Vector-borne infections in the tropics and health policy issues in the twenty-first century

Over the past 2 decades scientific advances and evolving strategies have significantly contributed to improved tools for control of vector-borne infections. These are: diagnostics--rapid assessment methods, non-invasive or minimally so yet sensitive and specific; new chemotherapeutics; pyrethroid insecticides and biological insecticidal products; refined strategies, such as combination therapy, rotation of insecticides for resistance management, community-directed treatment, standardized monitoring and evaluation to define programme progress; better epidemiological knowledge through improved identification of parasites and vectors; GIS, remote sensing and climate models which provide tools for epidemic prediction, planning control programmes and permit effective policy analysis; greater involvement of NGDOs (non-governmental development organizations) and CSOs (civil society organizations) in control; advent of donation programmes which involve community-based or directed mass drug distribution. Future problems could be: (1) the over-emphasis on inflexible financing by the insistence of donors on SWAps (sector-wide investment), (2) the over-reliance on pyrethroid pesticides, (3) the over-expectation that basic research will provide new drugs and vaccines for resource-poor settings in the necessary time scales, and (4) the failure to recognize that biological processes have an inherent capacity for change which outstrips the capacity of health services to respond. Malaria is a paradigm of an 'emerging disease'. (5) The challenge of implementing a 'vertical' approach to disease control within national health programmes, in the face of significant donor opposition to such programmes is a challenge even when such approaches will secure a 'public good'.

Current status and future prospects of the Global Lymphatic Filariasis Programme

Lymphatic filariasis is recognized as one of the world's most disabling diseases. Adult lymphatic filarial nematodes live for several years; they infest the lymphatic and blood systems, and are transmitted via mosquito vectors. Acute and chronic disease can develop, manifesting as acute inflammation, hydrocoele, lymphoedema and elephantiasis. The development of a global programme for the elimination of lymphatic filariasis (focusing on disease caused by Wuchereria bancrofti) followed a resolution by the World Health Assembly in 1997 that endemic countries should develop programmes to eliminate lymphatic filariasis as a public health problem. This developed from an earlier recommendation by the International Task Force for Disease Eradication in 1993 that lymphatic filariasis was one of six diseases that could, in theory, be eradicated. Herein we review the current status and future prospects of the Global Lymphatic Filariasis Programme, which was launched in 2000.

Satellite mapping of Loa loa prevalence in relation to ivermectin use in west and central Africa

For many years, ivermectin has been widely distributed throughout west Africa for the safe and effective control of onchocerclasis. However, recent events in Loa-loa-endemic areas of Cameroon, where severe adverse reactions have occurred, now constrain the public-health use of this drug in the forest habitat of the L. loa vector. We have created a model of L. loa prevalence to identify areas where high endemicity may be associated with the occurrence of such reactions. The model results have been mapped and the areas of overlap between high L. loa prevalence and planned ivermectin distribution for onchocerciasis control identified.

Variation in cuticular hydrocarbons among strains of the Anopheles gambiae sensu stricto by analysis of cuticular hydrocarbons using gas liquid chromatography of larvae

Cuticular hydrocarbons of larvae of individual strains of the Anopheles gambiae sensu stricto were investigated using gas liquid chromatography. Biomedical discriminant analysis involving multivariate statistics suggests that there was clear hydrocarbon difference between the Gambian(G3), the Nigerian (16CSS and, its malathion resistant substrain, REFMA) and the Tanzanian (KWA) strains. The high degree of segregation (95%) in hydrocarbons among the four strains investigated indicates that further analysis is needed to enable understanding of hydrocarbon variation in samples of An. gambiae especially from areas where these populations co-exist.

Forecasting and prevention of epidemic malaria: new perspectives on an old problem

There is a clear need for improved epidemic malaria surveillance mechanisms in areas prone to the disease. Epidemiological surveillance systems are rarely able to provide information in a sufficiently timely manner for adequate epidemic response. This is especially true in African countries where surveillance is poorly developed, and particularly so in remote regions of unstable malaria such as desert fringes. There is long standing evidence linking climatic variability and epidemic risk. The last ten years have seen significant developments in Environmental Information System (EIS) for a range of natural resource management purposes. The routine information products from these systems have been shown to be both spatially and temporally related to malaria transmission indicators across the African continent. EIS may therefore provide a useful and cost effective input to epidemic malaria control planning and response.

Transmission control and drug resistance in malaria: a crucial interaction

Drug resistance is a major problem affecting progress on malaria control, while many current programmes are seeking to introduce impregnated bednets to reduce transmission and hence child mortality and morbidity. David Molyneux, Katherine Floyd, Guy Barnish and Eric Fèvre propose that more consideration should be given to the interaction between transmission control and the development of drug resistance, and that vector control as a means of reducing disease transmission is involved in reducing the rate of development, and the level, of resistance. Therefore, investment in vector control can have important benefits in reducing the future expenditure on drugs (as well as other costs, such as hospitalization, management of resistant cases and severe disease, drug development and household expenditure on malaria chemotherapy). Modelling the many parameters that impact on this complex relationship will better inform policy makers.

Transformation, development, and transmission of axenically cultured amastigotes of Leishmania mexicana in vitro and in Lutzomyia longipalpis

Axenic cultures of Leishmania mexicana amastigotes were transformed to promastigotes in vitro and in vivo in Lutzomyia longipalpis. In vitro, both exponential phase and stationary phase amastigotes were capable of transforming and growing as promastigotes, but exponential phase amastigotes completed this transition more quickly. In vivo, both populations were capable of establishing infections in sand flies by membrane feeding and could be transmitted to BALB/c mice via bite. A variety of morphologic forms could be observed in vivo, including putative metacyclic promastigotes. Infection rates in sandflies with axenic amastigotes were comparable with those achieved with lesion-derived amastigotes, supporting the use of these cultured forms in studies of parasite biology.

Vector-borne parasitic diseases--an overview of recent changes

This paper summarises the impact of different changes (environmental, ecological, developmental) on the one hand, with the impact of control measures on the other. The former group of changes have tended to exacerbate the incidence and prevalence of vector-borne parasitic diseases while the reduced public funds available for the health sector have reduced disease surveillance systems. However, some vector control/eradication programmes have been successful. Vector control in onchocerciasis and Chagas' disease and immediate host control in Guinea worm have reduced the public health importance of these disease. This contrasts, with malaria, where the complexity of different ecological situations and the variable vector ecology have made control difficult and epidemics frequent and unpredictable. Advances in our knowledge of how to implement and sustain insecticide-impregnated bednets which reduce morbidity and mortality in under 5-year olds will be a key issue for the coming years. In African trypanosomiasis and leishmaniasis, where control is dependent on effective diagnosis and surveillance followed by high-cost drug treatment, the health services are faced with major challenges--lack of drug availability and diagnostics no vector control--the diseases in some areas assuming epidemic status yet health services are unable to respond. Human African trypanosomiasis and visceral leishmaniasis are fatal if untreated, and require an emergency response approach. Changing vector distribution of Glossina is related to the ability of riverine flies of Glossina palpalis group to adapt to new vegetation patterns. In leishmaniasis changes have occurred in the distribution of the disease associated with development impact, urbanisation, civil unrest and changed agroforestry practice.

Onchocerciasis and Chagas' disease control: the evolution of control via applied research through changing development scenarios

This paper addresses the development of control strategies of two different parasitic diseases and identifies commonalities which have contributed to the success of regional intercountry programmes of onchocerciasis control in Africa, the Onchocerciasis Control Programme (OCP), and the new African Programme for Onchocerciasis Control (APOC) and the Chagas' Disease Control Programme in the southern cone of South America.

Onchocerciasis control: Moving towards the millennium

The recognition of onchocerciasis as a major public health problem in the savanna belts of West Africa resulted in the establishment of the Onchocerciasis Control Programme (OCP) in 1974. Control was initially based on vector control by weekly larviciding. The OCP is now in transition towards its final phase in which repeated treatment with ivermectin, a safe and effective microfilaricide, is incorporated with vector control, or in certain circumstances is used alone. Ivermectin distribution hingeing on sustainable community systems is the basis of a new programme in endemic African countries outside the OCP and in the Americas. David Molyneux and John Davies describe the latest trends and developments related to onchocerciasis control.

Patterns of change in vector-borne diseases

The statuses of vector-borne diseases have changed over recent years. How a few such diseases have changed and the primary causes of change (urbanization, increased conflict, changes in water-resource management, ecological and environmental change, and reduced health service resourcing) are the subjects of the present review. The key impacts which these primary causes have on selected vectors and the infections they transmit are tabulated. The success of vector-control programmes against onchocerciasis and Chagas disease is discussed, and the methods used to evaluate the epidemiological impact of such controls are described. Bednet programmes for control of malaria are recognized as a potential future means of reducing morbidity and mortality in children. In contrast to the success achieved in limiting Simulium and Triatoma populations through vertical programmes, control of tsetse, whilst successful in Uganda, has not been utilized to stem recent epidemics of sleeping sickness in resource-stressed settings in Central Africa. Vector-borne diseases will continue to be a problem because of the adaptability of vectors, the potential problems of managing effective vector controls within decentralized health systems, and the influence of activities outside the health sector itself. Changes beyond the health sector can increase the problem posed by a vector and increase the frequency of transmission.

Variation in cuticular hydrocarbons among strains of Anopheles (Cellia) stephensi Liston possibly related to prior insecticide exposure

Cuticular lipids were extracted in hexane from the females of four strains of Anopheles stephensi and separated by capillary gas chromatography. When the chromatograms produced were quantified and compared by discriminant analysis, compositional variations in the hydrocarbons indicated that two of the strains, 'Russ' (originally isolated in the former (U.S.S.R.) and 'Iraq' (from Iraq), both of which were susceptible to DDT and malathion, could be confidently separated from 'Beech' from India and 'St Mal' from Pakistan, both of which were resistant to DDT and malathion. A high degree of hydrocarbon segregation between each of the four strains might be associated with geographical variation. It appears that there are significant and real differences in the hydrocarbons of these strains and these may be at least partially related to genetic alterations resulting from prior insecticide exposure. However, far more analysis is required if any relationship with prior exposure is to be confirmed.

Patterns of epidemiology and control of onchocerciasis in west Africa

This paper summarizes the work of the Onchocerciasis Control Programme (OCP) in West Africa, a programme which over a 22 year history has reduced the public health problems of blinding onchocerciasis in eleven countries of West Africa through vector control and, more recently, ivermectin distribution. The paper emphasizes the different approaches to control the programme has developed in the different parts of the programme area which have been determined by the epidemiology of the disease (savanna/forest form), the migratory characteristics of the vectors, intensity of the disease before commencement of treatment, the combined impact of vector control and ivermectin and the likelihood of infiltration of infective blackflies from outside the programme area. The programme has constantly monitored the impact of operations on the trends in prevalence, incidence, annual transmission potential, ocular morbidity and species of fly populations, and as a result, has identified areas where special interventions are required until the programme comes to an end in 2002. The paper illustrates the changes in intensity of infection as measured by community microfilarial load and annual transmission potential over the duration of the programme control activities. The paper also defines and justifies the control strategies in different areas and identifies areas for special interventions.

Cytotaxonomic identifications of the Simulium damnosum complex (Diptera:Simuliidae) from Nigeria

Cytotaxonomic analysis of Simulium damnosum s.l. larvae collected from 23 sites across 4 bioclimatic zones in Nigeria revealed the presence of 5 cytospecies (S. damnosum s.str., S. sirbanum, S. squamosum, S. yahense and S. soubrense (including the Beffa form). The biogeographical distribution of the sibling species was mostly similar to that observed further west in the OCP area, although geographic cytotaxonomic variation was recorded in S. squamosum, S. damnosum s.str. and S. sirbanum. Some aspects of the chemical and physical environment of the breeding habitats were investigated.