Towards a Sustainable Vector-Control Strategy in the Post Kala-Azar Elimination Era

Knockdown resistance mutations in Phlebotomus argentipes sand flies in Bihar, India

BACKGROUND

Vector control based on indoor residual spraying (IRS) is one of the main components of the visceral leishmaniasis (VL) elimination programme in India. Dichlorodiphenyltrichloroethane (DDT) was used for IRS until 2015 and was later replaced by the synthetic pyrethroid alpha-cypermethrin. Both classes of insecticides share the same target site, the voltage-gated sodium channel (Vgsc). As high levels of resistance to DDT have been documented in the local sand fly vector, Phlebotomus argentipes, it is possible that mutations in the Vgsc gene could provide resistance to alpha-cypermethrin, affecting current IRS pyrethroid-based vector control.

METHODS

This study aimed to compare frequencies of knockdown resistance (kdr) mutations in Vgsc between two sprayed and two unsprayed villages in Bihar state, India, which had the highest VL burden of the four endemic states. Across four villages, 350 female P. argentipes were collected as part of a 2019 molecular xenomonitoring study. DNA was extracted and used for sequence analysis of the IIS6 fragment of the Vgsc gene to assess the presence of kdr mutations.

RESULTS

Mutations were identified at various positions, most frequently at codon 1014, a common site known to be associated with insecticide resistance in mosquitoes and sand flies. Significant inter-village variation was observed, with sand flies from Dharampur, an unsprayed village, showing a significantly higher proportion of wild-type alleles (55.8%) compared with the three other villages (8.5-14.3%). The allele differences observed across the four villages may result from selection pressure caused by previous exposure to DDT.

CONCLUSIONS

While DDT resistance has been reported in Bihar, P. argentipes is still susceptible to pyrethroids. However, the presence of kdr mutations in sand flies could present a threat to IRS used for VL control in endemic villages in India. Continuous surveillance of vector bionomics and insecticide resistance, using bioassays and target genotyping, is required to inform India's vector control strategies and to ensure the VL elimination target is reached and sustained.

Vaccine value profile for leishmaniasis

Leishmania infections are global, occurring in 98 countries and all World Health Organization (WHO) regions with 600 million to 1 billion people at risk of infection. Visceral leishmaniasis is associated with almost 20,000 reported deaths annually, with children under 5 years of age being at the greatest risk of mortality. Amongst WHO-recognised Neglected Tropical Diseases (NTDs), leishmaniasis is one of the most important in terms of mortality and morbidity. With an increasing global burden of disease and a growing threat from climate change, urbanisation and drug resistance, there remains an imperative to develop leishmaniasis vaccines. New tools to understand correlates of protection and to assess vaccine efficacy are being developed to ease the transition into larger scale efficacy trials or provide alternate routes to licensure. Early indications suggest a diverse portfolio of manufacturers exists in endemic countries with an appetite to develop leishmaniasis vaccines. This Vaccine Value Profile (VVP) provides a high-level, comprehensive assessment of the currently available data to inform the potential public health, economic, and societal value of leishmaniasis vaccines. The leishmaniasis VVP was developed by a working group of subject matter experts from academia, public health groups, policy organizations, and non-profit organizations. All contributors have extensive expertise on various elements of the leishmaniasis VVP and have collectively described the state of knowledge and identified the current gaps. The VVP was developed using only existing and publicly available information.

Post kala-azar dermal leishmaniasis in the Indian sub-continent: challenges and strategies for elimination

Visceral leishmaniasis (VL) is a severe and often fatal form of leishmaniasis caused by Leishmania donovani in the Indian sub-continent. Post Kala-azar Dermal Leishmaniasis (PKDL) is a late cutaneous manifestation of VL, typically occurring after apparent cure of VL, but sometimes even without a prior history of VL in India. PKDL serves as a significant yet neglected reservoir of infection and plays a crucial role in the transmission of the disease, posing a serious threat to the VL elimination program in the Indian sub-continent. Therefore, the eradication of PKDL should be a priority within the current VL elimination program aimed at achieving a goal of less than 1 case per 10,000 in the population at the district or sub-district levels of VL endemic areas. To accomplish this, a comprehensive understanding of the pathogenesis of PKDL is essential, as well as developing strategies for disease management. This review provides an overview of the current status of diagnosis and treatment options for PKDL, highlighting our current knowledge of the immune responses underlying disease development and progression. Additionally, the review discusses the impact of PKDL on elimination programs and propose strategies to overcome this challenge and achieve the goal of elimination. By addressing the diagnostic and therapeutic gaps, optimizing surveillance and control measures, and implementing effective intervention strategies, it is possible to mitigate the burden of PKDL and facilitate the successful elimination of VL in the Indian sub-continent.

Immunisation with Transgenic L. tarentolae Expressing Gamma Glutamyl Cysteine Synthetase from Pathogenic Leishmania Species Protected against L. major and L. donovani Infection in a Murine Model

Leishmaniasis is a protozoan disease responsible for significant morbidity and mortality. There is no recommended vaccine to protect against infection. In this study, transgenic Leishmania tarentolae expressing gamma glutamyl cysteine synthetase (γGCS) from three pathogenic species were produced and their ability to protect against infection determined using models of cutaneous and visceral leishmaniasis. The ability of IL-2-producing PODS^® to act as an adjuvant was also determined in L. donovani studies. Two doses of the live vaccine caused a significant reduction in L. major (p < 0.001) and L. donovani (p < 0.05) parasite burdens compared to their respective controls. In contrast, immunisation with wild type L. tarentolae, using the same immunisation protocol, had no effect on parasite burdens compared to infection controls. Joint treatment with IL-2-producing PODS^® enhanced the protective effect of the live vaccine in L. donovani studies. Protection was associated with a Th1 response in L. major and a mixed Th1/Th2 response in L. donovani, based on specific IgG1 and IgG2a antibody and cytokine production from in vitro proliferation assays using antigen-stimulated splenocytes. The results of this study provide further proof that γGCS should be considered a candidate vaccine for leishmaniasis.

A Composite Recombinant Salivary Proteins Biomarker for Phlebotomus argentipes Provides a Surveillance Tool Postelimination of Visceral Leishmaniasis in India

Incidence of visceral leishmaniasis (VL) in the Indian subcontinent (ISC) has declined by more than 95% since initiation of the elimination program in 2005. As the ISC transitions to the postelimination surveillance phase, an accurate measurement of human-vector contact is needed to assure long-term success. To develop this tool, we identified PagSP02 and PagSP06 from saliva of Phlebotomus argentipes, the vector of Leishmania donovani in the ISC, as immunodominant proteins in humans. We also established the absence of cross-reactivity with Phlebotomus papatasi saliva, the only other human-biting sand fly in the ISC. Importantly, by combining recombinant rPagSP02 and rPagSP06 we achieved greater antibody recognition and specificity than single salivary proteins. The receiver operating characteristics curve for rPagSP02 + rPagSP06 predicts exposure to Ph. argentipes bites with 90% specificity and 87% sensitivity compared to negative control sera (P >.0001). Overall, rPagSP02 + rPagSP06 provides an effective surveillance tool for monitoring vector control efforts after VL elimination.

Assessing the susceptibility to permethrin and deltamethrin of two laboratory strains of Phlebotomus perniciosus from Madrid region, Spain

Leishmania infantum is a protozoan causing cutaneous and visceral leishmaniasis in several regions of the world, including the Mediterranean basin. Phlebotomus perniciosus is one of the most important vectors of leishmaniasis in the countries of the western Mediterranean basin. Sand fly vector control by insecticides remains a useful tool in the framework of leishmaniasis control programs. Pyrethroids are the most widely used class of insecticides for sand fly control. There is currently a lack of information on the insecticide susceptibility and discriminating concentrations (DCs) of P. perniciosus. The aim of this study was to determine lethal concentrations (LC₅₀, LC₉₅, and LC₉₉) and DCs of deltamethrin and permethrin against two strains of P. perniciosus from Madrid region (Spain). According to WHO tube bioassay protocol 24-h mortality obtained after 1-h exposure to deltamethrin (0.0003%, 0.001%, 0.003%, 0.01%, 0.03%, and 0.1%) and permethrin (0.003%, 0.01%, 0.03%, 0.1%, 0.3%, and 1%) was recorded. The LC₅₀, LC₉₅, and LC₉₉ as well as their respective 95% confidence intervals values were calculated from the baseline data using maximum probability estimates of parameters and binary logistic regression analysis (QCal software). The 100% mortality was recorded from 0.01% of deltamethrin for both P. perniciosus strains and from 0.1% and 0.3% permethrin for Fuenlabrada and Boadilla strains, respectively. Final DCs of deltamethrin and permethrin of each P. perniciosus strain were determined based on setting this parameter at twice the minimum concentration of insecticide that kills 99% (LC₉₉) at the following percentages: Fuenlabrada strain (0.0582% deltamethrin and 0.2648% permethrin) and Boadilla strain (0.0406% deltamethrin and 0.2446% permethrin). The results indicate that both P. perniciosus strains are susceptible to deltamethrin and permethrin and can be used in susceptibility tests, although Boadilla strain offers more consistent results. Due to the scarce existing literature on insecticide DCs for sand flies and the different current procedures to determine their susceptibility to insecticides it is a priority to multiply efforts in order to develop standards for monitoring insecticide resistance in sand flies.

Can floral nectars reduce transmission of Leishmania?

Background

Insect-vectored Leishmania are responsible for loss of more disability-adjusted life years than any parasite besides malaria. Elucidation of the environmental factors that affect parasite transmission by vectors is essential to develop sustainable methods of parasite control that do not have off-target effects on beneficial insects or environmental health. Many phytochemicals that inhibit growth of sand fly-vectored Leishmania—which have been exhaustively studied in the search for phytochemical-based drugs—are abundant in nectars, which provide sugar-based meals to infected sand flies.

Principle findings

In a quantitative meta-analysis, we compare inhibitory phytochemical concentrations for Leishmania to concentrations present in floral nectar and pollen. We show that nectar concentrations of several flowering plant species exceed those that inhibit growth of Leishmania cell cultures, suggesting an unexplored, landscape ecology-based approach to reduce Leishmania transmission.

Significance

If nectar compounds are as effective against parasites in the sand fly gut as predicted from experiments in vitro, strategic planting of antiparasitic phytochemical-rich floral resources or phytochemically enriched baits could reduce Leishmania loads in vectors. Such interventions could provide an environmentally friendly complement to existing means of disease control.

Leishmania parasites infect over a million people each year—including over 200,000 infections with deadly visceral leishmaniasis—resulting in a greater health burden than any human parasite besides malaria. Leishmania infections of humans are transmitted by blood-feeding sand flies, which also consume floral nectar. Nectar contains many chemicals that inhibit Leishmania growth and are candidate treatments for infection of humans. However, these same compounds could also reduce infection in nectar-consuming sand flies. By combining existing data on the chemistry of nectar and sensitivity of Leishmania to plant compounds, we show that some floral nectars contain sufficient chemical concentrations to inhibit growth of insect-stage Leishmania. Our results suggest that consumption of these nectars could reduce parasite loads in sand flies and transmission of parasites to new human hosts. In contrast to insecticide-based methods of sand fly control, incorporation of antiparasitic nectar sources into landscapes and domestic settings could benefit public health without threatening beneficial insects. These findings suggest an unexplored, landscape-based approach to reduce transmission of a major neglected tropical disease worldwide.