Schistosomiasis and soil-transmitted helminthiasis: common drugs for treatment and control

Comparison of tissue biomarkers between non-schistosoma and schistosoma-associated urothelial carcinoma

BACKGROUND

High-grade urothelial carcinoma either non-Schistosoma (NS-UBC) or Schistosoma (S-UBC)-associated is the tenth cause of death worldwide and represents a serious therapeutic problem.

AIM

Evaluation of the immmunohistochemical expression of tumor necrosis factor-alpha (TNFα), epidermal growth factor receptor (EGFR), programmed cell death protein-1 (PDL1), estrogen receptor-alpha (ERα) and UroplakinIII, in the high-grade in NS-UBC and S-UBC as potential prognostic and therapeutic targets analyzed through estimation of area percentage, optical density and international pathological scoring system for each marker.

MATERIAL AND METHODS

Sixty high grade urothelial carcinoma cases were enrolled in the study (30 cases of NS-UBC and 30 cases of S-UBC). The cases were immunohistochemically-assessed for TNFα, EGFR, PDL1, ERα and Uroplakin III expression. In S-UBC, parasite load was also evaluated for correlation with the immunohistochemical markers' expression in S-UBC.

RESULTS

The area percentage of immune-expression of TNFα and EGFR was higher in S-UBC compared to NS-UBC. On the other hand, the NS-UBC displayed statistically-higher expression of PDL1 and uroplakinIII (p-value <0.001). ERα revealed higher, yet, non-significant expressions in S-UBC compared to NS-UBC (p-value =0.459). PDL1 expression showed the most superior record regarding area percentage (64.6± 34.5). Regarding optical density, TNF-α showed the highest transmittance expression (2.4 ± 0.9). EGFR positively correlated with PDL1 in S-UBC (r= 0.578, p-value =0.001) whereas in NS-UBC, TNFα and PDL1 (r=0.382, p-value=0.037) had positive correlation. Schistosoma eggs in tissues oppose uroplakin III expression and trigger immunomodulation via PDL1.

CONCLUSION

Due to lower UroplakinIII expression, S-UBC is supposed to have a poorer prognosis. Hormonal therapy is not hypothesized due to a very minimal ERα expression in both NS-UBC and S-UBC. Regarding immunotherapy, anti-TNF-α is suggested for S-UBC whilst in NS-UBC, blockading PDL1 might be useful. Targeted EGFR therapy seems to carry emphasized outcomes in S-UBC. Correlations encourage combined immune therapy in NS-UBC; nevertheless, in S-UBC, combined anti-EGFR and PDL1 seem to be of benefit.

Praziquantel: An update on the mechanism of its action against schistosomiasis and new therapeutic perspectives

Praziquantel (PZQ) is the drug of choice for the treatment of all forms of schistosomiasis, although its mechanisms of action are not completely understood. PZQ acts largely on adult worms. This narrative literature review describes what is known about the mechanisms of action of PZQ against schistosomes from in vitro and in vivo studies and highlights the molecular targets in parasites and immune responses induced in definitive hosts by this drug. Moreover, new therapeutic uses of PZQ are discussed. Studies have demonstrated that in addition to impacting voltage-operated Ca2 + channels, PZQ may interact with other schistosome molecules, such as myosin regulatory light chain, glutathione S-transferase, and transient receptor potential channels. Following PZQ administration, increased T regulatory type 1 (Tr1) cell differentiation and decreased inflammation were observed, indicating that PZQ promotes immunoregulatory pathways. Although PZQ is widely used in mass drug administration schemes, the existence of resistant parasites has not been proven; however, it is a concern that should be constantly investigated in human populations. In addition, we discuss studies that evaluate health applications of PZQ (other than helminth infection), such as its effect in cancer therapy and its adjuvant action in vaccines against viruses.

Schistosoma Mansoni Infection and Therapeutic Efficacy of Praziquantel in Preschool-Aged Children

Schistosomiasis is one of the extreme scientific results which can be greater usual in sub-Saharan Africa. It impacts growth, bodily fitness, and cognitive function, mainly in children. The maximum not unusual place method to manipulate schistosomiasis is preventive chemotherapy. Though World Health Organization (WHO) recommends praziquantel for the manage and remedy of schistosomiasis, preschool-aged children (PSAC) are excluded from populace remedy applications specifically due to paucity of statistics on reaction rate. The findings of preceding research accomplished to evaluate the impact of chemotherapy on schistosomiasis confirmed a few variation. This indicates the need for in addition research in one of the kind populations.

Histone deacetylase 8 interacts with the GTPase SmRho1 in Schistosoma mansoni

Background

Schistosoma mansoni histone deacetylase 8 (SmHDAC8) has elicited considerable interest as a target for drug discovery. Invalidation of its transcripts by RNAi leads to impaired survival of the worms in infected mice and its inhibition causes cell apoptosis and death. To determine why it is a promising therapeutic target the study of the currently unknown cellular signaling pathways involving this enzyme is essential. Protein partners of SmHDAC8 were previously identified by yeast two-hybrid (Y2H) cDNA library screening and by mass spectrometry (MS) analysis. Among these partners we characterized SmRho1, the schistosome orthologue of human RhoA GTPase, which is involved in the regulation of the cytoskeleton. In this work, we validated the interaction between SmHDAC8 and SmRho1 and explored the role of the lysine deacetylase in cytoskeletal regulation.

Methodology/principal findings

We characterized two isoforms of SmRho1, SmRho1.1 and SmRho1.2. Co- immunoprecipitation (Co-IP)/Mass Spectrometry (MS) analysis identified SmRho1 partner proteins and we used two heterologous expression systems (Y2H assay and Xenopus laevis oocytes) to study interactions between SmHDAC8 and SmRho1 isoforms.

To confirm SmHDAC8 and SmRho1 interaction in adult worms and schistosomula, we performed Co-IP experiments and additionally demonstrated SmRho1 acetylation using a Nano LC-MS/MS approach. A major impact of SmHDAC8 in cytoskeleton organization was documented by treating adult worms and schistosomula with a selective SmHDAC8 inhibitor or using RNAi followed by confocal microscopy.

Conclusions/significance

Our results suggest that SmHDAC8 is involved in cytoskeleton organization via its interaction with the SmRho1.1 isoform. The SmRho1.2 isoform failed to interact with SmHDAC8, but did specifically interact with SmDia suggesting the existence of two distinct signaling pathways regulating S. mansoni cytoskeleton organization via the two SmRho1 isoforms. A specific interaction between SmHDAC8 and the C-terminal moiety of SmRho1.1 was demonstrated, and we showed that SmRho1 is acetylated on K136. SmHDAC8 inhibition or knockdown using RNAi caused extensive disruption of schistosomula actin cytoskeleton.

Schistosoma mansoni is the major parasitic platyhelminth species causing intestinal schistosomiasis. Currently one drug, praziquantel, is the treatment of choice but its use in mass treatment programs means that the development of resistance is likely and renders imperative the development of new therapeutic agents. As new potential targets we have focused on lysine deacetylases, and in particular S. mansoni histone deacetylase 8 (SmHDAC8). Previous studies showed that reduction in the level of transcripts of SmHDAC8 by RNAi led to the impaired survival of the worms after the infection of mice. The analysis of the 3D structure of SmHDAC8 by X-ray crystallography showed that the catalytic domain structure diverges significantly from that of human HDAC8 and this was exploited to develop novel potential anti-schistosomal drugs. The biological roles of SmHDAC8 are unknown. For this reason, we previously characterized its protein binding partners and identified the schistosome orthologue of the human RhoA GTPase, suggesting the involvement of SmHDAC8 in the modulation of cytoskeleton organization. Here we investigated the interaction between SmHDAC8 and SmRho1 and identified two SmRho1 isoforms (SmRho1.1 and SmRho1.2). Our study showed that SmHDAC8 is involved in schistosome cytoskeleton organization.

Mechanochemical Synthesis and Physicochemical Characterization of Previously Unreported Praziquantel Solvates with 2-Pyrrolidone and Acetic Acid

Two new solvates of the widely used anthelminthic Praziquantel (PZQ) were obtained through mechanochemical screening with different liquid additives. Specifically, 2-pyrrolidone and acetic acid gave solvates with 1:1 stoichiometry (PZQ-AA and PZQ-2P, respectively). A wide-ranging characterization of the new solid forms was carried out by means of powder X-ray diffraction, differential scanning calorimetry, FT-IR, solid-state NMR and biopharmaceutical analyses (solubility and intrinsic dissolution studies). Besides, the crystal structures of the two new solvates were solved from their Synchrotron-PXRD pattern: the solvates are isostructural, with equivalent triclinic packing. In both structures acetic acid and 2-pyrrolidone showed a strong interaction with the PZQ molecule via hydrogen bond. Even though previous studies have shown that PZQ is conformationally flexible, the same syn conformation as the PZQ Form A of the C=O groups of the piperazinone-cyclohexylcarbonyl segment is involved in these two new solid forms. In terms of biopharmaceutical properties, PZQ-AA and PZQ-2P exhibited water solubility and intrinsic dissolution rate much greater than those of anhydrous Form A.

Proteins as Targets in Anti-Schistosomal Drug Discovery and Vaccine Development

Proteins hardly function in isolation; they form complexes with other proteins or molecules to mediate cell signaling and control cellular processes in various organisms. Protein interactions control mechanisms that lead to normal and/or disease states. The use of competitive small molecule inhibitors to disrupt disease-relevant protein-protein interactions (PPIs) holds great promise for the development of new drugs. Schistosome invasion of the human host involves a variety of cross-species protein interactions. The pathogen expresses specific proteins that not only facilitate the breach of physical and biochemical barriers present in skin, but also evade the immune system and digestion of human hemoglobin, allowing for survival in the host for years. However, only a small number of specific protein interactions between the host and parasite have been functionally characterized; thus, in-depth understanding of the molecular mechanisms of these interactions is a key component in the development of new treatment methods. Efforts are now focused on developing a schistosomiasis vaccine, as a proposed better strategy used either alone or in combination with Praziquantel to control and eliminate this disease. This review will highlight protein interactions in schistosomes that can be targeted by specific PPI inhibitors for the design of an alternative treatment to Praziquantel.

Evaluation of Hookworm Diagnosis Techniques from Patients in Debre Elias and Sanja Districts of the Amhara Region, Ethiopia

BACKGROUND

Inappropriate diagnosis could intimidate the prevention and control of hookworm infection. Thus, this study was aimed at evaluating the performance of hookworm diagnosis methods.

METHODS

An institution-based cross-sectional study was conducted from patients in Debre Elias and Sanja districts of the Amhara region, Ethiopia, from November 2019 to January 2020. The study subjects were selected conveniently. After the data was entered into Statistical Package for the Social Sciences (SPSS), sensitivity, specificity, predictive values, test accuracy, and agreement of the different hookworm diagnosis methods, namely, test tube flotation technique (TFT), McMaster (MM), formol-ether concentration (FEC), Kato-Katz (KK), and direct wet mount microscopy (DWMM), were calculated by using SPSS software. The composite reference standard (CRS) was used as the gold standard method. The kappa (κ) test was used to measure the level of agreement between diagnosis tests.

RESULT

A total of 389 stool samples were collected from patients in the study. The overall prevalence of hookworm was 63.24%. The test tube flotation technique (TFT) was found to be the highest both in terms of sensitivity and diagnostic accuracy (100%). McMaster (MM) was the second most sensitive test (68.7%), followed by FEC (44.3%) and KK (38.2%). On the other hand, DWMM had the lowest sensitivity (37.4%), and its diagnostic accuracy was also the least (60%). Only TFT had a perfect agreement (agreement = 100%, kappa = 1) with the CRS. The sensitivity of DWMM, KK, and FEC showed a kind of linear function with the intensity of infection, but TFT and MM methods were not affected by the infection intensity.

CONCLUSION

Hookworm is still a public health problem in the study area. TFT is by far more sensitive than MM, FEC, KK, and DWMM techniques.

Structure, Immunoreactivity, and In Silico Epitope Determination of SmSPI S. mansoni Serpin for Immunodiagnostic Application

The human parasitic disease Schistosomiasis is caused by the Schistosoma trematode flatworm that infects freshwaters in tropical regions of the world, particularly in Sub-Saharan Africa, South America, and the Far-East. It has also been observed as an emerging disease in Europe, due to increased immigration. In addition to improved therapeutic strategies, it is imperative to develop novel, rapid, and sensitive diagnostic tests that can detect the Schistosoma parasite, allowing timely treatment. Present diagnosis is difficult and involves microscopy-based detection of Schistosoma eggs in the feces. In this context, we present the 3.22 Å resolution crystal structure of the circulating antigen Serine protease inhibitor from S. mansoni (SmSPI), and we describe it as a potential serodiagnostic marker. Moreover, we identify three potential immunoreactive epitopes using in silico-based epitope mapping methods. Here, we confirm effective immune sera reactivity of the recombinant antigen, suggesting the further investigation of the protein and/or its predicted epitopes as serodiagnostic Schistosomiasis biomarkers.

Control Strategies for Carcinogenic-Associated Helminthiases: An Integrated Overview

Helminthiases are extremely prevalent in the developing world. In addition, the chronic infection with some parasitic worms are classified as carcinogenic. Therefore, it is utmost importance to understand the parasite-host interactions, the mechanisms underlay carcinogenesis and how they could be counteracted. This knowledge may ultimately guide novel control strategies that include chemotherapy-based approaches targeting these pathogens and associated pathologies caused by their infections. Little is known on how some helminthiases are associated with cancer; however, it has been hypothesized that chemical carcinogenesis may be involved in the process. Here, we summarize the current knowledge on chemical carcinogenesis associated with helminthiases, along with available therapeutic options and potential therapeutic alternatives including chemotherapy and/or immunotherapy. Ideally, the treatment of the carcinogenic helminthiases should target both the parasite and associated pathologies. The success of any chemotherapeutic regimen often depends on the host immune response during the infection and nutritional status among other factors. The close association between chemotherapy and cell-mediated immunity suggests that a dual therapeutic approach would be advantageous. In addition, there is a pressing need for complementary drugs that antagonize the carcinogenesis process associated with the helminth infections.

Dynamic evolution of schistosomiasis distribution under different control strategies: Results from surveillance covering 1991-2014 in Guichi, China

Background

Since the founding of the China, the Chinese government, depending on the changing epidemiological situations over time, adopted different strategies to continue the progress towards elimination of schistosomiasis in the country. Although the changing pattern of schistosomiasis distribution in both time and space is well known and has been confirmed by numerous studies, the problem of how these patterns evolve under different control strategies is far from being understood. The purpose of this study is, therefore, to investigate the spatio-temporal change of the distribution of schistosomiasis with special reference to how these patterns evolve under different control strategies.

Methodology / Principal findings

Parasitological data at the village level were obtained through access to repeated cross-sectional surveys carried out during 1991–2014 in Guichi, a rural district along the Yangtze River in Anhui Province, China. A hierarchical dynamic spatio-temporal model was used to evaluate the evolving pattern of schistosomiasis prevalence, which accounted for mechanism of dynamics of the disease. Descriptive analysis indicates that schistosomiasis prevalence displayed fluctuating high-risk foci during implementation of the chemotherapy-based strategy (1991–2005), while it took on a homogenous pattern of decreasing magnitude in the following period when the integrated strategy was implemented (2006–2014). The dynamic model analysis showed that regularly global propagation of the disease was not present after the effect of proximity to river was taken into account but local pattern transition existed. Maps of predicted prevalence shows that relatively high prevalence (>4%) occasionally occurred before 2006 and prevalence presents a homogenous and decreasing trend over the study area afterwards.

Conclusions

Proximity to river is still an important determinant for schistosomiasis infection regardless of different types of implemented prevention and control strategies. Between the transition from the chemotherapy-based strategy to the integrated one, we noticed a decreased prevalence. However, schistosomiasis would remain an endemic challenge in these study areas. Further prevention and control countermeasures are warranted.

Schistosomiasis japonica is one of the most serious parasitic diseases in China. The Chinese government has launched three different rounds of national schistosomiasis control programs since 1950s. The latest two are the World Bank Loan Project (WBLP) that ushered in chemotherapy as the main control approach, active from 1992 to 2001, and the integrated control strategy that took its place in 2005. In this study, we investigated changes in the dynamics of schistosomiasis transmission over space and time under these different control strategies. Based on spatio-temporal analyses of the schistosomiasis prevalence data at the village level during 1991–2014 in Guichi, Anhui Province, we built a dynamic model to evaluate the evolving pattern of prevalence. We found that the schistosomiasis prevalence generally showed a north-western shift over the study area during 1991–2005, while there was no such trend during 2006–2014. This global shifting trend disappeared after the effect of proximity to river was taken into account, but local change still existed which was possibly due to the transition between the two latest national control strategies. We conclude that proximity to River is still an important determinant for schistosomiasis prevalence and that although the integrated control strategy is more effective than the WBPL in reducing schistosomiasis prevalence, the disease would remain endemic for the long term without further improvements of the control program.

Human water contact patterns in active schistosomiasis endemic areas

One major risk factor common to individuals in schistosomiasis endemic areas is water contact patterns. Effort to determine the dynamics in water contact patterns in different regions needs utmost attention in order to suggest a better control strategy for schistosome infection. Quantitative observations on human water contact activities were recorded in Yewa North Local Government Area of Ogun State for a period of two years. Frequency and duration of observed water contact activities were recorded. Males had the highest water contact during the rainy season with 51.1% compared to females with 48.9%. Females had the highest water contact with 51.0% while males had 49.0% during the dry season. The age group 10-19 years had the highest water contact with 27.1%, this was followed by 20-29 years and 30-39 years age groups with 23.6% and 22.1%, respectively, during the rainy season. Our results showed that water contact activities differ with respect to different communities, sex and age groups. Previous high prevalence of schistosome infection in the study areas could be attributed to high water contact activities. Therefore, provision of adequate pipe-borne water, good sanitation and improved knowledge on schistosome life cycle among the community members will reduce the high rate of human water contacts.

Praziquantel treatment coverage among school age children against Schistosomiasis and associated factors in Ethiopia: a cross-sectional survey, 2019

Background

World Health Organization estimated that 779 million people are at risk of getting schistosomiasis (SCH) and 240 million people were infected worldwide. SCH due to Schistosoma mansoni (S. mansoni) is a wide public health problem in Ethiopia. The aim of the survey was to quantify national and district disaggregated treatment coverage status for SCH and compare validated coverage with the one reported.

Methods

Community based cross-sectional survey was conducted in April 2019 among households with school age children (SAC) 5–14 years in seven purposively selected districts of the country. Segments to be surveyed were randomly selected and households to be interviewed from each segment were determined using systematic sampling technique. A total of 3378 households visited and 5679 SAC (5–14 years) were interviewed.

Results

Overall reported treatment coverage of Praziquantel (PZQ) against SCH was 4286 (75.5%). Males were 27% more likely to swallow the drug (AOR = 1.27; 95% CI: 1.09, 1.47) than females. SAC with age 10–14 years were 45% more likely to swallow the drug compared with their counter parts (5–9 years), (AOR =1.45; 95% CI: 1.25, 1.69). There is statistically significant association between PZQ swallowing status with school enrollment. (AOR = 20.90, 95% CI: 17.41, 25.08). Swallowing status of PZQ against SCH significantly higher for SAC treated in districts applied integrated treatment approach (87.5%) compared with SAC treated in vertical treatment approach (72.5%); P-value < 0.001. SACs were asked for reasons for not taking the drug and the main reported reason for not swallowing PZQ in the present study was none attending of the school.

Conclusions

Over all treatment coverage of PZQ against SCH in the present study was 75.5%. Although it is in accordance with WHO recommendation for Ethiopia, national programmatic improvements are necessary to achieve higher coverage in the future. To increase treatment coverage for PZQ against SCH in Ethiopia, school based training should target all schools. Moreover, mobilization, sensitization and implementation of the community wide treatment need to be improved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05519-0.

Performance Evaluation of Diagnostic Methods for Schistosoma mansoni Detection in Amhara Region, Northwest Ethiopia

Background

Schistosoma mansoni is a parasitic worm that infects humans throughout the world. It is more prevalent in sub-Saharan Africa including Ethiopia. Proper detection of Schistosoma mansoni using sensitive diagnostic methods is crucial in the prevention and control era. Since direct wet mount microscopy with its low sensitivity has been used as a diagnostic technique in Ethiopia, searching alternative diagnostic methods which have better sensitivity should be a priority agenda.

Objective

This study is aimed at evaluating the performance of diagnostic methods for Schistosoma mansoni in Amhara region.

Methods

A cross-sectional study was conducted among 520 school children from October to December 2019 in Amhara region. The study participants were selected by a systematic random sampling technique. Stool samples were collected from each participant and processed via formol-ether concentration, Kato-Katz, and spontaneous tube sedimentation techniques. The data was entered into EpiData version 3.1, and analysis was done using SPSS version 20. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated against the combined result as “Gold” standard. A kappa value was computed to measure the strength of agreement of the diagnostic methods.

Results

The overall prevalence of Schistosoma mansoni was 20.2% using a combination of three methods. The prevalence of 8.3%, 12.9%, and16.3%, respectively, was recorded by using formol-ether concentration, Kato-Katz, and spontaneous tube sedimentation. The spontaneous tube sedimentation method (81.0%) had better sensitivity compared to Kato-Katz (63.8%) and formol-ether concentration (41.0%) methods in Schistosoma mansoni detection.

Conclusion

The spontaneous tube sedimentation technique is more sensitive and has better detection rate to Schistosoma mansoni infection followed by the Kato-Katz technique. Therefore, updating the current diagnostic methods for Schistosoma mansoni could be a priority agenda to take action in schistosomiasis prevention and control.

Prevalence and intensity of neglected tropical diseases (schistosomiasis and soil-transmitted helminths) amongst rural female pupils in Ugu district, KwaZulu-Natal, South Africa

Background

Inadequate water supply and sanitation adversely affects the health and socio-economic development of communities and places them at risk of contracting schistosomiasis and soil-transmitted helminths (STHs). The aim of this study was to quantify the prevalence and intensity of schistosomiasis (bilharzia) and STHs amongst female school-going pupils in Ugu district.

Methods

A descriptive cross-sectional study was conducted in Ugu district amongst primary school pupils from 18 randomly selected schools in 2010. A structured questionnaire was used to collect information on the history and knowledge of bilharzia of 1057 pupils. One stool and 3 consecutive days of urine samples were collected per participant and screened for helminth ova. Findings were compared with those reported by the parasite control programme, which collected data in the same area in 1998.

Results

The prevalence of Ascaris lumbricoides and Trichuris trichiura was 25% and 26%, respectively, and their corresponding mean intensities of infection were 21 and 26 eggs per gram. The prevalence of Schistosoma haematobium was 32%, and its mean intensity of infection was 52 eggs per 10 mL urine. Of the pupils, 60% knew about schistosomiasis, 9% reported red urine in the past week and 22% had had dysuria before. Although the prevalence of ascariasis and trichuriasis had decreased since 1998 (62% and 59%, respectively), the prevalence of schistosomiasis had increased to 32% (p < 0.05).

Conclusion

Female pupils in rural schools remain at risk. A mass treatment campaign, increased public awareness and improved sanitation are required to reduce these infections and sustain a reduction of STHs and schistosomiasis.

Keywords

prevalence; intensity; schistosomiasis; soil-transmitted helminths; Ascaris lumbricoides; Trichuris trichiura; Schistosoma haematobium; parasite control programme; water contact.

In-vitro safety and off-target profile of the anti-parasitic arylmethylaminosteroid 1o

Parasite-mediated diseases like malaria and schistosomiasis are growing health problems worldwide and novel drug candidates are urgently needed. In this study, the in-vitro safety profile of steroid compound 1o (sc1o), effective against the parasites Plasmodium falciparum and Schistosoma mansoni with an IC₅₀ value of 5 nM, was characterized. We assessed viability/proliferation, apoptosis and cell cycle tests to determine the cytotoxic profile of sc1o in cancer cells. The mutagenic potential was determined with the AMES test. To identify off-target effects we investigated whether sc1o interacts with safety-relevant molecules such as cytochrome P450 (CYP) enzymes, phosphodiesterases (PDE), histone deacteylases (HDAC) and human ether-a-go-go related gene (hERG). Furthermore, to predict the potential bioavailability of sc1o, its effect on Caco-2 cell barrier integrity, by measurement of the transepithelial electrical resistance (TEER), was determined. Sc1o at 25 µM reduced cell viability, probably through cell-cycle arrest, but did not induce apoptosis in cancer cells. No adverse off-target effects nor mutagenic potential of sc1o were observed. Furthermore, sc1o did not disturb the integrity of the cell barrier, but exhibited low membrane permeability, apparently due to cell adherence. In conclusion, sc1o up to 10 µM showed a good in-vitro safety profile.

Anthelmintic drugs for treating ascariasis

BACKGROUND

Ascaris lumbricoides is a common infection, and mainly affects children living in low-income areas. Water and sanitation improvement, health education, and drug treatment may help break the cycle of transmission, and effective drugs will reduce morbidity.

OBJECTIVES

To compare the efficacy and safety of anthelmintic drugs (albendazole, mebendazole, ivermectin) for treating people with Ascaris infection.

SEARCH METHODS

We searched the Cochrane Infectious Disease Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, three other databases, and reference lists of included studies, without language restrictions, up to 4 July 2019.

SELECTION CRITERIA

Randomized controlled trials (RCT) that compared albendazole, mebendazole, and ivermectin in children and adults with confirmed Ascaris infection.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed risk of bias, and extracted data from the included trials. A third review author checked the quality of data extraction. We used the Cochrane 'Risk of bias' assessment tool to determine the risk of bias in included trials. We used risk ratios (RRs) with 95% confidence intervals (CIs) to compare dichotomous outcomes in treatment and control groups. We used the fixed-effect model for studies with low heterogeneity and the random-effects model for studies with moderate to high heterogeneity. We assessed the certainty of the evidence using the GRADE approach. We used the control rate average to provide illustrative cure rates in the comparison groups.

MAIN RESULTS

We included 30 parallel-group RCTs, which enrolled 6442 participants from 17 countries across Africa, Asia, Central America and the Caribbean, and South America. Participants were from 28 days to 82 years of age, recruited from school, communities, and health facilities. Twenty studies were funded or co-funded by manufacturers, while 10 studies were independent of manufacturer funding. Twenty-two trials had a high risk of bias for one or two domains (blinding, incomplete outcome data, selective reporting). Single dose of albendazole (four trials), mebendazole (three trials) or ivermectin (one trial) was compared to placebo. Parasitological cure at 14 to 60 days was high in all the studies (illustrative cure of 93.0% in the anthelmintic group and 16.1% in the placebo group; RR 6.29, 95% CI 3.91 to 10.12; 8 trials, 1578 participants; moderate-certainty evidence). Single dose of albendazole is as effective as multiple doses of albendazole (illustrative cure of 93.2% with single dose, 94.3% with multiple doses; RR 0.98, 95% CI 0.92 to 1.05; 3 trials, 307 participants; high-certainty evidence); or as single dose of mebendazole (illustrative cure of 98.0% with albendazole, 96.9% with mebendazole; RR 1.01, 95% CI 1.00 to 1.02; 6 trials, 2131 participants; high-certainty evidence). Studies did not detect a difference between a single dose of albendazole and a single dose of ivermectin (cure rates of 87.8% with albendazole, 90.2% with ivermectin; RR 0.99, 95% CI 0.91 to 1.08; 3 trials, 519 participants; moderate-certainty evidence). Across all the studies, failure after single dose of albendazole ranged from 0.0% to 30.3%, mebendazole from 0.0% to 22.2%, and ivermectin from 0.0% to 21.6%. The egg reduction rate (ERR) measured up to 60 days after the treatment was high in all treated groups, regardless of the anthelmintic used (range 96% to 100%). It was not possible to evaluate parasitological cure by classes of infection intensity. No included trials reported complication or serious adverse events. Other adverse events were apparently similar among the compared anthelmintic groups (moderate- to low-certainty evidence). The most commonly reported other adverse events were nausea, vomiting, abdominal pain, diarrhoea, headache, and fever.

AUTHORS' CONCLUSIONS

Single-dose of albendazole, mebendazole, and ivermectin all appeared effective against Ascaris lumbricoides infection, yielding high parasitological cure and large reductions in eggs excreted, with no differences detected between them. The drugs appear to be safe to treat children and adults with confirmed Ascaris infection. There is little to choose between drugs and regimens in terms of cure or adverse events.

Current and Novel Therapies Against Helminthic Infections: The Potential of Antioxidants Combined with Drugs

Infections caused by Schistosoma haematobium and Opisthorchisviverrini are classified as Group 1 biological carcinogen and it has been postulated that parasites produce oxysterol and estrogen-like metabolites that might be considered as initiators of infection-associated carcinogenesis. Chemotherapy for these helminthic infections relies on a single drug, praziquantel, (PZQ) that mainly targets the parasite. Additionally, PZQ has some major drawbacks as inefficacy against juvenile form and alone it is not capable to counteract pathologies associated to infections or prevent carcinogenesis. There is an urgent need to develop novel therapeutic approaches that not only target the parasite but also improve the pathologies associated to infection, and ultimately, counteract or/and prevent the carcinogenesis processes. Repurposing the drug in combination of compounds with different modes of action is a promising strategy to find novel therapeutics approaches against these helminthic infections and its pathologies. Here, we emphasized that using antioxidants either alone or combined with anthelmintic drugs could ameliorate tissue damage, infection-associated complications, moreover, could prevent the development of cancer associated to infections. Hence, antioxidants represent a potential adjuvant approach during treatment to reduce morbidity and mortality. Despite the success of some strategies, there is a long way to go to implement novel therapies for schistosomiasis.

π-Hole Interactions Involving Nitro Aromatic Ligands in Protein Structures

Studying noncanonical intermolecular interactions between a ligand and a protein constitutes an emerging research field. Identifying synthetically accessible molecular fragments that can engage in intermolecular interactions is a key objective in this area. Here, it is shown that so-called "π-hole interactions" are present between the nitro moiety in nitro aromatic ligands and lone pairs within protein structures (water and protein carbonyls and sulfurs). Ample structural evidence was found in a PDB analysis and computations reveal interaction energies of about -5 kcal mol-1 for ligand-protein π-hole interactions. Several examples are highlighted for which a π-hole interaction is implicated in the superior binding affinity or inhibition of a nitro aromatic ligand versus a similar non-nitro analogue. The discovery that π-hole interactions with nitro aromatics are significant within protein structures parallels the finding that halogen bonds are biologically relevant. This has implications for the interpretation of ligand-protein complexation phenomena, for example, involving the more than 50 approved drugs that contain a nitro aromatic moiety.

Nematocidal activity of 6-O-octanoyl- and 6-O-octyl-d-allose against larvae of Caenorhabditis elegans

The nematocidal activities of the fatty acid esters of d-allose were examined using the larvae of C. elegans. Among the fatty acid esters, 6-O-octanoyl-d-allose (3) showed significant activity. 6-O-octanoyl-d-glucose (5) showed no activity, indicating that the D-allose moiety is essential for the nematocidal activity of 3. A nonhydrolyzable alkoxy analog 6-O-octyl-d-allose (6) also showed activity equivalent to that of 3.

Development and validation of a simple, fast, and sensitive LC/MS/MS method for the quantification of oxfendazole in human plasma and its application to clinical pharmacokinetic study

The most popular standard treatments for soil transmitted helminths in humans including mebendazole, albendazole, levamisole, and pyrantel pamoate, show greatly variable efficacy against different species of parasites and have unfavorable pharmacokinetic characteristics, such as short half-life. The transition of oxfendazole, a potent broad-spectrum anthelmintic with long half-life, from veterinary medicine to human use has been considered as a promising approach. However, analytical methods for the quantitative detection of oxfendazole in human matrix are very limited and lack sensitivity. In this study, we have developed a high-performance liquid chromatography-tandem mass spectrometry (LC/MS/MS) method for the quantification of oxfendazole in human plasma using albendazole as an internal standard. The established method was fully validated with lower limit of quantitation (LLOQ) of 0.5 ng/mL and linearity in the range of 0.5-1000 ng/mL; intra-day and inter-day accuracies ranged from 2.6 to 9.5% for 3 quality control levels (1.5 ng/mL, 75 ng/mL, and 750 ng/mL) and LLOQ; intra-day and inter-day precision was ≤13.6% for quality controls and ≤15.1% for LLOQ; matrix factor and extraction recovery were consistent with coefficient of variation of less than 15.0%. Other parameters including matrix selectivity, injection carryover, reinjection reproducibility, hemolysis effect, interference of analyte with internal standard, dilution integrity, freeze/thaw stability, whole blood stability, and stock solution stability were also validated and met the acceptance criteria. The assay was successfully applied to quantify oxfendazole plasma concentration in healthy adult volunteers after the administration of multiple oral doses of oxfendazole.

Effect of omega-3 fatty acids administered as monotherapy or combined with artemether on experimental Schistosoma mansoni infection

Schistosomiasis is on the top list of endemic diseases in sub-Saharan Africa. Praziquantel is the drug of choice for treatment of human schistosomiasis. Yet, the sole dependence on the drug raises concerns about the potential for increased drug resistance, which would subsequently result in searching for alternative preventive chemotherapy options, ideally among natural compounds. Therefore, we conducted this work to assess the effect of omega-3 polyunsaturated fatty acids [(ω-3) PUFAs] monotherapy or combined therapy with artemether (ART) against Schistosoma mansoni infection in a mouse model. A total of 42 mice were divided into 4 groups and infected with 50 ± 5 S. mansoni cercariae for 10 weeks. Mice were treated orally with either (ω-3) PUFAs as 273 mg/ kg, 4 times/ week throughout the experiment, ART as a single dose of 400 mg/ kg, 3 weeks post-infection, or combined ART + (ω-3) PUFAs using the same respective treatment regimen, while infected untreated mice were served as controls. The study explored that combined administration of (ω-3) PUFAs and ART has the best schistosomicidal efficacy as it significantly reduced liver and spleen indices, worm count, egg burdens, and granulomas count as well as diameter. Besides, the combined regimen was associated with a significant decrease in both hepatic nitric oxide and serum interleukin-4 level. The results highlighted the possibility of using (ω-3) PUFA combined with ART as a novel anti-schistosomal combination therapy. However, further researches should be conducted to clarify the possible synergistic mechanism/s between the two natural compounds.

Prevalence and Reinfection Rates of Schistosoma mansoni and Praziquantel Efficacy against the Parasite among Primary School Children in Sanja Town, Northwest Ethiopia

BACKGROUND

Schistosomiasis is among the most widespread chronic infections in the world. The magnitude of the infection may show variations across different areas with respect to time. Praziquantel is a first line drug of choice for the treatment of schistosomiasis although its low cure rate has been reported in different parts of the world. Thus, an assessment of the magnitude of the diseases, the efficacy of currently available drugs, and reinfection rates is crucial.

OBJECTIVE

Our principal objective is to determine the prevalence and reinfection rates of Schistosoma mansoni and to evaluate the efficacy of PZQ against Schistosoma mansoni.

METHOD

A school-based cross-sectional study was conducted on Sanja Elementary Schools, Sanja town, northwest Ethiopia. Stool specimens were examined using Kato-Katz method. Schoolchildren who tested positive for intestinal schistosomiasis and fulfilled the inclusion criteria took part in the efficacy and reinfection study. Positive participants were treated with 40 mg/kg of Praziquantel. Cure and egg reduction rates were evaluated three weeks after treatment. The intensity of infection was determined following the WHO's guideline. Moreover, the reinfection rate of those who were cured was evaluated after a six-month posttreatment period. Data were analyzed using SPSS version 20.

RESULTS

At baseline, 130 (35%) of the 372 schoolchildren were found infected with Schistosoma mansoni. Out of the 130 infected schoolchildren, 112 (86.2%) had moderate infection intensity. Among the S. mansoni positive schoolchildren, 80 were included as study participants for the evaluation of PZQ efficacy, based on the inclusion criteria established by WHO. The cure and egg reduction rates were found to be 90% (72/80) and 99.5%, respectively. Of the seventy-two schoolchildren considered for the determination of reinfection rate, after 6 months of posttreatment, 13.9% were found to be reinfected.

CONCLUSION

The schoolchildren in the three primary schools of Sanja are at moderate risk of the infection caused by S. mansoni. Although the therapeutic potency of PZQ at 40 mg/kg was efficient against S. mansoni, a high rate of reinfection was reported in the study site, suggesting the need for integrated schistosomiasis control measures.

Schistosoma mansoni infection among preschool age children attending Erer Health Center, Ethiopia and the response rate to praziquantel

Objective

Preschool age children (PSAC) are excluded from community based praziquantel treatment programs mainly due to paucity of evidence on the magnitude of schistosomiasis, efficacy and safety of this treatment in PSAC. The aim of this study is to assess Schistosoma mansoni infection rate and evaluate response to praziquantel in PSAC. A facility based longitudinal study was employed from April to June 2016 at Erer Health Center, Eastern Ethiopia. Stool sample was examined for schistosomiasis in 236 PSAC and repeated after 4 weeks post-treatment in positive individuals. Treatment outcomes were recorded and interpreted.

Results

Out of the 236 study participants, 59 (25%) were infected with S. mansoni. Praziquantel treatment (40 mg/kg) resulted in 96.4% cure rate and 99.4% egg reduction rate. Children of 3–5 year old were significantly affected with S. mansoni infection. Nausea and fatigue were common mild adverse events within 4 h of treatment however moderate and severe adverse events and allergic reactions were not observed. In conclusion, praziquantel at 40 mg/kg, the dose utilized in standard care for school age children, is tolerable and efficacious in the treatment of S. mansoni infection in PSAC, which calls for the healthcare system to provide appropriate service for this population.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4246-8) contains supplementary material, which is available to authorized users.

Asian Schistosomiasis: Current Status and Prospects for Control Leading to Elimination

Schistosomiasis is an infectious disease caused by helminth parasites of the genus Schistosoma. Worldwide, an estimated 250 million people are infected with these parasites with the majority of cases occurring in sub-Saharan Africa. Within Asia, three species of Schistosoma cause disease. Schistosoma japonicum is the most prevalent, followed by S. mekongi and S. malayensis. All three species are zoonotic, which causes concern for their control, as successful elimination not only requires management of the human definitive host, but also the animal reservoir hosts. With regard to Asian schistosomiasis, most of the published research has focused on S. japonicum with comparatively little attention paid to S. mekongi and even less focus on S. malayensis. In this review, we examine the three Asian schistosomes and their current status in their endemic countries: Cambodia, Lao People's Democratic Republic, Myanmar, and Thailand (S. mekongi); Malaysia (S. malayensis); and Indonesia, People's Republic of China, and the Philippines (S. japonicum). Prospects for control that could potentially lead to elimination are highlighted as these can inform researchers and disease control managers in other schistosomiasis-endemic areas, particularly in Africa and the Americas.

PZQ Therapy: How Close are we in the Development of Effective Alternative Anti-schistosomal Drugs?

Today schistosomiasis, caused mainly by the three major schistosome species (S. mansoni, S. haematobium and S. japonicum), has for many decades and still continues to be on a rapid and swift rise globally, claiming thousands of lives every year and leaving 800 million people at the risk of infection. Due to the high prevalence of this disease and the steady increase in the infection rates, praziquantel (PZQ) remains the only effective drug against this acute disease although it has no effect on the juvenile schistosome parasite. However, no significant approaches have been made in recent years in the discovery of new or alternative drugs and unfortunately, resistance to this drug has been reported in some parts of the world. Therefore, it is imperative to develop a new drug for this debilitating disease. In this review, a brief history of past, present, and new promising anti-schistosomal drugs is presented.

Improved methods to capture the total societal benefits of zoonotic disease control: Demonstrating the cost-effectiveness of an integrated control programme for Taenia solium, soil transmitted helminths and classical swine fever in northern Lao PDR

BACKGROUND

Control and elimination of zoonotic diseases requires robust information about their effect on both human and livestock health in order to enable policy formulation and the allocation of resources. This study aimed to evaluate the cost-effectiveness of controlling Taenia solium taeniasis/cysticercosis in both humans and pigs, and soil-transmitted helminths (STH) in humans by integrating their control to on-going human and animal health control programmes in northern Lao People's Democratic Republic.

METHOD

A cross-sectional study was carried out in 49 households, focusing on the prevalence of T. solium taenias/cysticercosis and soil transmitted helminths before and after a twelve month intervention. The village data was collected using a semi-structured questionnaire through a door-to-door survey. The village data was then projected to the wider northern Lao PDR population using stochastic modelling and cost-effectiveness ratio (after aggregating the net cost to capture both human and animal health parameters) and GDP per capita as a threshold, to determine the cost-effectiveness of the integrated control of T. solium taeniasis/ cysticercosis and STH, assuming linear scaling out of the intervention. The zoonotic DALY (zDALY) approach was also used as an alternative method of estimating the cost-effectiveness ratio of controlling T. solium taeniasis/cysticercosis in humans and pigs.

FINDINGS

Using cost-effectiveness analysis after aggregating the net cost and control of T. solium taeniasis/cysticercosis alone as the base case, the study found that simultaneous control of T. solium taeniasis/cysticercosis in humans and pigs, STH in humans and Classical Swine Fever (CSF) in pigs was USD 14 per DALY averted and USD 234 per zDALY averted using zDALY method hence considered highly cost-effective whereas controlling T. solium taeniasis/cysticercosis without incorporating STH and CSF was the least cost-effective (USD 3,672 per DALY averted). Additionally, the cost-effectiveness of controlling T. solium taeniasis/cysticercosis in people and pigs using zDALY as an alternative method was USD 3,662 per zDALY averted which was quite close to our findings using the aggregate net cost method.

CONCLUSION

The study showed that control of T. solium taeniasis/cysticercosis alone in humans and pigs is not cost-effective in northern Lao PDR whereas control of STH is. Consequently, integrating T. solium taeniasis/cysticercosis control with other cost-effective programmes such as STH and CSF markedly improved the cost-effectiveness of the intervention. This is especially important in low resource countries where control of zoonotic neglected tropical diseases could be integrated with the human and animal health sectors to optimize use of the limited resources.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614001067662.

Schistosomiasis

Schistosomiasis (bilharzia) is a neglected tropical disease caused by parasitic flatworms (blood flukes) of the genus Schistosoma, with considerable morbidity in parts of the Middle East, South America, Southeast Asia and, particularly, in sub-Saharan Africa. Infective larvae grow in an intermediate host (fresh-water snails) before penetrating the skin of the definitive human host. Mature adult worms reside in the mesenteric (Schistosoma mansoni and Schistosoma japonicum) or pelvic (Schistosoma haematobium) veins, where female worms lay eggs, which are secreted in stool or urine. Eggs trapped in the surrounding tissues and organs, such as the liver and bladder, cause inflammatory immune responses (including granulomas) that result in intestinal, hepato-splenic or urogenital disease. Diagnosis requires the detection of eggs in excreta or worm antigens in the serum, and sensitive, rapid, point-of-care tests for populations living in endemic areas are needed. The anti-schistosomal drug praziquantel is safe and efficacious against adult worms of all the six Schistosoma spp. infecting humans; however, it does not prevent reinfection and the emergence of drug resistance is a concern. Schistosomiasis elimination will require a multifaceted approach, including: treatment; snail control; information, education and communication; improved water, sanitation and hygiene; accurate diagnostics; and surveillance-response systems that are readily tailored to social-ecological settings.

Chronic schistosomiasis suppresses HIV-specific responses to DNA-MVA and MVA-gp140 Env vaccine regimens despite antihelminthic treatment and increases helminth-associated pathology in a mouse model

Future HIV vaccines are expected to induce effective Th1 cell-mediated and Env-specific antibody responses that are necessary to offer protective immunity to HIV infection. However, HIV infections are highly prevalent in helminth endemic areas. Helminth infections induce polarised Th2 responses that may impair HIV vaccine-generated Th1 responses. In this study, we tested if Schistosoma mansoni (Sm) infection altered immune responses to SAAVI candidate HIV vaccines (DNA and MVA) and an HIV-1 gp140 Env protein vaccine (gp140) and whether parasite elimination by chemotherapy or the presence of Sm eggs (SmE) in the absence of active infection influenced the immunogenicity of these vaccines. In addition, we evaluated helminth-associated pathology in DNA and MVA vaccination groups. Mice were chronically infected with Sm and vaccinated with DNA+MVA in a prime+boost combination or MVA+gp140 in concurrent combination regimens. Some Sm-infected mice were treated with praziquantel (PZQ) prior to vaccinations. Other mice were inoculated with SmE before receiving vaccinations. Unvaccinated mice without Sm infection or SmE inoculation served as controls. HIV responses were evaluated in the blood and spleen while Sm-associated pathology was evaluated in the livers. Sm-infected mice had significantly lower magnitudes of HIV-specific cellular responses after vaccination with DNA+MVA or MVA+gp140 compared to uninfected control mice. Similarly, gp140 Env-specific antibody responses were significantly lower in vaccinated Sm-infected mice compared to controls. Treatment with PZQ partially restored cellular but not humoral immune responses in vaccinated Sm-infected mice. Gp140 Env-specific antibody responses were attenuated in mice that were inoculated with SmE compared to controls. Lastly, Sm-infected mice that were vaccinated with DNA+MVA displayed exacerbated liver pathology as indicated by larger granulomas and increased hepatosplenomegaly when compared with unvaccinated Sm-infected mice. This study shows that chronic schistosomiasis attenuates both HIV-specific T-cell and antibody responses and parasite elimination by chemotherapy may partially restore cellular but not antibody immunity, with additional data suggesting that the presence of SmE retained in the tissues after antihelminthic therapy contributes to lack of full immune restoration. Our data further suggest that helminthiasis may compromise HIV vaccine safety. Overall, these findings suggested a potential negative impact on future HIV vaccinations by helminthiasis in endemic areas.

Chronic parasitic worm infections are thought to reduce the efficacy of vaccines. Given that HIV and worm infections are common in sub-Saharan Africa (SSA) and their geographical distribution vastly overlaps, it is likely that future HIV vaccines in SSA will be administered to a large proportion of people with chronic worm infections. This study examined the impact of S. mansoni worm infections on the immunogenicity of candidate HIV vaccines in a mouse model. S. mansoni worm-infected animals had lower magnitudes of HIV vaccine responses compared with uninfected animals and elimination of worms by praziquantel treatment prior to vaccination conferred only partial restoration of normal immune responses to vaccination. The presence of S. mansoni eggs trapped in the tissues in the absence of live infection was associated with poor vaccine responses. In addition, this study found that effective immunization with some HIV vaccine regimens could potentially worsen worm-associated pathology when given to infected individuals. These novel findings suggest further research in HIV vaccines and future vaccination policies regarding the current clinical vaccines and future HIV vaccination with respect to parasitic worm infections especially in SSA.

Extracellular vesicles induce protective immunity against Trichuris muris

Gastrointestinal nematodes, such as Trichuris trichiura (human whipworm), are a major source of morbidity in humans and their livestock. There is a paucity of commercially available vaccines against these parasites, and vaccine development for T. trichiura has been impeded by a lack of known host protective antigens. Experimental vaccinations with T. muris (murine whipworm) soluble Excretory/Secretory (ES) material have demonstrated that it is possible to induce protective immunity in mice; however, the potential for extracellular vesicles (EVs) as a source of antigenic material has remained relatively unexplored. Here, we demonstrate that EVs isolated from T. muris ES can induce protective immunity in mice when administered as a vaccine without adjuvant and show that the protective properties of these EVs are dependent on intact vesicles. We also identified several proteins within EV preparations that are targeted by the host antibodies following vaccination and subsequent infection with T. muris. Many of these proteins, including VWD and vitellogenin N and DUF1943-domain-containing protein, vacuolar protein sorting-associated protein 52 and TSP-1 domain-containing protein, were detected in both soluble ES and EV samples and have homologues in other parasites of medical and veterinary importance, and as such are possible protective antigens.

Spatio-temporal pattern of schistosomiasis in Anhui Province, East China: Potential effect of the Yangtze River - Huaihe River Water Transfer Project

Anhui Province has been one of typical epidemic areas of schistosomiasis in East China as a wide range of large lake and marshland regions provide an ideal environment for growth and reproduction of the intermediate snail host. With the completion of the Yangtze River-Huaihe River Water Transfer Project (YHWTP), launched by the end of 2016, the epidemic areas are expected to expand and controlling schistosomiasis remains a challenge. Based on annual surveillance data at the county level in Anhui for the period 2006-2015, spatial and temporal cluster analyses were conducted to assess the pattern of risk through spatial (Local Moran's I and flexible scan statistic) and space-time scan statistic (Kulldorff). It was found that schistosomiasis sero-prevalence was dramatically reduced and maintained at a low level. Cluster results showed that spatial extent of schistosomiasis contracted, but snail distribution remained geographically stable across the study area. Clusters, both for schistosomiasis and snail presence, were common along the Yangtze River. Considering the effect of the ongoing YHWTP on the potential spread of schistosomiasis, Zongyang County and Anqing, which will be transected by the new water-transfer route, should be given a priority for strengthened surveillance and control. Attention should also be paid to Guichi since it is close to one of the planned inlets of the YHWTP.

Vaccination Against Whipworm: Identification of Potential Immunogenic Proteins in Trichuris muris Excretory/Secretory Material

Trichuris trichiura (whipworm) is one of the four major soil-transmitted helminth infections of man, affecting an estimated 465 million people worldwide. An effective vaccine that induces long-lasting protective immunity against T. trichiura would alleviate the morbidity associated with this intestinal-dwelling parasite, however the lack of known host protective antigens has hindered vaccine development. Here, we show that vaccination with ES products stimulates long-lasting protection against chronic infection in male C57BL/6 mice. We also provide a framework for the identification of immunogenic proteins within T. muris ES, and identify eleven candidates with direct homologues in T. trichiura that warrant further study. Given the extensive homology between T. muris and T. trichiura at both the genomic and transcriptomic levels, this work has the potential to advance vaccine design for T. trichiura.

Algorithmic Mapping and Characterization of the Drug-Induced Phenotypic-Response Space of Parasites Causing Schistosomiasis

Neglected tropical diseases, especially those caused by helminths, constitute some of the most common infections of the world's poorest people. Amongst these, schistosomiasis (bilharzia or 'snail fever'), caused by blood flukes of the genus Schistosoma, ranks second only to malaria in terms of human impact: two hundred million people are infected and close to 800 million are at risk of infection. Drug screening against helminths poses unique challenges: the parasite cannot be cloned and is difficult to target using gene knockouts or RNAi. Consequently, both lead identification and validation involve phenotypic screening, where parasites are exposed to compounds whose effects are determined through the analysis of the ensuing phenotypic responses. The efficacy of leads thus identified derives from one or more or even unknown molecular mechanisms of action. The two most immediate and significant challenges that confront the state-of-the-art in this area are: the development of automated and quantitative phenotypic screening techniques and the mapping and quantitative characterization of the totality of phenotypic responses of the parasite. In this paper, we investigate and propose solutions for the latter problem in terms of the following: (1) mathematical formulation and algorithms that allow rigorous representation of the phenotypic response space of the parasite, (2) application of graph-theoretic and network analysis techniques for quantitative modeling and characterization of the phenotypic space, and (3) application of the aforementioned methodology to analyze the phenotypic space of S. mansoni - one of the etiological agents of schistosomiasis, induced by compounds that target its polo-like kinase 1 (PLK 1) gene - a recently validated drug target. In our approach, first, bio-image analysis algorithms are used to quantify the phenotypic responses of different drugs. Next, these responses are linearly mapped into a low- dimensional space using Principle Component Analysis (PCA). The phenotype space is modeled using neighborhood graphs which are used to represent the similarity amongst the phenotypes. These graphs are characterized and explored using network analysis algorithms. We present a number of results related to both the nature of the phenotypic space of the S. mansoni parasite as well as algorithmic issues encountered in constructing and analyzing the phenotypic-response space. In particular, the phenotype distribution of the parasite was found to have a distinct shape and topology. We have also quantitatively characterized the phenotypic space by varying critical model parameters. Finally, these maps of the phenotype space allows visualization and reasoning about complex relationships between putative drugs and their system-wide effects and can serve as a highly efficient paradigm for assimilating and unifying information from phenotypic screens both during lead identification and lead optimization.

Pharmacological and immunological effects of praziquantel against Schistosoma japonicum: a scoping review of experimental studies

BACKGROUND

Chemotherapy for schistosomiasis has been around for 100 years. During the past century, great efforts have been made to develop new antischistosomal drugs from antimonials to nonantimonials, and some of these have been used extensively in clinical treatment. With the exception of a few drugs, such as oxamniquine and metrifonate, most of the antischistosomals developed in the pre-praziquantel period have variable limitations with respect to safety and efficacy. Although oxamniquine and metrifonate have been used for schistosomiasis control, they are only effective against Schistosoma mansoni and S. haematobium, respectively. Currently, praziquantel is the only drug used for treatment of all five species of human schistosomes. In this review, the pharmacological and immunological effects of praziquantel against S. japonicum are summarized and discussed.

MAIN TEXT

From the end of the 1970s until the 2000s, scientists have conducted a series of experimental studies on the effects of praziquantel against S. japonicum. These have included examining its unique pharmacological action on schistosomes, the characteristics in susceptibility of the different developmental stages of schistosomes to the drug, the relationship between plasma concentration of the drug and efficacy, the impact of host factors on cidal action of the drug, prevention and early treatment of schistosomal infection, as well as praziquantel-resistant schistosomiasis.

CONCLUSION

The effects of praziquantel against S. japonicum, as elucidated by the experimental studies that are reviewed in this paper, may have some reference significance for the development of new antischistosomals.

Inclusion of edaphic predictors for enhancement of models to determine distribution of soil-transmitted helminths: the case of Zimbabwe

Background

Reliable mapping of soil-transmitted helminth (STH) parasites requires rigorous statistical and machine learning algorithms capable of integrating the combined influence of several determinants to predict distributions. This study tested whether combining edaphic predictors with relevant environmental predictors improves model performance when predicting the distribution of STH, Ascaris lumbricoides and hookworms at a national scale in Zimbabwe.

Methods

Geo-referenced parasitological data obtained from a 2010/2011 national survey indicating a confirmed presence or absence of STH among school children aged 10–15 years was used to calibrate ten species distribution models (SDMs). The performance of SDMs calibrated with a set of environmental and edaphic variables was compared to that of SDMs calibrated with environmental variables only. Model performance was evaluated using the true skill statistic and receiver operating characteristic curve.

Results

Results show a significant improvement in model performance for both A. lumbricoides and hookworms for all ten SDMs after edaphic variables were combined with environmental variables in the modelling of the geographical distribution of the two STHs at national scale. Using the top three performing models, a consensus prediction was developed to generate the first continuous maps of the potential distribution of the two STHs in Zimbabwe.

Conclusions

The findings from this study demonstrate significant model improvement if relevant edaphic variables are included in model calibration resulting in more accurate mapping of STH. The results also provide spatially-explicit information to aid targeted control of STHs in Zimbabwe and other countries with STH burden.

Detection of duo-schistosome infection from filtered urine samples from school children in Zambia after MDA

Schistosomiasis is one of the major Neglected Tropical Diseases (NTDs) in sub-Saharan Africa. In sub-Saharan Africa, two major human schistosome species namely Schistosoma mansoni and S. haematobium often occur sympatrically largely affecting children. Recognizing the public health impact of Schistosomiasis, the World Health Organization (WHO) is urging member states to regularly treat at least 75% and up to 100%, of all school-aged children at risk of morbidity. For control strategies based on targeted mass drug administration (MDA) to succeed it is essential to have a simple and sensitive test for monitoring the success of these interventions. Current available diagnostic tests, such as egg detection in stool by Kato-Katz (KK) for S. mansoni and detection of eggs or blood (hematuria) in urine for S. haematobium have reduced sensitivity in low intensity settings. The objective of the study was to evaluate active single or duo schistosome infections in school children following MDA using molecular diagnostics (PCR) on filtered urine samples and comparing that against traditional diagnostic tests. This cross-sectional study was conducted among 111 school children aged 7–15 years in Chongwe and Siavonga Districts in Zambia. Species-specific cell-free repeat DNA fragment were amplified from 111 filtered urine samples. Our approach detected eight times more positive cases (total 77) than by KK (9) for S. mansoni and six times more (total 72) than by hematuria (11) for S. haematobium and even more against urine filtration (77 compared to only 6). The same pattern was observed when stratified for age group and sex specific analysis with 100% sensitivity and specificity devoid of any cross amplification. In addition, 69 individuals (62%) were co-infected by both parasites. We have demonstrated a significantly higher prevalence of both species than indicated by the traditional tests and the persistent maintenance of reservoir of infection after MDA. Our approach is an effective means of detecting low intensity infection, which will enhance the effectiveness of surveillance and assess the impact of MDA control programs against schistosomiasis.

Analysis of the interactome of Schistosoma mansoni histone deacetylase 8

BACKGROUND

Histone deacetylase 8 from Schistosoma mansoni (SmHDAC8) is essential to parasite growth and development within the mammalian host and is under investigation as a target for the development of selective inhibitors as novel schistosomicidal drugs. Although some protein substrates and protein partners of human HDAC8 have been characterized, notably indicating a role in the function of the cohesin complex, nothing is known of the partners and biological function of SmHDAC8.

METHODOLOGY/PRINCIPAL FINDINGS

We therefore employed two strategies to characterize the SmHDAC8 interactome. We first used SmHDAC8 as a bait protein in yeast two-hybrid (Y2H) screening of an S. mansoni cDNA library. This allowed the identification of 49 different sequences encoding proteins. We next performed co-immunoprecipitation (Co-IP) experiments on parasite extracts with an anti-SmHDAC8 antibody. Mass spectrometry (MS) analysis allowed the identification of 160 different proteins.

CONCLUSIONS/SIGNIFICANCE

SmHDAC8 partners are involved in about 40 different processes, included expected functions such as the cohesin complex, cytoskeleton organization, transcriptional and translational regulation, metabolism, DNA repair, the cell cycle, protein dephosphorylation, proteolysis, protein transport, but also some proteasome and ribosome components were detected. Our results show that SmHDAC8 is a versatile deacetylase, potentially involved in both cytosolic and nuclear processes.

Soil-Transmitted Helminths in Tropical Australia and Asia

Soil-transmitted helminths (STH) infect 2 billion people worldwide including significant numbers in South-East Asia (SEA). In Australia, STH are of less concern; however, indigenous communities are endemic for STH, including Strongyloides stercoralis, as well as for serious clinical infections due to other helminths such as Toxocara spp. The zoonotic hookworm Ancylostoma ceylanicum is also present in Australia and SEA, and may contribute to human infections particularly among pet owners. High human immigration rates to Australia from SEA, which is highly endemic for STH Strongyloides and Toxocara, has resulted in a high prevalence of these helminthic infections in immigrant communities, particularly since such individuals are not screened for worm infections upon entry. In this review, we consider the current state of STH infections in Australia and SEA.

Transcriptome analysis reveals molecular anthelmintic effects of procyanidins in C. elegans

Worldwide, more than 1 billion people are affected by infestations with soil-transmitted helminths and also in veterinary medicine helminthiases are a severe threat to livestock due to emerging resistances against the common anthelmintics. Proanthocyanidins have been increasingly investigated for their anthelmintic properties, however, except for an interaction with certain proteins of the nematodes, not much is known about their mode of action. To investigate the anthelmintic activity on a molecular level, a transcriptome analysis was performed in Caenorhabditis elegans after treatment with purified and fully characterized oligomeric procyanidins (OPC). The OPCs had previously been obtained from a hydro-ethanolic (1:1) extract from the leaves of Combretum mucronatum, a plant which is traditionally used in West Africa for the treatment of helminthiasis, therefore, also the crude extract was included in the study. Significant changes in differential gene expression were observed mainly for proteins related to the intestine, many of which were located extracellularly or within cellular membranes. Among the up-regulated genes, several hitherto undescribed orthologues of structural proteins in humans were identified, but also genes that are potentially involved in the worms' defense against tannins. For example, T22D1.2, an orthologue of human basic salivary proline-rich protein (PRB) 2, and numr-1 (nuclear localized metal responsive) were found to be strongly up-regulated. Down-regulated genes were mainly associated with lysosomal activity, glycoside hydrolysis or the worms' innate immune response. No major differences were found between the groups treated with purified OPCs versus the crude extract. Investigations using GFP reporter gene constructs of T22D1.2 and numr-1 corroborated the intestine as the predominant site of the anthelmintic activity. The current findings support previous hypotheses of OPCs interacting with intestinal surface proteins and provide the first insights into the nematode's response to OPCs on a molecular level as a base for the identification of future drug targets.

Ferrocenyl, Ruthenocenyl, and Benzyl Oxamniquine Derivatives with Cross-Species Activity against Schistosoma mansoni and Schistosoma haematobium

Schistosomiasis is a parasitic disease that affects more than 250 million people annually, mostly children in poor, tropical, rural areas. Only one treatment (praziquantel) is available, putting control efforts at risk should resistance occur. In pursuit of treatment alternatives, we derivatized an old antischistosomal agent, oxamniquine (OXA). Four organometallic derivatives of OXA were synthesized and tested against Schistosoma mansoni in vitro and in vivo. Of these, a ferrocenyl derivative, 1, killed larval and adult worms 24 h postexposure in vitro, in contrast to OXA, which lacks in vitro activity against adult worms. A dose of 200 mg/kg of 1 completely eliminated the worm burden in mice. Subsequently, a ruthenocenyl (5) and a benzyl derivative (6) of OXA were synthesized to probe the importance of the ferrocenyl group in 1. Compounds 1, 5, and 6 were lethal to both S. mansoni and S. haematobium adults in vitro. In vivo, at 100 mg/kg, all three compounds revealed S. mansoni worm burden reductions of 76 to 93%, commensurate with OXA. Our findings present three compounds with activity against S. mansoni in vitro, comparable activity in vivo, and high activity against S. haematobium in vitro. These compounds may possess a different binding mode or mode of action compared to OXA and present excellent starting points for further SAR studies.

In vitro and in vivo activity of R- and S- praziquantel enantiomers and the main human metabolite trans-4-hydroxy-praziquantel against Schistosoma haematobium

Background

Praziquantel (PZQ) is the mainstay of schistosomiasis control and has been successfully used for decades. However, its mechanism of action is not fully understood. While the majority of studies have been conducted on Schistosoma mansoni, it is not known which enantiomer, R- or S-praziquantel (R-/S-PZQ), is responsible for the activity on Schistosoma haematobium.

Methods

In vitro and in vivo studies were conducted to evaluate the activity of R- and S-PZQ, racemic PZQ and the main human metabolite, namely trans-4-OH-PZQ, on S. haematobium. IC₅₀ values on adult S. haematobium were determined in vitro. Dose-response relationship studies were performed in golden Syrian hamsters, harbouring a chronic S. haematobium infection.

Results

R-PZQ displayed the highest activity against adult worms in vitro, revealing an IC₅₀ of 0.007 μg/ml at 4 h and 0.01 μg/ml at 72 h. In contrast, S-PZQ was 501× less active (eudysmic ratio at 4 h), with an IC₅₀ of 3.51 and 3.40 μg/ml (4 and 72 h, respectively). Racemic PZQ and trans-4-OH-PZQ resulted in an IC₅₀ of 0.03 μg/ml and 1.47 μg/ml both at 4 and 72 h, respectively. In vivo, R-PZQ was the most potent drug with worm burden reductions (WBRs) of 98.5, 75.6 and 73.3% at 125.0, 62.5 and 31.0 mg/kg, respectively. A single oral dose of 250.0 mg/kg PZQ resulted in a WBR of 99.3%. S-PZQ was highly active in vivo at 250.0 and 500.0 mg/kg with WBRs of 83.0 and 94.1%, respectively. The lowest tested dose of S-PZQ, 125.0 mg/kg, showed moderate activity (WBR of 46.7%). The calculated ED₅₀ for R- and S-PZQ were 24.7 and 127.6 mg/kg, respectively, with a corresponding eudysmic ratio of 5.17.

Conclusion

Our data support the theory of R-PZQ driving the antischistosomal activity. Interestingly, also S-PZQ proved to possess a significant activity towards S. haematobium, particularly in vivo.

Medicinal plant extracts and plant-derived polyphenols with anthelmintic activity against intestinal nematodes

Covering: 2001 up to the end of 2016Polyphenols comprise a structurally diverse class of natural products. As the development of new anthelmintic drugs against soil-transmitted helminthiases is an urgent need and polyphenols are widely used in the treatment of nematode infections in traditional medicine and modern science, we summarize the state of knowledge in the period of mainly 2001 up to the end of 2016 on plant extracts with known polyphenolic composition and of defined polyphenols, mainly from the classes of condensed and hydrolysable tannins, flavonoids, and phenylpropanoids. The diverse biological activity against different helminths and the underlying mechanisms are reviewed.

High prevalence of helminths infection and associated risk factors among adults living in a rural setting, central Kenya: a cross-sectional study

Background

Schistosome infection and soil-transmitted helminths (STHs) are major public health problems in many developing countries where they contribute to the suffering of populations living in poor settings. A cross-sectional survey was conducted in four rural villages in central region of Kenya to provide information on the status of schistosome and STH infections. Previous studies conducted in the area among primary school children showed that there were high STH and Schistosoma mansoni infections. This paper presents the results of a parasitological investigation and the associated risk factors of infection among adults living in the study villages.

Methods

A total of 495 adults (18–84 years) from systematically selected households were sampled during this cross-sectional survey. They were interviewed and screened for S. mansoni and STHs using duplicate Kato-Katz thick smears. Comparison of prevalence by age group and gender was explored by confidence interval plots, and 95% CI were obtained by generalized least squares (GLS) random effects model. Risk factors associated with S. mansoni infection were determined using mixed effects logistic regression at 95% CI taking into account household clusters.

Results

The study revealed that the prevalence of S. mansoni infection was 33.5% (95% CI 29.6–38.0) among adults in the study villages, while the prevalence of STH infection was 0.2% (95% CI 0–1.4) with hookworm being the only detected STH species. However, the village and education level were the only risk factors which showed significant evidence of association with S. mansoni infections.

Conclusions

The current study shows that adult communities in the study area were highly infected with S. mansoni. The study suggests that it may be necessary to develop contemporary approaches towards preventive chemotherapy interventions to adults in high endemic areas to complement the ongoing school-based deworming programme.

Electronic supplementary material

The online version of this article (doi:10.1186/s41182-017-0055-8) contains supplementary material, which is available to authorized users.

Assessing environmental factors associated with regional schistosomiasis prevalence in Anhui Province, Peoples' Republic of China using a geographical detector method

Background

Schistosomiasis is a water-borne disease caused by trematode worms belonging to genus Schistosoma, which is prevalent most of the developing world. Transmission of the disease is usually associated with multiple biological characteristics and social factors but also factors can play a role. Few studies have assessed the exact and interactive influence of each factor promoting schistosomiasis transmission.

Methods

We used a series of different detectors (i.e., specific detector, risk detector, ecological detector and interaction detector) to evaluate separate and interactive effects of the environmental factors on schistosomiasis prevalence. Specifically, (i) specific detector quantifies the impact of a risk factor on an observed spatial disease pattern, which were ranked statistically by a value of Power of Determinate (PD) calculation; (ii) risk detector detects high risk areas of a disease on the condition that the study area is stratified by a potential risk factor; (iii) ecological detector explores whether a risk factor is more significant than another in controlling the spatial pattern of a disease; (iv) interaction detector probes whether two risk factors when taken together weaken or enhance one another, or whether they are independent in developing a disease. Infection data of schistosomiasis based on conventional surveys were obtained at the county level from the health authorities in Anhui Province, China and used in combination with information from Chinese weather stations and internationally available environmental data.

Results

The specific detector identified various factors of potential importance as follows: Proximity to Yangtze River (0.322) > Land cover (0.285) > sunshine hours (0.256) > population density (0.109) > altitude (0.090) > the normalized different vegetation index (NDVI) (0.077) > land surface temperature at daytime (LST_day) (0.007). The risk detector indicated that areas of schistosomiasis high risk were located within a buffer distance of 50 km from Yangtze River. The ecological detector disclosed that the factors investigated have significantly different effects. The interaction detector revealed that interaction between the factors enhanced their main effects in most cases.

Conclusion

Proximity to Yangtze River had the strongest effect on schistosomiasis prevalence followed by land cover and sunshine hours, while the remaining factors had only weak influence. Interaction between factors played an even more important role in influencing schistosomiasis prevalence than each factor on its own. High risk regions influenced by strong interactions need to be targeted for disease control intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0299-x) contains supplementary material, which is available to authorized users.

Trichuris trichiura infection and its relation to environmental factors in Mbeya region, Tanzania: A cross-sectional, population-based study

Background

The intestinal nematode Trichuris trichiura is among the most common causes of human infectious disease worldwide. As for other soil-transmitted nematodes, its reproductive success and thus prevalence and intensity of infection in a given area strongly depend on environmental conditions. Characterization of the influence of environmental factors can therefore aid to identify infection hot spots for targeted mass treatment.

Methodology

We analyzed data from a cross-sectional survey including 6234 participants from nine distinct study sites in Mbeya region, Tanzania. A geographic information system was used to combine remotely sensed and individual data, which were analyzed using uni- and multivariable Poisson regression. Household clustering was accounted for and when necessary, fractional polynomials were used to capture non-linear relationships between T. trichiura infection prevalence and environmental variables.

Principal findings

T. trichiura infection was restricted to the Kyela site, close to Lake Nyasa with only very few cases in the other eight sites. The prevalence of T. trichiura infection in Kyela was 26.6% (95% confidence interval (CI) 23.9 to 29.6%). Multivariable models revealed a positive association of infection with denser vegetation (prevalence ratio (PR) per 0.1 EVI units = 2.12, CI 1.28 to 3.50) and inverse associations with rainfall (PR per 100 mm = 0.54, CI 0.44 to 0.67) and elevation (PR per meter = 0.89, CI 0.86 to 0.93) while adjusting for age and previous worm treatment. Slope of the terrain was modelled non-linearly and also showed a positive association with T. trichiura infection (p-value p<0.001).

Conclusion/Significance

Higher prevalences of T. trichiura infection were only found in Kyela, a study site characterized by denser vegetation, high rainfall, low elevation and flat terrain. But even within this site, we found significant influences of vegetation density, rainfall, elevation and slope on T. trichiura infection. The inverse association of rainfall with infection in Kyela is likely due to the fact, that rainfall in this site is beyond the optimum conditions for egg development. Our findings demonstrate that use of remotely sensed environmental data can aid to predict high-risk areas for targeted helminth control.

Rapid mapping of urinary schistosomiasis: An appraisal of the diagnostic efficacy of some questionnaire-based indices among high school students in Katsina State, northwestern Nigeria

BACKGROUND

In sub-Saharan Africa, over 200 million individuals are estimated to be infected with urinary and intestinal schistosomiasis. In a bid to lay a foundation for effective future control programme, this study was carried out with the aim of assessing the diagnostic efficacy of some questionnaire-based rapid assessment indices of urinary schistosomiasis.

METHODOLOGY

A total number of 1,363 subjects were enrolled for the study. Questionnaires were administered basically in English and Hausa languages by trained personnel. Following informed consent, terminal urine samples were collected between 09:40 AM and 2:00 PM using clean 20 ml capacity universal bottles. 10μl of each urine residue was examined for the eggs of S. haematobium using x10 objective nose of Motic Binocular Light Microscope (China).

PRINCIPAL FINDINGS

The average age ± Standard Deviation (SD) of school children examined was 15.30 ± 2.30 years and 40.87% were females. The overall prevalence and geometric mean intensity of S. haematobium infection were 26.41% (24.10─28.85) and 6.59 (5.59─7.75) eggs / 10 ml of urine respectively. Interestingly, a questionnaire equivalence of the prevalence obtained in this survey was 26.41% (24.10─28.85) for Rapid Assessment Procedure based on self-reported blood in urine. The results of correlation analyses demonstrated significant associations between the prevalence of S. haematobium infection and contact with potentially infested open water sources (r = 0.741; P = 0.006). By regression model, cases of respondents with self-reported blood in urine are expected to rise to 24.75% if prevalence of the infection shoots up to 26.5%.

CONCLUSIONS/SIGNIFICANCE

The best RAP performance was obtained with self-reported blood in urine. Based on the overall prevalence value, the study area was at a "moderate-risk" of endemicity for urinary schistosomiasis. Chemotherapeutic intervention with Praziquantel, the rationale behind rapid assessment procedure for schistosomiasis, has been recommended to be carried out once in every 2 years for such communities.

Controlling schistosomiasis with praziquantel: How much longer without a viable alternative?

The current approach of morbidity control of schistosomiasis, a helminth disease of poverty with considerable public health and socioeconomic impact, is based on preventive chemotherapy with praziquantel. There is a pressing need for new drugs against this disease whose control entirely depends on this single drug that has been widely used over the past 40 years. We argue that a broader anthelminthic approach supplementing praziquantel with new antischistosomals targeting different parasite development stages would not only increase efficacy but also reduce the risk for drug resistance. Repositioning drugs already approved for other diseases provides a shortcut to clinical trials, as it is expected that such drugs rapidly pass the regulatory authorities. The antischistosomal properties of antimalarial drugs (e.g., semisynthetic artemisinins, synthetic trioxolanes, trioxaquines and mefloquine) and of drugs being developed or registered for other purposes (e.g., moxidectin and miltefosin), administered alone or in combination with praziquantel, have been tested in the laboratory and clinical trials. Another avenue to follow is the continued search for new antischistosomal properties in plants. Here, we summarise recent progress made in schistosomiasis chemotherapy, placing particular emphasis on repositioning of existing drugs against schistosomiasis.