analysis suggests a village-specific index of transmission potential and how this potential is modulated by time-varying factors, including climatological variables, seasonal water-contact patterns, and irrigation practices. These time-variable factors, a village's internal potential, and its connectedness to its neighbors provide a framework for evaluating the likelihood of sustained schistosomiasis transmission and suggest an approach to quantifying the role of environmental factors for other parasitic diseases.

Field evaluation of a test for praziquantel resistance in Schistosoma sp

A simple rapid test for detecting praziquantel resistance in Schistosoma sp., involving change in shape of miracidia on exposure to praziquantel, was evaluated in China. Tests on miracidia hatched from eggs collected from naturally infected goats were run in a field laboratory in Jiangxi Province and a research laboratory in Shanghai. The mean values in the two laboratories were not significantly different, but the variation between individual samples in the two laboratories suggests that a delineating dose will be required for routine diagnosis of resistance. Confirmation that resistance would have been detected in Schistosoma japonicum must await the isolation of a resistant isolate. The tests suggested that the infection in the goats was susceptible to praziquantel as did chemotherapy of water buffaloes with 25mg/kg. This gave a 95% cure rate on the first treatment and 100% with a second treatment, similar to that found previously in human patients.