Cortisol and Plasmodium falciparum infection in pregnant women in Kenya

Women living under holoendemic conditions of malaria in Kenya exhibited an increased prevalence of clinical malaria during pregnancy. In addition parasite rate and density were higher in primigravidae compared to multigravidae. Higher serum cortisol concentrations were found in women with patent malaria during pregnancy and the levels were higher before, during and after the malaria episode. A causal relation between serum cortisol levels and suppression of malaria immunity during pregnancy is discussed.     

Analysis of the effects of malaria chemoprophylaxis in children on haematological responses,morbidity and mortality

This paper reviews the evidence for beneficial effects of malaria chemoprophylaxis on haematological responses, morbidity, mortality, health service utilization and rebound immunity in children. As anaemia may play an important role in childhood mortality, it is important to assess evidence from controlled trials of the potential of chemoprophylaxis to reduce childhood anaemia. An analysis of trials found good evidence that malaria chemoprophylaxis improves mean haemoglobin levels and reduces severe anaemia, clinical malaria attacks, parasite and spleen rates. Significant reductions in outpatient attendance and hospital admissions have been achieved, and substantial evidence from Gambian studies shows reductions in mortality. Chemoprophylaxis in children does not seem to produce any sustained impairment of immunity to malaria, although rebound effects may be greater in children who receive prophylaxis during infancy. Short periods of targeted prophylaxis are likely to be preferable to continuous drug administration. Evidence of the protective efficacy of malaria chemoprophylaxis in children shows that this strategy could be considered within integrated health programmes for specific time periods. Intermittent routine combination therapy early in childhood may be appropriate for those living under holoendemic conditions. Large-scale studies over a number of years are needed to address this issue and the impact of this approach on health service utilization, mortality, and the emergence of drug-resistant parasites.     

Unstable malaria in Sudan: the influence of the dry season. Malaria in areas of unstable and seasonal transmission. Lessons from Daraweesh.

Most studies of the natural history of Plasmodium falciparum infection have been performed in areas of stable malaria transmission and the acquisition of immunity to malaria in individuals who live in such areas is well documented. For the past 10 years, we have monitored host-parasite relationships in an area characterized by unstable and seasonal malaria of low transmission intensity. The work was performed in the village Daraweesh located in north-eastern Sudan 16 km from Gedaref town. The climate of the region is characterized by well-defined wet and dry periods with a short rainy season followed by a long dry season. In some years the rains fail and there is little precipitation even during the wet season. Malaria cases are rare in the dry season and during droughts. In years with rains, falciparum malaria sweeps through Daraweesh during the wet season and 20-40% of the entire population suffer at least 1 attack of malaria. All age-groups are affected, but the risk of getting a clinical attack is about twice as high in the age-group from 5 to 20 years as in adults aged above 30 years. Serological data and evidence obtained by polymerase chain reaction indicate that only about half of new blood-stage infections cause clinical disease. Together these findings suggest that many new infections are controlled immunologically and that individuals aged over 30 years are more successful in controlling infections than are teenagers. Parasite strains collected in Daraweesh are genotypically diverse and it is likely that the outcome of new P. falciparum infections depends on the preparedness of the host immune system to mount an attack against polymorphic or variable antigens expressed by the infecting parasite.     

An assessment of low birthweight risk in primiparae as an indicator of malaria control in pregnancy

Malaria is an important environmental factor which reduces fetal growth in primiparae more than multiparae living under holoendemic conditions for malaria. This relates to greater susceptibility to malaria infection in first pregnancies. The relative risk for low birthweight (less than 2500 g) associated with primiparity is increased in malaria-endemic areas and significantly correlates with the malaria parasite rate at delivery in primiparae. Because of this association, the relative risk is proposed as an indicator to assess malaria control in pregnant women as well as in the community. The sensitivity and specificity of the relative risk for low birthweight in primiparae are calculated for 13 malarious and 15 non-malarious populations. The highest sensitivity and specificity is achieved at a relative risk of 1.7. Social and environmental variables which could alter the sensitivity of the estimate are discussed. Estimates of the population-attributable risk per cent of low birthweight due to malaria in primiparae are calculated and vary between 10% and 40% in endemic areas. The method is applied to observations from malaria-intervention studies in pregnancy in the Solomon Islands and Papua New Guinea and appears sensitive in these prospective studies to changes in malaria prevalence. Calculation of these estimates is straightforward and their use to assess malaria control measures in areas of high transmission has not been suggested previously, it could have wide epidemiological application and requires further field evaluation.     

The influence of the genetic complexity of Plasmodium falciparum infections on the epidemiology of malaria

Genetic characterization of malaria parasites in human blood stage infections has provided important insights into the genetics of Plasmodium falciparum populations and given rise to a field frequently referred to as 'molecular epidemiology'. This might be defined as the combination of parasite population genetic analysis with clinical and epidemiological analysis of a study population in order to achieve a better understanding of infection and immunity and long-term patterns of disease incidence and severity. Longitudinal studies on infection and clinical disease incidence, combined with improvements in the sensitivity of detection of low level, normally asymptomatic, parasite infections have formed an important part of this effort. Two molecular epidemiological studies of malaria under low and moderate intensity transmission, in Sudan and Ghana respectively, are reviewed here to illustrate how the parasite genotyping approaches based on deoxyribonucleic acid which Douglas Barker pioneered in the study of Leishmania have developed after their application to malaria research.     

5. Variation of Plasmodium falciparum msp1 block 2 and msp2 allele prevalence and of infection complexity in two neighbouring Senegalese villages with different transmission conditions

To investigate the impact of transmission on the development of immunity to malaria and on parasite diversity, longitudinal surveys have been conducted for several years in Dielmo and Ndiop, 2 neighbouring Senegalese villages with holo- and mesoendemic transmission conditions, respectively. We analysed Plasmodium falciparum msp1 block 2 and msp2 genotypes of isolates collected from 58% of the Dielmo villagers during the same week as those studied recently from Ndiop. Allele frequencies differed in both villages, indicating considerable microgeographical heterogeneity of parasite populations. The complexity of the infections, estimated using individual or combined msp1 and msp2 genotyping, in Dielmo was more than double that in Ndiop and it was age-dependent in Dielmo but not in Ndiop. Thus, this study confirmed the influence of age on the complexity of asymptomatic malaria infections in a holoendemic area. The age distribution of complexity in Dielmo substantiates the interpretation that the number of parasite types per isolate reflects acquired antiparasite immunity. This cross-sectional survey also confirms that the sickle cell trait has no impact on complexity but influences the distribution of P. falciparum genotypes.     

Variation of Plasmodium falciparum msp1 block 2 and msp2 allele prevalence and of infection complexity in two neighbouring Senegalese villages with different transmission conditions

To investigate the impact of transmission on the development of immunity to malaria and on parasite diversity, longitudinal surveys have been conducted for several years in Dielmo and Ndiop, 2 neighbouring Senegalese villages with holo- and mesoendemic transmission conditions, respectively. We analysed Plasmodium falciparum msp1 block 2 and msp2 genotypes of isolates collected from 58% of the Dielmo villagers during the same week as those studied recently from Ndiop. Allele frequencies differed in both villages, indicating considerable microgeographical heterogeneity of parasite populations. The complexity of the infections, estimated using individual or combined msp1 and msp2 genotyping, in Dielmo was more than double that in Ndiop and it was age-dependent in Dielmo but not in Ndiop. Thus, this study confirmed the influence of age on the complexity of asymptomatic malaria infections in a holoendemic area. The age distribution of complexity in Dielmo substantiates the interpretation that the number of parasite types per isolate reflects acquired antiparasite immunity. This cross-sectional survey also confirms that the sickle cell trait has no impact on complexity but influences the distribution of P. falciparum genotypes.     

7. Dynamics of multiple Plasmodium falciparum infections in infants in a highly endemic area of Tanzania

The force of infection and recovery rate for malaria in infants in a highly endemic area of Tanzania were analysed using polymerase chain reaction-restriction fragment length polymorphism genotyping of the Plasmodium falciparum msp2 locus in 99 paired blood samples. Overall, new genotypes were acquired at a rate of 0·064 per day, and the average duration of infections was estimated to be 23 d. The highest recovery rates were in children under 4 months of age. The higher susceptibility of infants to clinical malaria in comparison with older children, in areas of very high transmission, may be largely a consequence of the short duration of infections which precludes the establishment of concomitant immunity. The high turnover of infections also implies that infection prevalence and multiplicity approach an equilibrium even in very young children, and calls into question the use of infant conversion rates as a measure of transmission intensity.     

Genetic analysis of Plasmodium falciparum infections on the north-western border of Thailand

Genetic characterization of Plasmodium falciparum infections in north-western Thailand, a region of low transmission intensity (1 infection/person each year), has found a comparable number of parasite genotypes per infected person to regions with hyperendemic malaria. Clone multiplicity and parasite diversity were found to be homogeneous across 129 infected individuals comprising a range of age-groups (1.32 parasite genotypes; n = 98), patients (aged 2-16 years) with recrudescent infections (1.54; n = 13), and pregnant women (1.61; n = 18). Individuals belonging to groups with a high risk of infection, as deduced by clinical epidemiology, did not harbour a higher number of clones per infection, nor greater parasite diversity than low-risk groups. In fact, multiple genotype infections were as common in low-risk groups, suggesting that there is frequent transmission of polyclonal infections from a single inoculum, rather than superinfection. Such a polyclonal transmission system would enable generation of extensive parasite diversity by recombination, despite the low level of transmission. However, co-infection with P. vivax was associated with fewer P. falciparum genotypes per infection.     

Evaluating malaria attributable morbidity in endemic areas

There are no specific clinical signs or symptoms of malaria. Fever attacks, anemia, or signs of severity like coma or respiratory distress cannot easily be attributed to malaria in people who are infected most of the time. Ascribing clinical manifestations to malaria is problematic in populations that are regularly exposed to the transmission of human plasmodia. The more transmission is intense and regular, the higher the prevalence of asymptomatic infections. In areas of intense and perennial malaria transmission, more than 90% of the population may be infected and the simple detection of a plasmodial infection is not enough to attribute clinical manifestations to malaria. Naturally acquired anti-malaria immunity permitting asymptomatic infections is incomplete and temporary. It is an obstacle to the estimation of the malaria burden in endemic areas. The positive association between parasite density and fever allows the attribution of clinical attacks to malaria. The relationship between parasitaemia and the risk of fever is not continuous. An age- and endemicity-dependent threshold effect of parasite density has been demonstrated and can be used to distinguish clinical attacks due to malaria from others. Clinical diagnosis and evaluation of malaria are problematic in three situations: in public health to estimate the malaria burden for health services, in clinical research to evaluate treatments or prophylactic measures (drug, vaccine, anti-vectorial devices), and in basic research on pathophysiology, immunology or genetic susceptibility to clinical malaria. No one diagnostic definition nor procedure for detecting cases is adequate for all three purposes. Case detection may be passive (in health structures for example) or active (in population). The choice of methods for diagnosis and recruitment depends on the objectives and whether a "pragmatic" or "explicative" approach is used. The radical differences between these approaches are often unsuspected or ignored.     

Selection of a strain of albino mice refractory to Plasmodium berghei infection

Some features of the natural history of malaria in holoendemic areas can be explained by the presence of acquired immunity. There is also evidence that transmission of humoral antibodies in utero from the immune mother plays some part in the transient protection of the offspring. Little is known about the importance of a genetic factor.     

Models to predict the intensity of Plasmodium falciparum transmission: applications to the burden of disease in Kenya.

There is an increasing need to provide spatial distribution maps of the clinical burden of Plasmodium falciparum malaria in Africa. Recent evidence suggests that risk groups and the clinical spectrum of severe malaria are related to the intensity of P. falciparum transmission. Climate operates to affect the vectorial capacity of P. falciparum transmission and this is particularly important in the Horn of Africa and parts of East Africa. We have used a fuzzy logic climate suitability model to define areas of Kenya unsuitable for stable transmission. Kenya's unstable transmission areas can be divided into areas where transmission potential is limited by low rainfall or low temperature and, combined, encompass over 8 million people. Among areas of stable transmission we have used empirical data on P. falciparum infection rates among 124 childhood populations in Kenya to develop a climate-based statistical model of transmission intensity. This model correctly identified 75% (95% confidence interval CI 70-85) of 3 endemicity classes (low, < 20%; high, > or = 70%; and intermediate parasite prevalences). The model was applied to meteorological and remote sensed data using a geographical information system to provide estimates of endemicity for all of the 1080 populated fourth level administrative regions in Kenya. National census data for 1989 on the childhood populations within each administrative region were projected to provide 1997 estimates. Endemicity-specific estimates of morbidity and mortality were derived from published and unpublished sources and applied to their corresponding exposed-to-risk childhood populations. This combined transmission, population and disease-risk model suggested that every day in Kenya approximately 72 and 400 children below the age of 5 years either die or develop clinical malaria warranting in-patient care, respectively. Despite several limitations, such an approach goes beyond 'best guesses' to provide informed estimates of the geographical burden of malaria and its fatal consequences in Kenya.     

Local-scale variation in malaria infection amongst rural Gambian children estimated by satellite remote sensing

We investigated local-scale variation in malaria transmission and infection in children within a continuous landscape by retrospective spatial analysis of entomological and clinical data collected during 1988 and 1989 in The Gambia, West Africa. Parasite prevalence was negatively correlated with vector abundance and exposure to malaria parasites in 10 villages where entomological surveillance had been carried out. Variation in bednet use did not explain this finding. Mosquito-breeding habitat was retrospectively mapped using 20-m spatial resolution multispectral SPOT satellite imagery from 1988. From these data we estimated by linear regression the risk of exposure to malaria parasites in 26 villages where clinical surveys of children had been made. As exposure increased, so did parasite prevalence; but at higher levels of exposure, parasite prevalence declined. Our findings demonstrate marked differences in exposure to malaria in villages over distances of less than 2 km from mosquito breeding sites and suggest that there are also large differences in immunity between neighbouring settlements.     

Attributable fraction estimates and case definitions for malaria in endemic

Asymptomatic carriage of malaria parasites occurs frequently in endemic areas and the detection of parasites in a blood film from a febrile individual does not necessarily indicate clinical malaria. In areas of low and moderate endemicity the parasite prevalence in fever cases can be compared with that in community controls to estimate the fraction of cases which are attributable to malaria. In areas of very high transmission such estimates of the attributable fraction may be imprecise because very few individuals are without parasites. Furthermore, non-malarial fevers appear to suppress low levels of parasitaemia resulting in biased estimates of the attributable fraction. Alternative estimation techniques were therefore explored using data collected during 1989-1991 from a highly endemic area of Tanzania, where over 80 per cent of young children are parasitaemic. Logistic regression methods which model fever risk as a continuous function of parasite density give more precise estimates than simple analyses of parasite prevalence and overcome problems of bias caused by the effects of non-malarial fevers. Such models can be used to estimate the probability that any individual episode is malaria-attributable and can be extended to allow for covariates. A case definition for symptomatic malaria that is used widely in endemic areas requires fever together with a parasite density above a specific cutoff. The choice of a cutoff value can be assisted by using the probabilities derived from the logistic model to estimate the sensitivity and specificity of the case definition.     

Epidemiology of malaria transmission in forest and plain ecotype villages in Sundargarh District, Orissa, India

A study of the epidemiology of malaria transmission was undertaken in 13 tribal villages located in forest and plain areas of Sundargarh District of Orissa state, India, from January 2001 to December 2003. In forest areas, intense transmission of malaria is attributed to the highly anthropophagic vector Anopheles fluviatilis sibling species S and is complemented by A. culicifacies sibling species C. In plain areas, A. culicifacies sibling species C is responsible for malaria transmission. The entomological inoculation rate in the forest and plain areas was 0.311 and 0.014 infective bites/person/night, respectively, during 2003. Malaria transmission is perennial both in forest and plain areas but is markedly low in the plain area compared with the forest area. Plasmodium falciparum accounted for 85.0% of the total malaria cases during the study period. In forest and plain areas, the number of P. falciparum cases per 1000 population per year was 284.1 and 31.2, respectively, whereas the parasite rate was 14.0% and 1.7%, respectively. In forest areas, clinical malaria occurs more frequently in children aged 0-5 years and declines gradually with increasing age. The study showed that villages in forest and plain areas separated by short geographical distances have distinct epidemiology of malaria transmission.     

Quantifying variation in the potential for antibody-mediated apparent competition among nine genotypes of the rodent malaria parasite Plasmodium chabaudi

Within-host competition among parasite genotypes affects epidemiology as well as the evolution of virulence. In the rodent malaria Plasmodium chabaudi, competition among genotypes, as well as clone-specific and clone-transcending immunity are well documented. However, variation among genotypes in the induction of antibodies is not well understood, despite the important role of antibodies in the clearance of malaria infection. Here, we quantify the potential for antibodies induced by one clone to bind another (i.e., to cause antibody-mediated apparent competition) for nine genetically distinct P. chabaudi clones. We hypothesised that clones would vary in the strength of antibody induction, and that the propensity for clone-transcending immunity between a pair of clones would increase with increasing genetic relatedness at key antigenic loci. Using serum collected from mice 35 days post-infection, we measured titres of antibody to an unrelated antigen, Keyhole Limpet Haemocyanin (KLH), and two malaria antigens: recombinant Apical Membrane Antigen-1 (AMA-1) and Merozoite Surface Protein-1₁₉ (MSP-1₁₉). Amino acid sequence homology within each antigenic locus was used as a measure of relatedness. We found significant parasite genetic variation for the strength of antibody induction. We also found that relatedness at MSP-1₁₉ but not AMA-1 predicted clone-transcending binding. Our results help explain the outcome of chronic-phase mixed infections and generate testable predictions about the pairwise competitive ability of P. chabaudi clones.     

Anti-sporozoite antibodies and immunity to malaria in a rural Gambian population

A conserved repeated epitope, (NANP)3, of the circumsporozoite protein of Plasmodium falciparum has been identified previously as a putative target for artificially induced immunity to malaria. We examined the role of humoral responses to this epitope in acquired immunity to malaria in a rural African population. Seropositivity to (NANP)3 was slow to develop (9% positive in subjects aged 1-11 years; 88% in those of 30 years and above), and responses in younger subjects were transient. The poor response in younger subjects did not appear to be due to immunosuppression by concomitant blood stage parasitization. The relationship between levels of anti-(NANP)3 antibodies and parasitaemia changed from positive to negative with age. 126 subjects age 1-11 years were followed through an entire transmission season; those who were seropositive at the beginning ended the season with lower parasite rates (20% vs 59%) and experienced fewer episodes of clinical malaria (0.43 vs 0.67). However, the trend towards increasing susceptibility to clinical malaria in subjects entering the transmission season with lower levels of anti-(NANP)3 antibodies was modest, and combined cross-sectional and longitudinal data indicated that the humoral response to (NANP)3 did not play a major role in the development of immunity to clinical malaria in the population we studied.     

The conditions of malaria transmission in Katsina Province, Northern Nigeria, and a discussion of the effects of dichlorvos application

A study has been made of the conditions of malaria transmission in the northern part of the Guinea savannah belt of West Central Africa. It was found that, in this holoendemic area, transmission occurs principally from August to December but continues on a much reduced scale throughout the rest of the year, even when anopheline densities are as low as 0.02 per hut. Longitudinal parasitological studies on infants, carried out on an area rather than an individual village basis, provide the most useful epidemiological technique during the minor transmission period. Examination of the spleens of children from areas that had been treated with dichlorvos suggested that the reduced hut anopheline densities resulting from the treatment were subsequently reflected in the reduced number of children showing markedly enlarged spleens.     

Mechanisms of malarial immunity.

Immunity to malaria in many species, including man, is acquired only after long exposure to infection and is associated with chronic low-grade parasitaemia. Vaccination of Rhesus monkeys with P. knowlesi merozoites in FCA induces sterilizing immunity which is species specific. Merozoite-blocking (inhibitory) antibody usually correlates with clinical immunity and protection can be passively transferred with immune sera. However, vaccination using adjuvants other than FCA may induce inhibitory antibody without clinical protection. In addition, vaccinated animals usually become susceptible to challenge 4 to 5 weeks after splenectomy, although inhibitory antibody levels are not reduced. These observations indicate that immunity induced by merozoite vaccination involves merozoite blocking (inhibitory) antibody and also specific antibody or immune complexes acting synergistically with cytotoxic splenic cells stimulated by FCA. During natural infection on the other hand soluble circulating antigens, partly derived from the merozoite coat during red cell penetration, are produced and these may block immune effector mechanisms and promote parasite survival.     

A mathematical model for Plasmodium vivax malaria transmission: estimation of the impact of transmission-blocking immunity in an endemic area.

We have developed a multi-state mathematical model to describe the transmission of Plasmodium vivax malaria; the model accommodates variable transmission-blocking/enhancing immunity during the course of a blood infection, a short memory for boosting immunity, and relapses. Using the model, we simulated the incidence of human malaria, sporozoite rates in the vector population, and the level of transmission-blocking immunity for the infected population over a period of time. Field data from an epidemiological study conducted in Kataragama in the south of Sri Lanka were used to test the results obtained. The incidence of malaria during the study period was simulated satisfactorily. The impact of naturally-acquired transmission-blocking immunity on malaria transmission under different vectorial capacities was also simulated. The results show that at low vectorial capacities, e.g., just above the threshold for transmission, the effect of transmission-blocking immunity is very significant; however, the effect is lower at higher vectorial capacities.