Immunoepidemiology of human schistosomes: taking the theory into the field

Zoonotic transmission of intestinal helminths in southeast Asia: Implications for control and elimination

Intestinal helminths are extremely widespread and highly prevalent infections of humans, particularly in rural and poor urban areas of low and middle-income countries. These parasites have chronic and often insidious effects on human health and child development including abdominal problems, anaemia, stunting and wasting. Certain animals play a fundamental role in the transmission of many intestinal helminths to humans. However, the contribution of zoonotic transmission to the overall burden of human intestinal helminth infection and the relative importance of different animal reservoirs remains incomplete. Moreover, control programmes and transmission models for intestinal helminths often do not consider the role of zoonotic reservoirs of infection. Such reservoirs will become increasingly important as control is scaled up and there is a move towards interruption and even elimination of parasite transmission. With a focus on southeast Asia, and the Philippines in particular, this review summarises the major zoonotic intestinal helminths, risk factors for infection and highlights knowledge gaps related to their epidemiology and transmission. Various methodologies are discussed, including parasite genomics, mathematical modelling and socio-economic analysis, that could be employed to improve understanding of intestinal helminth spread, reservoir attribution and the burden associated with infection, as well as assess effectiveness of interventions. For sustainable control and ultimately elimination of intestinal helminths, there is a need to move beyond scheduled mass deworming and to consider animal and environmental reservoirs. A One Health approach to control of intestinal helminths is proposed, integrating interventions targeting humans, animals and the environment, including improved access to water, hygiene and sanitation. This will require coordination and collaboration across different sectors to achieve best health outcomes for all.

Infection and treatment immunizations for successful parasite vaccines

Since the advent of techniques for the expression of recombinant peptide antigens, the availability of human vaccines for parasitic diseases has been ‘imminent’. Yet vaccines based on recombinant proteins are still largely aspirations, not realities. It is now apparent that vaccine development needs additional knowledge about host protective immune response(s), antigen characteristics, and the delivery required to induce those responses. The most successful immune protection against parasites has been generated by infection and treatment, the induction of protective immunity by truncating the course of an infection with drug treatment. Here, we consider the characteristics of an effective, protective anti-parasite vaccine and propose a conceptual framework to aid parasite vaccine development using malaria and schistosomiasis as examples.

Integrated analysis of innate, Th1, Th2, Th17, and regulatory cytokines identifies changes in immune polarisation following treatment of human schistosomiasis

Background. Schistosomiasis elicits cross-regulatory immune responses, but it is unclear how antihelminthic treatment affects this balance. This study integrates data on 13 cytokines elicited by 3 schistosome to examine how praziquantel treatment alters immune polarization and whether post-treatment cytokine profiles influence reinfection status.

Methods. Venous blood from 72 Schistosoma haematobium–exposed participants was cultured with schistosome egg, adult worm, and cercaria antigens pre– and 6 weeks post–praziquantel treatment. Innate inflammatory (tumor necrosis factor α [TNF-α], interleukin(IL-)-6, IL-8), Th1 (interferon γ [IFN-γ], IL-2, IL-12p70), Th2 (IL-4, IL-5, IL-13), Th17 (IL-17A, IL-21, IL-23p19), and regulatory (IL-10) cytokines were quantified via enzyme-linked immunosorbent assay. Cytokine data was integrated using nonmetric multidimensional scaling and factor analysis.

Results. Egg-specific cytokine phenotypes became more proinflammatory post-treatment due to increased TNF-α, IL-6, IL-8, IFN-γ, IL-12p70, and IL-23 levels. Post-treatment cercariae-specific responses were also more proinflammatory reflecting elevated IL-8. In contrast, post-treatment adult worm-specific responses were less inflammatory, reflecting lower post-treatment IL-6. A combination of egg-induced IL-6, IL-12p70, IL-21, and IL-23 and adult worm-induced IL-5 and IL-21 post-treatment was associated with reduced reinfection risk 18 months later.

Conclusions. Praziquantel treatment markedly alters polarization of schistosome-specific cytokine responses, and these changes, particularly in response to egg-stage parasites, may promote resistance to reinfection.

Patterns in parasite epidemiology: the peak shift

A characteristic relationship between infection and host age, with levels of infection reaching a peak in particular age classes, has been reported for many parasites. However, several field studies have shown that this relationship is not invariant: if age-infection data are compared across host populations, the peak level of infection is higher and occurs at a younger age when the transmission rate is high, and is lower and occurs at an older age when it is low. This pattern is called the ;peak shift'. Here, Mark Woolhouse reviews the evidence for and the implications of the peak shift. The peak shift is consistent with the predictions of mathematical models that assume gradually acquired protective immunity, and this interpretation is supported by experimental studies using animals. This agreement between theory, experimental evidence and field studies strongly suggests that acquired immunity has a major impact on epidemiological patterns not only for parasites such as malaria, where the importance of acquired immunity is not in doubt, but also for many parasitic helminths, where the role of acquired immunity is less widely accepted.

Schistosome immunology: more questions than answers

The past 30 years have seen research on the immunology of schistosomiasis move to encompass studies of responses in naturally exposed human populations, in addition to the studies in animal model systems. While animal systems still retain an important place in research on the immunology of schistosomiasis, recent debate has centred on aspects of human immunological responses that may or may not be associated with resistance or susceptibility to infection. In this article, Paul Hagan, Patricia Ndhlovu and David Dunne take stock of the present state of knowledge and offer their views on prospects for the future.

Immunoepidemiology of Wuchereria bancrofti infection: parasite transmission intensity, filaria-specific antibodies, and host immunity in two East African communities

We compared the age profiles of infection and specific antibody intensities in two communities with different transmission levels in East Africa to examine the contribution of humoral responses to human immunity to the vector-borne helminth Wuchereria bancrofti. The worm intensities were higher and exhibited a nonlinear age pattern in a high-transmission community, Masaika, in contrast to the low but linearly increasing age infection profile observed for a low-transmission community, Kingwede. The mean levels of specific immunoglobulin G1 (IgG1), IgG2, IgG4, and IgE were also higher in Masaika, but intriguingly, the IgG3 response was higher in Kingwede. The age-antibody patterns differed in the two communities but in a manner apparently contrary to a role in acquired immunity when the data were assessed using simple correlation methods. By contrast, multivariate analyses showed that the antibody response to infection may be classified into three types and that two of these types, a IgG3-type response and a response measuring a trade-off in host production of IgG4 and IgG3 versus production of IgG1, IgG2, and IgE, had a negative effect on Wuchereria circulating antigen levels in a manner that supported a role for these responses in the generation of acquired immunity to infection. Mathematical modeling supported the conclusions drawn from empirical data analyses that variations in both transmission and worm intensity can explain community differences in the age profiles and impacts of these antibody response types. This study showed that parasite-specific antibody responses may be associated with the generation of acquired immunity to human filarial infection but in a form which is dependent on worm transmission intensity and interactions between immune components.

Immuno-epidemiology of human Schistosoma haematobium infection: preferential IgG3 antibody responsiveness to a recombinant antigen dependent on age and parasite burden

Background

Schistosomiasis is a major parasitic disease affecting over 200 million people in the developing world with a further 400 million people at risk of infection. The aim of this study was to identify a single antigen from adult Schistosoma haematobium worms and subsequently use this antigen to study the development of schistosome-acquired immunity in a human population.

Methods

The full-length cDNA sequence of a S. haematobium protein, a putative orthologue of the S. mansoni tegumental antigen Sm13, was obtained from a cDNA library of adult S. haematobium worms and named Sh13 following a small-scale expressed sequence tags (EST) project. The recombinant Sh13 protein expressed in E. coli, was used to investigate immuno-epidemiological patterns in 147 Zimbabweans (7–18 years old) exposed to S. haematobium.

Results

Sequence analysis of the full-length cDNA sequence of the S. haematobium protein Sh13, indicated that the protein has an N-terminal signal peptide and encodes an 85-amino acid mature protein with a highly conserved predicted transmembrane domain (86 % identity with the S. mansoni tegumental antigen Sm13). The recombinant Sh13 protein was used in ELISA assays to determine the reactivity of sera from the study participants. Antibody responses against Sh13 were predominantly IgG3 isotype compared to responses against crude worm antigens which were predominantly IgG1 and IgG4. The relationship between anti-Sh13 IgG3 levels and infection intensity varied significantly with host age. The youngest children (7–10 years old) had relatively low levels of both infection and anti-Sh13 IgG3. In older children (11–12 years old) rising infection levels were accompanied by a significant increase in anti-Sh13 IgG3 levels. Subsequently, infection intensity declined significantly in 13–18 year olds but levels of the antibody continued to rise. The changing relationship between infection intensity and anti-Sh13 IgG3 levels with host age is consistent with the profile of a protective immune response predicted from theoretical work.

Conclusion

We have identified and characterised a novel S. haematobium antigen Sh13, a putative tegumental protein, and shown that it is recognised predominantly by IgG3 antibodies from people infected with/exposed to S. haematobium parasites. We have also shown that, the anti-Sh13 IgG3 response is maximal in older individuals with the lowest infection intensity, and that the age profile of the relationship between anti-Sh13 IgG3 and infection intensity is consistent with that predicted by theoretical work for a protective response stimulated by and directed against adult worms.

Differences in prevalence, intensity of infection and parasite-specific antibody levels do not predict different age-infection profiles

Acquired immunity is believed to influence the age-infection profile of Schistosoma infections. We compared antibody responses against Schistosoma mansoni adult worm antigen (AWA) and soluble egg antigen (SEA) in 164 residents of two communities with different levels of infection. IgG, IgA, IgM, IgE, and IgG subclass 1 to 4 antibodies were determined by ELISA. Seventy-five of the subjects were from Harbu, an area with a prevalence of 39% and an intensity of infection of 116 eggs per gram of stool (EPG), whereas 89 subjects were from Bati, with a prevalence of 66% and intensity of infection of 256 EPG. In both communities the prevalence and the intensity of infection were highest in the age group 10-14 years, although both were significantly higher in Bati than in Harbu. Mean levels of AWA-specific IgA, IgM, IgG, IgG1 and IgG2, and of SEA-specific IgG, IgM, IgG2 and IgG3 were significantly higher in Bati than in Harbu. However, mean levels of IgE against worm and egg antigens were significantly higher in Harbu than in Bati. Significant differences were detected in the levels of IgA, IgE, IgG, IgM, IgG1 and IgG2 against AWA, and in IgE, IgM, IgG2 and IgG3 against SEA according to the place of residence. The levels of anti-AWA IgG, IgG1 and IgG2 and anti-SEA IgG, IgG1 and IgG4 were significantly associated with the intensity of infection. Anti-AWA IgM levels were associated with age, whereas sex and age had interacting effects on the levels of AWA-specific IgG1 and SEA-specific IgG and IgM. Antibody responses exhibited different age-related patterns in the two communities. This may indicate that differences in history of exposure influence the evolution of immune responses. However, the study did not support the view that differences in antibody levels between communities subject to different levels of infection result in a systematic deviation in age-infection profile (the "peak shift").

Immunoepidemiology--bridging the gap between immunology and epidemiology

'Immunoepidemiology' combines individual- and population-oriented approaches to create new perspectives. It examines how inter-individual differences in immune responses affect the population dynamics of micro- and macro-parasites to produce the epidemiological patterns of infection observed in heterogeneous host populations. Here, I discuss how research has only just begun to tap the potential of this integrative discipline that incorporates immunology, parasitology, genetics, epidemiology, ecology, mathematical modelling and statistics.

The immunoepidemiology of nematode parasites of farmed animals: a mathematical approach

The population dynamics of farmed animals are controlled by humans, and often involve high host densities, which encourage higher parasite burdens than would be usual in wild animals. As a result, the immunity to reinfection acquired by the host is an important determinant of parasite population dynamics. For example, lambs are highly susceptible to gastrointestinal nematodes as they begin to graze, but develop an immunity that accounts for the observed within-year variation in parasite load and pasture contamination. In the longer term, control measures are compromised by the development of parasite strains resistant to chemotherapy, focusing attention on the development of 'natural' measures, including the selection for resistant hosts and the development of antiparasite vaccines. Mick Roberts here considers the immunoepidemiology of parasites of farmed animals on three levels: the interaction between the parasite and the host's immune system determining the individual's level of protection; the development of acquired immunity determining the within-year parasite population dynamics; and the long-term effects of control measures on the between-year parasite population dynamics.

Herd immunity to filarial infection is a function of vector biting rate

Despite the existence of an impressive body of work on human immune responses against filarial infections, the occurrence of a protective response to infection remains unclear. Here, we use a combined modelling and comparative data analysis framework to address this issue for human infections with the filarial parasite, Wuchereria bancrofti. By analogy with previous work, the analysis involves the comparison of observed field patterns of infection with epidemiological patterns predicted by a mathematical model of parasite immunity. Unlike most other human helminths, which are transmitted by ingestion or dermal penetration, exposure to infection with lymphatic filariasis can be measured explicitly in terms of vector mosquito biting rates, thereby also allowing, probably for the first time, examination of the suggested role of exposure in generating herd immunity to macroparasites. Observed field patterns in this study were derived from 19 different published studies, which gave parallel estimates of community exposure rates and the corresponding age--prevalence patterns of infection, while predictions of the epidemiological impact of herd immunity were obtained using a catalytic model framework. The results provide the first conclusive evidence to date that variations in the observed age--prevalence patterns of infection in filariasis can be effectively explained by the occurrence of an exposure-driven acquisition of herd immunity. We discuss this result in terms of implications for the new World Health Organization-led initiative for the global control of this parasitic disease.

Human schistosomiasis: potential long-term consequences of vaccination programmes

Fields trials of new schistosomiasis vaccines are anticipated within the next few years, but there remains great uncertainty regarding the optimal design of vaccination programmes. Mathematical models are used here to explore the potential long-term consequences of vaccination, assuming that the vaccines provide partial protection for a limited period. The analysis suggests that vaccines acting to reduce infection rates or egg output will have a similar impact on levels of infection, that this impact may be highly sensitive to the duration as well as the degree of protection, that it may take several decades for the full impact to become apparent, and that one consequence will be peak levels of infection occurring in older age classes. In terms of lowering levels of infection there may be advantages in delaying vaccination until children reach school age, especially if the vaccine gives short-lived protection, or to repeat vaccination. The short-term advantages can be greatly increased by combining the introduction of a vaccination programme with initial mass chemotherapy. Continuous combined vaccination and chemotherapy programmes may also be more effective than either intervention alone. More research is needed on the consequences of vaccinating previously vaccinated, infected, and infected and treated individuals and the importance of natural boosting of vaccine-induced immunity.

Modelling the dynamic effects of community chemotherapy on patterns of morbidity due to Schistosoma mansoni

This paper uses a mathematical framework to predict the long-term consequences of chemotherapy for the age distribution of schistosomiasis morbidity. The framework incorporates a previously validated transmission model, which is here extended to capture effects on 2 forms of Schistosoma mansoni morbidity: early disease exemplified by hepatomegaly and late disease exemplified by Symmer's fibrosis. The main aim of this analysis is to show how such an approach could be used to explore the probable public health consequences of decades of control. It is suggested that this procedure could usefully inform current approaches to the design of long-term control programmes.

On estimating the basic reproduction number for Schistosoma haematobium

Existing estimates of the basic reproduction number, Ro, for human schistosomes are mostly in the range 1-4, implying that schistosomes should be relatively easy to eliminate from endemic areas, which is contrary to practical experience. An estimate of Ro for a site in Zimbabwe is obtained here using a mathematical model explicitly incorporating two features believed to be epidemiologically significant; age-dependent exposure and acquired immunity. Parameter estimates are, as far as possible, obtained independently, but the coefficients representing man-snail and snail-man transmission, as well as parameters representing effects of acquired immunity, must be estimated indirectly by fitting the model to field data. Heterogeneity in human exposure and contamination is crudely incorporated by considering "wormy' and non-wormy' fractions of the population. The results suggest Ro to be in the range 4-5 or more, higher than previous estimates and despite only moderate levels of infection at this site. It is shown that this estimate is sensitive to the form of the underlying model. The application of less realistic models may lead to less reliable estimates of Ro.

A pocket guide to host-parasite models

Mathematical models have been used to describe the population dynamics of a wide range of host-parasite interactions. Mick Roberts here discusses mathematical models for the dynamics of helminth endoparasites of non-human mammalian hosts, paying particular attention to the density-dependent factors that regulate the parasite populations, and the interaction between parasite and wild or feral animal host populations.

The interpretation of intensity and aggregation data for infections of Schistosoma haematobium

The relationships between mean intensities of infection, the aggregation of infection among hosts, and host age are analysed using data from 2 large (> 3000 individuals) field studies of Schistosoma haematobium infection. The data show a convex relationship between mean intensity and age, a convex relationship between an inverse index of aggregation and age, and an age-dependent relationship between the mean and aggregation of infection intensity when levels of infection are high. These patterns are qualitatively compared with the output of mathematical models based on an immigration-death process (model I), and incorporating age-dependent changes in the distribution of exposure to infection as suggested by field data (model II), or reductions in the rate of infection as a function of either current (model III) or cumulative (model IV) parasite burdens, that is, density-dependent processes without or with memory, respectively. Models II and III were able to reproduce observed patterns, but model IV, which is a possible representation of acquired immunity, was not. These results are consistent with the following assumptions: (i) age-related patterns of aggregation can be generated without recourse to density-dependent processes; (ii) the epidemiological impact of density-dependent processes depends on whether these act with or without memory; and (iii) any acquired immunity to human S. haematobium infection may be significantly less than life-long.

A theoretical framework for the immunoepidemiology of blocking antibodies to helminth infection

Epidemiological evidence is widely cited in support of the hypothesis that certain antibody responses to human helminth, especially schistosome, infection exhibit blocking activity. This evidence includes positive correlations between antibody levels and the rate of re-establishment of infection following chemotherapy, antibody levels which peak in younger and more susceptible age classes, lower ratios of blocking antibodies to others in older and less susceptible age classes. In this paper simple mathematical models are used to explore expected age-specific relationships between antibody levels, parasite burdens and re-establishment rates for different combinations of protective, neutral and blocking immune responses. In general, all the above cited patterns may be generated without invoking blocking activity, especially if the abilities to produce different antibody responses have different immunological memories, i.e. persist for different lengths of time in the absence of continued exposure to antigen. None of these patterns, including a positive correlation between antibody levels and rates of re-establishment following chemotherapy, offers unambiguous evidence for blocking activity. Blocking activity is also predicted to affect the shape of the age-intensity curve and the relationship between susceptibility to infection and age in ways which are not necessarily consistent with the epidemiological evidence. The importance of the blocking activity, which has been convincingly demonstrated in vitro, to population level immunoepidemiological patterns in the field therefore remains uncertain.