Rate of expulsion of Trichuris trichiura with multiple and single dose regimens of albendazole

Revisiting density-dependent fecundity in schistosomes using sibship reconstruction

The stability of parasite populations is regulated by density-dependent processes occurring at different stages of their life cycle. In dioecious helminth infections, density-dependent fecundity is one such regulatory process that describes the reduction in egg production by female worms in high worm burden within-host environments. In human schistosomiasis, the operation of density-dependent fecundity is equivocal and investigation is hampered by the inaccessibility of adult worms that are located intravascularly. Current understanding is almost exclusively limited to data collected from two human autopsy studies conducted over 40 years ago, with subsequent analyses having reached conflicting conclusions. Whether egg production is regulated in a density-dependent manner is key to predicting the effectiveness of interventions targeting the elimination of schistosomiasis and to the interpretation of parasitological data collected during monitoring and evaluation activities. Here, we revisit density-dependent fecundity in the two most globally important human Schistosoma spp. using a statistical modelling approach that combines molecular inference on the number of parents/adult worms in individual human hosts with parasitological egg count data from mainland Tanzania and Zanzibar. We find a non-proportional relationship between S. haematobium egg counts and inferred numbers of female worms, providing the first clear evidence of density-dependent fecundity in this schistosome species. We do not find robust evidence for density-dependent fecundity in S. mansoni because of high sensitivity to some modelling assumptions and the lower statistical power of the available data. We discuss the strengths and limitations of our model-based analytical approach and its potential for improving our understanding of density dependence in schistosomiasis and other human helminthiases earmarked for elimination.

Schistosomiasis is a devastating disease of poverty currently estimated to infect over 220 million people. It is caused by parasitic worms (blood flukes) that live for, on average, 5–7 years inside the blood vessels of infected hosts and produce hundreds of eggs daily. Whether egg production is regulated in a density-dependent manner, and if so under what conditions, has been controversial for schistosomiasis, and investigation is hampered due to the inaccessible location of adult worms. Resolving this fundamental question is important because density dependencies determine the resilience of helminthiases to interventions. Here, we have revisited this longstanding and unresolved question of density-dependent fecundity in human schistosomes using a novel statistical modelling approach that combines information from molecular and parasitological data. We report the first clear evidence of density-dependent fecundity in S. haematobium, the causative agent of millions of cases of urogenital schistosomiasis. Our findings are of critical importance both to mathematical modellers predicting the impact of interventions and to public health policy makers striving to meet the 2030 elimination targets for schistosomiasis. This study also serves to illustrate a new biostatistical approach that could be applied to investigate density dependencies in other helminthiases where adult parasites are inaccessible.

Estimating helminth burdens using sibship reconstruction

BACKGROUND

Sibship reconstruction is a form of parentage analysis that can be used to identify the number of helminth parental genotypes infecting individual hosts using genetic data on only their offspring. This has the potential to be used for estimating individual worm burdens when adult parasites are otherwise inaccessible, the case for many of the most globally important human helminthiases and neglected tropical diseases. Yet methods of inferring worm burdens from sibship reconstruction data on numbers of unique parental genotypes are lacking, limiting the method's scope of application.

RESULTS

We developed a novel statistical method for estimating female worm burdens from data on the number of unique female parental genotypes derived from sibship reconstruction. We illustrate the approach using genotypic data on Schistosoma mansoni (miracidial) offspring collected from schoolchildren in Tanzania. We show how the bias and precision of worm burden estimates critically depends on the number of sampled offspring and we discuss strategies for obtaining sufficient sample sizes and for incorporating judiciously formulated prior information to improve the accuracy of estimates.

CONCLUSIONS

This work provides a novel approach for estimating individual-level worm burdens using genetic data on helminth offspring. This represents a step towards a wider scope of application of parentage analysis techniques. We discuss how the method could be used to assist in the interpretation of monitoring and evaluation data collected during mass drug administration programmes targeting human helminthiases and to help resolve outstanding questions on key population biological processes that govern the transmission dynamics of these neglected tropical diseases.

Testing for soil-transmitted helminth transmission elimination: Analysing the impact of the sensitivity of different diagnostic tools

In recent years, an increased focus has been placed upon the possibility of the elimination of soil-transmitted helminth (STH) transmission using various interventions including mass drug administration. The primary diagnostic tool recommended by the WHO is the detection of STH eggs in stool using the Kato-Katz (KK) method. However, detecting infected individuals using this method becomes increasingly difficult as the intensity of infection decreases. Newer techniques, such as qPCR, have been shown to have greater sensitivity than KK, especially at low prevalence. However, the impact of using qPCR on elimination thresholds is yet to be investigated. In this paper, we aim to quantify how the sensitivity of these two diagnostic tools affects the optimal prevalence threshold at which to declare the interruption of transmission with a defined level of confidence. A stochastic, individual-based STH transmission model was used in this study to simulate the transmission dynamics of Ascaris and hookworm. Data from a Kenyan deworming study were used to parameterize the diagnostic model which was based on egg detection probabilities. The positive and negative predictive values (PPV and NPV) were calculated to assess the quality of any given threshold, with the optimal threshold value taken to be that at which both were maximised. The threshold prevalence of infection values for declaring elimination of Ascaris transmission were 6% and 12% for KK and qPCR respectively. For hookworm, these threshold values are lower at 0.5% and 2% respectively. Diagnostic tests with greater sensitivity are becoming increasingly important as we approach the elimination of STH transmission in some regions of the world. For declaring the elimination of transmission, using qPCR to diagnose STH infection results in the definition of a higher prevalence, than when KK is used.

Systematic review of studies generating individual participant data on the efficacy of drugs for treating soil-transmitted helminthiases and the case for data-sharing

Background

Preventive chemotherapy and transmission control (PCT) by mass drug administration is the cornerstone of the World Health Organization (WHO)’s policy to control soil-transmitted helminthiases (STHs) caused by Ascaris lumbricoides (roundworm), Trichuris trichiura (whipworm) and hookworm species (Necator americanus and Ancylostama duodenale) which affect over 1 billion people globally. Despite consensus that drug efficacies should be monitored for signs of decline that could jeopardise the effectiveness of PCT, systematic monitoring and evaluation is seldom implemented. Drug trials mostly report aggregate efficacies in groups of participants, but heterogeneities in design complicate classical meta-analyses of these data. Individual participant data (IPD) permit more detailed analysis of drug efficacies, offering increased sensitivity to identify atypical responses potentially caused by emerging drug resistance.

Methodology

We performed a systematic literature review to identify studies concluding after 2000 that collected IPD suitable for estimating drug efficacy against STH. We included studies that administered a variety of anthelmintics with follow ups less than 60 days after treatment. We estimated the number of IPD and extracted cohort- and study-level meta-data.

Principal findings

We estimate that there exist individual data on approximately 35,000 participants from 129 studies conducted in 39 countries, including 34 out of 103 countries where PCT is recommended. We find significant heterogeneity in diagnostic methods, times of outcome assessment, and the reported measure of efficacy. We also quantify cohorts comprising pre-school age children, pregnant women, and co-infected participants, including with HIV.

Conclusions

We argue that establishing a global IPD repository would improve the capacity to monitor and evaluate the efficacy of anthelmintic drugs, respond to changes and safeguard the ongoing effectiveness of PCT. Establishing a fair, transparent data governance policy will be key for the engagement of the global STH community.

Soil-transmitted helminthiases (STHs) caused by roundworm, whipworm or hookworm affect over one billion of the world’s poorest people mostly living in low and middle income countries, exerting a major health and economic toll. These infections are controlled by regular mass drug distribution to affected populations. But with very few alternative medicines, the effectiveness of treatment programmes is vulnerable to the potential emergence of drug resistance. Despite a recent scale-up of mass drug distribution, systematic monitoring and evaluation of the efficacy of treatment is too rarely undertaken and our knowledge of how the drugs are performing is largely based on information from clinical trials. However, the design and reporting of information from these trials is very variable which makes it difficult to form a comprehensive picture of the status and trends in drug efficacy. Here, we present a systematic review of published studies completed since 2000, characterise variation in their design, implementation and reporting and estimate the abundance of individual participant data. We argue that the co-ordinated sharing of these individual data would greatly increase the capacity of the global health community to monitor effectively drug efficacy, to respond accordingly to changes, and thereby to safeguard the effectiveness of STH control.

Sources of variability in the measurement of Ascaris lumbricoides infection intensity by Kato-Katz and qPCR

Background

Understanding and quantifying the sources and implications of error in the measurement of helminth egg intensity using Kato-Katz (KK) and the newly emerging “gold standard” quantitative polymerase chain reaction (qPCR) technique is necessary for the appropriate design of epidemiological studies, including impact assessments for deworming programs.

Methods

Repeated measurements of Ascaris lumbricoides infection intensity were made from samples collected in western Kenya using the qPCR and KK techniques. These data were combined with data on post-treatment worm expulsions. Random effects regression models were used to quantify the variability associated with different technical and biological factors for qPCR and KK diagnosis. The relative precision of these methods was compared, as was the precision of multiple qPCR replicates.

Results

For both KK and qPCR, intensity measurements were largely determined by the identity of the stool donor. Stool donor explained 92.4% of variability in qPCR measurements and 54.5% of observed measurement variance for KK. An additional 39.1% of variance in KK measurements was attributable to having expelled adult A. lumbricoides worms following anthelmintic treatment. For qPCR, the remaining 7.6% of variability was explained by the efficiency of the DNA extraction (2.4%), plate-to-plate variability (0.2%) and other residual factors (5%). Differences in replicate measurements by qPCR were comparatively small. In addition to KK variability based on stool donor infection levels, the slide reader was highly statistically significant, although it only explained 1.4% of the total variation. In a comparison of qPCR and KK variance to mean ratios under ideal conditions, the coefficient of variation was on average 3.6 times larger for KK highlighting increased precision of qPCR.

Conclusions

Person-to-person differences explain the majority of variability in egg intensity measurements by qPCR and KK, with very little additional variability explained by the technical factors associated with the practical implementation of these techniques. qPCR provides approximately 3.6 times more precision in estimating A. lumbricoides egg intensity than KK, and could potentially be made more cost-effective by testing each sample only once without diminishing the power of a study to assess population-level intensity and prevalence.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-017-2164-y) contains supplementary material, which is available to authorized users.

Multi-parallel qPCR provides increased sensitivity and diagnostic breadth for gastrointestinal parasites of humans: field-based inferences on the impact of mass deworming

BACKGROUND

Although chronic morbidity in humans from soil transmitted helminth (STH) infections can be reduced by anthelmintic treatment, inconsistent diagnostic tools make it difficult to reliably measure the impact of deworming programs and often miss light helminth infections.

METHODS

Cryopreserved stool samples from 796 people (aged 2-81 years) in four villages in Bungoma County, western Kenya, were assessed using multi-parallel qPCR for 8 parasites and compared to point-of-contact assessments of the same stools by the 2-stool 2-slide Kato-Katz (KK) method. All subjects were treated with albendazole and all Ascaris lumbricoides expelled post-treatment were collected. Three months later, samples from 633 of these people were re-assessed by both qPCR and KK, re-treated with albendazole and the expelled worms collected.

RESULTS

Baseline prevalence by qPCR (n = 796) was 17 % for A. lumbricoides, 18 % for Necator americanus, 41 % for Giardia lamblia and 15% for Entamoeba histolytica. The prevalence was <1% for Trichuris trichiura, Ancylostoma duodenale, Strongyloides stercoralis and Cryptosporidium parvum. The sensitivity of qPCR was 98% for A. lumbricoides and N. americanus, whereas KK sensitivity was 70% and 32%, respectively. Furthermore, qPCR detected infections with T. trichiura and S. stercoralis that were missed by KK, and infections with G. lamblia and E. histolytica that cannot be detected by KK. Infection intensities measured by qPCR and by KK were correlated for A. lumbricoides (r = 0.83, p < 0.0001) and N. americanus (r = 0.55, p < 0.0001). The number of A. lumbricoides worms expelled was correlated (p < 0.0001) with both the KK (r = 0.63) and qPCR intensity measurements (r = 0.60).

CONCLUSIONS

KK may be an inadequate tool for stool-based surveillance in areas where hookworm or Strongyloides are common or where intensity of helminth infection is low after repeated rounds of chemotherapy. Because deworming programs need to distinguish between populations where parasitic infection is controlled and those where further treatment is required, multi-parallel qPCR (or similar high throughput molecular diagnostics) may provide new and important diagnostic information.

Faecal egg counts and expulsion dynamics of the whipworm, Trichuris trichiura following self-infection

More than 400 million humans are estimated to be infected with the intestinal helminth parasite, Trichuris trichiura. The infection is chronic in nature and high-intensity infection can lead to colitis, anaemia, Trichuris Dysentery Syndrome and reduced cognitive performance. Single doses of 400 mg albendazole or 500 mg mebendazole (MBZ) are used in mass drug administration programmes, but this has been shown to be insufficient. In this study, worm expulsion dynamics are described after MBZ treatment, given as a multi-dose and single-dose treatment in two separate T. trichiura self-infection studies. Worm expulsion dynamics post-treatment showed a similar pattern regardless of the dose regime, with the first worms observed on day 2 and the last worms expelled on days 9 and 13 post-treatment. Establishment of a chronic infection was observed following the inefficient single-dose treatment. The prepatent period was 13–16 weeks in both studies and worms were found to have a lifespan of at least 1 year and 10 months. These self-infection studies provide key information on the chronicity of T. trichiura infections, expulsion dynamics after anthelmintic treatment and the prepatent period, as well as the fecundity of female worms, which was around 18,000 eggs/female per day.

Albendazole and mebendazole have low efficacy against Trichuristrichiura in school-age children in Kabale District, Uganda

Three groups of Trichuris trichiura-infected school-age children were treated with one dose 400mg albendazole, 100mg mebendazole twice daily for 3 d, or 100mg mebendazole twice daily for 5 d. The albendazole study investigated cure and egg reduction rates and found that only 5 of 66 infected children were egg-negative 7 d post-treatment, giving a cure rate of 8% and a geometric mean egg reduction rate of 89%. However, at day 14 post-treatment, all children were again egg-positive with significantly higher egg counts than at day 7 (P<0.001). The two mebendazole studies aimed for the recovery of adult T. trichiura worms. After the 3 d course of mebendazole treatment, only four worms were recovered on days 3-5 after start of treatment from 2 of 34 infected children. With the 5 d course of mebendazole treatment, 10 of 21 infected children expelled a total of 27 worms. In the last case the first worm appeared on day 4 post-treatment, and the highest number of worms was recovered when the study ended at day 7. In conclusion, even with the longest treatment regimen and collecting stool samples over seven consecutive days, only very few worms were recovered. The results of this study suggest that alternative drugs and/or alternative regimens in current control programmes against T. trichiura need renewed attention.

Multiplex PCR on single unembryonated Ascaris (roundworm) eggs

A sensitive and inexpensive method for DNA isolation and amplification by polymerase chain reaction (PCR) from single unembryonated Ascaris sp. eggs is described. The resistant shell of single eggs was crushed mechanically and PCR applied to the crude egg contents without any further purification steps. The ITS1 region of the rDNA and three regions of the mtDNA could be successfully amplified. Using two primer sets, it was possible to amplify the rDNA and mtDNA simultaneously in one single reaction. The ability to perform PCR on single unembryonated eggs may result in better and more precise species identification of eggs recovered from faecal material, environmental samples and possibly archaeological samples. In addition, single egg PCR makes it possible to perform population genetic studies without having to recover adult worms by deworming or autopsy.

Randomised trial of albendazole and pyrantel in symptomless trichuriasis in children

BACKGROUND

We aimed to find out whether symptomless infection with Trichuris trichiura is associated with impairment of growth and to assess the effect of a multiple-doses regimen of anthelmintic drugs on the growth of children.

METHODS

In a community based trial, 622 Mexican children were randomly allocated one of three treatment regimens: 3 days of albendazole 400 mg daily (high efficacy); one dose of albendazole 400 mg (moderate efficacy); one dose of pyrantel (pyrantel embonate) 11 mg/kg (low efficacy). Growth was monitored for 12 months. Analyses were by intention to treat.

FINDINGS

113 (18%) children were lost to follow-up--34 from the pyrantel group, 45 from the albendazole 400 mg group, and 34 from the albendazole 1200 mg group. Among the 127 children with heavy pretreatment infections, albendazole 1200 mg was better than pyrantel in terms of an increase in arm circumference (mean 0.26 cm, p=0.044). Among the 381 children with low pretreatment levels of infection, changes in weight (mean difference between groups -0.33 kg, p=0.036), arm circumference (-0.18 cm, p=0.0095), and thickness of triceps skinfold (-0.41 mm, p=0.0031) were less in children on albendazole 1200 mg than in those on pyrantel.

INTERPRETATION

Symptomless trichuriasis impairs growth and albendazole or pyrantel may affect growth, independently of a therapeutic action on parasites. Possible toxic effects of high-dose albendazole require further investigation.

Embryonation and infectivity of Ascaris suum eggs isolated from worms expelled by pigs treated with albendazole , pyrantel pamoate, ivermectin or piperazine dihydrochloride

The effect of anthelmintic treatment of pigs on the embryonation and infectivity of Ascaris suum eggs isolated from expelled worms was investigated. Four groups of two naturally infected pigs were dosed with albendazole, pyrantel pamoate, ivermectin or piperazine dihydrochloride, respectively. Following worm expulsion, the eggs were removed from the uteri of female worms and embryonated in sulphuric acid. The infectivity of the embryonated eggs was tested through mouse inoculation. Egg development appeared normal in cultures from worms of the piperazine. pyrantel and ivermectin treated groups. In the albendazole cultures, egg development was largely arrested at the one-cell stage (81%). Where development occurred, irregular cell division was observed and only 7% of the eggs in the culture developed into fullgrown larvae. Following mouse inoculation with 2500 embryonated eggs, significantly lower lung larval counts on day 8 post inoculation (p.i.) were observed for mice in the piperazine and pyrantel treated groups (P < 0.01) compared to untreated controls. The larvae that developed in the eggs from ivermectin and albendazole treated groups appeared fully infective for mice. It was concluded that ovicidal activity of albendazole in vivo inhibits subsequent A. suum egg development in vitro; albendazole is, therefore, not suitable to obtain worms for egg embryonation to produce experimental inoculums. The anthelmintic treatment of pigs with ivermectin had only a limited effect on both embryonation and infectivity of A. suum eggs isolated from expelled worms.

Plasma proteins in children with trichuris dysentery syndrome

AIMS

To determine whether in Trichuris trichiura dysentery there is (1) evidence of a systemic inflammatory response, (2) evidence that the plasma protein disturbance has special characteristics compared with uninfected children in the endemic environment.

METHODS

Three groups of children (age 1.6 to 11.4 years) were studied: 53 cases of trichuris dysentery syndrome (TDS), 16 cases of chronic non-secretory diarrhoea not infected with the parasite ("disease controls", DC), and 20 asymptomatic, parasite-free primary schoolchildren (normal controls, NC). C reactive protein, alpha 1 antitrypsin, caeruloplasmin, albumin, total globulin, fibrinogen, fibronectin, ferritin, and transferrin were measured on a single occasion for each. The study was thus a cross sectional descriptive survey for group comparison. Plasma viscosity was measured on admission for TDS and DC and repeated after six weeks and six months for TDS.

RESULTS

Plasma C reactive protein, alpha 1 antitrypsin, total globulin, fibronectin, and viscosity were significantly higher in TDS than in NC. DC children also had acute phase protein elevations (C reactive protein, caeruloplasmin, viscosity). However, the increase in caeruloplasmin was specific to the DC group while an increase in fibronectin was specific to the TDS group. Serial measurement of viscosity in TDS showed a modest but significant fall during the six months following treatment.

CONCLUSIONS

There is an acute phase response in intense trichuriasis and a specific elevation of plasma fibronectin. Plasma viscosity remains abnormally high six months after treatment, although lower than at diagnosis.

Enterobius, trichuris, capillaria, and hookworm including ancylostoma caninum

Infections by the nematodes Enterobius, Trichuris, Capillaria, and hookworm are some of the most widespread gastrointestinal infections worldwide. This article is designed not only to provide an overview of the different parasites in terms of epidemiology, clinical manifestation, and disease but also to highlight particular areas of intensive research activity that are providing new insights into both the biology of the host-parasite relationship and possible new approaches to infection management for the future.

The major secreted product of the whipworm, Trichuris, is a pore-forming protein

The data presented here describe the first unequivocable characterization of a pore-forming protein in any helminth parasite. The excretory/secretory (E/S) material of the human whipworm T. trichiura contains a highly abundant protein of molecular mass 47 kDa (TT47); the murine model parasite, T. muris, contains a similarly abundant protein of molecular mass 43 kDa (TM43). When purified to homogeneity, these proteins induce ion-conducting pores in lipid bilayers. Antibodies raised against TM43 abolish channel activity. Pore formation in epithelial cell membranes may facilitate invasion of the host gut by Trichuris and enable the parasite to maintain its syncytial environment in the caecal epithelium. The observation that this activity may be inhibited by antibody opens a possible avenue for drug and vaccine development.

Genetic relatedness as a determinant of predisposition to Ascaris lumbricoides and Trichuris trichiura infection

The present study examines the role of host genetics in predisposition to Ascaris lumbricoides and Trichuris trichiura infection, by comparing the associations between age-standardized infection intensities of parents and their children (genetically related), with age-standardized infection intensities of parents alone (not related), within families previously demonstrated to exhibit familial predisposition. The lack of a consistent trend in infection intensity associations within families, in particular the lack of a stronger association between parents and their children than between unrelated parents, suggests that host genetic factors are not a major determinant of infection status. If there is a genetic basis for predisposition, then the data suggest that the effects of this genetic basis are overwhelmed by other, environmental or behavioural features of the family household.

Aggregation and predisposition to Ascaris lumbricoides and Trichuris trichiura at the familial level

This study examines the persistence of familial aggregation and familial predisposition to Ascaris lumbricoides and Trichuris trichiura infection over 2 periods of treatment and reinfection, in an urban community in Kuala Lumpur, Malaysia. Both parasite species were shown to be aggregated (assessed by the variance to mean ratio) within families at all 3 interventions, although no consistent trend in aggregation was observed over the period of the study. Associations between mean A. lumbricoides and T. trichiura infection levels of families, at all 3 interventions, were highly significant (P < 0.0001), suggesting persistent predisposition at the family level.

The relationship between Trichuris trichiura transmission intensity and the age-profiles of parasite-specific antibody isotypes in two endemic communities

The present study compares parasite-specific antibody responses in two Caribbean communities with high and low levels of Trichuris trichiura transmission. The age-dependency of antibody levels suggest that IgG1 and IgG2 levels relate to the current intensity of infection (as assessed by density of eggs in stool (e.p.g.) and reflect the age-intensity profile at the population level. IgG4, IgE and IgA levels persist into early adulthood and the subsequent decline is gradual. In the low transmission area, lower infection levels are reflected in lower parasite-specific antibody levels (of all isotypes) in the community as a whole. Despite a significantly greater past experience of infection in the high transmission area, antibody levels are not maintained at significantly higher levels throughout adulthood. The production of IgA appears to require a threshold for triggering, and a vigorous IgA response is maintained into early adulthood only in the high transmission village where peak intensity is greatest and the age-convexity of intensity is most marked. Experimental and theoretical studies focusing on the dynamic nature of host-helminth interactions in hosts exposed to high and low infection levels, and the putative role of acquired immunity, are discussed in relation to the data presented.

The effect of repeated chemotherapy on age-related predisposition to Ascaris lumbricoides and Trichuris trichiura

This study examines the persistence of predisposition to Ascaris lumbricoides and Trichuris trichiura during repeated chemotherapy in an urban community in Kuala Lumpur, Malaysia. Significant predisposition was observed over 2 periods of reinfection with and without age-standardization of data. Analysis of different age groups indicated that predisposition was most strongly detectable in the younger age classes. The intensities of infection with both parasites were strongly correlated at each cycle of intervention, suggesting that individuals were similarly predisposed to both species.

Response of pre-adult and adult stages of Trichuris muris to common anthelmintics in mice

The common anthelmintics, oxantel, mebendazole, albendazole and pyrantel were assessed for their comparative activity against Trichuris muris in mice. Mice were infected with T. muris and the infection was maintained by a brief cortisone administration during the second week of infection. Mice carrying the infection with different life cycle stages, viz. fourth stage larvae (L4), pre-adult and adult stages were dosed with anthelminitics. The worm burdens in control infection groups varied although infection dose and other conditions were uniformly followed. With various dose regimens tested, oxantel was highly potent; it eliminated completely pre-adult and adult stages, respectively at 25 and 12.5 mg kg-1 dose levels with significant activity also against adult worms at a 1.56 mg kg-1 dose level and against pre-adults at a 6.25 mg kg-1 level. Pre-adults required twice the dose given to that of adults for complete (100%) activity. Mebendazole was the next most active; a dosage of 37.5 mg kg-1 was completely active against pre-adults whereas a dosage of 2 x 50 mg kg-1 was required for complete elimination of adult worms. In addition, about 90% of the worms were eliminated with a single dose of 150 mg kg-1. However, a significant activity was seen against adults at a 25 mg kg-1 level and pre-adults at 37.5 mg kg-1, the lowest level tested. In comparison, albendazole did not induce complete clearance of pre-adult and adult stages even when tested at dose levels as high as 150 and 2 x 75 mg kg-1, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Humoral immune responses in human infection with the whipworm Trichuris trichiura

The humoral immune response to infection with Trichuris trichirua was investigated by ELISA and immunoblotting using human sera from the Caribbean island of St Lucia. Immunoblot analysis of the degree of cross-reactivity with the related trichuroid Trichinella spiralis and with the other commonly co-existent nematodes, Ascaris lumbricoides and Toxocara canis, was carried out using selected sera. The IgM, IgA, IgE, and IgG subclass antibody levels were measured in ELISA using a detergent solubilized extract of adult T. trichiura. The IgG and IgE responses were highly Trichuris specific. Anti-T. trichiura IgM responses were totally cross-reactive with A. lumbricoides and were completely ablated by pre-incubation of sera with Ascaris antigen. The IgG response was predominantly of the IgG1 subclass with a minimal IgG3 response. Only 1 person out of 130 tested had a detectable IgG3 response. The IgG2 response appeared to be directed primarily against carbohydrate or polysaccharide antigens as pre-treatment of the ELISA plates with poly-L-lysine was necessary before a response could be detected. These data are the first demonstration of human isotypic responses to infection with T. trichiura.

The rate of ingestion of Ascaris lumbricoides and Trichuris trichiura eggs in soil and its relationship to infection in two children's homes in Jamaica

The rate of exposure to geohelminth infection of children living in 2 institutions in Jamaica, West Indies, was estimated from the product of their rates of ingestion of soil and the density of parasite eggs in the environment. The estimated mean rate of egg ingestion was 9-20 Ascaris lumbricoides eggs and 6-60 Trichuris trichiura eggs per year, although the distribution was highly overdispersed so that some individuals had an estimated annual exposure of several hundred eggs. The estimated individual rates of exposure correlated significantly with the observed worm burdens in children at one of the homes, but not at the other. It is suggested that the susceptibility of the children and the distribution of infective stages in the environment may be important in determining the relationship between exposure and the rate of acquisition of infection.

Reinfection of Somali children with Trichuris trichiura after chemotherapy: relevance of immunostimulation

The intestinal helminth status of an age-stratified sample (6 to 20 years old) from a Somalian community has been assessed and the typical pattern of highly aggregated parasite distribution found. A reinfection study on a sample of 40 children (treated and untreated with a pentapeptide identical to the active site of the thymic hormone thymopoietin) seemed to indicate that immunological factors play a significant role in modulating the population dynamics of infection in endemic communities.

Measurement of Ascaris lumbricoides infection intensity and the dynamics of expulsion following treatment with mebendazole

Intensity of Ascaris lumbricoides infection was measured in terms of egg counts and worm burden in children 2-10 years of age. The expulsion of A. lumbricoides with a 3-day treatment of mebendazole occurred over 8 days, beginning on the second day of treatment. Ninety-seven percent of the worms were expelled between the second and seventh days. A rapid means of estimating eggs per gram (epg) by the Kato Katz technique correlated well with the method described by Martin & Beaver (1968). In spite of apparent density dependence in egg production, A. lumbricoides egg counts correlated well with worm burdens. It is concluded that, within the context of community surveys, epg is a reasonable means of identifying heavily infected individuals and that epg can be estimated rapidly by a slight modification to the standard Kato Katz technique.

Effect of age and initial infection intensity on the rate of reinfection with Trichuris trichiura after treatment

The study examines the rate of re-acquisition of Trichuris trichiura infection after treatment in two populations, one of mixed age and the other of children with known pre-intervention infection intensity. A population living in a Caribbean village was treated with mebendazole and the rate of reacquisition of infection of four age classes (2-4, 5-10, 11-30, 30+ years) monitored over a 20-month period. The reinfection rate was higher in the child age-classes indicating either that children are more exposed to infection or that adults slowly develop a partially effective acquired immunity. A cohort of children (mean age 4.5 years) was separated into 3 intensity categories on the basis of expelled worm burdens and their rate of reacquisition of infection monitored over a 12-month period. The rate of reinfection was directly and positively associated with initial infection status. This may indicate that children with low intensity infections are consistently less exposed to infection or that they have effective immune responses. The latter conclusion, however, would imply that they had acquired this immunity early in life, and so appears to contradict the suggestion that resistance is only slowly acquired by adults. Reconciling these two conclusions may require more sophisticated immunological models than have been suggested previously for geohelminthiases.

The evidence for predisposition to trichuriasis in humans: comparison of institutional and community studies

This article compares the results of two studies of Trichuris trichiura infection, one conducted in a children's home and the other in a village. In both, the intensity of infection of a cohort of children was determined by antihelminthic expulsion initially, and again after a period of re-infection. The cohort of village children showed a predisposition to a particular intensity of infection. An individual with a heavy infection initially was likely to re-acquire a heavier than average worm burden. No such correlation was observed for the cohort of institutionalized children. It is suggested that the causation of predisposition is multifactorial, and that the contrasting results of the two studies may be due in part to differing levels of heterogeneity in exposure to infection, the village children being exposed to dissimilar domestic environments and the institutionalized children to only one.

Epidemiology and population dynamics of Ascaris lumbricoides and Trichuris trichiura infection in the same community

The gastrointestinal helminth infection status of an age-stratified sample from a single Caribbean community was assessed using anthelmintic expulsion techniques. The same sample was re-assessed in a similar manner after a 17 month period of re-infection. The age-prevalence profile of Ascaris lumbricoides was convex while that of Trichuris trichiura was asymptotic. The age-intensity profiles of both species were convex. These differing patterns are attributed to differences in the absolute worm burdens of the 2 species. The frequency distributions of infection intensity were similar for both species, and largely independent of host age. The basic reproductive rate of A. lumbricoides (Ro = 1-1.8) was similar to that recorded elsewhere and much lower than that of T. trichiura (Ro = 4-6), implying that the latter is intrinsically more resistant to control. Individual hosts were predisposed to high (or low) intensity infection with either species, although predisposition to both species simultaneously was not conclusively demonstrated. Further studies are required to determine the cause of these observations.

The mode of action of some benzimidazole drugs on Trichinella spiralis

In an attempt to find possible targets for benzimidazole action in muscle-stage larvae of Trichinella spiralis, the effects of mebendazole and thiabendazole were tested in vivo by oral treatment of infested mice and in vitro by including these anthelmintics in an adequate maintenance medium containing decapsulated larvae. The effects of the anthelmintics on succinate dehydrogenase and fumarate reductase activities, measured in the mitochondrial fraction obtained from the in vivo- or in vitro-treated larvae showed that only thiabendazole causes significant inhibition of fumarate reductase activity. On the other hand, measurements of free glucose, glycogen reserves and soluble protein in the treated larvae indicate that in vivo, mebendazole and thiabendazole clearly diminish free glucose levels, although in vitro only mebendazole produces the same diminution. Both the glycogen and protein contents of the larvae remained unchanged after treatment in vivo or in vitro. The importance of these findings with regard to a possible site of action for mebendazole and thiabendazole is discussed.

Predisposition to Trichuris trichiura infection in humans

The study examines the distribution of Trichuris trichiura infection in a village community in St Lucia, West Indies. The infection intensity of the same age-stratified population was assessed (by drug expelled worm burden and faecal egg count) at the initiation of the study, and after 17 months of reinfection following treatment. The frequency distribution of worm numbers per person was similar at both periods of sampling. There was a significant correlation between the initial infection intensity of an individual, and the intensity acquired by the same individual following the 17 month period of reinfection. This relationship was observed in a broad range of host age classes. The study provides firm evidence that individuals are predisposed to heavy (or light) T. trichiura infection.

Age-related prevalence and intensity of Trichuris trichiura infection in a St. Lucian community

Age-related changes in the average worm burden and the prevalence of Trichuris trichiura infection, in a village community in St. Lucia, were examined by field studies based on worm expulsion techniques. Horizontal age-intensity profiles were convex in form with peak parasite loads occurring in the 2 to 15-year-old children. Prevalence is shown to be a poor indicator of changes in average worm load with age. Faecal egg counts (epg and epd) provide a qualitative measure of worm burdens since fecundity is shown to be approximately independent of worm load. The parasites were highly aggregated within the study community, with most people harbouring low burdens while a few individuals harboured very heavy burdens. Of the total parasite populations in the study sample, 84% were harboured by the 2 to 15-year-old children. Of those individuals harbouring 100 worms or more, 87% were in the 2 to 10-year-old age range. Crude estimates of population parameters (basic reproductive rate, 4-5; rate of reinfection, 90 year-1) suggest that the rate of reinfection is higher than for other helminth parasites of man. The control of morbidity and parasite transmission is discussed in the context of targeting drug treatment at the child segment of the study population.

Epidemiological aspects of Trichuris and trichuriasis in Caribbean communities

The review argues for a reappraisal of the health significance of the human whipworm, Trichuris trichiura. Infections with this geohelminth are at least as prevalent as Ascaris lumbricoides in many localities, and are associated with significant morbidity. Infection may result in severe trichuriasis syndrome or, more frequently, in a chronic colitis associated with growth stunting. Under-reporting of the chronic manifestations of disease has resulted in a gross under-estimation of the health impact of trichuriasis. Furthermore, estimation of the population dynamical parameters of T. trichiura transmission suggests that whipworm infections are intrinsically more resistant to control than those of other common geohelminths. A major determinant of the transmission dynamics and morbidity characteristics of this helminthiasis is the aggregation of worm burdens in certain predisposed individuals and age groups. It is suggested that improved understanding of the factors generating this distribution of infection intensity is a pre-requisite for effective control of both infection and morbidity.