Do intestinal parasites interfere with the seroepidemiologic surveillance of Schistosoma mansoni infection?

Accuracy of commercial ELISA and ICT for screening schistosomiasis infections at a low endemicity area in Brazil

BACKGROUND

Control interventions recommended by the World Health Organization have successfully resulted in low-intensity schistosomiasis transmission areas. To achieve elimination of transmission, new diagnostic screening tools are needed to overcome less than adequate sensitivity of the currently used Kato-Katz faecal thick smear method. Ideally, in-house serological tests should be avoided due to not having a continuous supply of kits as would be necessary for large population studies. Quality assurance provided by manufacturers and proper performance evaluations are also needed. We evaluated the accuracy of two commercially available serology tests as screening methods for detecting light schistosomiasis infections.

METHODS

Serum samples were collected in 2015 from individuals living in a low-endemicity locality in northeastern Brazil and deposited in a biorepository. We evaluated immunoglobulin G (IgG) and IgM enzyme-linked immunosorbent assays (ELISAs) and an immunochromatographic test (ICT). The Helmintex method was used to define true-positive samples.

RESULTS

Overall sensitivity was close to 90% for both the IgG ELISA and ICT, yet specificity was 28% and 18%, respectively. For the IgM ELISA, the values were estimated to be 55% and 43%, respectively.

CONCLUSIONS

Poor specificity and positive predictive values prevent these tests from being recommended for screening populations in low-intensity schistosomiasis-endemic areas.

Potential of antibody test using Schistosoma mansoni recombinant serpin and RP26 to detect light-intensity infections in endemic areas

Schistosomiasis remains a worldwide public health problem, especially in sub-Saharan Africa. The World Health Organization targets the goal for its elimination as a public health problem in the 2030 Neglected Tropical Diseases (NTDs) Roadmap. Concerted action and agile responses to challenges will be necessary to achieve the targets. Better diagnostic tests can accelerate progress towards the elimination by monitoring disease trends and evaluating the effectiveness of interventions; however, current examinations such as Kato-Katz technique are of limited power to detect light-intensity infections. The point-of-care circulating cathodic antigen (POC-CCA) test shows a higher sensitivity compared to the reference standard, Kato-Katz technique, but it still lacks sufficient sensitivity with low infection intensity. In this study, we examined antibody reactions against recombinant protein antigens; Schistosoma mansoni serine protease-inhibitor (SmSerpin) and RP26, by enzyme-linked immunosorbent assay (ELISA) in plasma samples with light-intensity infection. The sensitivity using the cocktail antigen of recombinant SmSerpin and RP26 showed 83.7%. The sensitivity using S. mansoni soluble egg antigen (SmSEA) was 90.8%, but it showed poor specificity (29.7%), while the cocktail antigen presented improved specificity (61.4%). We conclude that antibody detection to the SmSerpin and RP26 protein antigens is effective to detect S. mansoni light-intensity infections. Our study indicates the potential of detecting antibody against recombinant protein antigens to monitor the transmission of schistosomiasis in low endemicity contexts.

Use of Schistosoma mansoni soluble egg antigen (SEA) for antibody detection and diagnosis of schistosomiasis: The need for improved accuracy evaluations of diagnostic tools

Many antigens for use in antibody-detection systems for schistosomiasis have been investigated over the past 40 years. In particular, soluble egg antigens (SEA) are still widely used in enzyme-linked immunosorbent assays (ELISAs) for detection of immunoglobulin classes and subclasses. Here, we conducted a literature review to examine accuracy evaluations of SEA-Immunoglobulin G (IgG)-ELISAs performed to detect Schistosoma mansoni infections and published between 1979 and 2019. S. mansoni is the main causative agent for intestinal schistosomiasis in many countries in Africa and Central and South America. After retrieving 214 relevant abstracts from the PubMed database, we selected 15 publications to undergo a full review. Sensitivity and specificity values varied from 71 to 99%, and from 6 to 100%, respectively. In addition, 11/15 studies did not state confidence intervals. Therefore, the findings from this review indicate that after four decades, we still do not have consistent evaluation estimates of SEA-IgG-ELISAs. Antigen mass per well and dilution of test sera in these articles varied from 0.018 µg to 1.5 µg, and from 1:50 to 1:500, respectively. Most of the reported accuracy evaluations used control sera which were selected based on parasitological examinations for egg detection, although ill-defined criteria were also noted. The number and composition of control serum panels was considered not adequate in approximately half of the studies. It is also noteworthy that among more than 30 diagnostic antigen preparations under development since the 1970s, most were not validated in the field and they failed to reach populations in need. Thus, attention to guidelines for standardization, estimations of accuracy, and reporting of results is needed to facilitate coordinated efforts aimed at schistosomiasis control and elimination.

Proteomic and immunomic analysis of Schistosoma mekongi egg proteins

Schistosomiasis remains a global health problem. In the Mekong river basin, approximately 80,000 people are at risk of infection by Schistosoma mekongi. The parasite's eggs become entrapped in the host's organs and induce massive inflammation, contributing to the pathogenesis of schistosomiasis. In addition, egg antigens are important in circumoval precipitin tests (COPTs) and other diagnostic techniques. Little is known regarding the egg proteins of S. mekongi, and so we applied immunoblotting and mass spectrometry-based proteomic approaches to study these proteins and their antigenicity. A total of 360 unique proteins were identified in S. mekongi eggs using proteomic analyses. The major protein components of S. mekongi eggs were classified into several groups by functions, including proteins of unknown function, structural proteins, and regulators of transcription and translation. The most abundant proteins in S. mekongi eggs were antioxidant proteins, potentially reflecting the need to neutralize reactive oxidative species released from host immune cells. Immunomic analyses revealed that only DNA replication factor Cdt1 and heat shock protein 70 overlap between the proteins recognized by sera of infected mice and humans, illustrating the challenges of knowledge transfer from animal models to human patients. Forty-one immunoreactive protein bands were recognized by either mouse or patient sera. Phosphoglycerate kinase, fructose-1,6-bisphosphate aldolase and elongation factor 1 appeared to be interesting immunogens of S. mekongi eggs as these proteins were recognized by polyclonal IgMs and IgGs in patient sera. Our findings provide new information on the protein composition of S. mekongi eggs as well as the beginnings of a S. mekongi immunogen dataset. These data may help us better understand the pathology of schistosomiasis as well as natural antibody responses against S. mekongi egg proteins, both of which may be useful in including S. mekongi to other schistosoma diagnostic, vaccine and immunotherapy development.

Schistosoma mekongi cathepsin B and its use in the development of an immunodiagnosis

Schistosomiasis mekongi is one of the most important human parasitic diseases caused by Schistosoma mekongi in South-east Asia. The endemic area is the Mekong River sub-region from Laos to Cambodia. This parasite also infects dogs and pigs which are its alternative host species. Currently, the lack of reliable rapid diagnosis makes it difficult to monitor the infection and spreading of the disease. In this study, we screened the antigens of the parasite with sera of infected mice using Western blotting and identified proteins of interest with LC-MS/MS to obtain potential candidate proteins for diagnostic development. This assay yielded 2 immunoreactive bands at molecular masses of 31 and 22kDa. The 31kDa protein was the major band identified as cathepsin B, and its gene was cloned to obtain a full cDNA sequence (SmekCatB). The cDNA consisted of 1123bp and its longest reading frame encoded for 342 amino acids with some putative post translation modifications. The recombinant SmekCatB (rSmekCatB) with hexahistidine tag at the C-terminus was expressed in Escherichia coli and purified by Ni-NTA resin under denaturing conditions. The rSmekCatB reacted with sera of S. mekongi-infected mice. Indirect ELISA using rSmekCatB as the antigen to detect mouse antibodies, revealed a sensitivity of 91.67% for schistosomiasis mekongi and the specificity of 100%. Our data suggested that SmekCatB is one of the most promising parasitic antigens that could be used for the diagnosis of S. mekongi infection.

Necator americanus and helminth co-infections: further down-modulation of hookworm-specific type 1 immune responses

Background

Helminth co-infection in humans is common in tropical regions of the world where transmission of soil-transmitted helminths such as Ascaris lumbricoides, Trichuris trichiura, and the hookworms Necator americanus and Ancylostoma duodenale as well as other helminths such as Schistosoma mansoni often occur simultaneously.

Methodology

We investigated whether co-infection with another helminth(s) altered the human immune response to crude antigen extracts from either different stages of N. americanus infection (infective third stage or adult) or different crude antigen extract preparations (adult somatic and adult excretory/secretory). Using these antigens, we compared the cellular and humoral immune responses of individuals mono-infected with hookworm (N. americanus) and individuals co-infected with hookworm and other helminth infections, namely co-infection with either A. lumbricoides, Schistosoma mansoni, or both. Immunological variables were compared between hookworm infection group (mono- versus co-infected) by bootstrap, and principal component analysis (PCA) was used as a data reduction method.

Conclusions

Contrary to several animal studies of helminth co-infection, we found that co-infected individuals had a further downmodulated Th1 cytokine response (e.g., reduced INF-γ), accompanied by a significant increase in the hookworm-specific humoral immune response (e.g. higher levels of IgE or IgG4 to crude antigen extracts) compared with mono- infected individuals. Neither of these changes was associated with a reduction of hookworm infection intensity in helminth co-infected individuals. From the standpoint of hookworm vaccine development, these results are relevant; i.e., the specific immune response to hookworm vaccine antigens might be altered by infection with another helminth.

Parasitic infections in humans are common in tropical regions and under bad housing and sanitation conditions multiple parasitic infections are the rule rather than the exception. For helminth infections, which are thought to affect almost a quarter of the world's population, most common combinations include soil-transmitted helminths, such as hookworm, roundworm, and whipworm, as well as extra-intestinal infections by schistosomes. In order to develop and test a hookworm vaccine in endemic areas, the understanding of the impact of multiple helminth infections (co-infection) on the immune response against hookworm in infected individuals is crucial. The authors report in their article, that several parameters of the cellular (T cell markers, cytokines, chemokines) and humoral immune response (e.g. IgG4 and IgE antibodies) against hookworm are significantly affected or modulated in individuals co-infected with hookworm, roundworm and/or schistosomes. These results imply that the immune response against components of a hookworm vaccine might be altered by previous contact with other helminth species in endemic areas.

Immuno-epidemiology of Schistosoma mansoni infections in endemic populations co-infected with soil-transmitted helminths: present knowledge, challenges, and the need for further studies

This article reviews studies on epidemiological and immunological interactions between Schistosoma mansoni and soil-transmitted helminths (STH) in co-infected patients from endemic areas. In Brazil, co-infections with schistosomes and intestinal nematodes, such as Ascaris lumbricoides, Trichuris trichiura and the hookworms, are still common, especially in poor rural areas. Important factors in the co-occurrence of different helminth species are favorable environmental conditions supporting intermediate hosts and the survival of larval stages outside the human host, widespread poverty, and low levels of hygiene and sanitation. The few existing epidemiological surveys on helminth co-infections in humans indicate positive associations between schistosomes and STH, which means high prevalences of mixed infections, as well as higher intensities of infection in co-infected patients. However, these positive interactions appear to depend on the number of different helminth species present and on the intensity of infection in each individual. For the humoral immune response in co-infected patients, much cross-reactivity in antibody responses against antigenic preparations from schistosomes and STH is observed. Data on cellular immune responses in multiply infected patients are still scarce and additive effects on the cellular reactivity and the down-modulation of cytokines are proposed.

Epizootiology of spirorchiid infection in green turtles (Chelonia mydas) in Hawaii

We describe the epizootiology of spirorchiid trematode infections in Hawaiian green turtles (Chelonia mydas) by quantifying tissue egg burdens in turtles submitted for necropsy and by assessing antibody response to crude adult worm and egg antigens among a variety of age groups. Hapalotrema sp. and Laeredius sp. predominated in turtles infected with spirorchiids. Tissue egg burdens decreased with increasing size and increased with deteriorating body condition of turtles. No relationship was found between tissue egg burdens and sex or fibropapillomatosis status. Tissue egg burdens increased in turtles from southeast to northwest in the main Hawaiian Islands (Hawaii to Kauai). Hatchling and captive-reared turtles had significantly lower levels of antibodies against crude worm and egg antigens. Based on tissue egg burdens and antibody status, we hypothesize that immature turtles become infected with spirorchiids shortly after recruiting into coastal foraging pastures from the pelagic environment, that infection levels decrease with age, and that spirorchiids detrimentally affect the body condition of sea turtles independent of tumor burden. The low intensity of infection in turtles with the endemic trematode Carettacola hawaiiensis suggests either that turtles are less susceptible to infection with this parasite or that the parasite is outcompeted by species of Hapalotrema and Laeredius. Given that the 2 latter species are found in the Pacific and other oceans, they are not likely endemic and were probably introduced into Hawaii through an undetermined route.

The immunoepidemiology of human hookworm infection

Advances in hookworm immunoepidemiology are reviewed. Recent studies demonstrate a mixed Th1/Th2 response in human hookworm infection, with immunosuppression of specific and nonspecific IFN-gamma responses. There is increasing evidence for protective immunity in human hookworm infection, including anti-larval IL-5- and IgE-dependent mechanisms, and for immunological interactions between hookworm infection and other diseases.

Laboratory diagnosis of Schistosomiasis in areas of low transmission: a review of a line of research

After 57 years of successful control of schistosomiasis in Venezuela, the prevalence and intensity of infection have declined. Approximately 80% of the individuals eliminate less than 100 eggs/g of stools, therefore morbidity is mild and the majority are asymptomatic. The sensitivity of Kato-Katz decreases to approximately 60%. Available serological methods for the detection of circulating antigens only reach a 70% of sensitivity. Tests based on the detection of antibodies by immunoenzymatic assays have been improved. The circumoval precipitine test has shown a high sensitivity (97%), specificity (100%), and correlation with oviposition, being considered the best confirmatory diagnostic test. Additionally to the classical immunoenzymatic assays, the development of the alkaline phosphatase immunoassay, allowed to reach a 100% specificity with an 89% sensitivity. Recently, we have developed a modified ELISA in which the soluble egg antigen is treated with sodium metaperiodate (SMP-ELISA) in order to eliminate the glycosilated epitopes responsible for the false positive reactions. The specificity and sensitivity reaches 97% and 99%, respectively. Synthetic peptides from the excretory-secretory enzymes, cathepsin B (Sm31) legumain (Sm32) and cathepsin D (Sm45), have been synthesized. The combination of two peptides derived from the Sm31 have been evaluated, reaching a sensitivity of 96% when analyzed independently and with a 100% specificity. Antibodies raised in rabbits against peptides derived from the Sm31 and Sm32 are currently evaluated in two different antigen-capture-based assays. The development of a simple, cheap and reliable test that correlates with parasite activity is a major goal.

Infection with Schistosoma mansoni correlates with altered immune responses to Ascaris lumbricoides and hookworm

Studies were performed on humoral and cellular immune responses of patients from areas in Brazil endemic for hookworm and Ascaris lumbricoides, and either endemic or non-endemic for Schistosoma mansoni. Humoral and cellular responses were evaluated by enzyme-linked immunosorbant assay (ELISA) and peripheral blood mononuclear cell (PBMC) proliferation assays against larval hookworm antigens, A. lumbricoides egg antigens, and soluble egg antigens (SEA) or soluble whole adult antigenic preparation (SWAP) from S. mansoni. Patients from S. mansoni-endemic areas, who currently had only hookworm or Ascaris infections, expressed lower humoral and cellular responses to hookworm or Ascaris antigens, respectively, than did their counterparts from areas not endemic for S. mansoni. Individuals from S. mansoni endemic area, although without detectable S. mansoni infection, do mount humoral and cellular responses to SEA and SWAP. This group of individuals has been probably in contact with S. mansoni antigens, since the groups harboring A. lumbricoides or hookworm infections from non-S. mansoni endemic areas do not have detectable anti-S. mansoni responses. PBMC proliferative responses discriminated well between patients with active hookworm infections versus ascariasis, if they were from areas not endemic for S. mansoni.

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.

Isolation and characterization of a major allergen from the fish parasite Anisakis simplex

BACKGROUND

Ingestion of raw or undercooked fish can lead to infection of human subjects by the fish parasite Anisakis simplex, a disease known as anisakiasis or anisakidosis. Patients sensitized to this fish parasite show high levels of total and specific IgE. Cross-reactions seem to explain the fact that specific IgE antibodies are also found in a high number of normal subjects, as reported in other parasitoses.

OBJECTIVE

We sought to purify and characterize a major IgE-binding protein from the parasite.

METHODS

A protein was purified from the crude parasite extract by means of ethanol precipitation and reversed-phase HPLC. Its clinical relevance was tested on 20 parasite-positive sera by using IgE and IgG4 immunoblotting. A monospecific human serum was used to study its localization in the parasite body.

RESULTS

A 24-kd protein was purified, to which only 45% of the sera had specific IgG4, but 85% of sera had specific IgE. The protein was present only in the excretory gland, as shown by immunohistochemistry. N-terminal amino acid sequence (17 residues) showed no homology to previously described proteins.

CONCLUSION

A simplex contains a potent allergen in the excretory gland. This major parasite allergen, named Ani s 1, could have important clinical relevance, as shown by the high number of positive sera in the specific IgE immunoblotting.

Schistosoma mansoni: immunodiagnosis is improved by sodium metaperiodate which reduces cross-reactivity due to glycosylated epitopes of soluble egg antigen

ELISA with soluble egg antigen (SEA) from Schistosoma mansoni is widely used in the diagnosis of schistosomiasis, but cross-reactivity with other intestinal helminths, overestimating the true prevalence, represents a great limitation. The role of glycoproteins of SEA in cross-reactions was investigated. SEA was oxidized with sodium metaperiodate (SMP) in ELISA and immunoblot. One hundred schistosomiasis-negative individuals sera were submitted to SMP-ELISA improving the specificity from 73% without SMP treatment to 97% with SMP. On the other hand, 94 S. mansoni-positive sera were evaluated showing that 99% were positive in ELISA either with or without SMP treatment, indicating the maintenance of high sensitivity under SMP treatment. By immunoblot, 24 sera from persons with schistosomiasis and 10 sera from schistosomiasis-free persons were assayed under reducing and nonreducing conditions with or without SMP, looking for specific infection markers and cross-reactivity markers. Reactivity from positive sera showed that specific molecules were mainly low-molecular-mass antigens and seem to have predominant proteic epitopes. The unspecific molecules reacting with some schistosomiasis-negative individuals harboring other intestinal parasites (false-positive sera) were mostly larger than 60 kDa and seemed to be basically glycosylated. Glycosylated epitopes have an important role in cross-reaction and SMP can successfully be used to reduce the false reactivity of SEA with no decrease in sensitivity, especially in ELISA as an immunodiagnostic screening surveillance method, which is useful in areas of low schistosomiasis transmission.

The last fifteen years of schistosomiasis in Venezuela: features and evolution

Control of schistosomiasis in Venezuela has been a topic of major interest and controversy among the metaxenic parasitosis. A small area of transmission of approximately 15,000 km2 was thought to be eradicated some years ago. However, some epidemiological characteristics of our transmission area have limited the success on the way toward eradication. Since 1945, when the Schistosomiasis Control Program started, the prevalence in the endemic area has decreased from 14% in 1943 to 1.4% in 1996. Until 1982, the surveillance of active cases was based on massive stool examination. Since then, the Schistosomiasis Research Group (SRG) recommended the additional use of serologic tests in the Control Program and the selective or massive chemotherapy depending on serological and parasitological prevalence of each community. At present, the real prevalence is underestimated due to the fact that approximately 80% of the individuals eliminate less than 100 eggs/g of feces. Those persons could be responsible for the maintenance of the foci going on and therefore limiting the impact of the control measures. Efforts of the SRG are being oriented toward improvement of immunodiagnostic tests by using defined antigens (enzymes) and chemically synthesized peptides, derived from relevant molecules of the parasite, either for antibodies or antigens search. On the other hand, introduction of snail competitors has been a biological weapon in the control of the intermediate host in certain areas. However, the recent reinfestation of water courses by Biomphalaria glabrata, the increased prevalence in some areas, together with important administrative changes at the Control Program of the Minister of Health, have arisen new questions and doubts, challenging the eradication strategy proposed during the last decade.

Evaluation of alkaline phosphatase immunoassay and comparison with other diagnostic methods in areas of low transmission of schistosomiasis

The alkaline phosphatase immunoassay (APIA) is an antibody detection technique which permits the diagnosis of schistosomiasis using a butanolic extract preparation from adult worms. APIA has demonstrated high sensitivity and specificity in previous reports with well characterized human sera. Its potential as a diagnostic tool for epidemiological surveillance was assessed in comparison with three other diagnostic tests: stool examination, ELISA with soluble egg antigen (SEA) and the circumoval precipitin test (COPT). APIA was 100% specific in an area without Schistosoma mansoni transmission and had 89% sensitivity in an endemic area where 69% of the infected subjects excreted less than 100 eggs g of faeces. It was found to be less sensitive in children under 5 years of age who were positive by the COPT test. APIA can be applied as an initial screening test, based on its high sensitivity, specificity, absence of cross-reactivity with intestinal parasites and the fact that it is a technique suitable for use in epidemiological surveillance.