Immunotechniques for epidemiology of malaria: appropriate tools for integration of primary health care with malaria research and control

Evaluation of biological sample preparation for immunosignature-based diagnostics

To address the need for a universal system to assess health status, we previously described a method termed "immunosignaturing" which splays the entire humoral antibody repertoire across a peptide microarray. Two important issues relative to the potential broad use of immunosignatures are sample preparation and stability. In the present study, we compared the immunosignatures developed from serum, plasma, saliva, and antibodies eluted from blood dried onto filter paper. We found that serum and plasma provide identical immunosignatures. Immunosignatures derived from dried blood also correlated well with those from nondried serum from the same individual. Immunosignatures derived from dried blood were capable of distinguishing naïve mice from those infected with influenza virus. Saliva was applied to the arrays, and the IgA immunosignature correlated strongly with that from dried blood. Finally, we demonstrate that dried blood retains immunosignature information even when exposed to high temperature. This work expands the potential diagnostic uses for immunosignatures. These features suggest that different forms of archival samples can be used for diagnosis development and that in prospective studies samples can be easily procured.

Dried blood spots as a source of anti-malarial antibodies for epidemiological studies

Background

Blood spots collected onto filter paper are an established and convenient source of antibodies for serological diagnosis and epidemiological surveys. Although recommendations for the storage and analysis of small molecule analytes in blood spots exist, there are no published systematic studies of the stability of antibodies under different storage conditions.

Methods

Blood spots, on filter paper or glass fibre mats and containing malaria-endemic plasma, were desiccated and stored at various temperatures for different times. Eluates of these spots were assayed for antibodies against two Plasmodium falciparum antigens, MSP-1₁₉ and MSP2, and calculated titres used to fit an exponential (first order kinetic) decay model. The first order rate constants (k) for each spot storage temperature were used to fit an Arrhenius equation, in order to estimate the thermal and temporal stability of antibodies in dried blood spots. The utility of blood spots for serological assays was confirmed by comparing antibodies eluted from blood spots with the equivalent plasma values in a series of samples from North Eastern Tanzania and by using blood spot-derived antibodies to estimate malaria transmission intensity in this site and for two localities in Uganda.

Results

Antibodies in spots on filter paper and glass fibre paper had similar stabilities but blood was more easily absorbed onto filter papers than glass fibre, spots were more regular and spot size was more closely correlated with blood volume for filter paper spots. Desiccated spots could be stored at or below 4°C for extended periods, but were stable for only very limited periods at ambient temperature. When desiccated, recoveries of antibodies that are predominantly of IgG1 or IgG3 subclasses were similar. Recoveries of antibodies from paired samples of serum and of blood spots from Tanzania which had been suitably stored showed similar recoveries of antibodies, but spots which had been stored for extended periods at ambient humidity and temperature showed severe loss of recoveries. Estimates of malaria transmission intensity obtained from serum and from blood spots were similar, and values obtained using blood spots agreed well with entomologically determined values.

Conclusion

This study has demonstrated the suitability of filter paper blood spots paper for collection of serum antibodies, and provided clear guidelines for the treatment and storage of filter papers which emphasize the importance of desiccation and minimisation of time spent at ambient temperatures. A recommended protocol for collecting, storing and assaying blood spots is provided.

Malaria vector analysis and control

Antivector measures in malaria control should aim for a cost-effective reduction of the transmission potential ideally to below the critical level for sustained transmission. The available measures include those that decrease vector abundance, vector-human contact and vector survival rate or that increase the length of the sporogonic cycle. These have widely different impact on malaria transmission, as shown by epidemiological modelling. Direct modification of vector receptivity to Plasmodium is also hypothetically attainable by the use of transmission-blocking vaccines or by genetic manipulation and replacement of the vector population. Vector analysis constitutes the essential prerequisite for basic malaria epidemiology as well as for the development, planning and evaluation of antivector measures. The rationale, the problems and the perspectives of vector analysis are reviewed here by Mario Coluzzi, on the basis of his experience with Afrotropical and Mediterranean malaria vectors.

Malaria and its possible control on the island of Príncipe

BACKGROUND

Malaria can be eradicated from islands. To assess the prospects for eradication of malaria from the island of Príncipe in the Gulf of Guinea, we fitted a mathematical model to age-prevalence curves and thus obtained estimates of the vectorial capacity and of the basic reproductive number (R0) for malaria.

METHODS

A cross-sectional malariological survey was carried out, in mid-1999, in six communities, comprising circa 17% of the total 6,000 population of the island. All houses in these communities were registered and their mode of construction recorded. Thick and thin blood films were prepared from all consenting individuals. Each individual was asked whether they possessed a mosquito net, whether they had slept under a mosquito net the previous night, whether they were allergic to chloroquine, and whether they had visited the main island of São Tomé since the beginning of the year. Outpatient records from March 1999 until the end of December 2000 were also examined and the age and place of residence of diagnosed cases noted.

RESULTS

203 (19.8%) of the 1,026 individuals examined were found to be infected with Plasmodium falciparum. By fitting the mathematical model of the Garki project to the age-prevalence curve we estimate that the basic reproductive number, R0, on the island is approximately 1.6. Over a period of one year, a total of 1,792 P. falciparum cases reported to an outpatient facility at the island's hospital. Overall, 54% of the people interviewed slept under mosquito nets and were at reduced risk of infection. Conversely, people living in houses with openings between the top of the wall and the roof had higher risk of infection.

CONCLUSION

This high incidence suggests that most of the malaria cases on the island attend the hospital and that treatment of these cases is an important factor reducing the effective rate of transmission. Providing that clinical cases are effectively treated, endemic malaria can probably be eliminated from the island mainly by reducing exposure to the vector with simple measures such as insecticide-treated nets and mosquito-proofing of dwellings. In contrast to traditional malaria eradication strategies, this would avoid the risk of malaria epidemics because the reduction in R0 should be sustainable.

'A mate or a meal'--pre-gravid behaviour of female Anopheles gambiae from the islands of São Tomé and Príncipe, West Africa

BACKGROUND

Malaria prevalence differs between the two islands that comprise the archipelago of São Tomé and Príncipe. This may be due to differences in the biology of local Anopheles gambiae, the only vector on the islands. Survival rate and feeding frequency are two factors influencing vectorial capacity. Anophelines generally feed just once per gonotrophic (oviposition) cycle. Newly emerged insects, however, may feed two or more times during their first oviposition cycle thus increasing the likelihood of becoming infected. The reasons for multiple feeding are not clearly understood and it is still uncertain whether the behaviour is facultative or obligatory. We, therefore, determined survival and sporozoite rates, and examined the behaviour of An. gambiae from the two islands during their first gonotrophic cycle.

METHODS

The wing size of 1,410, abdominal condition of 687, gonotrophic age and mated status of 7,264 female M form An. gambiae collected by light-trap, landing catch, resting outdoors or in copula, was determined from four sites in the archipelago. Sporozoite rates assessed by ELISA in 15,533 females from São Tomé and 2,111 from Príncipe were determined.

RESULTS

Estimated survival rates ranged between 0.834-0.849 per day in São Tomé and 0.801-0.818 per day in Príncipe. Sporozoite rates of 0.63% in São Tomé were significantly higher than the 0.24% from Príncipe. Overall 49% of females mated on the second night after emergence before feeding, and 51% on the third night and thus fed before mating. The likelihood of mating before feeding increased with wing size. None of the 3,776 parous insects collected showed evidence of recent mating. All but two of the 198 females collected in copula had undeveloped ovaries. Mean wing sizes and the number of insects collected in a sentinel light-trap varied but the proportion of newly emerged insects in the collection did not. The estimated survival rate of the smallest insects was lower than other size groups, but the overall size distribution of each age group was normal. Parous insects were gonotrophically concordant.

CONCLUSION

Differences in mosquito survival contributed to the lower sporozoite rates and endemicity of malaria on Príncipe compared to São Tomé. On both islands all newly emerged insects blood fed on the second night following emergence but only became gonotrophically active on the third night after emergence. Smaller insects had a higher 'mortality/emigration' rate than larger ones. We suggest that insufficiency of Juvenile Hormone until the third day of adult life is responsible for gonotrophic inactivity and that by partitioning mating between the second or third day after emergence females maximise their chances of out-crossing.

Insecticide-treated materials, mosquito adaptation and mass effect: entomological observations after five years of vector control in Burkina Faso

Insecticide-treated bednets and curtains have been shown to be successful in reducing malaria transmission and child mortality in Africa over periods of up to 2 years. A major concern relating to this approach is that, in time, it will be compromised by the selection of mosquito genotypes that are resistant at the biochemical or behavioural level. We report entomological data from a large area in Burkina Faso where insecticide-treated curtains have been in use for up to 5 years. Longitudinal indoor and outdoor CDC light-trap catches were performed in 4 sentinel villages. In addition cross-sectional surveys using indoor spray catches and outdoor CDC light-trap catches were performed each September in a larger number of villages, including 8 located outside the intervention area. We found no evidence of the selection of mosquito phenotypes that might compromise the intervention. Indoor and outdoor vector densities remained very low after 5 years of intervention, both compared with pre-intervention levels and with concurrent levels outside the intervention area. We found no evidence of a switch to outdoor rather than indoor biting. The proportion of blood meals taken on humans may have decreased but our data are inconclusive on this point. We observed higher vector densities and sporozoite rates at the periphery of the intervention zone than at the centre, which may reflect re-invasion of peripheral villages by mosquitoes from outside the intervention area. In 'real life' programmes, with perhaps patchy, less than optimal coverage, the protection against malaria transmission provided to individuals using insecticide-treated materials may be less than that achieved in the randomized controlled trials which demonstrated an impact of insecticide-treated materials on child mortality.

Malaria in São Tomé and Príncipe: parasite prevalences and vector densities

A cross-sectional survey was carried out in 16 localities on the island of São Tomé and three on the island of Príncipe, at the end of the rainy season of 1997, to determine malaria prevalence and vector densities. Blood samples from 664 inhabitants of all ages were examined by optical microscopy (OM) and PCR. Mosquito collections were made by outdoor landing captures from 21:00-23:00 h. Great differences were found between OM and PCR readings. OM had a sensitivity of 66%, a specificity of 79% and failed to reveal any mixed-infections. Overall prevalence, determined by PCR, was higher in São Tomé (53%) than in Príncipe (35%). It was highest in children below 16 years-old. All four human Plasmodium species occurred in São Tomé but P. ovale was not detected in Príncipe. The human population was largely asymptomatic. Bednet users had lower prevalence than did non-users. The FOREST form of Anopheles gambiae s.s., identified by PCR and cytogenetics, was the only vector on the islands. The sporozoite rate in São Tomé, assessed by ELISA, was 0.5%. Parasite prevalence and vector densities were positively correlated in São Tomé, where malaria transmission must occur predominantly in the more populated coastal areas.

Different response to Plasmodium falciparum malaria in west African sympatric ethnic groups

The comparison of malaria indicators among populations that have different genetic backgrounds and are uniformly exposed to the same parasite strains is one approach to the study of human heterogeneties in the response to the infection. We report the results of comparative surveys on three sympatric West African ethnic groups, Fulani, Mossi, and Rimaibé, living in the same conditions of hyperendemic transmission in a Sudan savanna area northeast of Ouagadougou, Burkina Faso. The Mossi and Rimaibé are Sudanese negroid populations with a long tradition of sedentary farming, while the Fulani are nomadic pastoralists, partly settled and characterized by non-negroid features of possible caucasoid origin. Parasitological, clinical, and immunological investigations showed consistent interethnic differences in Plasmodium falciparum infection rates, malaria morbidity, and prevalence and levels of antibodies to various P. falciparum antigens. The data point to a remarkably similar response to malaria in the Mossi and Rimaibé, while the Fulani are clearly less parasitized, less affected by the disease, and more responsive to all antigens tested. No difference in the use of malaria protective measures was demonstrated that could account for these findings, and sociocultural or environmental factors do not seem to be involved. Known genetic factors of resistance to malaria did not show higher frequencies in the Fulani. The differences in the immune response were not explained by the entomological observations, which indicated substantially uniform exposure to infective bites. The available data support the existence of unknown genetic factors, possibly related to humoral immune responses, determining interethnic differences in the susceptibility to malaria.

Village-based diagnosis and treatment of malaria

Village-based volunteer workers have played an important role in malaria diagnosis and treatment in many different settings for more than 35 years. Two of these programs stand out in terms of their size and longevity: the Volunteer Collaborator Network of Latin America and the Village Voluntary Malaria Collaborator Program of Thailand. The success of these programs is based on a tradition of active community participation and sustained commitment and support from the national malaria control programs. As epidemiological conditions and program priorities change, these programs will have to be sufficiently flexible to keep pace. Perhaps the greatest challenge facing these single disease, vertical programs in the future is their integration into the general health services in a manner that will preserve their best features.

Anopheles arabiensis and An. gambiae chromosomal inversion polymorphism, feeding and resting behaviour in relation to insecticide house-spraying in Tanzania

Differential responses of the mosquitoes Anopheles arabiensis and An. gambiae sensu stricto to house-spraying with DDT or lambda-cyhalothrin were evaluated in relation to chromosomal inversion polymorphism, feeding and resting behaviour of these malaria vectors in Tanzania. Blood-fed mosquitoes from pit traps outdoors, exit traps on windows and indoor-resting catches were identified cytogenetically and the chromosomal inversion frequencies compared between samples and species. Their outdoor-resting behaviour was assessed by a mark-release-recapture experiment and by determining the proportion of freshly blood-fed individuals in exit traps. The source of bloodmeals was analysed by an ELISA method. Endophagic females of An. arabiensis were more likely than those of An.gambiae to exit from a house on the night of blood-feeding. Only in one out of three villages was there evidence that chromosomally distinct individuals within a species had different preferences for resting sites. There were indications, but not conclusive evidence, that mosquitoes caught indoors or outdoors had a tendency to return to the same type of resting site. In villages sprayed with either insecticide, the mean age of the vector populations was greatly reduced, compared with those in the unsprayed villages. An.arabiensis females exited from DDT sprayed houses after blood-feeding, whereas with lambda-cyhalothrin those exiting were mostly unfed and there was a decline in the human blood index. The excitorepellency of DDT was perceived as a disadvantage, whereas lambda-cyhalothrin apparently had more impact on malaria transmission by An.arabiensis.

Control of endophagic Anopheles mosquitoes and human malaria in Guinea Bissau, West Africa by permethrin-treated bed nets

We compared the anti-mosquito and antimalarial potentialities of placebo-treated versus permethrin-impregnated bed nets in north-western Guinea Bissau. Baseline, pre-intervention entomological and parasitological data were collected during the rainy season of 1990 and bed nets were distributed shortly before the rainy season of 1991. Pairs of 3 ethnically different villages were investigated. The villages in each pair were at least 2 km apart but belonged to the same ethnic group in an ecologically similar area. After one year permethrin-treated bed nets were provided to all people in one village of each pair and placebo-treated bed nets to the other villages. About 98% of mosquitoes caught in bedrooms belonged to Anopheles gambiae and A. melas, which we consider to be the main malaria vectors in the study villages. Mean Plasmodium falciparum sporozoite rate in A. gambiae (9.6%) and A. melas (12.4%) was highest during October-November. The Plasmodium index in children 2-9 years old in the 6 villages, at the end of the rainy season 1990, ranged between 44% and 79%. Of these, 98% were identified as P. falciparum, 1% as P. malariae and 1% as mixed infections of these species. Significant reductions of Anopheles indoor resting densities and malaria parasite rates in humans were recorded in villages which had received permethrin-treated nets, but not in the control villages. The mean number of P. falciparum-infective mosquito bites received indoors in untreated villages during the rainy season was estimated to be about 4 per child and 20 per adult. This inoculation rate was reduced by at least 78% by the use of permethrin-impregnated bed nets. The malaria parasite rates and proportions of people experiencing 'disease with fever' decreased significantly in villages provided with permethrin-treated nets but not in the control villages. Impregnated nets may be an important tool to reduce disease and death due to malaria in Guinea Bissau.

Human mobility and malaria risk in the Naya river basin of Colombia

This paper develops and tests a methodology for examining the manner and the extent to which human mobility can be associated with malaria risk within an endemic area. The paper presents entomological, epidemiological and mobility results obtained from macro data and micro data. Results indicate that malaria is concentrated in the delta zone of the Naya river basin where the circulation of people into this zone for economic reasons occurs at a time when vector densities are high. High human density combined with high vector density ensures continuous and intense transmission of malaria. In attempting to measure intensity of transmission, microscopic analysis of parasitaemia was found to underestimate prevalence showing it to be very low or negligible, whereas serological data collected during the same period of time reveal that prevalence is high, and similar for both sexes. Serological data also indicate that prevalence increases with age particularly from adolescence onwards. Since mobility for agricultural purposes involves able-bodied males and females, there seems ample justification for concluding that human mobility into certain areas increases the risk of infection for adults, particularly when such mobility coincides with peak rainfall and vector densities. Micro-level data are critical in pinpointing causation and small area variations in risk. Thus the beach area is a high risk area within the delta region, particularly for adults, and this is likely to be because of high vector biting rates in the beach environment. One conclusion is that micro analysis of behaviour, when linked to epidemiological data are particularly useful in defining and locating areas and groups at highest risk; using such information to achieve intensive coverage on a small scale may be more cost-effective than attempting to achieve vector or chemotherapeutic control over a wider area for all groups.

In vitro immune recognition of synthetic peptides from the Plasmodium falciparum CS protein by individuals naturally exposed to different sporozoite challenge

The impact of duration and intensity of sporozoite challenge on the in vitro cell immune response to synthetic peptides of the circumsporozoite (CS) protein of Plasmodium falciparum was investigated in residents of a malaria endemic area in Burkina Faso (West Africa). Lymphocyte proliferation and interferon-gamma (IFN-gamma) production were used to assess immune recognition of synthetic peptides corresponding to the polymorphic Th2R and Th3R regions, to the conserved CS.T3 sequence and to NANP and degenerate NVDP repeats. Immune responses were measured in adults and children from a village where they received more than 100 sporozoite inoculations per year and in adults living in a town, exposed to a 10-100 times lower challenge. A lifetime intense exposure apparently increased the ability to proliferate in response to most peptides in the rural adults, who all produced antibodies to NANP repeats. Surprisingly, cell cultures from these subjects seldom contained appreciable levels of IFN-gamma. In the urban adults, possibly due to the moderate challenge they are exposed to, significant differences in the proliferative potentials of the peptides could be detected. The highest stimulation indices were obtained with the genetically unrestricted CS.T3 peptide. Remarkably, proliferative responses to Th2R and Th3R appeared to be correlated with the humoral response to the CS protein, indicating a T helper significance of the epitopes. The differing proliferative potential of the polymorphic epitopes in the urban adults suggests that polymorphism might delay the development of immune responsiveness under conditions of sporadic transmission. The children from the highly malarious village displayed the lowest proliferative scores, accompanied by a high prevalence of antibodies to NANP repeats. On the basis of these findings, the hypothesis is proposed that a pure B cell reactivity to NANP repeats could ontogenetically precede the mounting of a conventional T-B cooperative immune response.

Synthetic peptides for Plasmodium vivax malaria sero-epidemiology. Application of Fmoc-polyamide and displacement chromatography

The immunodominant epitope of Plasmodium vivax, one of the major causative agents of malaria in man, consists of the tandem repetitions of a nonapeptide sequence, AspArgAlaAsp/AlaGlyGlnProAlaGly, with Asp (variant d) or Ala (variant a), in the fourth position. Synthetic peptides corresponding to the P. vivax epitope, containing a different number of nonapeptide sequences, were prepared by solid-phase synthesis according to the Fmoc-polyamide method. Three peptides, containing 1, 2, and 4 copies of the d variant, were assembled on the gel polymer; none of these peptides, however, was suitable for P. vivax sero-epidemiology. A 45-peptide containing both the d and a variants, ddaad, was prepared by continuous-flow Fmoc-polyamide (flow-polyamide). Among the cleavage procedures evaluated for the removal of the five Mtr groups only TFMSA/TFA/1,2-ethanedithiol (1:89:10 by vol) brought deblocking to completion; a substantial level of impurities originated, however, from these procedures. The product was purified by reversed-phase displacement chromatography, a technique only recently applied to peptides, which shows distinct advantages over conventional, linear elution chromatography. In a single experiment, 107 mg of the crude mixture were loaded onto an analytical column (250 x 4 mm), obtaining in purified form 85% of the desired material present in the sample. An ELISA test base on the ddaad peptide was developed and is being applied to the sero-epidemiology of P. vivax malaria.

Introduction to, and evaluation of, immunoassays in a malaria research institute in Tanzania

Various immunoassays have been introduced into, and evaluated at, the Amani Medical Centre in north-east Tanzania. These include immunoblotting to identify mosquito bloodmeals, immunoradiometric and immunoenzymatic assays to assess the presence of circumsporozoite protein in mosquitoes, and enzyme-linked immunosorbent assays to measure antibodies to circumsporozoite antibody in people. The assays were shown to be reliable and practicable for use in the study of malaria epidemiology.