CHARACTERIZATION, CLONING, AND EXPRESSION OF TWO DIAGNOSTIC ANTIGENS FOR TAENIA SOLIUM TAPEWORM INFECTION

Multiantigen print immunoassay (MAPIA) for the diagnosis of neurocysticercosis: a single-center diagnostic optimization and accuracy study in Lima, Peru

Neurocysticercosis (NCC) is the most common helminthic infection of the human central nervous system. The antibody detection assay of choice is the enzyme-linked immunoelectrotransfer blot assay using lentil-lectin purified parasite antigens (LLGP-EITB, Western blot), an immunoassay with exceptional performance in clinical samples. However, its use is mainly restricted to a few research laboratories because the assay is labor-intensive and requires sophisticated equipment, expertise, and large amounts of parasite material for preparation of reagents. We report a new immunoprint assay (MAPIA) that overcomes most of these barriers. We initially compared the performance of five different antigen combinations in a subset of defined samples in the MAPIA format. After selecting the best-performing assay format (a combination of rGP50 + rT24H + sTs14 antigens), 148 archived serum samples were tested, including 40 from individuals with parenchymal NCC, 40 with subarachnoid NCC, and 68 healthy controls with no evidence of neurologic disease. MAPIA using three antigens (rGP50 + rT24H + sTs14) was highly sensitive and specific for detecting antibodies in NCC. It detected 39 out of 40 (97.5%) parenchymal NCC cases and 40/40 (100%) subarachnoid cases and was negative in 67 out of 68 (98.53%) negative samples. MAPIA using three recombinant and synthetic antigens is a simple and economical tool with a performance equivalent to the LLGP-EITB assay for the detection of specific antibodies to NCC. The MAPIA overcomes existing barriers to adoption of the EITG LLGP and is a candidate for worldwide use.

Evaluation of an Antibody Detecting Point of Care Test for Diagnosis of Taenia solium Cysticercosis in a Zambian Rural Community: A Prospective Diagnostic Accuracy Study

The lack of cheap, easy-to-use, rapid diagnostic tests has led to the development of several rapid diagnostic tests for cysticercosis. The new prototype two-strip, Taenia solium point of care test (TS POC) detects antibodies against taeniosis (TS POC T) and cysticercosis (TS POC CC). This study evaluated the diagnostic performance of the TS POC CC in the Sinda district in eastern Zambia. A sample of 1254 participants was recruited and tested with the TS POC. Out of the 1249 participants with a valid TS POC result, 177 (14%) tested positive while 1072 (86%) tested negative. All individuals with a positive TS POC and a subset of negative TS POC participants were selected for serum sampling, and were subjected to the recombinant glycoprotein T24H enzyme-linked immunoelectrotransfer blot (rT24H EITB) and the serum B60/158 (serum Ag) enzyme-linked immunosorbent assay (Ag ELISA). Performance characteristics were estimated using a Bayesian approach with probabilistic constraints. Based on 255 complete cases, the estimated sensitivity and specificity of the TS POC CC test were 35% (95% CI: 14–63%) and 87% (95% CI: 83–90%), respectively. The diagnostic performance needs to be improved, possibly by titrating antigen and other reagents’ concentration in the strip to produce a performance similar to existing cysticercosis tests such as the rT24H EITB.

Challenges Encountered When Evaluating an Antibody-Detecting Point-of-Care Test for Taeniosis in an Endemic Community in Zambia: A Prospective Diagnostic Accuracy Study

Taenia solium taeniosis diagnosis is challenging because current tests perform sub-optimally and/or are expensive, require sophisticated equipment, infrastructure and trained manpower, and therefore are not community deployable. A recently-developed, multi-strip, T. solium point-of-care test (TS POC) for simultaneous detection of tapeworm (TS POC T) and cysticercus (TS POC CC) human antibodies was evaluated for diagnostic accuracy on consecutively recruited community participants in Sinda district, Zambia. All participants were tested using the TS POC test. All test-positives and 20% of the test-negative participants were invited to give a blood and stool sample for reference testing. Three different reference tests were used for taeniosis diagnosis: recombinant rES33 enzyme-linked immunoelectrotransfer blot (rES33 EITB), copro PCR and copro Ag ELISA. Bayesian analysis with probabilistic constraints was used to estimate sensitivity and specificity. In total, 1254 participants were tested with the TS POC test, of whom 13 tested positive using the TS POC T. Based on 161 participants with complete data, the estimated sensitivity and specificity for the TS POC T test were 38% (95% CI: 5–93%) and 99% (95% CI: 98–100%), respectively. The challenge of highly variable inter-assay performance is highlighted. We recommend either increasing the sensitivity or redesigning the test.

Trial Design of a Prospective Multicenter Diagnostic Accuracy Study of a Point-of-Care Test for the Detection of Taenia solium Taeniosis and Neurocysticercosis in Hospital-Based Settings in Tanzania

Taenia solium diagnosis is challenging as trained personnel, good diagnostic tools, and infrastructure is lacking in resource-poor areas. This paper aims to describe the study trial design adopted to evaluate a newly developed rapid point-of-care test that simultaneously detects taeniosis and neurocysticercosis (TS POC) in three district hospitals in Tanzania. The two-stage design included three types of patients: patients with specific neurological signs and symptoms (group 1); patients with complaints compatible with intestinal worm infections (group 2); patients with other symptom(s) (group 3). For group 1, all patients were tested using the TS POC test (stage 1), after which all positive, and a subset of negative, patients were selected for laboratory reference tests, clinical examination, and a brain computed tomography (CT) scan (stage 2). For groups 2 and 3, a similar design was adopted, but clinical examination and a brain CT scan (stage 2) were only performed in patients who were TS POC test-positive for cysticercosis. Due to the lack of a gold standard, a Bayesian approach was used to determine test accuracy for taeniosis and cysticercosis. For neurocysticercosis, a composite case definition was used as the reference standard. If successful, this study will help the future developments (commercialization and implementation) of the rapid test and improve patient management and disease prevention.

Operational characteristics of an antibody detecting point of care test for Taenia solium infections in a community and hospital setting

Background

Diagnostic test evaluation includes measures of performance and assessment of operational characteristics. The latter focuses on end-user understanding of instructions to perform the test, ease of use, test turnaround time and ease of result interpretation. This study aimed to assess user comprehension of training for and ease of use of a Taenia solium point of care test (TS POC) evaluated in a community and hospital setting in Zambia and Tanzania, respectively.

Methods

The TS POC is a three-step in-house-produced rapid diagnostic test (RDT) for the simultaneous detection of taeniosis (TST) and cysticercosis (TSCC) antibodies. Data collected by administering questionnaires to 29 end-users and from the main evaluation database was analyzed quantitatively.

Results

End-users (28/29, 97%) perceived that the training they received for performing the test was sufficient. They performed 4080 tests, of which 80 were invalid. The community-based study and TST tests had higher invalid rates. The overall result interpretation was within the acceptable range of RDTs with an overall disagreement between readers of 3.3%. The Kappa coefficient of agreement was 85 and 82% for TSCC and TST, respectively. There was more disagreement among readers in the community-based study.

Conclusion

End-users rated the TS POC kit moderate in terms of ease of use citing long test turnaround time and difficulties in using the blood transfer device. Overall, the operational performance of the TS POC kit and end-users was within the established acceptable performance range.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06320-3.

Trial Design for a Diagnostic Accuracy Study of a Point-of-Care Test for the Detection of Taenia solium Taeniosis and (Neuro)Cysticercosis in Community Settings of Highly Endemic, Resource-Poor Areas in Zambia: Challenges and Rationale

Field-applicable, high-quality, and low-cost diagnostic tools are urgently needed for Taenia solium. The aim of this paper is to describe the design, challenges, and rationale for the design of a diagnostic accuracy study in low-resource community settings in Zambia. The trial was designed as a prospective study with a two-stage design to evaluate a new point-of-care test (TS POC) for the detection of taeniosis and (neuro)cysticercosis. Participants within randomly selected households were tested with the TS POC test (index test). Participants who tested TS POC positive for taeniosis and/or cysticercosis and a subset of the negatives were requested to give blood and stool samples for reference testing, and to undergo clinical examination and a cerebral CT scan. The difficulties of conducting a clinical trial in settings with limited research and neuroimaging infrastructure as well as peculiarities specifically related to the disease (low prevalence of taeniosis and the lack of a gold standard) were taken into consideration for the design of this study. The two-stage design increased the efficiency of the study by reducing the number of samples, clinical examinations, and CT scans. Simplified flows and sampling processes were preferred over complex follow-up and randomization systems, aiming to reduce bias and increase the generalizability of the study.

Taenia solium taeniasis/cysticercosis: From parasite biology and immunology to diagnosis and control

Infection with the pork tapeworm (Taenia solium) is responsible for a substantial global burden of disease, not only restricted to its impact on human health, but also resulting in a considerable economic burden to smallholder pig farmers due to pig cysticercosis infection. The life-cycle, parasitology and immunology of T. solium are complex, involving pigs (the intermediate host, harbouring the larval metacestode stage), humans (the definitive host, harbouring the adult tapeworm, in addition to acting as accidental intermediate hosts) and the environment (the source of infection with eggs/proglottids). We review the parasitology, immunology, and epidemiology of the infection associated with each of the T. solium life-cycle stages, including the pre-adult/adult tapeworm responsible for human taeniasis; post-oncosphere and cysticercus associated with porcine and human cysticercosis, and the biological characteristics of eggs in the environment. We discuss the burden associated, in endemic settings, with neurocysticercosis (NCC) in humans, and the broader cross-sectoral economic impact associated both with NCC and porcine cysticercosis, the latter impacting food-value chains. Existing tools for diagnostics and control interventions that target different stages of the T. solium transmission cycle are reviewed and their limitations discussed. Currently, no national T. solium control programmes have been established in endemic areas, with further work required to identify optimal strategies according to epidemiological setting. There is increasing evidence suggesting that cross-sectoral interventions which target the parasite in both the human and pig host provide the most effective approaches for achieving control and ultimately elimination. We discuss future avenues for research on T. solium to support the attainment of the goals proposed in the revised World Health Organisation neglected tropical diseases roadmap for 2021-2030 adopted at the 73rd World Health Assembly in November 2020.

Cysticercosis, a Potential Public Health Concern in Kuwait: A New Diagnostic Method to Screen Taenia solium Taeniasis Carriers in the Expatriate Population

OBJECTIVE

Taenia solium infection is not endemic to Kuwait, butseveral casesof cysticercosis have been detected in Kuwaiti nationals with no history of travelling to endemic countries. Infected domestic helpers/food handlers from endemic countries who may have escaped detection of infection by microscopy at the time of their arrival in Kuwait have been suspected as the possible source of infection. This study determined the seroprevalence of T. solium among domestic helpers/food handlers by screening their blood using a sensitive taeniasis-specific anti-rES33 antibody assay.

SUBJECTS AND METHODS

Newly arrived domestic helpers (n = 500) and food handlers (n = 500) from endemic countries were enrolled in the period 2015-2017. T. solium-specific rES33 antigen was expressed and purified from human embryonic kidney (HEK)293-6E cells using the pTT5 mammalian expression vector. Stool samples were processed for microscopy, and blood samples were screened to detect anti-T. soliumtaeniasis-specific IgG antibodies by ELISA.

RESULTS

All stool samples were negative for T. soliumparasiteeggs by microscopy. However, 42 individuals (4.2%) tested positive for T. soliumtaeniasis-specific IgG antibodies. Though statistically not significant, the IgG seropositivity was higher in individuals with a lower education level, a low-income background, and a lower frequency of hand-washing.

CONCLUSIONS

This is the first report from Kuwait and the Middle East on the detection of anti-T. soliumtaeniasis-specific serum IgG antibodies among the high-risk expatriate population. The results emphasize the importance of efficient and sensitive screening of T. solium carriers and thus the prevention of infection transmission and development of cysticercosis in the local population.

Biological role of excretory-secretory proteins in endemic parasites of Latin America and the Caribbean

Neglected tropical diseases (NTDs) share certain traits: they are parasitic infections, prevailing in tropical environments and affecting marginalized sectors of the population. Six NTDs - ascariasis, cysticercosis, echinococcosis, hookworm infection, onchocerciasis and trichuriasis - all of them endemic in Latin America and the Caribbean (LAC), are analysed in this work. This review aims to discuss key information on the function of excretory/secretory (E/S) proteins from these parasites in their infectivity, pathogeny and diagnosis. The modulation of the host immune system to favour the permanence and survival of the parasite is also discussed. An updated knowledge on the function of E/S molecules in endemic parasitoses in LAC may lead to new approaches for the clinical management and diagnosis of these diseases. In turn, this could allow us to optimize their treatment and make it more affordable - a relevant goal given the economic constraints that the region is facing.

Human taeniasis/cysticercosis: a potentially emerging parasitic disease in Europe

Taenia saginata (T. saginata)/Taenia solium (T. solium) taeniasis/cysticercosis disease complexes remain a significant challenge for food safety and public health. Human taeniasis is an infectious disease caused by the ingestion of the metacestode larval stage, the cysticerci of T. saginata in beef or T. solium in pork. Humans can also become infected via the ingestion of T. solium eggs. In this case, the cysticerci can establish in the central nervous system, causing the infection called neurocysticercosis. T. solium is of higher importance than T. saginata because the former species can cause neurocysticercosis in humans, a major cause of neurological morbidity in the world. The taeniasis/cysticercosis complex is included in the list of neglected zoonotic diseases by the World Health Organization and Food and Agriculture Organization, with T. solium being the number one foodborne parasite; it occurs mostly in developing countries, such as regions of Asia, Africa and Latin America, where the disease remains endemic. Long absent in Western Europe and other developed countries, cysticercosis has been recently re-emerged as a result of immigration, travel and commerce. In this review, cysticercosis is presented with special emphasis on some aspects of this neglected disease: the main clinical manifestations, risk factors and epidemiology. In addition, any recent advances in diagnostic approaches and treatment are discussed. Finally, the complexities involved in the control of the disease and the need to revise current management strategies are highlighted.

Present status of laboratory diagnosis of human taeniosis/cysticercosis in Europe

Human cysticercosis (CC) is a parasitic zoonosis caused by the larval stage (cyst) of the Taenia solium. Cysts can establish in the human central nervous system (neurocysticercosis, NCC) and other organs and tissues; they also develop in pigs, the natural intermediate host. Human taeniosis may be caused by T. solium, Taenia saginata and Taenia asiatica tapeworms; these infections are usually asymptomatic, but show a significant relevance as they perpetuate the parasites’ life cycle, and, in the case of T. solium, they are the origin of (N)CC. In European Union (EU) member states and associated countries, the occurrence of autochthonous T. solium cases is debated, and imported cases have significantly increased lately; the status of T. asiatica has been never reported, whereas T. saginata is prevalent and causes an economic impact due to condemned carcasses. Based on their effects on the EU society, the specific diagnosis of these pathologies is relevant for their prevention and control. The aims of this study were to know the diagnostic tests used in European laboratories for human taeniosis/cysticercosis by means of a questionnaire, to determine potential gaps in their detection, and to obtain preliminary data on the number of diagnosed taeniosis/CC cases.

Human taeniasis: current insights into prevention and management strategies in endemic countries

Human taeniasis is a zoonotic condition resulting from infection with the adult stages of Taenia saginata ("beef tapeworm"), Taenia solium ("pork tapeworm") or Taenia asiatica ("Asian tapeworm"). Although these parasites have a worldwide distribution, the overwhelming burden is felt by communities in low- and middle-income countries. This is particularly true for T. solium, whereby infection of the central nervous system with the larval stage of the parasite (neurocysticercosis) is a major cause of acquired epilepsy in low-resource settings. With a focus on endemic countries, this review provides an insight into the prevention and management of human taeniasis, concluding with some recent case studies describing their implementation. Discussion of the opportunities and challenges regarding current fecal and serological diagnostic assays for detecting Taenia spp. highlights the importance of accurate and accessible diagnostic options for the field situation. The lack of long-term impact on the parasites' lifecycle from human anthelmintic treatment, coupled with the propensity for adverse reactions, highlights the importance of a "two-pronged" approach that considers the relevant animal hosts, particularly in the case of T. solium. Aside from the therapeutic options, this review reiterates the importance of adequate assessment and consideration of the associated behavioral and policy aspects around sanitation, hygiene and meat inspection that have been shown to support parasite control, and potential elimination, in endemic regions.

Survey of Obstetrician-Gynecologists in the United States About Taeniasis and Cysticercosis

An estimated 50 million persons worldwide are infected with cysticerci, the larval forms of the Taenia solium tapeworm. Neurocysticercosis can cause seizures, epilepsy, and hydrocephalus, and fatal cases have been reported in the United States in immigrants and in travelers returning from endemic countries. Pregnant women with symptomatic neurocysticercosis present treatment challenges, whereas those with the adult tapeworm infection (i.e., taeniasis) can put their infants and other family members, as well as obstetrician-gynecologists and their staff, at risk for cysticercosis. A questionnaire developed by the American College of Obstetricians and Gynecologists was sent to a representative sample of 1,000 physicians to assess their awareness of T. solium infection and the potential for it to be encountered in an obstetrics and gynecology setting. In total, 31.4% of respondents correctly answered that taeniasis is caused by eating undercooked pork containing T. solium cysts (95% confidence interval [CI] = 26.6-36.5). While only 14.5% (95% CI = 11.0-18.6) of respondents correctly answered that cysticercosis is acquired by ingesting tapeworm eggs shed in human stools, twice that number (30.3%; 95% CI = 25.5-35.3) correctly answered that a mother with taeniasis can cause cysticercosis in her infant. Practicing in a state in which cysticercosis was reportable at the time of the survey was not significantly associated with answering any of the 12 knowledge questions correctly. Overall, knowledge of T. solium infection among U.S. obstetricians-gynecologists is limited. This may result in missed opportunities to diagnose and treat pregnant women with taeniasis, which may put family members and obstetrics clinical staff at risk for cysticercosis.

Microbiological laboratory diagnostics of neglected zoonotic diseases (NZDs)

This review reports on laboratory diagnostic approaches for selected, highly pathogenic neglected zoonotic diseases, i.e. anthrax, bovine tuberculosis, brucellosis, echinococcosis, leishmaniasis, rabies, Taenia solium-associated diseases (neuro-/cysticercosis & taeniasis) and trypanosomiasis. Diagnostic options, including microscopy, culture, matrix-assisted laser-desorption-ionisation time-of-flight mass spectrometry, molecular approaches and serology are introduced. These procedures are critically discussed regarding their diagnostic reliability and state of evaluation. For rare diseases reliable evaluation data are scarce due to the rarity of samples. If bio-safety level 3 is required for cultural growth, but such high standards of laboratory infrastructure are not available, serological and molecular approaches from inactivated sample material might be alternatives. Multiple subsequent testing using various test platforms in a stepwise approach may improve sensitivity and specificity. Cheap and easy to use tests, usually called "rapid diagnostic tests" (RDTs) may impact disease control measures, but should not preclude developing countries from state of the art diagnostics.

Association between Taenia solium infection and HIV/AIDS in northern Tanzania: a matched cross sectional-study

BACKGROUND

The frequency of Taenia solium, a zoonotic helminth, is increasing in many countries of sub-Saharan Africa, where the prevalence of the human immunodeficiency virus (HIV) is also high. However, little is known about how these two infections interact. The aim of this study was to compare the proportion of HIV positive (+) and negative (-) individuals who are infected with Taenia solium (TSOL) and who present with clinical and neurological manifestations of cysticercosis (CC).

METHODS

In northern Tanzania, 170 HIV+ individuals and 170 HIV- controls matched for gender, age and village of origin were recruited. HIV staging and serological tests for TSOL antibodies (Ab) and antigen (Ag) were performed. Neurocysticercosis (NCC) was determined by computed tomography (CT) using standard diagnostic criteria. Neurological manifestations were confirmed by a standard neurological examination. In addition, demographic, clinical and neuroimaging data were collected. Further, CD4⁺ cell counts as well as information on highly active antiretroviral treatment (HAART) were noted.

RESULTS

No significant differences between HIV+ and HIV- individuals regarding the sero-prevalence of taeniosis-Ab (0.6% vs 1.2%), CC-Ab (2.4% vs 2.4%) and CC-Ag (0.6% vs 0.0%) were detected. A total of six NCC cases (3 HIV+ and 3 HIV-) were detected in the group of matched participants. Two individuals (1 HIV+ and 1 HIV-) presented with headaches as the main symptom for NCC, and four with asymptomatic NCC. Among the HIV+ group, TSOL was not associated with CD4⁺ cell counts, HAART duration or HIV stage.

CONCLUSIONS

This study found lower prevalence of taeniosis, CC and NCC than had been reported in the region to date. This low level of infection may have resulted in an inability to find cross-sectional associations between HIV status and TSOL infection or NCC. Larger sample sizes will be required in future studies conducted in that area to conclude if HIV influences the way NCC manifests itself.

Monitoring the outcomes of interventions against Taenia solium: options and suggestions

There is an increasing interest in reducing the incidence of human neurocysticercosis, caused by infection with the larval stage of Taenia solium. Several intervention trials are currently assessing various options for control of T. solium transmission. A critical aspect of these trials will be the evaluation of whether the interventions have been successful. However, there is no consensus about the most appropriate or valuable methods that should be used. Here, we undertake a critical assessment of the diagnostic tests which are currently available for human T. solium taeniasis and human and porcine cysticercosis, as well as their suitability for evaluation of intervention trial outcomes. Suggestions are made about which of the measures that are available for evaluation of T. solium interventions would be most suitable, and which methodologies are the most appropriate given currently available technologies. Suggestions are also made in relation to the most urgent research needs in order to address deficiencies in current diagnostic methods.

Analysis on Gene Expression Profile in Oncospheres and Early Stage Metacestodes from Echinococcus multilocularis

Alveolar echinococcosis is a worldwide zoonosis of great public health concern. Analysis of genome data for Echinococcus multilocularis has identified antigen families that can be used in diagnostic assays and vaccine development. However, little gene expression data is available for antigens of the egg and early larval stages. To address this information gap, we used a Next-Generation Sequencing approach to investigate three different stages (non-activated and activated oncospheres, and early stage metacestodes) of E. multilocularis (Nemuro strain). Transcriptome data analysis revealed that some diagnostic antigen gp50 isoforms and the antigen Eg95 family dominated in activated oncospheres, and the antigen B family dominated in early stage metacestodes. Furthermore, heat shock proteins and antigen II/3 are constantly expressed in the three stages. The expression pattern of various known antigens in E. multilocularis may give fundamental information for choosing candidate genes used in diagnosis and vaccine development.

Diagnosis of human taeniasis

Taenia solium, T. saginata and T. asiatica are taeniid tapeworms that cause taeniasis in humans and cysticercosis in intermediate host animals. T. solium can also cause cysticercosis in humans. A number of diagnostic methods have been developed to diagnose Taenia species that infect humans. This article is aimed at providing an overview of currently available diagnostic methods for human taeniasis.

An Unusual Presentation of Neurocysticercosis: A Space-Occupying Lesion in the Fourth Ventricle Associated with Progressive Cognitive Decline

We communicate a case of a middle-aged Brazilian patient with an unusual presentation of fourth ventricular neurocysticercosis: occurrence of two intraventricular cysts at different locations in the brain within 2 years and cognitive decline as the only neurological symptom. Neurocysticercosis was confirmed by magnetic resonance imaging, serology, histology, and genetic analysis. Neurocysticercosis should be considered as a differential diagnosis in cases with atypical neurologic or psychiatric symptoms, atypical neuroimaging and travel history. Especially, fourth ventricular cysts carry the risk of obstructive hydrocephalus and brainstem compression and therefore should be extirpated completely. If complete removal of the cystic structures cannot be proven in cases with surgically treated neurocysticercosis, anthelminthic therapy and thorough follow-up examinations should be conducted.

Exposure to multiple parasites is associated with the prevalence of active convulsive epilepsy in sub-Saharan Africa

Background

Epilepsy is common in developing countries, and it is often associated with parasitic infections. We investigated the relationship between exposure to parasitic infections, particularly multiple infections and active convulsive epilepsy (ACE), in five sites across sub-Saharan Africa.

Methods and Findings

A case-control design that matched on age and location was used. Blood samples were collected from 986 prevalent cases and 1,313 age-matched community controls and tested for presence of antibodies to Onchocerca volvulus, Toxocara canis, Toxoplasma gondii, Plasmodium falciparum, Taenia solium and HIV. Exposure (seropositivity) to Onchocerca volvulus (OR = 1.98; 95%CI: 1.52–2.58, p<0.001), Toxocara canis (OR = 1.52; 95%CI: 1.23–1.87, p<0.001), Toxoplasma gondii (OR = 1.28; 95%CI: 1.04–1.56, p = 0.018) and higher antibody levels (top tertile) to Toxocara canis (OR = 1.70; 95%CI: 1.30–2.24, p<0.001) were associated with an increased prevalence of ACE. Exposure to multiple infections was common (73.8% of cases and 65.5% of controls had been exposed to two or more infections), and for T. gondii and O. volvulus co-infection, their combined effect on the prevalence of ACE, as determined by the relative excess risk due to interaction (RERI), was more than additive (T. gondii and O. volvulus, RERI = 1.19). The prevalence of T. solium antibodies was low (2.8% of cases and 2.2% of controls) and was not associated with ACE in the study areas.

Conclusion

This study investigates how the degree of exposure to parasites and multiple parasitic infections are associated with ACE and may explain conflicting results obtained when only seropositivity is considered. The findings from this study should be further validated.

The prevalence of epilepsy is greater in developing countries compared to developed countries, and parasitic infestations are thought to contribute to this increased burden. We conducted a case-control study across five sites in sub-Saharan Africa to investigate the relationship between epilepsy and exposure to parasitic infections, and the association between epilepsy and multiple co-incidental infections. Exposure to Onchocerca volvulus, Toxocara canis and Toxoplasma gondii as well as high antibody levels (top tertile) to Toxocara canis was positively associated with the prevalence of active convulsive epilepsy (ACE). Multiple co-incidental parasitic infections were common, and the combined effect of T. gondii and O. volvulus co-infection on ACE was greater than the sum of the individual effects. The contribution of each of these parasitic infections on the burden of epilepsy in sub-Saharan Africa should be explored.

Cysticercus cellulosae antigens in the serodiagnosis of neurocysticercosis

Neurocysticercosis (NCC) is difficult to diagnose clinically because of its varied clinical presentation. However, an accurate diagnosis is possible only after suspicion on epidemiological grounds, proper interpretation of the clinical data, analysis of the findings on imaging studies, and specific immunological tests on the serum and cerebrospinal fluid (CSF). The diagnosis of NCC by any single parameter thus continues to remain difficult. In the past, detection of NCC was based on autopsy studies and histological confirmation. In recent times, the advent of imaging methods such as computed tomography and magnetic resonance imaging have provided excellent non-invasive tools for easy detection of NCC. Nevertheless, an imaging technique of the brain, although useful, is not considered as a gold standard for the diagnosis of NCC. Serological tests are being increasingly used in adjunct with imaging techniques, to aid the diagnosis of NCC. Immunodiagnostic techniques include detection methods for specific antibodies and for circulating parasite antigens in the serum and CSF. Currently, many of the immunodiagnostic tests, including the enzyme-linked immunosorbent assay and enzyme immunotransfer blot, use purified native antigens for the immunodiagnosis of NCC. Nevertheless, the main problem with the use of native cysticercal antigens is that the native proteins often show cross reactions with sera from humans infected with other parasites. The preparation of native antigens also demand a constant supply of parasitic material from the intermediate host pig. In order to overcome the problems in using native antigens, the recombinant antigens or synthetic peptides, which can be produced under stable conditions, are being evaluated for the serodiagnosis of NCC.

Prevention and control of Taenia solium taeniasis/cysticercosis in Peru

Taenia solium is endemic in most of the world, causing seizures and other neurological symptoms. Transmission is mainly maintained in rural areas by a human to pig cycle. Despite claims on its eradicability, sustainable interruption of transmission has not yet been reported. This manuscript reviews the conceptual basis for control, available diagnostic and control tools, and recent experiences on control in the field performed in Peru along the past decade.

Proteomic characterization of larval and adult developmental stages in Echinococcus granulosus reveals novel insight into host-parasite interactions

Cystic hydatid disease is an important zoonosis caused by Echinococcus granulosus infection. The expression profiles of its parasitic life stages and host-Echinococcus interactions remain to be elucidated. Here, we identified 157 adult and 1588 protoscolex proteins (1610 in all), including 1290 novel identifications. Paramyosins and an antigen B (AgB) were the dominant adult proteins. Dog proteins (30) identified in adults indicated diminished local inflammation caused by adult infection. The protoscolex expresses proteins that have been reported to be antigens in other parasites, such as 6-phosphofructokinase and calcineurin B. Pathway analyses suggested that E. granulosus uses both aerobic and anaerobic carbohydrate metabolisms to generate ATP. E. granulosus expresses proteins involved in synthesis and metabolism of lipids or steroids. At least 339 of 390 sheep proteins identified in protoscolex were novel identifications not seen in previous analyses. IgGs and lambda light chains were the most abundant antibody species. Sheep proteins were enriched for detoxification pathways, implying that host detoxification effects play a central role during host-parasite interactions. Our study provides valuable data on E. granulosus expression characteristics, allowing novel insights into the molecular mechanisms involved in host-parasite interactions.

BIOLOGICAL SIGNIFICANCE

In this study, the Echinococcus granulosus adult worm proteome was analyzed for the first time. The protein identification of E. granulosus protoscoleces was extended dramatically. We also identified the most abundant host proteins co-purified with Echinococcus. The results provide useful information pertaining to the molecular mechanisms behind host-Echinococcus interaction and Echinococcus biology. This data also increases the potential for identifying vaccine candidates and new therapeutic targets, and may aid in the development of protein probes for selective and sensitive diagnosis of echinococcosis infection. In addition, the data collected here represents a valuable proteomic resource for subsequent genome annotation.

Characterization of the Taenia spp HDP2 sequence and development of a novel PCR-based assay for discrimination of Taenia saginata from Taenia asiatica

A previously described Taenia saginata HDP2 DNA sequence, a 4-kb polymorphic fragment, was previously used as the basis for developing PCR diagnostic protocols for the species-specific discrimination of T. saginata from T. solium and for the differentiation of T. saginata from T. asiatica. The latter was shown subsequently to lack the required specificity, so we undertook genetic studies of the HDP2 sequence from T. saginata and T. asiatica to determine why, and to develop a novel HDP2-PCR protocol for the simultaneous unambiguous identification of human taeniids. Sequencing and further analysis of the HDP2 DNA fragments of 19 Asiatic isolates of T. saginata and T. asiatica indicated that the HDP2 sequences of both species exhibited clear genomic variability, due to polymorphic variable fragments, that could correspond to the non-transcribed region of ribosomal DNA. This newly observed polymorphism allowed us to develop a novel, reproducible and reliable HDP2-PCR protocol which permitted the simultaneous discrimination of all T. saginata and T. asiatica isolates examined. This species-specific identification was based on, and facilitated by, the clear size difference in amplicon profiles generated: fragments of 1300 bp, 600 bp and 300 bp were produced for T. asiatica, amplicons of 1300 bp and 300 bp being obtained for T. saginata. Control T. solium samples produced one amplicon of 600 bp with the HDP2-PCR protocol. The assay has the potential to prove useful as a diagnostic tool in areas such as South East Asia where T. saginata, T. asiatica and T. solium coexist.

Development and evaluation of a magnetic immunochromatographic test to detect Taenia solium, which causes taeniasis and neurocysticercosis in humans

Taeniasis/cysticercosis caused by Taenia solium is a frequent parasitic infection of the human brain in most of the world. Rapid and simple screening tools to identify taeniasis and cysticercosis cases are needed for control programs, mostly to identify tapeworm carriers which are the source of infection and need to be treated, or as tools for point-of-care case detection or confirmation. These screening assays should be affordable, reliable, rapid, and easy to perform. Immunochromatographic tests meet these criteria. To demonstrate proof of principle, we developed and evaluated two magnetic immunochromatographic tests (MICTs) for detection of human Taenia solium taeniasis antibodies (ES33-MICT) and neurocysticercosis antibodies (T24-MICT). These assays detected stage-specific antibodies by using two recombinant proteins, rES33 for detection of taeniasis antibodies and rT24H for detection of cysticercosis antibodies. The sensitivity and specificity of the ES33-MICT to detect taeniasis infections were 94.5% and 96%, respectively, and those of the T24-MICT to detect cases of human cysticercosis with two or more viable brain cysts were 93.9% and 98.9%, respectively. These data provide proof of principle that the ES33- and T24-MICTs provide rapid and suitable methods to identify individuals with taeniasis and cysticercosis.

Multiantigen print immunoassay for comparison of diagnostic antigens for Taenia solium cysticercosis and taeniasis

One of the best-characterized tests for the diagnosis of neurocysticercosis is the enzyme-linked immunoelectrotransfer blot assay, developed at the CDC, which uses lentil lectin-purified glycoproteins (LLGPs) extracted from Taenia solium cysticerci. The purification of the LLGP antigens has been difficult to standardize, and the polyacrylamide gel system used for the immunoblot assay is not easily transferable to other laboratories. In this study, we developed a multiantigen printing immunoassay (MAPIA) to compare the performance of multiple recombinant Taenia solium proteins with the potential for the detection of cysticercosis and taeniasis. We prepared MAPIA strips using six cysticercosis and two taeniasis diagnostic proteins and compared the performance of the proteins with sera collected from defined cysticercosis and taeniasis cases. Of the six cysticercosis antigens, rT24H performed well in detecting cases with two or more viable cysts in the brain (sensitivity and specificity, 97% and 99.4%, respectively); the use of a combination of cysticercosis antigens did not improve the sensitivity of the test and decreased the specificity. None of the antigens could differentiate the different clinical presentations of cysticercosis. Both of the taeniasis antigens (rES33 and rES38) had the same sensitivity of 99.4% and specificities of 93.9% and 94.5%, respectively. Some cross-reactivity against rES33 and rES38 was found, especially with sera from cases infected with Schistosoma mansoni. We conclude that MAPIA is a simple and effective tool that may be used to compare antibody responses to different cysticercosis and taeniasis antigens and, in this case, may be useful for the rapid detection of T. solium cases.

Intestinal cestodes

PURPOSE OF REVIEW

This review summarizes the biology, clinical aspects, diagnosis, treatment and epidemiology for the common and rarer (zoonotic) intestinal cestodes of humans.

RECENT FINDINGS

Mass drug application to eliminate Taenia solium carriers may have only temporary effects on cysticercosis transmission. At least two major world genotypes of T. solium have been identified and greater genetic heterogeneity may occur at the regional level. A new human taeniid T. asiatica has been confirmed which occurs sympatrically with T. saginata and T. solium in Southeast Asia. Coproantigen and PCR tests for Taenia spp. have greatly improved diagnostic efficacy and epidemiological studies. There appears to be an increase in human diphyllobothriasis in Europe, Japan and the Americas.

SUMMARY

Human intestinal cestode infections are globally primarily caused by species in three genera: Taenia, Hymenolepis or Diphyllobothrium. Sporadic zoonotic infections caused by nontaeniids are usually food-borne or due to accidental ingestion of invertebrate hosts. Intestinal cestode infections generally result in only mild symptoms characterized chiefly by abdominal discomfort and diarrhoea. Most human intestinal cestode infections can be treated with a single oral dose of praziquantel or niclosamide.

Strategies for the elimination of taeniasis/cysticercosis

Advances in the field of neurocysticercosis continue to shape our understanding of the disease and our efforts to control it. Several attempts have been made to eradicate the disease with active interventions such as changing domestic pig-raising practices, mass chemotherapy of porcine cysticercosis and taeniasis, selective detection and treatment of taeniasis, and community health education. Moreover, ongoing progress in the diagnosis of taeniasis and the development of a porcine vaccine against cysticercosis in Australia, Mexico and Peru has yielded at least one effective vaccine that is currently available. Thus far, however, attempted interventions have only been successful in temporarily disrupting transmission of the disease. Controlled data on the efficacy and acceptability of the different interventions is urgently needed to provide a base-line schematic for intervention which could later be tailored to each particular endemic scenario.

False positive reactivity of recombinant, diagnostic, glycoproteins produced in High Five insect cells: effect of glycosylation

Baculovirus-mediated expression of recombinant proteins for use in diagnostic assays is commonplace. We expressed a diagnostic antigen for cysticercosis, GP50, caused by the larval stage of Taenia solium, in both High Five and Sf9 insect cells. Upon evaluation of the specificity of recombinant GP50 (rGP50) in a western blot assay, we observed that 12.5% (21/168) of the serum samples from persons with a variety of parasitic infections other than cysticercosis reacted positive when rGP50 was produced in High Five cells. The same samples reacted negative when rGP50 was produced in Sf9 cells. The false positive reactivities of these other parasitic infection sera were abolished when rGP50, expressed in High Five cells, was deglycosylated. In addition, the same sera that reacted with rGP50 from High Five cells also reacted with recombinant human transferrin (rhTf) when expressed in High Five cells, but not Sf9 cells. High Five cells, but not Sf9 cells, modify many glycoproteins with a core alpha(1,3)-fucose. This same modification is found in the glycoproteins of several parasitic worms and is known to be immunogenic. Since the distribution of these worms is widespread and millions of people are infected, the use of recombinant proteins with N-linked glycosylation produced in High Five cells for diagnostic antigens is likely to result in a number of false positive reactions and a decrease in assay specificity.

DEVELOPMENT OF AN ENZYME-LINKED IMMUNOELECTROTRANSFER BLOT (EITB) ASSAY USING TWO BACULOVIRUS EXPRESSED RECOMBINANT ANTIGENS FOR DIAGNOSIS OF TAENIA SOLIUM TAENIASIS

Taeniasis diagnosis is an important step in the control and elimination of both cysticercosis and taeniasis. We report the development of 2 serological taeniasis diagnostic tests using recombinant antigens rES33 and rES38 expressed by baculovirus in insect cells in an EITB format. In laboratory testing with defined sera from nonendemic areas, rES33 has a sensitivity of 98% (n = 167) and a specificity of 99% (n = 310) (J index: 0.97); rES38 has a sensitivity of 99% (n = 146) and a specificity of 97% (n = 275) (J index: 0.96). Independent field testing in Peru showed 97% (n = 203) of the taeniasis sera were positive with rES33, and 100% of the nontaeniasis sera (n = 272) were negative with rES33; 98% (n = 198) of taeniasis sera were positive with rES38, and 91% (n = 274) of the nontaeniasis sera were negative with rES38. Among the Peruvian sera tested, 17 of 26 Peruvian Taenia saginata sera were false positive with rES38 test. Both tests were also examined with cysticercosis sera, with a positive rate ranging from 21% to 46%. rES33 and rES38 tests offer sensitive and specific diagnosis of taeniasis and easy sample collection through finger sticks that can be used in large-scale studies. They are currently being used in cysticercosis elimination programs in Peru.

Characterization and cloning of T24, a Taenia solium antigen diagnostic for cysticercosis

The third and final diagnostic antigen of the lentil lectin purified glycoproteins (LLGP) extracted from the larval stage of Taenia solium has been characterized, cloned, and expressed. T24 is an integral membrane protein that belongs to the tetraspanin superfamily. It migrates at a position corresponding to 24-kDa and as a homodimer at 42-kDa. Antibodies from cysticercosis patients recognize secondary structure epitopes that are dependent upon correctly formed disulfide bonds. A portion of T24, the large, extracellular loop domain, was expressed in an immunologically reactive form in insect cells. When tested in a Western blot assay with a large battery of serum samples, this protein, T24H, has a sensitivity of 94% (101/107), for detecting cases of cysticercosis with two or more viable cysts, and a specificity of 98% (284/290). The identification and expression of T24H sets the stage for the development of an ELISA suitable for testing single samples and for large-scale serosurveys that is not dependent upon the isolation and purification of antigens from parasite materials.

Progress in diagnosis, treatment and elimination of echinococcosis and cysticercosis

Here I review the current status of geographical occurrence and public health significance of echinococcosis (Echinococcus spp. infections) and cysticercosis (Taenia solium infection) with special emphasis on the remarkable technologic progress achieved in recent decades that has led to greater understanding of the biology and epidemiology of these cestode infections. The greatest remaining challenges are to apply this knowledge and technology to improved medical management and prevention of these infections.

Vaccines for viral and parasitic diseases produced with baculovirus vectors

The baculovirus-insect cell expression system is an approved system for the production of viral antigens with vaccine potential for humans and animals and has been used for production of subunit vaccines against parasitic diseases as well. Many candidate subunit vaccines have been expressed in this system and immunization commonly led to protective immunity against pathogen challenge. The first vaccines produced in insect cells for animal use are now on the market. This chapter deals with the tailoring of the baculovirus-insect cell expression system for vaccine production in terms of expression levels, integrity and immunogenicity of recombinant proteins, and baculovirus genome stability. Various expression strategies are discussed including chimeric, virus-like particles, baculovirus display of foreign antigens on budded virions or in occlusion bodies, and specialized baculovirus vectors with mammalian promoters that express the antigen in the immunized individual. A historical overview shows the wide variety of viral (glyco)proteins that have successfully been expressed in this system for vaccine purposes. The potential of this expression system for antiparasite vaccines is illustrated. The combination of subunit vaccines and marker tests, both based on antigens expressed in insect cells, provides a powerful tool to combat disease and to monitor infectious agents.

Control of Taenia solium taeniasis/cysticercosis: From research towards implementation

Theoretically, considering the biology of its transmission and reservoirs, global eradication of Taenia solium taeniasis and cysticercosis is feasible. Recently much progress has been made in research on diagnosis, treatment and prevention of human taeniasis and porcine cysticercosis, although more operational research is still needed. In spite of this, global eradication of T. solium infection is still unlikely in the near future. Major obstacles to practical implementation of control measures include low levels of sanitation and health education amongst endemic populations, ineffective health services infrastructure and inadequate socioeconomic development in these areas. The continued public health impact of neurocysticercosis, especially fatalities and epilepsy, force us to identify improved options for control. In order to implement control measures in highly endemic areas the active involvement of medical services in controlling T. solium infection and more effective collaboration between medical and veterinary services is necessary. A switch is suggested from total reliance on meat inspection to active diagnosis and treatment of human taeniasis, protection of pigs against infection, promotion of health education and improved surveillance preparing chemotherapeutic and/or sanitary interventions. This could be implemented in areas where active transmission causes substantial morbidity and mortality provided there is the political will, social support, better financing and an effective organizational framework.

Cysticercosis: Recent Advances in Diagnosis and Management of Neurocysticercosis

Neurocysticercosis, caused by infection with the pork tapeworm Taenia solium, is increasingly recognized as a cause of neurologic disease worldwide. Because the clinical presentation is nonspecific, diagnosis has been difficult. Advances in imaging studies and serodiagnostic techniques are facilitating the diagnosis of neurocysticercosis and tapeworm carriers. Neurocysticercosis represents a spectrum of disease. Seizures are the main clinical manifestation in parenchymal neurocysticercosis. Recent studies emphasize that such seizures are the result of the host inflammatory response, even in patients who only have calcifications with no viable cysticerci. Controlled clinical trials have demonstrated that antiparasitic drugs can decrease the number of generalized seizures, although the benefit is small and confined to a subgroup of patients. Corticosteroids can also decrease seizure frequency. Case studies have demonstrated that endoscopic surgery appears to be the optimal approach to ventricular cysts. Recombinant vaccines are being developed and may prove important in disease control.