Prophylaxis of Plasmodium falciparum malaria with azithromycin administered to volunteers

OBJECTIVE

To determine whether azithromycin, 250 mg/d, is effective prophylaxis for liver infection or for both liver and subsequent blood infection with Plasmodium falciparum.

DESIGN

Controlled phase II trial with two cohorts entered sequentially.

SETTING

Clinical trials center of Walter Reed Army Institute of Research, Washington, D.C.

PATIENTS

Each of the two cohorts consisted of 12 normal adult volunteers who had not had malaria during the previous 2 years: 10 who received azithromycin prophylaxis and 2 controls who did not received treatment.

INTERVENTION

For cohort 1, prophylactic efficacy against liver infection alone during the initial 7 days of the infection was determined by loading participants with azithromycin before challenge with P. falciparum-infected mosquitoes on day 0 and by then giving the drug for 7 days after the challenge. The regimen was 500 mg on day 14 before the challenge, followed by 250 mg/d from day 13 before the challenge through day 7 after the challenge. For cohort 2, prophylactic efficacy against both the liver infection and the subsequent blood infection was determined by continuing drug administration for 28 days after the challenge.

MEASUREMENTS

Plasmodium falciparum infection was diagnosed through peripheral blood smears obtained up to 70 days after challenge. Malarial symptoms and adverse drug reactions were also monitored.

RESULTS

In cohort 1, 4 of 10 volunteers who received azithromycin prophylaxis (40%) did not develop parasitemia. In cohort 2, none of the 10 volunteers receiving azithromycin prophylaxis (100%) developed parasitemia. For each cohort, both control volunteers became parasitemic on days 9 through 13 after the challenge. Adverse drug reactions were few and mild.

CONCLUSIONS

In this model, prophylaxis with azithromycin (250 mg/d) was partially effective against liver parasites and completely successful against the combination of liver and blood parasites. These data suggest that azithromycin has the potential to be an effective, well-tolerated clinical prophylactic agent for P. falciparum malaria.

A comparison of the efficacy of insecticide-treated and untreated bed nets in preventing malaria in Gambian children

An evaluation of the Gambian national insecticide bed net programme, which has introduced insecticide treatment of bed nets into all primary health care (PHC) villages in The Gambia, provided an opportunity to compare the individual risk of malaria in children who slept under untreated or insecticide-treated bed nets. 2300 children 1-4 years old were selected for a survey at the end of the 1992 rainy season, 1500 from PHC villages and 800 from non-PHC villages. All malariometric indices were lower, and the mean packed cell volume was higher, in children who slept regularly under treated or untreated bed nets than in those who did not use a net. This study suggested that untreated bed nets provide some individual protection against malaria, although not as efficiently as that provided by insecticide-treated bed nets which were particularly effective at preventing infections accompanied by high parasitaemia.

Intracellular antigens (microtubule-associated protein copurified with glycosomal enzymes)--possible vaccines against trypanosomiasis

African trypanosomes are motile unicellular eukaryotes that can cause diseases such as sleeping sickness in humans and nagana in animals, debilitating millions of people and livestock. All members of the Trypanosomatidae family contain subpellicular microtubules cross-linked to each other and to the plasma membrane by unique trypanosomal microtubule-associated proteins (MAPs). These MAPs may serve as specific intracellular target sites for therapeutic attack against trypanosomiasis. A trypanosomal MAP (p52) copurifies with two glycosomal enzymes (aldolase and GAPDH) on phosphocellulose columns. Rats and mice vaccinated with antigen preparation p52 containing the glycosomal enzymes were protected against a potentially fatal Trypanosoma brucei infection. Sera of protected animals caused in vitro aggregation of trypanosomes, and immunoelectron microscopy of these aggregates located antibodies in the cytoplasm of the trypanosomes.

Antimalarial effects of C18 fatty acids on Plasmodium falciparum in culture and on Plasmodium vinckei petteri and Plasmodium yoelii nigeriensis in vivo

Following the demonstration of the antimalarial effect of the long chain saturated alcohol n-hentriacontanol ((CH2)29CH2OH), isolated from the Bolivian endemic solanaceous plant Cuatresia sp., we have tested the effect of the C18 fatty acids oleic, elaidic, linoleic, and linoleic on malaria parasites. These fatty acids inhibited the parasitemic development in mice infected with Plasmodium vinckei petteri or with Plasmodium yoelii nigeriensis in a 4-day suppressive test. To gain a deeper discernment of the antimalarial mode of action, the effects of these compounds were evaluated on Plasmodium falciparum growth in culture. Whereas n-hentriacontanol did not show any inhibition of this parasite, on the contrary, the C18 acids displayed a considerably inhibitory activity at < or = 200 micrograms/ml both in intact infected cells and in free parasites. In order to understand the mechanism of their antimalarial action, several tests were performed. No hemolysis of infected cells could be observed up to 500 microgram/ml. No effect on the lipid peroxidation, ATP levels, transport through the parasite-induced permeability pathways, or on the phagocytosis of the infected cells could be observed. The cytotoxic effect of the fatty acids was very rapid: full inhibition of nucleic acids and protein syntheses was observed in less than 30 min. This inhibition was not relieved by the addition of deferrioxamine or FeCl3, indicating that fatty acids (FA) do not act by facilitating the transport of iron. Inhibition was relieved in neither the presence of orotic acid or its methyl ester, indicating that FA do not act at the mitochondrial level of pyrimidine synthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

The chemotherapeutic efficacy of diminazene aceturate and lithium chloride against relapse infection of Trypanosoma brucei brucei in rats

The chemotherapeutic efficacy of diminazene aceturate (Berenil) and lithium chloride (LiCl) in relapse infection of trypanosomiasis was investigated in rats experimentally infected with Trypanosoma brucei brucei. The study showed that the combination of diminazene aceturate at (7 mg/kg) and LiCl (10 micrograms/kg) appeared more effective therapeutically than diminazene aceturate, or diminazene aceturate and LiCl and dexamethasone group, as more of the rats in the diminazene aceturate and LiCl treated-group remained aparasitaemic for longer days (60 days). Relapse parasitaemia occurred on days 10 and 12 in diminazene aceturate (7 mg/kg); diminazene aceturate (7 mg/kg) and LiCl (10 micrograms/kg) plus dexamethasone (1 mg/kg) treated group respectively, while relapse parasitaemia did not occur in the diminazene aceturate and LiCl treated group until day 20. Histopathological examination of the brain did not show any signs of inflammatory reaction in the diminazene aceturate and LiCl and dexamethasone treated group. However lesions associated with meningoencephalitis, such as cellular infiltration of mononuclear cells, perivascular cuffings and perivascular congestion and oedema were observed in the diminazene aceturate; diminazene aceturate and LiCl treated groups.

Primaquine for prophylaxis against malaria among nonimmune transmigrants in Irian Jaya, Indonesia

A comparison of primaquine versus chloroquine for prophylaxis among nonimmune transmigrants from Java and Bali in the hyperendemic Arso region of Irian Jaya, Indonesia was conducted. Forty-five subjects received 0.5 mg of primaquine base/kg of body weight every other day, and 54 people in the same village received weekly 5 mg of chloroquine base/kg for 16-19 weeks beginning in December 1992. Plasmodium falciparum accounted for 18 of 30 infections with chloroquine, and four of five infections among subjects receiving primaquine. Plasmodium vivax was found in 12 people taking chloroquine but in just one person taking primaquine. The risk of malaria among people taking chloroquine relative to that among subjects taking primaquine was 3.96 (P = 0.014) for P. falciparum and 10.56 (P = 0.012) for P. vivax. Primaquine was better tolerated than chloroquine. The minimal protective efficacy for primaquine prophylaxis was 74% against P. falciparum and 90% against P. vivax among nonimmune children and adults living in Irian Jaya. These findings require confirmation with randomized, double-blinded, and placebo-controlled trials.

Dietary fish oils and long-term malaria protection in mice

Previous studies indicate a suppressive influence of fish oils on rodent malaria. The present work was carried out to study (i) the dose-effect relation between dietary fish oils and lethality of primary malaria infection in mice; (ii) the modifying influence of vitamin E; and (iii) the effect of previous fish oil feeding on parasitemia and lethality of a rechallenge infection. For two or four weeks, groups of weanling male mice were fed a standard laboratory diet or one of eight purified diets containing various amounts of fish oil (providing 6-21% of energy). The diets were prepared with and without vitamin E. After the two- or four-week feeding period, the mice were injected intraperitoneally with Plasmodium yoelii-infected erythrocytes. Six months after the primary infection (four months after discontinuing fish oil feeding), the surviving mice were again injected intraperitoneally with parasitized red blood cells (or even better--erythrocytes, erythrocytes are used elsewhere). Primary malaria infection was lethal in mice fed standard diet alone or with fish oil and vitamin E added. In contrast, feeding a fish oil-based diet without vitamin E improved survival to at least 70% if the mice had been fed these diets for four weeks. Protection against malaria did not seem to be related to the fish oil dose used. Regardless of the previous fish oil dose, all the mice surviving the primary infection survived the rechallenge infection with low parasitaemias.(ABSTRACT TRUNCATED AT 250 WORDS)

The effectiveness of insecticide-impregnated bed nets in reducing cases of malaria infection: a meta-analysis of published results

The use of insecticide-impregnated bed nets to minimize human-vector contact may reduce the incidence of malaria. Consequently, several field trials have evaluated their effectiveness as a malaria prevention strategy. A meta-analysis of published reports of field trials that measured the incidence of infections was performed to provide a measure of the effectiveness of insecticide-treated bed nets in preventing clinical malaria. Subsetted analyses were performed on the 10 field trials to calculate pooled incidence rate ratios of infection among the study groups. For the studies comparing insecticide-impregnated bed nets with untreated bed nets, the summary incidence rate ratio for acquiring malarial infections was 0.757 (95% confidence interval [CI] = 0.612-0.938), representing a reduction of 24%. For the studies comparing permethrin-impregnated bed nets with controls without bed nets, the summary incidence rate ratio was 0.497 (95% CI = 0.417-0.592) (Rothman-Boice heterogeneity statistics = 17.27 [P = 0.004] and 23.55 [P = 0.0003], respectively). These data suggest that insecticide-impregnated bed nets are effective in preventing malaria, decreasing the incidence rate ratio by approximately 50% in field trials performed to date.

Vitamin A supplementation and childhood malaria in northern Ghana

Two companion, randomized, placebo-controlled trials of prophylactic vitamin A supplementation provided the opportunity to assess the impact of supplementation on malaria parasitemia, morbidity, and mortality in young children in northern Ghana. In the mortality study, 21,906 children were visited every 4 mo over 2 y, and in the morbidity study 1455 children were visited weekly for 1 y. There was no difference between children supplemented with vitamin A and those given placebo in malaria mortality rates (rate ratio = 1.03; 95% CI 0.74, 1.43) or fever incidence based on reported symptoms. Malaria parasitemia rates, parasite densities in children with a positive blood smear, and rates of probable malaria illness also did not differ between treatment groups. There was no correlation between serum retinol at the beginning of the trial and subsequent malaria parasitemia in children who received placebo (r = 0.01). It is concluded that vitamin A supplementation had no impact on malaria in this population.

Strain variation limits protective activity of vaccines based on soluble Babesia canis antigens

Groups of five dogs were immunized with vaccines containing soluble parasite antigens (SPA) derived from in vitro culture of Babesis canis parasites, either obtained commercially (Pirodog) or produced at laboratory scale. Both vaccines generated antibodies that reacted with parasitised erythrocytes (PE). Upon challenge infection with homologous parasites, protection was evident from less severe decreases of haematocrit values, and reduced morbidity. Vaccinated animals, however, were not protected against challenge infection with heterologous B. canis parasites. Recovery from challenge infection coincided with the production of antibodies against parasitized erythrocytes. The results suggest that SPA from B. canis carry strain-specific determinants that are crucial for inducing protection in dogs against challenge infection, and explain vaccination failures in the field.

Plasmodium falciparum: passive immunization of Aotus lemurinus griseimembra with immune serum

Owl monkeys (Aotus lemurinus griseimembra) were immunized against Plasmodium falciparum by infection and drug cure. After challenge, 3 of 4 monkeys developed extended prepatent periods and low grade parasitemias followed by self cure. The fourth monkey did not develop a patent infection. Immune monkey serum passively transferred at the time of challenge conferred immunity to 20 naive monkeys. Immunity was characterized by extended prepatent periods in 19 monkeys, low levels of parasitemia (< or = 1%) followed by self cure in 12 animals, and lack of detectable infection in 3 recipient monkeys. Immune serum collected from monkeys undergoing repeated challenges afforded more protection than serum from singly infected monkeys. However, single doses of hyperimmune serum appeared to be as effective as multiple doses. Normal serum had no effect on the course of infection in 12 monkeys. These studies confirm that owl monkeys can be immunized by infection and cure and demonstrate that this immunity can, in large part, be transferred to nonimmune recipients with serum from immune donors.

Screening donor blood for malaria by polymerase chain reaction

In countries where malaria is endemic, its transmission is a hazard of blood transfusion. The microscopical and immunological methods in current use for malaria diagnosis are unsatisfactory for low levels of parasitaemia in blood donations. The polymerase chain reaction (PCR) can be 100-fold more sensitive than thick blood film examination when appropriate primers are used and can detect and distinguish Plasmodium falciparum and P. vivax in a single tube. A study of 1506 blood donations in Ho Chi Minh City (3 of which were positive) suggests that PCR can provide an effective screen for P. falciparum under local conditions. Studies in a region of Viet Nam where malaria is common showed that PCR detects many more cases of low-level parasitaemia (19/30) than thick blood films (4/30).

Protective immunity induced in squirrel monkeys with recombinant apical membrane antigen-1 of Plasmodium fragile

Saimiri sciureus boliviensis monkeys were immunized with the Plasmodium fragile form of the merozoite apical membrane antigen-1 produced using the baculovirus expression system and combined with Montanide ISA 720 adjuvant. Following three immunizations, monkeys were challenged with 10,000 P. fragile trophozoite parasites. Antibody titers determined by fluorescence microscopy indicated an enhanced response following the second immunization. Four of five control animals had parasite counts > 5% 18-26 days following challenge. Four of five immunized monkeys had reduced levels of maximum parasitemia or delays in accumulated parasite counts, suggestive of protection. Rechallenge of the animals with P. falciparum resulted in three of four adjuvant control animals developing patent parasitemia whereas none of five immunized animals were infected, suggesting some level of heterologous protection.

The efficacy of antimalarial regimens containing sulfadoxine-pyrimethamine and/or chloroquine in preventing peripheral and placental Plasmodium falciparum infection among pregnant women in Malawi

To define an effective and deliverable antimalarial regimen for use during pregnancy, pregnant women at highest risk of malaria (those in their first or second pregnancy) in an area of Malawi with high transmission of chloroquine (CQ)-resistant Plasmodium falciparum were placed on CQ and/or sulfadoxine-pyrimethamine (SP). Of 38 pregnant women who received CQ treatment followed by weekly CQ prophylaxis (CQ/CQ) for at least 45 days prior to delivery, 32% had placental malaria infection, compared with 26% of 50 pregnant women who received a treatment dose of SP followed by weekly CQ prophylaxis (SP/CQ), and only 9% of 71 pregnant women who received a two-dose SP regimen (SP/SP; given once during the second trimester and repeated at the beginning of the third trimester) (P = 0.006, by chi-square test). During the peak transmission season from April to July, 47% of the women who received CQ/CQ had placental malaria infection at delivery, as compared with 37% of the women who received SP/CQ, and 10% of women who received SP/SP (P = 0.004, by chi-square test). Among women in their first or second pregnancy, two treatment doses of SP were highly effective in decreasing the proportion of women with placental malaria infection at delivery.

Safety, immunogenicity, and efficacy of a malaria sporozoite vaccine administered with monophosphoryl lipid A, cell wall skeleton of mycobacteria, and squalane as adjuvant

A Plasmodium falciparum circumsporozoite protein (PfCSP) recombinant fusion protein, R32NS1(81), formulated with monophosphoryl lipid A, cell wall skeleton of mycobacteria, and squalane (Detox) was administered to 12 volunteers. One volunteer had malaise and self-limited painful induration at the injection site after the second dose and declined further immunization. The other 11 volunteers tolerated the three doses of 1,230 micrograms of vaccine, but most complained of sore arms; in five cases the pain or malaise was severe enough to interfere with work or sleep. Two weeks after the third dose of vaccine, four of the 11 immunized volunteers had > or = 14 micrograms/ml of antibodies to the repeat region of the PfCSP in their serum. Two of these four volunteers did not develop P. falciparum parasitemia when challenged by the bite of five mosquitoes carrying P. falciparum sporozoites. The seven volunteers with lower levels of antibodies and 11 of 11 controls developed parasitemia. These data are consistent with other studies, and indicate that vaccine-induced antibodies against the repeat region of PfCSP can prevent effective sporozoite infection of hepatocytes in humans. The challenge is to improve the immunogenicity of PfCSP-based vaccines, and to develop methods for including PfCSP peptides as components of multitarget malaria vaccines.

Antibodies to ring-infected erythrocyte surface antigen (Pf155/RESA) protect against P. falciparum parasitemia in highly exposed multigravidas women in Malawi

To determine whether antibodies to defined B-cell epitopes of Plasmodium falciparum antigens were related to protection against parasitemic attacks in highly exposed pregnant women, two samples of 235 with no initial P. falciparum parasitemia (NP) and 89 multigravidas who presented initial P. falciparum parasitemia (IP) were enrolled in an antimalarial prophylaxis trial in the Mangochi District in Malawi. Sera were collected under effective prophylaxis and tested for antibody measurement using FAST-ELISA. Mean antibody titers to synthetic peptides reproducing the 3 major B-cell epitopes of the ring-infected erythrocyte surface antigen (Pf155/RESA), as (EENV)4, (EENVEHDA)4 and (DDEHVEEPTVA)3, were higher in the NP than in the IP multigravidas, and this remained consistent within the season of malaria transmission (all p < 0.05). All antibodies to Pf155/RESA were positively intercorrelated within each group. Mean antibody titers to peptide (PNAN)5 reproducing the major B-cell epitope of the circumsporozoite protein (CS protein) were similar between NP and IP multigravidas in both dry and rainy season. Antibodies to Pf155/RESA epitopes may contribute to immune protection against blood-stage parasite multiplication in these highly malaria-exposed pregnant women.

Immunoglobulin G2a isotype may have a protective role in Plasmodium berghei NK65 infection in immunised mice

All CBA mice that had been immunised by means of four successive inoculations of Plasmodium berghei NK65, each inoculation being followed by chemotherapy, survived an intravenous challenge inoculation of parasite, with 4/12 mice developing patent parasitaemia that resolved within 2 weeks. In contrast, all non-immunised control mice died before the 10th day post-challenge. Examination of sera for antibodies revealed that the immunised mice, all of which survived the challenge, had significantly high anti-plasmodial whole IgG, IgG1, and IgG2a titres before the challenge. A 16-fold rise in IgG2a titre alone was recorded on the 5th day post-challenge, with a further boosting of the titre to 4096 being observed on day 10. In comparison, the titres of Ig isotypes in the non-immunised control mice that succumbed to the challenge remained below 4. Specific IgG subclasses, in particular IgG2a, could be involved in the humoral immune protection against this rodent parasite.

Twelve patients with severe malaria treated with partial exchange transfusion. Comparison between mathematically predicted and observed effect on parasitaemia

Imported malaria is increasing in Western countries, which results in considerable morbidity and mortality, the latter mainly due to delayed diagnosis and treatment. Partial exchange transfusion has been proposed as a therapy for very severe falciparum malaria, but the utility of this procedure has not been proven. We report on 12 patients with severe Plasmodium falciparum malaria, treated with exchange transfusion in 5 Belgian hospitals between 1987 and 1991. The mean parasitaemia before exchange was 17.2% (range 6-35%). An average of 3.1 l was exchanged within 3 to 7 hours. Ten of the 12 patients survived. One patient recovered initially, but died as a consequence of a cascade of complications of dialysis. Three patients developed the adult respiratory distress syndrome (ARDS), two had less serious pulmonary involvement, and five had temporary renal failure; none of the survivors had sequelae. A formula is proposed to calculate the expected reduction in parasitized erythrocytes by exchange transfusion in function of the initial parasitaemia, the initial haemoglobin level and the volume of blood exchanged. Comparison between the mathematically predicted and the observed decline in parasitaemia shows on average a 25% excess of observed over predicted efficacy per unit of blood exchanged. After introducing this correction the formula enables the clinician to estimate roughly the volume of blood that has to be exchanged in order to bring the initial parasitaemia down to a desired level.

Murine tumour necrosis factor plays a protective role during the initial phase of the experimental infection with Trypanosoma brucei brucei

Soluble extracts from salivarian trypanosomes (Trypanosoma brucei brucei, T. evansi and T. congolense) were shown to be capable of inducing murine tumour necrosis factor (mTNF) secretion, both in vivo and in vitro, whereas the soluble extract of an intracellular trypanosome (T. cruzi) failed to do so. Furthermore, the role of mTNF during the initial phase of experimental infections with T. brucei was studied by treating infected mice with mTNF-inducing trypanosoma soluble extract and with neutralizing monoclonal anti-mTNF antibodies. Treatment of the infected animals with different doses of T. brucei soluble extract resulted in a lower first parasitaemia peak (low lysate dose) and in a longer survival time or in a nearly total inhibition of parasite development (high lysate dose). Cotreatment of the infected mice with both anti-mTNF antibodies and a high dose of soluble extract completely restored the parasite development in both trypanosusceptible C3H/He mice and trypanosubtolerant CBA Ca mice, indicating a protective role of mTNF during the parasitaemia. Collectively these results suggest a negative influence of mTNF on T. brucei development in vivo.