Maintaining Plasmodium falciparum gametocyte infectivity during blood collection and transport for mosquito feeding assays in the field

Asymptomatic school children and adults are important for the human infectious reservoir for Plasmodium falciparum malaria in an area of low endemicity in The Gambia

OBJECTIVES

In The Gambia, the scale-up of malaria control intervention in the past decades resulted in a substantial decrease of the malaria burden. However, low levels of malaria transmission persist.

METHODS

We conducted an observational cohort study in eastern Gambia to better understand the relative contribution of symptomatic- and asymptomatic malaria infections to the infectious reservoir. Parasite and gametocyte carriage were determined by molecular methods. Infectiousness to mosquitoes was assessed by mosquito membrane feeding assays on a subset of symptomatic and asymptomatic individuals identified by passive case detection and community surveys.

RESULTS

Incidence of clinical malaria was 1.46 episodes/100 person-months. Prevalence of malaria infection as determined by PCR in community surveys was 10.5%. Among asymptomatic malaria-infected individuals, total parasite density was positively associated with gametocyte density (β = 0.40; P<.0001). Mosquito infection rates in membrane feeding experiments were positively associated with gametocyte density (β = 2.81; P<0.0001). More than 84% of mosquito infections occurred from asymptomatic individuals with patent infections, with the highest contribution from older children (40.3%), and adolescents and adults (45.5%). Clinical malaria cases identified by passive case detection were responsible for only 1% of mosquito infections; if the definition of clinical malaria included infected individuals identified by community surveys with history of fever in the preceding week, the contribution of clinical cases to mosquito infections increased to 16%.

CONCLUSIONS

In eastern Gambia, malaria transmission is maintained by asymptomatic malaria-infected individuals, mostly adults, adolescents and school age children, while clinical cases are comparatively less important for transmission.

[Effect of low-dose primaquine treatment on Plasmodium vivax recurrence and transmission-blocking activity in southwest Ethiopia: a longitudinal cohort study

BACKGROUND

Existing malaria control strategies for Plasmodium vivax are challenging due to its dormant and relapsing liver stages, as well as the early onset of gametocytogenesis. Primaquine (PQ) effectively eliminates dormant stages and can kill gametocytes; however, it necessitates repeated dosing. In this study, the effectiveness of chloroquine (CQ) plus low-dose of PQ on recurrence and its transmission-blocking activity was evaluated.

METHODS

Between September 2019 and July 2022, a prospective cohort study was conducted in the Jimma-Arjo and Dabo-Hanna districts of the Oromia region in Ethiopia. A total of 214 uncomplicated cases of P. vivax malaria were enrolled in the study. Participants were treated with either CQ alone (106) or CQ + PQ (108), based on whether their district was targeted for P. vivax elimination by the national malaria programme or not. After enrolment, participants were followed for clinical illness and parasitaemia on days 28, 42, and monthly for one year. To assess the effect of different treatment regimens on transmission-blocking activity, Anopheles arabiensis mosquitoes were used in direct membrane-feeding assays (DMFA) at baseline (pre-treatment) and on day 42 (post-treatment). Based on polymerase chain reaction (PCR) positivity, the time to the first recurrence was estimated using Kaplan-Meier survival analysis. Cox regression models were employed to assess risk factors for recurrence.

RESULTS

Of 3,590 individuals screened for malaria, 323 tested positive for P. vivax, and 214 were enrolled. Of these, 98.6% (211/214) completed the day 28 follow-up, and 67.3% (144/214) completed the one-year follow-up. Between days 28 and 42, 24% (95% CI 15.8-32.2%) of those individuals receiving CQ alone were PCR positive, and 10.3% (95% CI 4.5-16.0%) in those receiving CQ plus PQ. This represented a 57.3% reduction P. vivax recurrence in the CQ + PQ treatment group compared to CQ alone (risk ratio = 0.427, 95% CI 0.222-0.824, p = 0.008). During the year of follow-up at least one recurrence occurred in 70% (95% CI 59.1-80.2%) of the CQ alone and 46% (95% CI 35.5-58.1%) in the CQ + PQ treatment group (p < 0.001). Treatment regimen, high baseline parasitaemia and presence of gametocytaemia were risk factors for P. vivax recurrence. Compared to baseline DMFA at day 42, individuals showed an inhibition intensity of 39.0% in the CQ alone versus 77.8% in the CQ + PQ treatment group (p = 0.016), while inhibition prevalence was 35.2% in the CQ alone and 70.1% in the CQ + PQ treatment group (p = 0.021).

CONCLUSIONS

This study demonstrate that with limited supervision of CQ + PQ treatment significantly lowers the risk of P. vivax recurrence in health clinics of southwest Ethiopia compared to CQ alone. Adding PQ to CQ also reduced P. vivax transmission to mosquito vectors relative to CQ alone but did not result in a complete transmission-blocking effect by day 42 post-treatment. Therefore, improved health education on treatment adherence and bed net use could enhance the effectiveness of PQ plus CQ. Higher doses of PQ for a shorter duration may be necessary to enhance treatment adherence, reduce recurrence rates, and decrease the risk of transmission.

Plasmodium falciparum Pfs47 haplotype compatibility to Anopheles gambiae in Kisumu, a malaria-endemic region of Kenya

Insecticide resistance and outdoor transmission have reduced the effectiveness of existing malaria transmission prevention strategies. As a result, targeted approaches to support continuing malaria control, such as transmission-blocking vaccines, are required. Cross-sectional mass blood screening in children between 5 and 15 years was conducted in Chulaimbo, Kisumu, during the dry and wet seasons in 2018 and 2019. Plasmodium falciparum gametocyte carriers were identified by Microscopy. Subsequently, carriers were used to feed colony bred Anopheles gambiae females in serum replacement and whole blood membrane feeding experiments. The infection prevalence was 19.7% (95% Cl 0.003-0.007) with 95% of the infections being caused by P. falciparum. Of all confirmed P. falciparum infections, 16.9% were gametocytes. Thirty-seven paired experiments showed infection rates of 0.9% and 0.5% in the serum replacement and whole blood experiments, respectively, with no significant difference (P = 0.738). Six Pfs47 haplotypes were identified from 24 sequenced infectious blood samples: Hap_1 (E27D and L240I), Hap_2 (S98T); Hap_3 (E27D); Hap_4 (L240I); Hap_5 (E188D); and Hap_6 without mutations. Haplotype 4 had the highest frequency of 29.2% followed by Hap_3 and Hap_6 at 20.8% each then Hap_1 with a frequency of 16.7%, whereas Hap_5 and Hap_2 had frequencies of 8.3% and 4.2% respectively. Varying frequencies of Pfs47 haplotypes observed from genetically heterogeneous parasite populations in endemic regions illuminates vector compatibility to refracting P. falciparum using the hypothesized lock and key analogy. This acts as a bottleneck that increases the frequency of P. falciparum haplotypes that escape elimination by vector immune responses. The interaction can be used as a potential target for transmission blocking through a refractory host.

Simplified Plasmodium falciparum membrane feeding assay using small Petri dishes and gel warmers

Studies on Plasmodium falciparum transmission require blood-feeding infectious gametocytes to mosquitoes using standard membrane-feeding assays (SMFAs). SMFAs are routinely performed using electric heating coils or glass membrane feeders connected to a circulatory water bath using tubing and clamps. Each of these approaches is expensive and requires a complex setup, hence restricting the number of assays that can be performed simultaneously. Furthermore, existing methods cannot be easily applied in low-resource field settings. This study presents a low-cost and simplified method for feeding mosquitoes with an infectious blood meal using 35 mm Petri dishes where temperature is maintained by using reusable gel warmers. The intensity and prevalence of infection in mosquitoes (Anopheles stephensi and Anopheles gambiae) fed via a Petri dish overlaid with gel warmers were comparable to mosquitoes fed using standard glass membrane feeders. The methodology described here can be easily applied in low-resource and field settings due to its low cost, ease of set up, and use of easily available supplies, such as Petri dishes, and reusable gel warmers. We believe a wide range of laboratories can easily adapt this method for P. falciparum transmission studies.

Single jar for collecting and rearing mosquito life stages: An innovative prototype

BACKGROUND OBJECTIVES

Mosquitoes vectors are the key threat that spread viruses, bacteria, nematodes, protozoans, and other infections responsible for the transmission of serious public health ailments including dengue, yellow fever, malaria, and chikungunya.

METHODS

To rear and cultivate mosquitoes at multiple stages of development (egg, larva, pupa, and adult) to be employed in various biomedical research, an innovative tool mosquito larva adult 2-in-1 rearing jar was designed and developed. The eggs/larvae or adults collected from the field or laboratory cultures can be released into the lower larvae or upper adult-rearing chamber so that they can find a suitable breeding place to oviposit or metamorphose into wrigglers and tumblers attaining the adult stage. Aedes, Anopheles, and Culex are three significant genera (Diptera: Culicidae) that were reared in experiments using this jar (Method I) in contrast to other conventional instruments available (Method II).

RESULTS

Results of one-way ANOVA showed that the prototype was compatible and competitive for rearing, as the data was non-significant when compared in both groups. However, throughout the trials, it was discovered that the prototype had a greater record of mean percentage of adult emergence (98.33), which supports the novelty of the instrument.

INTERPRETATION CONCLUSION

This unique device eliminates the need for multiple tools, causes minimum bodily damage to stages during handling, can be used in both the lab and the field, is inexpensive, lightweight, portable, and requires single manpower to operate.

A Novel Ex Vivo Assay to Evaluate Functional Effectiveness of Plasmodium vivax Transmission-Blocking Vaccine Using Pvs25 Transgenic Plasmodium berghei

BACKGROUND

Plasmodium falciparum and Plasmodium vivax account for >90% global malaria burden. Transmission intervention strategies encompassing transmission-blocking vaccines (TBV) and drugs represent ideal public health tools to eliminate malaria at the population level. The availability of mature P. falciparum gametocytes through in vitro culture has facilitated development of a standard membrane feeding assay to assess efficacy of transmission interventions against P. falciparum. The lack of in vitro culture for P. vivax has significantly hampered similar progress on P. vivax and limited studies have been possible using blood from infected patients in endemic areas. The ethical and logistical limitations of on-time access to blood from patients have impeded the development of P. vivax TBVs.

METHODS

Transgenic murine malaria parasites (Plasmodium berghei) expressing TBV candidates offer a promising alternative for evaluation of P. vivax TBVs through in vivo studies in mice, and ex vivo membrane feeding assay (MFA).

RESULTS

We describe the development of transmission-competent transgenic TgPbvs25 parasites and optimization of parameters to establish an ex vivo MFA to evaluate P. vivax TBV based on Pvs25 antigen.

CONCLUSIONS

The MFA is expected to expedite Pvs25-based TBV development without dependence on blood from P. vivax-infected patients in endemic areas for evaluation.

Quantification of sporozoite expelling by Anopheles mosquitoes infected with laboratory and naturally circulating P. falciparum gametocytes

It is currently unknown whether all Plasmodium falciparum-infected mosquitoes are equally infectious. We assessed sporogonic development using cultured gametocytes in the Netherlands and naturally circulating strains in Burkina Faso. We quantified the number of sporozoites expelled into artificial skin in relation to intact oocysts, ruptured oocysts, and residual salivary gland sporozoites. In laboratory conditions, higher total sporozoite burden was associated with shorter duration of sporogony (p<0.001). Overall, 53% (116/216) of infected Anopheles stephensi mosquitoes expelled sporozoites into artificial skin with a median of 136 expelled sporozoites (interquartile range [IQR], 34-501). There was a strong positive correlation between ruptured oocyst number and salivary gland sporozoite load (ρ = 0.8; p<0.0001) and a weaker positive correlation between salivary gland sporozoite load and number of sporozoites expelled (ρ = 0.35; p=0.0002). In Burkina Faso, Anopheles coluzzii mosquitoes were infected by natural gametocyte carriers. Among salivary gland sporozoite positive mosquitoes, 89% (33/37) expelled sporozoites with a median of 1035 expelled sporozoites (IQR, 171-2969). Again, we observed a strong correlation between ruptured oocyst number and salivary gland sporozoite load (ρ = 0.9; p<0.0001) and a positive correlation between salivary gland sporozoite load and the number of sporozoites expelled (ρ = 0.7; p<0.0001). Several mosquitoes expelled multiple parasite clones during probing. Whilst sporozoite expelling was regularly observed from mosquitoes with low infection burdens, our findings indicate that mosquito infection burden is positively associated with the number of expelled sporozoites. Future work is required to determine the direct implications of these findings for transmission potential.

In-vitro susceptibility and ex-vivo evaluation of macrocyclic lactone endectocides sub-lethal concentrations against Plasmodium vivax oocyst development in Anopheles arabiensis

BACKGROUND

Asymptomatic malaria transmission has become a public health concern across malaria-endemic Africa including Ethiopia. Specifically, Plasmodium vivax is more efficient at transmitting earlier in the infection and at lower densities than Plasmodium falciparum. Consequently, a greater proportion of individuals infected with P. vivax can transmit without detectable gametocytaemia. Mass treatment of livestock with macrocyclic lactones (MLs), e.g., ivermectin and doramectin, was suggested as a complementary malaria vector tool because of their insecticidal effects. However, the effects of MLs on P. vivax in Anopheles arabiensis has not yet been fully explored. Hence, comparative in-vitro susceptibility and ex-vivo studies were conducted to evaluate the effects of ivermectin, doramectin and moxidectin sub-lethal concentrations on P. vivax oocyst development in An. arabiensis.

METHODS

The 7-day sub-lethal concentrations of 25% (LC25) and 5% (LC5) were determined from in-vitro susceptibility tests on female An. arabiensis in Hemotek® membrane feeding assay. Next, an ex-vivo study was conducted using P. vivax gametocytes infected patient's blood spiked with the LC25 and LC5 of the MLs. At 7-days post-feeding, each mosquito was dissected under a dissection stereo microscope, stained with 0.5% (w/v) mercurochrome solution, and examined for the presence of P. vivax oocysts. Statistical analysis was based on a generalized mixed model with binomially distributed error terms.

RESULTS

A 7-day lethal concentration of 25% (LC25, in ng/mL) of 7.1 (95% CI: [6.3;8.0]), 20.0 (95%CI:[17.8;22.5]) and 794.3 (95%CI:[716.4;1516.3]) were obtained for ivermectin, doramectin and moxidectin, respectively. Similarly, a lethal concentration of 5% (LC5, in ng/mL) of 0.6 (95% CI: [0.5;0.7]), 1.8 (95% CI:[1.6;2.0]) and 53.7 (95% CI:[ 48.4;102.5]) were obtained respectively for ivermectin, doramectin and moxidectin. The oocyst prevalence in treatment and control groups did not differ significantly (p > 0.05) from each other. Therefore, no direct effect of ML endectocides on P. vivax infection in An. arabiensis mosquitoes was observed at the sub-lethal concentration (LC25 and LC5).

CONCLUSIONS

The effects of ivermectin and doramectin on malaria parasite is more likely via indirect effects, particularly by reducing the vectors lifespan and causing mortality before completing the parasite's sporogony cycle or reducing their vector capacity as it affects the locomotor activity of the mosquito.

Sermé S, Bolscher JM, T. G. Huijs T, S. Coulibaly A, Sombié S, Ouédraogo N, Diarra A, Zongo S, Guelbéogo WM, Nébié I, Sirima SB, Tiono AB, Pietro A, Collins KA, Dechering KJ, Bousema T. Assessment of the transmission blocking activity of antimalarial compounds by membrane feeding assays using natural Plasmodium falciparum gametocyte isolates from West-Africa

Antimalarial drugs that can block the transmission of Plasmodium gametocytes to mosquito vectors would be highly beneficial for malaria elimination efforts. Identifying transmission-blocking drugs currently relies on evaluation of their activity against gametocyte-producing laboratory parasite strains and would benefit from a testing pipeline with genetically diverse field isolates. The aims of this study were to develop a pipeline to test drugs against P. falciparum gametocyte field isolates and to evaluate the transmission-blocking activity of a set of novel compounds. Two assays were designed so they could identify both the overall transmission-blocking activity of a number of marketed and experimental drugs by direct membrane feeding assays (DMFA), and then also discriminate between those that are active against the gametocytes (gametocyte killing or sterilizing) or those that block development in the mosquito (sporontocidal). These DMFA assays used venous blood samples from naturally infected Plasmodium falciparum gametocyte carriers and locally reared Anopheles gambiae s.s. mosquitoes. Overall transmission-blocking activity was assessed following a 24 hour incubation of compound with gametocyte infected blood (TB-DMFA). Sporontocidal activity was evaluated following addition of compound directly prior to feeding, without incubation (SPORO-DMFA); Gametocyte viability was retained during 24-hour incubation at 37°C when gametocyte infected red blood cells were reconstituted in RPMI/serum. Methylene-blue, MMV693183, DDD107498, atovaquone and P218 showed potent transmission-blocking activity in the TB-DMFA, and both atovaquone and the novel antifolate P218 were potent inhibitors of sporogonic development in the SPORO-DMA. This work establishes a pipeline for the integral use of field isolates to assess the transmission-blocking capacity of antimalarial drugs to block transmission that should be validated in future studies.

HM, Lee HF, Marshall JM, Dimopoulos G, James AA. Dual effector population modification gene-drive strains of the African malaria mosquitoes, Anopheles gambiae and Anopheles coluzzii

Proposed genetic approaches for reducing human malaria include population modification, which introduces genes into vector mosquitoes to reduce or prevent parasite transmission. We demonstrate the potential of Cas9/guide RNA (gRNA)-based gene-drive systems linked to dual antiparasite effector genes to spread rapidly through mosquito populations. Two strains have an autonomous gene-drive system coupled to dual anti-Plasmodium falciparum effector genes comprising single-chain variable fragment monoclonal antibodies targeting parasite ookinetes and sporozoites in the African malaria mosquitoes Anopheles gambiae (AgTP13) and Anopheles coluzzii (AcTP13). The gene-drive systems achieved full introduction within 3 to 6 mo after release in small cage trials. Life-table analyses revealed no fitness loads affecting AcTP13 gene-drive dynamics but AgTP13 males were less competitive than wild types. The effector molecules reduced significantly both parasite prevalence and infection intensities. These data supported transmission modeling of conceptual field releases in an island setting that shows meaningful epidemiological impacts at different sporozoite threshold levels (2.5 to 10 k) for human infection by reducing malaria incidence in optimal simulations by 50 to 90% within as few as 1 to 2 mo after a series of releases, and by ≥90% within 3 mo. Modeling outcomes for low sporozoite thresholds are sensitive to gene-drive system fitness loads, gametocytemia infection intensities during parasite challenges, and the formation of potentially drive-resistant genome target sites, extending the predicted times to achieve reduced incidence. TP13-based strains could be effective for malaria control strategies following validation of sporozoite transmission threshold numbers and testing field-derived parasite strains. These or similar strains are viable candidates for future field trials in a malaria-endemic region.

A Novel Ex Vivo Drug Assay for Assessing the Transmission-Blocking Activity of Compounds on Field-Isolated Plasmodium falciparum Gametocytes

The discovery and development of transmission-blocking therapies challenge malaria elimination and necessitate standard and reproducible bioassays to measure the blocking properties of antimalarial drugs and candidate compounds. Most of the current bioassays evaluating the transmission-blocking activity of compounds rely on laboratory-adapted Plasmodium strains. Transmission-blocking data from clinical gametocyte isolates could help select novel transmission-blocking candidates for further development. Using freshly collected Plasmodium falciparum gametocytes from asymptomatic individuals, we first optimized ex vivo culture conditions to improve gametocyte viability and infectiousness by testing several culture parameters. We next pre-exposed ex vivo field-isolated gametocytes to chloroquine, dihydroartemisinin, primaquine, KDU691, GNF179, and oryzalin for 48 h prior to direct membrane feeding. We measured the activity of the drug on the ability of gametocytes to resume the sexual life cycle in Anopheles after drug exposure. Using 57 blood samples collected from Malian volunteers aged 6 to 15 years, we demonstrate that the infectivity of freshly collected field gametocytes can be preserved and improved ex vivo in a culture medium supplemented with 10% horse serum at 4% hematocrit for 48 h. Moreover, our optimized drug assay displays the weak transmission-blocking activity of chloroquine and dihydroartemisinin, while primaquine and oryzalin exhibited a transmission-blocking activity of ~50% at 1 μM. KDU691 and GNF179 both interrupted Plasmodium transmission at 1 μM and 5 nM, respectively. This new approach, if implemented, has the potential to accelerate the screening of compounds with transmission-blocking activity.

Infectivity of Symptomatic Malaria Patients to Anopheles farauti Colony Mosquitoes in Papua New Guinea

Plasmodium transmission from humans to mosquitoes is an understudied bottleneck in the transmission of malaria. Direct membrane feeding assays (DMFA) allow detailed malaria transmission studies from humans to mosquitoes. Especially for Plasmodium vivax, which cannot be cultured long-term under laboratory conditions, implementation of DMFAs requires proximity to P. vivax endemic areas. In this study, we investigated the infectivity of symptomatic Plasmodium infections to Anopheles farauti colony mosquitoes in Papua New Guinea (PNG). A total of 182 DMFAs were performed with venous blood collected from rapid diagnostic test (RDT) positive symptomatic malaria patients and subsequently analysed by light microscopy and quantitative real time polymerase chain reaction (qPCR). DMFAs resulted in mosquito infections in 20.9% (38/182) of cases. By light microscopy and qPCR, 10 - 11% of P. falciparum and 32 - 44% of P. vivax positive individuals infected An. farauti. Fifty-eight percent of P. vivax and 15% of P. falciparum gametocytaemic infections infected An farauti.

Infectivity of patent Plasmodium falciparum gametocyte carriers to mosquitoes: establishing capacity to investigate the infectious reservoir of malaria in a low-transmission setting in The Gambia

BACKGROUND

Understanding the human malaria infectious reservoir is important for elimination initiatives. Here, we implemented mosquito membrane feeding experiments to prepare for larger studies to quantify the transmission potential and relative contribution of the human infectious reservoir.

METHODS

Patients with clinical malaria attending four health facilities with at least 16 Plasmodium falciparum gametocytes per μL were recruited during the 2018 transmission season. Infectiousness to mosquitoes was assessed by direct membrane feeding assay (DMFA). We compared our results with a Bayesian predictive model to investigate the relationship between infectiousness and gametocyte density and explore the impact of fever on gametocyte infectivity.

RESULTS

A total of 3177 suspected malaria cases were screened; 43.3% (1376) had microscopically patent P. falciparum parasites and 3.6% (114) of them had gametocytes. Out of 68 DMFAs, 38 (55.9%) resulted in at least one infected mosquito, with a total of 15.4% (1178/7667) of mosquitoes infected with 1-475 oocysts per gut. The relationship between mosquito infection prevalence and gametocytaemia was similar to other African settings and negatively associated with fever (OR: 0.188, 95% CI 0.0603 to 0.585, p=0.0039).

CONCLUSIONS

Among symptomatic malaria patients, fever is strongly associated with transmission failure. Future studies can use DMFA to better understand the human malaria reservoir in settings of low endemicity in The Gambia and inform malaria elimination initiatives.