Are Alternative Strategies Required to Accelerate the Global Elimination of Lymphatic Filariasis? Insights From Mathematical Models

Background

With the 2020 target year for elimination of lymphatic filariasis (LF) approaching, there is an urgent need to assess how long mass drug administration (MDA) programs with annual ivermectin + albendazole (IA) or diethylcarbamazine + albendazole (DA) would still have to be continued, and how elimination can be accelerated. We addressed this using mathematical modeling.

Methods

We used 3 structurally different mathematical models for LF transmission (EPIFIL, LYMFASIM, TRANSFIL) to simulate trends in microfilariae (mf) prevalence for a range of endemic settings, both for the current annual MDA strategy and alternative strategies, assessing the required duration to bring mf prevalence below the critical threshold of 1%.

Results

Three annual MDA rounds with IA or DA and good coverage (≥65%) are sufficient to reach the threshold in settings that are currently at mf prevalence <4%, but the required duration increases with increasing mf prevalence. Switching to biannual MDA or employing triple-drug therapy (ivermectin, diethylcarbamazine, and albendazole [IDA]) could reduce program duration by about one-third. Optimization of coverage reduces the time to elimination and is particularly important for settings with a history of poorly implemented MDA (low coverage, high systematic noncompliance).

Conclusions

Modeling suggests that, in several settings, current annual MDA strategies will be insufficient to achieve the 2020 LF elimination targets, and programs could consider policy adjustment to accelerate, guided by recent monitoring and evaluation data. Biannual treatment and IDA hold promise in reducing program duration, provided that coverage is good, but their efficacy remains to be confirmed by more extensive field studies.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

The sharp end - experiences from the Tanzanian programme for the elimination of lymphatic filariasis: notes from the end of the road

The Tanzania Lymphatic Filariasis Programme, which was launched in 2000, is, in terms of geographical coverage, among the largest disease-control programmes in Tanzania's history, currently reaching 9.4 million people in 34 districts. The issues associated with this programme's implementation are reviewed here, in the context of the various players/stakeholders involved. This article provides an insight of how the programme began and discusses key areas in the programme's design. Mainly, however, it gives some impressions of how the programme is perceived by, and how it affects, village healthworkers, patients and politicians - the people who contribute to the implementation of the programme at various levels.

Bancroftian filariasis: house-to-house variation in the vectors and transmission -- and the relationship to human infection -- in an endemic community of coastal Tanzania

The house-to-house variation in Wuchereria bancrofti vector abundance and transmission intensity, and the relationship of these parameters to human infection, were investigated in an endemic community in coastal Tanzania. Vector mosquitoes were collected in light traps set up in 50 randomly selected households once weekly for 1 year. They were identified, dissected and checked for filarial larvae. Vector densities and transmission potentials varied markedly between households, both for all vectors combined and for the individual vector species (Anopheles gambiae s.1., An. funestus and Culex quinquefasciatus), even between households located close to each other. The variation in vector abundance was probably mainly attributable to differences in the distance to breeding sites, to specific household features likely to ease mosquito entry and hiding, and to the number of household inhabitants. Household annual biting rates (ABR) correlated positively with household annual transmission potentials (ATP), indicating that intense vector biting led to a high transmission intensity. Intriguingly, however, the human filarial-infection status (as indicated by microfilaraemia or circulating filarial antigenemia) did not differ significantly between households with relatively high and lower ABR or ATP. Possible reasons for this result include the long time required for W. bancrofti infection to establish in humans, human behaviour affecting exposure, the sharing of mosquito populations between households, and differential susceptibility of humans to infection. The marked heterogeneity in exposure between households, and the lack of immediate relationship between transmission and detectable human infection at household level, should be taken into account when considering the transmission pattern of lymphatic filariasis.

Colposcopic management of high-grade referral smears: a retrospective audit supporting 'see and treat'?

OBJECTIVE

The National Health Service Cervical Screening Programme monitors the quality of colposcopy services through the annual KC65 returns. The 2002 returns demonstrated that Standard 7c, which specifies a biopsy rate > or = 90% at first colposcopy visit for high-grade referrals, was not met in the assessed 3-month period. This was investigated along with the other standards.

METHODS

Retrospective colposcopy records were accessed for the 597 new referrals, excluding 10 pregnant patients, seen at the colposcopy clinic at the Royal Victoria Infirmary between 1 July 2001 and 31 December 2002, following an abnormal high-grade smear. Cytology and histopathology computer records were checked for confirmation. The results were assessed against the colposcopy standards applicable at that time and the revised standards (2004).

RESULTS

Biopsies were taken from 94.47% (Standard > or = 90%) of women at index colposcopy visit including wire loop excision biopsies from 66.16% (87.97% of high-grade colposcopic appearances). Cervical intraepithelial neoplasia (CIN) on histology was found in 91.79% in the study group (Standard > or = 85%) and in 96.71% of index visit biopsies (Standard > or = 90%), meeting the applicable colposcopy standards. The revised 2004 standards specify a biopsy in > or = 95% of high-grade referrals and excision biopsies in 95% if colposcopic appearances are also high-grade, if colposcopy is low grade but the smear is severely dyskaryotic, or when the lesion extends into the canal. The positive predictive value of high-grade cytology for this entire group was 75.54% with CIN present in 90.95%.

CONCLUSION

From this study it appears that high-grade cytology in this centre reliably indicates high-grade CIN. Therefore, in women referred for colposcopy following a high-grade smear, excision biopsies should be performed in a higher proportion at the first visit to comply with the revised standards.

Transmission dynamics of lymphatic filariasis: vector-specific density dependence in the development of Wuchereria bancrofti infective larvae in mosquitoes

The principles of meta-analysis developed in a previous study were extended to investigate the process of Wuchereria bancrofti (Cobbold) (Filarioidea: Onchocercidae) infection in mosquito (Diptera: Culicidae) hosts, focusing specifically on the functional forms and strength of density dependence in the development of ingested microfilariae (mf) to infective (third instar) larvae (L3). Mathematical models describing observed mf-L3 functional responses for each of the major three parasite-transmitting vector genera, Aedes, Culex and Anopheles mosquitoes, were fitted to paired mf-L3 data collated from all available studies in the published literature. Model parameters were estimated and compared by deriving and applying a data synthetic framework, based on applying a non-linear weighted regression model for fitting mathematical models to multistudy data. The results confirm previous findings of the existence of significant between-genera differences in the mf-L3 development relationship, particularly with regard to the occurrence of limitation in Culex mosquitoes and facilitation in Aedes and Anopheles mosquitoes. New and unexpected findings regarding L3 development from ingested mf were discovered as follows: (1) for Culex, overcompensation in L3 development at higher intensities of mf (or a peaked mf-L3 functional response) was detected; (2) for Aedes mosquitoes, facilitation (with an apparent asymptotic constraint on L3 development at high mf densities) was shown to be the major process governing L3 development, and (3) for Anopheles, a stronger facilitation type of response with no apparent saturation in L3 development appears to govern L3 output from ingested mf. These results yield major new insights regarding filarial vector infection dynamics and their potential impacts on parasite control, and demonstrate the efficacy of employing a data synthetic approach to reveal and estimate parasitic infection processes in host populations.

Bancroftian filariasis: patterns of vector abundance and transmission in two East African communities with different levels of endemicity

Intensive monitoring of Wuchereria bancrofti vector abundance and transmission intensity was carried out in two communities, one with high-level endemicity for bancroftian filariasis (Masaika, Tanzania) and the other with low-level (Kingwede, Kenya), on the East African coast. Mosquitoes were collected in light traps, from 50 randomly selected households in each community, once weekly for 1 year. They were identified, dissected and checked for parity and filarial larvae. Anopheles gambiae s. l., An. funestus and Culex quinquefasciatus transmitted W. bancrofti in the two communities but the importance of each of these taxa differed between the communities and by season. The overall vector densities and transmission intensities were significantly higher in Masaika than in Kingwede (the annual biting rate by 3.7 times and the annual transmission potential by 14.6 times), primarily because of differences in the available breeding sites for the vectors and in the vectorial capacity of the predominant vector species. A marked seasonal variation in vector abundance and transmission potential contributed to the complex transmission pattern in the communities. Generally, these indices were higher during and shortly after the rainy seasons than at other times of the year. Considerable differences in W. bancrofti transmission were thus observed between communities within a relatively small geographical area (mainly because of environmentally-determined differences in vector habitats), and these were reflected in the marked differences in infection level in the human populations. The variation in vector abundance, vector composition and transmission intensity in the two communities is discussed in respect to its cause, its effects, and its significance to those attempting to control bancroftian filariasis.

A model for the dynamics of human lymphatic filariasis

In this paper, Bryan Gren fell, Edwin Michael and David Denham review the appropriateness of feline filariasis as a model of the population dynamics of human lymphatic filarial infection and disease. Because of the longevity of infection and our inability to measure the adult parasite population in humans, research in filariasis is particularly dependent on the use of laboratory animal models. We demonstrate that Brugia pahangi infection patterns in the cat closely parallel those of Brugia and Wuchereria in humans. Although primary infections in 'susceptible' cats are long-lived, repeatedly infected animals show evidence of concomitant immunity which prevents the establishment of later cohorts of infective larvae. Furthermore, there is some evidence from macro filarial length distributions of 'stunting' of adult worms during long-term repeat infections. Cats can also show an 'acute' response that spontaneously eliminates infections, and this appears to be due to a combination of intrinsic and dynamic mechanisms. As in humans, pathology in cat filariasis develops as a sequel to the asymptomatic microfilaremic state, largely as a result of re-expression of immunity. The relationship between macro filarial burdens and microfilariae in blood is positive but portrays a high degree of variability. The cat model provides an important tool for elucidating the relationships between infection, immunity and disease dynamics in lymphatic filariasis, and we conclude by suggesting directions for further work in this area.

Global mapping of lymphatic filariasis

Disease maps are becoming increasingly important in infectious disease epidemiology and control. For lymphatic filariasis, the development of such maps has been hampered in the past by the lack of data on the geographical distribution of levels of infection or disease. Here, Edwin Michael and Don Bundy present an atlas for this parasitic disease derived from a recently compiled geographical database. Focusing on mapping and analysis of case prevalence data at the global and regional levels, the authors show how mapping the geographical distribution is integral not only to assessing spatial patterns in the infection and disease distribution but also to stratifying endemic areas by infection and/or disease rate.

Immuno-epidemiology of Ascaris lumbricoides infection in a high transmission community: antibody responses and their impact on current and future infection intensity

The role of the humoral immune system in human infection with Ascaris lumbricoides remains unclear. This study documents an epidemiological investigation in a highly endemic community in Vietnam, whereby serum antibody levels were assessed before treatment and after a 6-month reinfection period. These data were examined by correlation with infection status using an age-structured approach in an attempt to help shed light on the role of the humoral immune response. The first part of this study characterized levels of all serum antibody isotypes from the community in response to antigens of both adult and larval A. lumbricoides. Data were assessed in terms of their relation to host age and infection intensity with the aim to provide a broadly detailed account of immune responses to the parasite. In the second part, antibody responses to both life-stages of A. lumbricoides in serum samples collected before anthelmintic chemotherapy were analysed in relation to intensity of re-infection with the parasite 6 months following treatment. The results suggest that antibody responses may not confer protection from current infection or re-infection with A. lumbricoides and may not serve as reliable indicators of future infection intensity. Our results thereby lend support to the theory that immunity to A. lumbricoides may not be based on the humoral immune system.

BMP controls nitric oxide-mediated regulation of cell numbers in the developing neural tube

Balanced cell proliferation and cell death determines neural precursor cell numbers in early stages of neural tube (NT) development. We have previously shown that nitric oxide (NO) regulates cell numbers locally in the NT of eight to 12 somite embryos. Here, we demonstrate that bone morphogenetic protein-4 (BMP-4), which is expressed in the ectoderm and dorsal NT at these developmental stages, induces programmed cell death (PCD) and promotes entry into the S-phase, via nitric oxide synthase (NOS) activity. These effects can be reversed by BMP-4 antagonists, such as follistatin and noggin, or by specific NOS inhibitors, resulting in low NO levels that facilitate mitosis and reduce PCD. Ectopic BMP-4 induction of PCD is restricted to the dorsal NT, whereas promotion of the S-phase is evenly observed across the dorsal-ventral (D-V) axis. Prolonged exposure to either BMP-4 or NOS inhibitors, which results in high or low NO levels, respectively, causes NT defects. The results presented here throw new light on the BMP signaling pathway. The local presence of BMP-4 helps to regulate cell numbers in the developing NT by a NO-mediated pathway, which is essential for normal NT formation.

Transmission dynamics of lymphatic filariasis: density-dependence in the uptake of Wuchereria bancrofti microfilariae by vector mosquitoes

Gaining a better understanding of parasite infection dynamics in the vector mosquito (Diptera: Culicidae) population is central to improving knowledge regarding the transmission, persistence and hence control of lymphatic filariasis. Here, we use data on mosquito feeding experiments collated from the published literature to examine the available evidence regarding the functional form of the first component of this parasite-vector relationship for Wuchereria bancrofti (Filarioidea: Onchocercidae) causing Bancroftian filariasis, i.e. the rate of microfilariae (mf) uptake from the blood of infected humans by the feeding mosquito vector. Using a simple logarithmic regression model for describing the observed relationships between the mean numbers of mf ingested per mosquito and parasite load in humans in each study, and a linear mixed-effects meta-analytical framework for synthesizing the observed regressions across studies, we show here for the first time clear evidence for the existence of density-dependence in this process for all the three major filariasis transmitting mosquito vectors. An important finding of this study is that this regulation of mf uptake also varies significantly between the vector genera, being weakest in Culex, comparatively stronger in Aedes and most severe and occurring at significantly lower human mf loads in Anopheles mosquitoes. The analysis of the corresponding mf uptake prevalence data has further highlighted how density-dependence in mf uptake may influence the observed distributions of mf in vector populations. These results show that whereas strong regulation of mf uptake, especially when it leads to saturation in uptake at low human parasite intensities, can lead to static distributions of mf per mosquito with host parasite intensity, a weaker regulation of mf ingestion can give rise to changes in both mean mf loads and in the frequency distribution of parasites/mosquito with increasing human parasite intensity. These findings highlight the importance of considering local vector infection dynamics when attempting to predict the impacts of community-based filariasis control. They also emphasize the value of developing and applying robust meta-analytic methods for estimating functional relationships regarding parasitic infection from population ecological data.

Sequence variation in the Trichuris trichiura beta-tubulin locus: implications for the development of benzimidazole resistance

Benzimidazole resistance has evolved in a variety of organisms and typically results from mutations in the beta-tubulin locus at specific amino acid sites. Despite widespread treatment of human intestinal nematodes with benzimidazole drugs, there have been no unambiguous reports of resistance. However, since beta-tubulin mutations conferring resistance are generally recessive, frequencies of resistance alleles less than 30% would be difficult to detect on the basis of drug treatment failures. Here we investigate sequence variation in a 1079 bp segment of the beta-tubulin locus in the human whipworm Trichuris trichiura from 72 individual nematodes from seven countries. We did not observe any alleles with amino acid mutations indicative of resistance, and of 40 point mutations there were only four non-synonymous mutations all of which were singletons. Estimated effective population sizes are an order of magnitude lower than those from another nematode species in which benzimidazole resistance has developed (Haemonchus contortus). Both the lower diversity and reduced population sizes suggest that benzimidazole resistance is likely to evolve less rapidly in Trichuris than in trichostrongyle parasites of livestock. We observed moderate levels of population subdivision (Phi(ST)=0.26) comparable with that previously observed in Ascaris lumbricoides, and identical alleles were frequently found in parasites from different continents, suggestive of recent admixture. A particularly interesting feature of the data is the high nucleotide diversities observed in nematodes from the Caribbean. This genetic complexity may be a direct result of extensive admixture and complex history of human populations in this region of the world. These data should encourage (but not make complacent) those involved in large-scale benzimidazole treatment of human intestinal nematodes.

A geostatistical analysis of the geographic distribution of lymphatic filariasis prevalence in southern India

Gaining a better understanding of the spatial population structure of infectious agents is increasingly recognized as being key to their more effective mapping and to improving knowledge of their overall population dynamics and control. Here, we investigate the spatial structure of bancroftian filariasis distribution using geostatistical methods in an endemic region in Southern India. Analysis of a parasite antigenemia prevalence dataset assembled by sampling 79 villages selected using a World Health Organization (WHO) proposed 25 x 25 km grid sampling procedure in a 225 x 225 km area within this region was compared with that of a corresponding microfilaraemia prevalence dataset assembled by sampling 119 randomly selected villages from a smaller subregion located within the main study area. A major finding from the analysis was that once large-scale spatial trends were removed, the antigenemia data did not show evidence for the existence of any small-scale dependency at the study sampling interval of 25 km. By contrast, analysis of the randomly sampled microfilaraemia data indicated strong spatial contagion in prevalence up to a distance of approximately 6.6 kms, suggesting the likely existence of small spatial patches or foci of transmission in the study area occurring below the sampling scale used for sampling the antigenemia data. While this could indicate differences in parasite spatial population dynamics based on antigenemia versus microfilaraemia data, the result may also suggest that the WHO recommended 25 x 25 km sampling grid for rapid filariasis mapping could have been too coarse a scale to capture and describe the likely local variation in filariasis infection in this endemic location and highlights the need for caution when applying uniform sampling schemes in diverse endemic regions for investigating the spatial pattern of this parasitic infection. The present results, on the other hand, imply that both small-scale spatial processes and large-scale factors may characterize the observed distribution of filariasis in the study region. Our preliminary analysis of a mountain range associated large-scale trend in the antigenemia data suggested that a nonlinear relationship of infection prevalence with elevation might be a factor behind such observed global spatial patterns. We conclude that geostatistic methods can provide a powerful framework for carrying out the empirical investigation and analysis of parasite spatial population structure. This study shows that their successful application, however, will crucially depend on our gaining a more thorough understanding of the appropriate geographic scales at which spatial studies should be carried out.

Impact of untreated bednets on prevalence of Wuchereria bancrofti transmitted by Anopheles farauti in Papua New Guinea

Despite the growing evidence that insecticide-treated mosquito nets reduce malaria morbidity and mortality in a variety of epidemiological conditions, their value against lymphatic filariasis infection and disease is yet to be established. The impact of untreated bednets on the prevalence of Wuchereria bancrofti (Cobbold) (Nematoda: Filarioidea) infection and disease was investigated on Bagabag island in Papua New Guinea, where both malaria and filariasis are transmitted by the same vector mosquitoes of the Anopheles punctulatus Dönitz group (Diptera: Culicidae). Community-wide surveys were conducted recording demographic characteristics including bednet usage. Physical examinations for hydrocoele and lymphoedema were performed and blood samples assessed for filarial and malaria parasites. Mosquitoes were sampled using the all-night landing catch method and individually dissected to determine W. bancrofti infection and infective rates. Bednet usage among residents was 61% and the mean age of users (25.6 years) was similar to non-users (22.5 years). Anopheles farauti Laveran was the only species were found to contain filarial larvae: 2.7% infected (all stages), 0.5% infective (L3). The overall W. bancrofti microfilaraemia and antigenaemia rates were 28.5% and 53.1%, respectively. Bednet users had lower prevalence of W. bancrofti microfilaraemia, antigenaemia and hydrocoele rates than non-users. In comparison, untreated bednets had no effect on the prevalence and intensity of Plasmodium falciparum and P. vivax infections. The impact of bednet usage on rates of microfilaraemia and antigenaemia remained significant even when confounding factors such as age, location and sex were taken into account, suggesting that untreated bednets protect against W. bancrofti infection.

Quantifying mosquito biting patterns on humans by DNA fingerprinting of bloodmeals

A major debate in infectious disease epidemiology concerns the relative importance of exposure and host factors, such as sex and acquired immunity, in determining observed age patterns of parasitic infection in endemic communities. Nonhomogeneous contact between hosts and vectors is also expected to increase the reproductive rate, and hence transmission, of mosquito-borne infections. Resolution of these questions for human parasitic diseases has been frustrated by the lack of a quantitative tool for quantifying the exposure rate of people in communities. Here, we show that the polymerase chain reaction (PCR) technique for amplifying and fingerprinting human DNA from mosquito bloodmeals can address this problem for mosquito-borne diseases. Analysis of parallel human and mosquito (resting Culex quinquefasciatus) samples from the same households in an urban endemic focus for bancroftian filariasis in South India demonstrates that a 9-locus radioactive short-tandem repeat system is able to identify the source of human DNA within the bloodmeals of nearly 80% of mosquitoes. The results show that a person's exposure rate, and hence the age and sex patterns of exposure to bites in an endemic community, can be successfully quantified by this method. Out of 276 bloodmeal PCR fingerprints, we also found that on average, 27% of the mosquitoes caught resting within individual households had fed on people outside the household. Additionally, 13% of mosquitoes biting within households contained blood from at least 2 people, with the rate of multiple feeding depending on the density of humans in the household. These complex vector feeding behaviors may partly account for the discrepancies in estimates of the infection rates of mosquito-borne diseases calculated parasitologically and entomologically, and they underline the potential of this tool for investigating the transmission dynamics of infection.

A simple and quick method for enhanced detection of specific IgE in serum from lymphatic filariasis patients

A new simple and quick technique, using a suspension of protein A agarose beads to absorb IgG4 from sera prior to determination of filarial-specific IgE in ELISA, is presented. The optimal ratio between serum and absorbant was determined by absorbing fixed volumes of sera from individuals from a Wuchereria bancrofti endemic area with different volumes of the protein A agarose bead suspension and testing supernatants for filaria-specific IgG4 and IgE. The effect of absorption on measured IgG4 and IgE intensities in sera from various categories of individuals from the endemic area was thereafter examined. Overall, absorption resulted in a 96.5% decrease in mean ELISA OD values for IgG4 and a 41.6% increase in mean ELISA OD values for IgE. Higher increases in IgE measurements were seen with sera from circulating filarial antigen (CFA) negative individuals (64.7%), microfilaria (mf) negative individuals (56.1%) and individuals with chronic filarial disease (62.7%) than with sera from individuals who were CFA positive (23.4%), mf positive (10.0%), or without chronic disease (36.5%). These differences indicate that the degree to which IgE detection in unabsorbed serum is blocked by IgG4 varies with infection and disease status. Absorption of IgG4 from serum with a protein A agarose bead suspension prior to measurement of specific IgE is a useful alternative to conventional gel column absorption methods, particularly when processing many samples.

Transmission intensity and the immunoepidemiology of bancroftian filariasis in East Africa

Previous attempts to determine the interactions between filariasis transmission intensity, infection and chronic disease have been limited by a lack of a theoretical framework that allows the explicit examination of mechanisms that may link these variables at the community level. Here, we show how deterministic mathematical models, in conjunction with analyses of standardized field data from communities with varying parasite transmission intensities, can provide a particularly powerful framework for investigating this topic. These models were based on adult worm population dynamics, worm initiated chronic disease and two major forms of acquired immunity (larval- versus adult-worm generated) explicitly linked to community transmission intensity as measured by the Annual Transmission Potential (ATP). They were then fitted to data from low, moderate and moderately high transmission communities from East Africa to determine the mechanistic relationships between transmission, infection and observed filarial morbidity. The results indicate a profound effect of transmission intensity on patent infection and chronic disease, and on the generation and impact of immunity on these variables. For infection, the analysis indicates that in areas of higher parasite transmission, community-specific microfilarial rates may increase proportionately with transmission intensity until moderated by the generation of herd immunity. This supports recent suggestions that acquired immunity in filariasis is transmission driven and may be significant only in areas of high transmission. In East Africa, this transmission threshold is likely to be higher than an ATP of at least 100. A new finding from the analysis of the disease data is that per capita worm pathogenicity could increase with transmission intensity such that the prevalences of both hydrocele and lymphoedema, even without immunopathological involvement, may increase disproportionately with transmission intensity. For lymphoedema, this rise may be further accelerated with the onset of immunopathology. An intriguing finding is that there may be at least two types of immunity operating in filariasis: one implicated in anti-infection immunity and generated by past experience of adult worms, the other involved in immune-mediated pathology and based on cumulative experience of infective larvae. If confirmed, these findings have important implications for the new global initiative to achieve control of this disease.

Wuchereria bancrofti in a community with seasonal transmission: stability of microfilaraemia, antigenaemia and filarial-specific antibody concentrations

The effect of seasonal transmission on microfilaraemia, antigenaemia and filarial-specific antibody levels in individuals infected with Wuchereria bancrofti was investigated in a follow-up study in an endemic community in north-eastern Tanzania. The subjects were 37 adult male residents who were found to be positive for circulating filarial antigen (CFA) at the beginning of the study (26 of whom were also found microfilaraemic with W. bancrofti at this time). Blood samples were collected from each subject in July 1998, January 1999 and July 1999, during the seasons when transmission intensity was high, low and high, respectively. The mean intensities of microfilaraemia and the mean concentrations of CFA were each slightly higher during the low-transmission season than during the two high-transmission seasons but the differences were not statistically significant (P > 0.05). Similarly, the mean levels of filarial-specific IgG1, IgG2, IgG3, IgG4 or IgE did not differ to a statistically significant degree between the three examination times. Microfilaraemias and the levels of CFA and filarial-specific antibodies all therefore appeared to be remarkably stable and largely unaffected by the seasonal variation in transmission. That no variation in the mean IgG4/IgE ratio was observed over the study period may indicate that the level of resistance to W. bancrofti infection in the study subjects was also unaffected by the transmission season.

The potential of geographical information systems and remote sensing in the epidemiology and control of human helminth infections

Geographic information systems (GIS) and remote sensing (RS) technologies are being used increasingly to study the spatial and temporal patterns of infectious diseases. For helminth infections, however, such applications have only recently begun despite the recognition that infection distribution patterns in endemic areas may have profound effects on parasite population dynamics and therefore the design and implementation of successful control programmes. Here, we review the early applications of these technologies to the major human helminths (geohelminths, schistosomes and the major lymphatic filarial worms), which demonstrate the potential of these tools to serve as: (1) an effective data capture, mapping and analysis tool for the development of helminth atlases; (2) an environment for modeling the spatial distribution of infection in relation to RS and environmental variables, hence furthering the understanding of the impact of density-independent factors in underlying observed parasite spatial distributions and their effective prediction; and (3) a focal tool in parasite control programming given their abilities to (i) better define endemic areas, (ii) provide more precise estimates of populations-at-risk, (iii) map their distribution in relation to health facilities and (iv) by facilitating the stratification of areas by infection risk probabilities, to aid in the design of optimal drug or health measure delivery systems. These applications suggest a successful role for GIS/RS applications in investigating the spatial epidemiology of the major human helminths. It is evident that further work addressing a range of critical issues include problems of data quality, the need for a better understanding of the population biological impact of environmental factors on critical stages of the parasite life-cycle, the impacts and consequences of spatial scale on these relationships, and the development and use of appropriate spatially-explicit statistical and modeling techniques in data analysis, is required if the true potential of this tool to helminthology is to be fully realized.

Mapping of lymphatic filariasis in India

The derivation of detailed epidemiological maps, at the relevant spatial resolution, is being increasingly recognized as vital to the effective design and implementation of successful programmes for the control of parasites and their vectors. Geographical information systems (GIS) and a recently complied database on the distribution of lymphatic filariasis in India have now been used to develop the first maps at district-level (i.e. the level at which control against this parasite will be enacted in India) of filariasis endemicity in this country. The derived maps indicate both the substantial extent as well as the marked variability in the geographical distribution of this disease in India. The causative infection and/or the symptomatic disease were detected in most (257) of the 289 districts surveyed up to 1995. Currently there may be up to 27.09 million microfilaraemics, 20.83 million cases of symptomatic filariasis, and about 429.32 million individuals potentially at risk of infection in the country. Probability mapping, based on data quantiles, clearly indicates that the risk of filarial infection in India is not constant throughout the country but exhibits strong regional trends. Filariasis in general may be a particular problem of the eastern half of the country. The results indicate the potentially vital role that GIS-based mapping approaches can play in the development of filariasis-control campaigns in India and elsewhere.

Targeted disruption of the epidermal growth factor receptor inhibits development of papillomas and carcinomas from human papillomavirus-immortalized keratinocytes

The epidermal growth factor receptor (EGF-R) is frequently overexpressed in human papillomavirus (HPV)-associated dysplasias and carcinomas, implying that it is important for the progression of keratinocytes to malignancy. We used mice with a targeted disruption of the EGF-R gene to directly examine its role in cell immortalization and tumor development. Epidermal keratinocytes were cultured from EGF-R knockout, heterozygous, and wild-type mice, infected with retroviruses encoding HPV-16 E6 and E7 oncogenes, and grafted to nude mice. E6/E7 induced immortalization of EGF-R wild-type cells 5-fold more efficiently than null cells. Immortal EGF-R null cells grew more slowly, achieved a lower saturation density, and were more sensitive to apoptosis than the immortalized wild-type or heterozygous cells. Analyses using cDNA expression arrays showed that EGF-R null cells expressed increased levels of RNAs encoding p21waf and insulin-like growth factor-binding protein-2. EGF-R-positive immortal keratinocytes formed papillomas in 17% (15 of 90) of skin grafts, and seven grafts progressed to squamous carcinoma after 6-12 months. EGF-R null keratinocytes did not form papillomas, but 1 of 96 grafts progressed to a squamous carcinoma after 1 year. However, treatment with the tumor promoter 12-O-tetradecanoylphorbol-13-acetate induced tumors in 18 and 35% of grafts containing EGF-R null or EGF-R-positive cells, respectively. Transduction with an activated v-Ha-ras gene, which signals downstream of the EGF-R, induced rapidly growing carcinomas in all grafts regardless of EGF-R genotype. These results directly show that the EGF-R is important, but not essential, for immortalization by HPV and for progression of immortal cells to papillomas and carcinomas.

The economic burden of lymphatic filariasis in India

Lymphatic filariasis affects 119 million people living in 73 countries, with India accounting for 40% of the global prevalence of infection. Despite its debilitating effects, lymphatic filariasis is given very low control priority. One of the reasons for this is paucity of information on the economic burden of the disease. Recent studies in rural areas of south India have shown that the treatment costs and loss of work time due to the disease are considerable. Based on the results of these studies, Kapa Ramaiah et al. here estimate the annual economic loss because of lymphatic filariasis for India and discuss the implications of their findings.

EPIFIL: the development of an age-structured model for describing the transmission dynamics and control of lymphatic filariasis

Mathematical models of transmission dynamics of infectious diseases provide a useful tool for investigating the impact of community based control measures. Previously, we used a dynamic (constant force-of-infection) model for lymphatic filariasis to describe observed patterns of infection and disease in endemic communities. In this paper, we expand the model to examine the effects of control options against filariasis by incorporating the impact of age structure of the human community and by addressing explicitly the dynamics of parasite transmission from and to the vector population. This model is tested using data for Wuchereria bancrofti transmitted by Culex quinquefasciatus in Pondicherry, South India. The results show that chemotherapy has a larger short-term impact than vector control but that the effects of vector control can last beyond the treatment period. In addition we compare rates of recrudescence for drugs with different macrofilaricidal effects.

The control of the human filariases

There is a growing momentum for the global control and elimination of the major human filariases as public health problems worldwide. The renewed optimism for undertaking this objective reflects the development of simple and potentially cost-effective strategies for mass drug delivery in onchocerciasis and the availability of new extremely effective drug combinations to treat infection, and new methods of morbidity control in lymphatic filariasis. It also reflects the development and current availability of very effective diagnostic, surveillance and control modeling tools for both parasites. Control programming will also be aided by our greater understanding of the biology of transmission, host immunity and disease pathogenesis.

Cardiac exposure history as a determinant of symptoms and emergency department utilization in noncardiac chest pain patients

Although comparative studies differentiate noncardiac chest pain (NCCP), panic disorder, and coronary artery disease (CAD), little research has examined the defining features of NCCP, such as cardiac complaints, medical utilization, and learning history. We administered self-report measures to 80 Emergency Department (ED) patients with a primary complaint of chest pain who were subsequently found to not have CAD. Forty-eight percent of the ED utilization variance was accounted for by NCCP duration, age, cardiac distress symptoms, and prior exposure to both siblings' and friends' cardiac distress symptoms. In turn, 67% of the variance in cardiac distress symptoms was explained by education, age, NCCP duration, number of illnesses, noncardiac panic symptoms, prior exposure (friends), and prior observation of others' cardiac distress. No effects emerged for gender, ethnicity, avoidance, or depression. Results suggest that beyond the effects of age and distress intensity, prior exposure to other people's cardiac distress may influence NCCP.

Epidemiology of soil-transmitted nematode infections in Ha Nam Province, Vietnam

Baseline epidemiological data are presented from a parasitological survey conducted in Thuy Loi commune, Ha Nam province, Vietnam; a farming community where night soil is routinely used as fertilizer for crops. 177 households were visited and 543 individuals (aged 1-88 years) recruited to the study. Helminth infection intensity was assessed by Kato-Katz to determine the density of parasite eggs per gram of stool (epg). Ascaris lumbricoides, Trichuris trichiura and hookworm infections were the only species detected. 83% of individuals were infected with A. lumbricoides (mean epg = 11,971), 94% with T. trichiura (mean epg = 793) and 59% with hookworm (mean epg = 302). Age-dependent patterns of infection prevalence and intensity were similar for A. lumbricoides and T. trichiura, but markedly different for hookworm infection. Similarly, age-dependency in the k-values for the three infections was due to covariance with the respective mean intensities with age rather than to independent age effects, with similar patterns for A. lumbricoides and T. trichiura, and a different pattern for hookworm. Three major conclusions can be drawn from the multiple-species analyses: There is positive interaction between A. lumbricoides and T. trichiura infections; high-intensity A. lumbricoides infections are significantly associated with high-intensity T. trichiura infections; and there is positive interaction between these two species such that infection intensity of A. lumbricoides is higher in individuals with concurrent T. trichiura infection than in individuals without and vice versa.

Epifil: a dynamic model of infection and disease in lymphatic filariasis

The lack of a quantitative framework that describes the dynamic relationships between infection and morbidity has constrained efforts aimed at the community-level control of lymphatic filariasis. In this paper, we describe the development and validation of EPIFIL, a dynamic model of filariasis infection intensity and chronic disease. Infection dynamics are modeled using the well established immigration-death formulation, incorporating the acquisition of immunity to infective larvae over time. The dynamics of disease (lymphodema and hydrocele) are modeled as a catalytic function of a variety of factors, including worm load and the impact of immunopathological responses. The model was parameterized using age-stratified data collected from a Bancroftian filariasis endemic area in Pondicherry in southern India. The fitted parameters suggest that a relatively simple model including only acquired immunity to infection and irreversible progression to disease can satisfactorily explain the observed infection and disease patterns. Disease progression is assumed to be a consequence of worm induced damage and to occur at a high rate for hydrocele and a low rate for lymphodema. This suggests that immunopathology involvement may not be a necessary component of observed age-disease profiles. These findings support a central role for worm burden in the initiation and progression of chronic filarial disease.

A review of the present status of lymphatic filariasis in Vietnam

Establishing the current status of an infectious disease forms the starting point of any attempt at parasite control. Although data on the prevalence and distribution of lymphatic filariasis exist for Vietnam from the early 1900s, the present situation regarding the disease is less well-known. Here, we review the results of recent surveys conducted by the Institute of Malariology, Parasitology and Entomology, Hanoi, to update the existing information on filariasis epidemiology and distribution for this country. The present results are from surveys carried out on some 135,000 individuals in 24 provinces of Vietnam. The highest prevalences of microfilaraemia (primarily Brugia malayi ) are observed in lowland areas of the Red River Delta and in Quang-binh Province where the survey results show microfilaraemia (mf) prevalences in the range of 0.9-5.5%. The most common type of chronic clinical manifestation is shown to be leg elephantiasis. A significant finding is that an overall decrease in mf prevalence was observed to occur in five communities which were surveyed twice over an 11-21-year period, even though no interventions were carried out between the two surveys. The changes are probably caused by environmental changes, such as increased standards of housing and drainage. Studies on the effect of selective chemotherapy and mass chemotherapy using diethylcarbamazine showed reductions in community mf prevalences of 69 and 72-88%, respectively. Furthermore, cats do not appear to represent significant reservoirs of infection. These findings of geographical restriction of infection, effective and well-tolerated drug therapy, low significance of animal reservoirs, together with the existence of an effective national health network, suggest a good prognosis for the control of filariasis in this country.

Herd immunity to filarial infection is a function of vector biting rate

Despite the existence of an impressive body of work on human immune responses against filarial infections, the occurrence of a protective response to infection remains unclear. Here, we use a combined modelling and comparative data analysis framework to address this issue for human infections with the filarial parasite, Wuchereria bancrofti. By analogy with previous work, the analysis involves the comparison of observed field patterns of infection with epidemiological patterns predicted by a mathematical model of parasite immunity. Unlike most other human helminths, which are transmitted by ingestion or dermal penetration, exposure to infection with lymphatic filariasis can be measured explicitly in terms of vector mosquito biting rates, thereby also allowing, probably for the first time, examination of the suggested role of exposure in generating herd immunity to macroparasites. Observed field patterns in this study were derived from 19 different published studies, which gave parallel estimates of community exposure rates and the corresponding age--prevalence patterns of infection, while predictions of the epidemiological impact of herd immunity were obtained using a catalytic model framework. The results provide the first conclusive evidence to date that variations in the observed age--prevalence patterns of infection in filariasis can be effectively explained by the occurrence of an exposure-driven acquisition of herd immunity. We discuss this result in terms of implications for the new World Health Organization-led initiative for the global control of this parasitic disease.

Modelling variability in lymphatic filariasis: macrofilarial dynamics in the Brugia pahangi--cat model

A striking feature of lymphatic filariasis is the considerable heterogeneity in infection burden observed between hosts, which greatly complicates the analysis of the population dynamics of the disease. Here, we describe the first application of the moment closure equation approach to model the sources and the impact of this heterogeneity for macrofilarial population dynamics. The analysis is based on the closest laboratory equivalent of the life cycle and immunology of infection in humans--cats chronically infected with the filarial nematode Brugia pahangi. Two sets of long-term experiments are analysed: hosts given either single primary infections or given repeat infections. We begin by quantifying changes in the mean and aggregation of adult parasites (inversely measured by the negative binomial parameter, kappa in cohorts of hosts using generalized linear models. We then apply simple stochastic models to interpret observed patterns. The models and empirical data indicate that parasite aggregation tracks the decline in the mean burden with host age in primary infections. Conversely, in repeat infections, aggregation increases as the worm burden declines with experience of infection. The results show that the primary infection variability is consistent with heterogeneities in parasite survival between hosts. By contrast, the models indicate that the reduction in parasite variability with time in repeat infections is most likely due to the 'filtering' effect of a strong, acquired immune response, which gradually acts to remove the initial variability generated by heterogeneities in larval mortality. We discuss this result in terms of the homogenizing effect of host immunity-driven density-dependence on macrofilarial burden in older hosts.

Wuchereria bancrofti microfilaraemia in children in relation to parental infection status

A total of 946 families with 2302 children was surveyed for microfilaraemia due to Wuchereria bancrofti. The prevalence of microfilaraemia among offspring born to microfilaraemic parents was significantly higher than in those born to amicrofilaraemic parents (P = 0.0049; relative risk = 3.40). However, there was no statistically significant difference between the prevalence of microfilaraemia in children born to microfilaraemic mothers or microfilaraemic fathers, suggesting that parental (not only maternal) infection is the important risk factor, and it may be exposure within the household which is important. Logistic regression analyses also confirmed that the risk of infection for offspring born to either microfilaraemic mothers or microfilaraemic fathers was higher than that for offspring born to amicrofilaraemic parents and indicated that infection in children < or = 20 years old was primarily dependent on parental infection status and minimally influenced by factors other than household exposure.