Pseudouridines and pseudouridine synthases of the ribosome

psi are ubiquitous in ribosomal RNA. Eubacteria, Archaea, and eukaryotes all contain psi, although their number varies widely, with eukaryotes having the most. The small ribosomal subunit can apparently do without psi in some organisms, even though others have as many as 40 or more. Large subunits appear to need at least one psi but can have up to 50-60. psi is made by a set of site-specific enzymes in eubacteria, and in eukaryotes by a single enzyme complexed with auxiliary proteins and specificity-conferring guide RNAs. The mechanism is not known in Archaea, but based on an analysis of the kinds of psi synthases found in sequenced archaeal genomes, it is likely to involve use of guide RNAs. All psi synthases can be classified into one of four related groups, virtually all of which have a conserved aspartate residue in a conserved sequence motif. The aspartate is essential for psi formation in all twelve synthases examined so far. When the need for psi in E. coli was examined, the only synthase whose absence caused a major decrease in growth rate under normal conditions was RluD, the synthase that makes psi 1911, psi 1915, and psi 1917 in the helix 69 end-loop. This growth defect was the result of a major failure in assembly of the large ribosomal subunit. The defect could be prevented by supplying the rluD structural gene in trans, and also by providing a point mutant gene that made a synthase unable to make psi. Therefore, the RluD synthase protein appears to be directly involved in 50S subunit assembly, possibly as an RNA chaperone, and this activity is independent of its ability to form psi. This result is not without precedent. Depletion of PET56, a 2'-O-methyltransferase specific for G2251 (E. coli numbering) in yeast mitochondria virtually blocks 50S subunit assembly and mitochondrial function (Sirum-Connolly et al. 1995), but the methylation activity of the enzyme is not required (T. Mason, pers. comm.). The absence of FtsJ, a heat shock protein that makes Um2552 in E. coli, makes the 50S subunit less stable at 1 mM Mg++ (Bügl et al. 2000) and inhibits subunit joining (Caldas et al. 2000), but, in this case, it is not yet known whether the effects are due to the lack of 2'-O-methylation or to the absence of the enzyme itself. Is there any role for the psi residues themselves? First, as noted above, the 3 psi made by RluD which cluster in the end-loop of helix 69 are highly conserved, with one being universal (Fig. 2B). In the 70S-tRNA structure (Yusupov et al. 2001), the loop of this helix containing the psi supports the anticodon arm of A-site tRNA near its juncture with the amino acid arm. The middle of helix 69 does the same thing for P-site tRNA. Unfortunately, the resolution is not yet sufficient to provide a more precise alignment of the psi residues with the other structural elements of the tRNA-ribosome complex so that one cannot yet determine what role, if any, is played by the N-1 H that distinguishes psi from U. Second, and more generally, some psi residues in the LSU appear to be near the site of peptide-bond formation or tRNA binding but not actually at it (Fig. 2B) (Nissen et al. 2000; Yusupov et al. 2001). For example, position 2492 is commonly psi and is only six residues away from A2486, the A postulated to catalyze peptide-bond formation. Position 2589 is psi in all the eukaryotes and is next to 2588, which base-pairs with the C75 of A-site tRNA. Residue 2620, which interacts with the A76 of A-site-bound tRNA, is a psi or is next to a psi in eukaryotes and Archaea, and is five residues away from psi 2580 in E. coli. A2637, which is between the two CCA ends of P- and A-site tRNA, is near psi 2639, psi 2640, and psi 2641, found in a number of organisms. Residue 2529, which contacts the backbone of A-site tRNA residues 74-76, is near psi 2527 psi 2528 in H. marismortui. Residues 2505-2507, which contact A-site tRNA residues 50-53, are near psi 2509 in higher eukaryotes, and residues 2517-2519 in contact with A-site tRNA residues 64-65 are within 1-3 nucleotides of psi 2520 in higher eukaryotes and psi 2514 in H. marismortui. A way to rationalize this might be to invoke the concept suggested in the Introduction that psi acts as a molecular glue to hold loose elements in a more rigid configuration. It may well be that this is more important near the site of peptide-bond formation and tRNA binding, accounting for the preponderance of psi in this vicinity. What might be the role of all the other psi in eukaryotes? One can only surmise that cells, having once acquired the ability to make psi with guide RNAs, took advantage of the system to inexpensively place psi wherever an undesirable loose region was found. It might be that in some of these cases, psi performs the role played by proteins in other regions, namely that of holding the rRNA in its proper configuration. Confirmation of this hypothesis will have to await structural determination of eukaryotic ribosomes.

The use of spatial analysis in mapping the distribution of bancroftian filariasis in four West African countries

The geographical distribution of human infection with Wuchereria bancrofti was investigated in four West African countries (Benin, Burkina Faso, Ghana and Togo), using a commercial immunochromatographic test for filarial antigen. Efforts were made to cover each health-system implementation unit and to ensure no sampling point was >50 km from another, but otherwise the 401 study communities were selected at random. The aim was to enable spatial analysis of the data, to provide a prediction of the overall spatial relationships of the infection. The results, which were subjected to an independent random validation in Burkina Faso and Ghana, revealed that prevalence in the adult population of some communities exceeded 70% and that, over large areas of Burkina Faso, community prevalences were between 30% and 50%. Most of Togo, southern Benin and much of southern Ghana appeared completely free of the infection. Although there were foci on the Ghanaian coast with prevalences of 10%-30%, such high prevalences did not extend into coastal Togo or costal Benin. The prevalence map produced should be useful in prioritizing areas for filariasis control, identifying potential overlap with ivermectin-distribution activities undertaken by onchocerciasis-control programmes, and enabling inter-country and sub-regional planning to be initiated. The results indicate that bancroftian filariasis is more widely distributed in arid areas of Burkina Faso than hitherto recognized and that the prevalences of infection have remained fairly stable for at least 30 years. The campaign to eliminate lymphatic filariasis as a public-health problem in Africa will require significantly more resources (human, financial, and logistic) than previously anticipated.

Onchocerciasis: the clinical and epidemiological burden of skin disease in Africa

An attempt was made to assess the true public-health importance of onchocercal skin disease throughout the African region and hence provide an objective basis for the rational planning of onchocerciasis control in the area. The seven collaborative centres that participated in the study (three in Nigeria and one each in Ghana, Cameroon, Tanzania and Uganda) were all in areas of rainforest or savannah-forest mosaic where onchocercal blindness is not common. A cross-sectional dermatological survey was undertaken at each site following a standard protocol. At each site, the aim was to examine at least 750 individuals aged 5 years and living in highly endemic communities and 220-250 individuals aged 5 years and living in a hypo-endemic (control) community. Overall, there were 5459 and 1451 subjects from hyper-and hypo-endemic communities, respectively. In the highly endemic communities, the prevalence of itching increased with age until 20 years and then plateaued, affecting 42% of the population aged 20 years. There was a strong correlation between the prevalence of itching and the level of endemicity (as measured by the prevalence of nodules; r=0.75; P<0.001). The results of a multivariate logistic regression analysis showed that, at the individual level, the presence of onchocercal reactive skin lesions (acute papular onchodermatitis, chronic papular onchodermatitis and/or lichenified onchodermatitis) was the most important risk factor for pruritus, with an odds ratio (OR) of 18.3 and 95% confidence interval (CI) of 15.19-22.04, followed by the presence of palpable onchocercal nodules (OR=4.63; CI=4.05-5.29). In contrast, non-onchocercal skin disease contributed very little to pruritus in the study communities (OR=1.29; CI=1.1-1.51). Onchocercal skin lesions affected 28% of the population in the endemic villages. The commonest type was chronic papular onchodermatitis (13%), followed by depigmentation (10%) and acute papular onchodermatitis (7%). The highest correlation with endemicity was seen for the prevalence of any onchocercal skin lesion and/or pruritus combined (r=0.8; P<0.001). Cutaneous onchocerciasis was found to be a common problem in many endemic areas in Africa which do not have high levels of onchocercal blindness. These findings, together with recent observations that onchocercal skin disease can have major, adverse, psycho-social and socio-economic effects, justify the inclusion of regions with onchocercal skin disease in control programmes based on ivermectin distribution. On the basis of these findings, the World Health Organization launched a control programme for onchocerciasis, the African Programme for Onchocerciasis Control (APOC), that covers 17 endemic countries in Africa.

Rapid epidemiological mapping of onchocerciasis (REMO): its application by the African Programme for Onchocerciasis Control (APOC)

One of the fundamental challenges that the African Programme for Onchocerciasis Control (APOC) has had to face is how to identify the endemic communities where its mass ivermectin-treatment operations are to be carried out in conformity with its stated objective of targetting the most highly endemic, affected and at-risk populations. This it has done by adopting a technique, known as the rapid epidemiological mapping of onchocerciasis (REMO), that provides data on the distribution and prevalence of onchocerciasis. Integration of the REMO data into a geographical information system (GIS) enables delineation of zones of various levels of endemicity, and this is an important step in the planning process for onchocerciasis control. Zones are included in (or excluded from) the APOC-funded programme of community-directed treatment with ivermectin (CDTI), depending on whether or not their levels of onchocercal endemicity reach the threshold set by APOC. This review describes the application of the REMO/GIS technique by APOC in its operations, and identifies the remaining related challenges.

Monitoring community-directed treatment programmes for sustainability: lessons from the African Programme for Onchocerciasis Control (APOC)

Community-directed treatment is a relatively new strategy that was adopted in 1997 by the African Programme for Onchocerciasis Control (APOC), for large-scale distribution of ivermectin (Mectizan). Participatory monitoring of 39 of the control projects based on community-directed treatment with ivermectin (CDTI) was undertaken from 1998-2000, with a focus on process implementation of the strategy and the predictors of sustainability. Data from 14,925 household interviews in 2314 villages, 183 complete treatment records, 382 focus-group discussions, and the results of interviews with 669 community leaders, 757 trained community-directed drug distributors (CDD) and 146 health personnel (in 26 projects in four countries) were analysed. The data show that CDD dispensed ivermectin to 65.4% of the total population (71.2% of the eligible population), with no significant gender differences in coverage (P > 0.05). Treatment coverage ranged from 60.2% of the eligible subjects in Cameroon to 76.9% in Uganda. There was no significant relationship between the provision of incentives to CDD and treatment coverage (P > 0.05). The frequency of treatment refusal was highest in Cameroon (29.2%). Although most (72.1%) of the communities investigated selected their CDD on the basis of a community decision at a village meeting, only 37.9% chose their distribution period in the same way. There is clearly a need to improve communication strategies, to address the issues of absentees and refusals, to emphasise community ownership and to de-emphasise incentives for CDD. The investigation of the 'predictor indicators' of sustainability should enable APOC to understand the determinants of project performance and to initiate any appropriate changes in the programme.

Using ivermectin-treatment coverage among schoolchildren monitored by schoolteachers as a proxy of population coverage in areas of Uganda where onchocerciasis is endemic

In the control of onchocerciasis using mass treatment with ivermectin, coverage needs to be monitored regularly so that communities with poor or insufficient coverage can be identified and timely and appropriate interventions then instituted. The aim of the present study was to assess whether ivermectin-treatment coverage in schoolchildren, as monitored by schoolteachers, could be used as a proxy of population coverage. Although the coverages estimated in schoolchildren were found to be significantly correlated with estimates based on household surveys (P=0.01), there was poor correlation between either school and household-survey coverage and the values recorded in community registers. Although the community-register figures are the ones which the district health services normally use to report treatment coverage, they may be unreliable. Ivermectin-treatment coverage in schoolchildren monitored by schoolteachers could give a good and more accurate approximation of total population coverage. Further, large-scale studies, that take into consideration the cost-effectiveness of the various methods available to validate reported treatment coverage, are recommended.

Itraconazole in the treatment of tinea corporis and tinea cruris: comparison of two treatment schedules

The efficacy and safety of two dos-ages of itraconazole in the treatment of tinea corporis or cruris were compared in a multicentre, randomized, double-blind, parallel-group trial. Fifty-four patients received itraconazole 100 mg daily for 2 weeks and 60 received itraconazole 200 mg daily for 1 week. After a 6-week follow-up period, mycological cure was achieved in 70% of patients in the 100 mg/2 weeks group and in 60% of those in the 200 mg/1 week group (not significantly equivalent); in the worst-case and intention-to-treat analyses, mycological cure rates (45-49%) were borderline equivalent at the end of follow-up. Clinical response was seen in 80% of evaluable patients in the 100 mg/2 weeks group and in 73% in the 200 mg/1 week group at the end of follow-up (borderline equivalent). Similar results were found in the intention-to-treat analysis. The tolerability ratings for the two regimens were significantly equivalent. Thirteen patients (24%) in the 100 mg/2 weeks group but only nine (15%) in the 200 mg/1 week group reported adverse events during treatment. Two patients in the 200 mg/1 week group stopped treatment because of adverse events. No clinically significant changes were seen in laboratory parameters in either treatment group. This trial showed that itraconazole 200 mg for 1 week is similarly effective, equally well tolerated and at least as safe as the established regimen of itraconazole 100 mg for 2 weeks in the treatment of tinea corporis or cruris.

Multiple functions of the transcribed spacers in ribosomal RNA operons

rRNA operons contain about 25% transcribed spacer sequences in addition to the 16S, 23S, 5S and tRNA genes. The spacer sequences are removed from the primary rRNA transcript by a series of co-ordinated nucleolytic events. Besides the role in rRNA processing, the spacer sequences are also involved in transcription and the ribosome assembly. In this study we analyze the spacer between tRNA and 23S rRNA genes. Based on computer modeling and chemical probing data, a model for the transient secondary structure of the intergenic spacer is proposed. Mutational analysis has shown that the transient secondary structure around the 5' end of 23S rRNA is involved in ribosome assembly. We propose that the transient structure at the 5' end of 23S rRNA directs 23S rRNA folding into the mature structure and facilitates ribosomal large subunit assembly.

Base-pairing of 23 S rRNA ends is essential for ribosomal large subunit assembly

In ribosomal RNA precursors the spacer sequences bracketing mature 16 S and 23 S rRNA are base-paired to form long helices (processing stems). In pre-23 S rRNA, the processing stem is continued by eight base-pairs of mature 23 S rRNA known as helix 1. Recently, we have found that any part of 23 S rRNA between positions 40 and 2773 could be deleted without the loss of ribosome-like particle formation, while both end regions were indispensable. In this paper we have analyzed the role of the 5' and 3' end regions of 23 S rRNA during ribosomal 50 S assembly in vivo by using mutants of the 23 S rRNA gene. Deletions and substitutions in both strands of the helix 1 lead to the loss of plasmid derived 50 S formation. Compensatory mutations restoring helix 1 were assembled into functional 50 S subunits. We conclude that the helix 1 of 23 S rRNA is the main RNA determinant for ribosomal large-subunit assembly. Deletions in both the 5' and 3' strand of the processing stem reduced the ability of the 23 S rRNA to form ribosomal 50 S subunits. However, even the complete removal of either the 5' or the 3' strand of the processing stem did not abolish the 50 S assembly completely. Thus, processing stem facilitates, but is not essential for assembly.

Mutational analysis of the donor substrate binding site of the ribosomal peptidyltransferase center

Previous experiments have shown that the top of helix 90 of 23S rRNA is highly important for the ribosomal peptidyltransferase activity and might be part of the donor (P) site. Developing on these studies, mutations in the 23S rRNA at the highly conserved positions G2505, G2582, and G2583 were investigated. None of the mutations affected assembly, subunit association, or the capacity of tRNA binding to A and P sites. A "selective transpeptidation assay" revealed that the mutations specifically impaired peptide bond formation. Results with a modified "fragment" assay using the minimal donor substrate pA-fMet are consistent with a model where the nucleotides psiGG2582 form a binding pocket for C75 of the tRNA.

An A to U transversion at position 1067 of 23 S rRNA from Escherichia coli impairs EF-Tu and EF-G function

Escherichia coli ribosomes with an A to U transversion at nucleotide 1067 of their 23 S rRNA are impaired in their effective association rate constants (kcat/KM) for both EF-Tu and EF-G binding. In addition, the times that EF-G and EF-Tu spend on the ribosome during elongation are significantly increased by the A to U transversion. The U1067 mutation impairs EF-Tu function more than EF-G function. The increase in the time that EF-Tu remains bound to ribosome is caused, both by a slower rate of GTP-hydrolysis in ternary complex and by a slower EF-Tu.GDP release from the mutated ribosomes. There is, at the same time, no change in ribosomal accuracy for aminoacyl-tRNA recognition. With support from these new data we propose that nucleotide 1067 is part of the ribosomal A-site where it directly interacts with both EF-G and EF-Tu.

Mutational analysis of two highly conserved UGG sequences of 23 S rRNA from Escherichia coli

The 23 S-type rRNA contains two phylogenetically conserved UGG sequences, which have the potential to bind the universal CCA-3'-ends of tRNAs at the ribosomal peptidyltransferase center by base pairing. The first two positions, UG, of these sequences at the helix-loop 80 (U2249G2250) and helix-loop 90 (Psi2580G2581) and some related nucleotides were tested by site-directed mutagenesis for their involvement in ribosomal function, i.e. peptidyltransferase. The plasmid-derived mutated 23 S rRNA comprised about 50% of the total 23 S rRNA. None of the single mutations caused an assembly defect, and all 50 S subunits carrying an altered 23 S rRNA could freely exchange with the pools of 70S ribosomes and polysomes. The mutations at the helix-loop 80 region hardly affected bacterial growth. However, mutations at the helix 90 caused severe growth effects and severely impaired the in vitro protein synthesis, showing that this 23 S rRNA region is of high importance for ribosomal function.

Analysis of the ribosome large subunit assembly and 23 S rRNA stability in vivo

The ability of mutant 23 S ribosomal RNA to form particles with proteins of the large ribosomal subunit in vivo was studied. A series of overlapping deletions covering the entire 23 S rRNA, were constructed in the plasmid copy of an E. coli 23 S rRNA gene. The mutant genes were expressed in vivo using an inducible tac promoter. Mutant species of 23 S rRNA, containing deletions between positions 40 and 2773, were incorporated into stable ribonucleoprotein particles. In contrast, if one end of the 23 S rRNA was deleted, the mutant rRNA was unstable and did not form ribosomal particles. Protein composition of the mutant particles was specific; the presence of the primary rRNA-binding proteins corresponded to their known binding sites. Furthermore, several previously unknown ribosomal protein binding sites in 23 S rRNA were identified. Implications of the results on ribosome assembly are discussed.

The impact of five years of annual ivermectin treatment on skin microfilarial loads in the onchocerciasis focus of Asubende, Ghana

Following the registration of ivermectin (Mectizan) for human use in the treatment of onchocerciasis, in 1987 the Onchocerciasis Control Programme in West Africa (OCP) begun a series of trials in order to determine the safety of the drug when used on a large scale and its potential for morbidity control. This paper reports the changes in skin microfilarial loads during the first 5 years of annual treatment in the holoendemic focus of Asubende in Ghana, which was the largest trial area and which also had the longest series of follow-up surveys. The general observed pattern was a marked reduction of microfilarial loads shortly after each treatment followed by a steady repopulation of the skin until a subsequent treatment round. The overall reduction of microfilarial loads observed between the base line survey and one year after the last treatment was 90% for the total population examined and over 93% for a cohort which received the drug at all 5 treatment rounds. In contrast, there was only a very gradual decrease in the prevalence of infection in the population after subsequent treatments. The study further emphasizes that even a single treatment with ivermectin has a significant medium-term impact on microfilarial loads. Microfilarial counts barely increased after 14-16 months of treatment and stabilized around 55% of pre-treatment counts 2-4 years after a single treatment.

Distribution of onchocerciasis in selected river basins of four west African countries

Detailed epidemiological mapping of eight river basins was conducted in four West African countries as part of an effort to identify the communities at risk of onchocercal blindness to guide a programme of large scale ivermectin distribution, attempting control of eye disease. The results show a surprising variability of pattern in the geographical distribution of intensity of onchocerciasis infections in the communities of the river basins investigated. These patterns were at time very different from what was expected on the basis of the available entomological and demographic information. The technique of detailed mapping proved very useful in achieving an excellent coverage of the communities at risk of onchocercal blindness where, so far, satisfactory treatment coverage has been attained for four consecutive yearly treatments.

Coupling of rRNA transcription and ribosomal assembly in vivo. Formation of active ribosomal subunits in Escherichia coli requires transcription of rRNA genes by host RNA polymerase which cannot be replaced by bacteriophage T7 RNA polymerase

Transcription of a plasmid-located rrnB operon and the corresponding formation of ribosomes in vivo were studied using either T7 RNA polymerase or host RNA polymerase as transcriptase. The 23 S rRNA gene on the plasmid carried an A1067-->T mutation, which confers resistance against the drug thiostrepton. The proportion of particles containing plasmid-borne 23 S rRNA versus chromosome-borne rRNA was quantified with a precision of better than 10% by scanning sequence autoradiograms around nucleotide 1067. The activity of these particles was determined in the presence of thiostrepton which exclusively abolishes the activity of chromosomal wild-type ribosomes. When the plasmid rrnB operon was transcribed with phage T7 RNA polymerase, up to 80% of the rRNA synthesis was plasmid-directed (pulse labelling) in the late induction phase, most of which (about 85%) became degraded. The cells accumulated 50 S particles with plasmid-borne intact rRNA that was hardly found in 70 S ribosomes, i.e. particles harbouring plasmid-borne rRNA did not enter the pool of active ribosomes. The particles with plasmid-derived rRNAs were also practically inactive in protein synthesis in vitro. However, the rRNA was functional as shown by reconstitution analysis. The same patterns were found at various expression levels of the plasmid rrnB operon, indicating that not the overproduction of rRNA but rather the T7 transcriptase was responsible for the observed effects. However, when the plasmid rrnB operon was transcribed with host RNA polymerase, growth was not affected upon induction, the 30 S to 50 S to 70 S ratios in the cell were not altered, both 50 S subunits and 70 S ribosomes contained large amounts of plasmid-borne rRNA, and the particles with plasmid-derived rRNA were active in vitro. When the induction of rRNA transcription by T7 RNA polymerase was performed at 25 degrees C instead of 37 degrees C, an almost normal pattern was observed. Inactive 50 S particles did not accumulate, and large amounts of plasmid-borne rRNA were found in the pool of 70 S ribosomes. Lowering the induction temperature reduces the transcription rate by T7 RNA polymerase, which is five times faster at 37 degrees C than the host polymerase. The results suggest that the formation of active ribosomal subunits in vivo requires a fine adaptation of the transcription rate of rRNAs and the assembly process, underlining the importance of a coupling between rRNA transcription and ribosome assembly in vivo. T7 RNA polymerase cannot replace the host RNA polymerase in this process at 37 degrees C.

Distribution and severity of onchocerciasis in southern Benin, Ghana and Togo

The Onchocerciasis Control Programme in West Africa has recently extended its operation in southern Benin, Ghana and Togo. To estimate the number of people infected and blinded by onchocerciasis and to describe the distribution and severity of the disease in the extension area, 99 villages were selected, using a stratified random sampling procedure, and surveyed. All the ecological and entomological information available was used in the sampling procedure and in the selection of 87 non-representative villages surveyed to confirm the findings. The study estimated that 590,468 people are infected and 11,715 blind from onchocerciasis out of a rural population of 1,878,234. The Pru, Asukawkaw and Mono river basins were areas with high risk of onchocercal blindness. The Oueme and Zou river basins in Benin and the mountainous areas between Ghana and Togo were classified as areas with medium risk of onchocercal blindness. The other parts of the study area presented low or no risk of onchocercal blindness. By detecting the river basins where villagers are at risk of onchocercal disease this study permits the selection of populations for disease control based on mass distribution of ivermectin, a microfilaricide.

Novel mutants of 23S RNA: characterization of functional properties

Single point mutations corresponding to the positions G2505 and G2583 have been constructed in the gene encoding E.coli 23S rRNA. These mutations were linked to the second mutation A1067 to T, known to confer resistance to thiostrepton (1). Mutant ribosomes were analyzed in vitro for their ability to direct poly(U) dependent translation, their missence error frequency and in addition their sensitivity to peptidyltransferase inhibitors. It was evident that the mutated ribosomes had an altered dependence on [Mg2+] and an increased sensitivity to chloramphenicol during poly(U) directed poly(Phe) synthesis. In a transpeptidation assay mutated ribosomes were as sensitive to chloramphenicol as wild-type ribosomes. However, the mutant ribosomes exhibited an increased sensitivity to lincomycin. An increase in translational accuracy was attributed to the mutations at the position 2583: accuracy increased in the order G less than A less than U less than C.

Ocular onchocerciasis and the intensity of infection in the community. IV. The degraded forest of Sierra Leone

To assess the pattern of onchocercal ocular disease and blindness in south Sierra Leone, ophthalmological surveys were carried out in 13 highly infected villages located in various river basins. The most important finding was the blinding potential of onchocerciasis in the degraded forest area where the prevalence of onchocercal blindness reached levels of up to 6%. This is remarkable since previous studies have claimed onchocerciasis in the forest to cause little blindness. Ocular onchocerciasis undoubtedly constitutes a problem of public health importance in south Sierra Leone. The rates of onchocercal ocular disease and blindness, however, were significantly lower than those found in savanna villages with similar levels of endemicity. The community pattern of ocular onchocerciasis was not significantly different from the classical pattern in the forest but this could be explained by the low endemicity levels in the forest villages studied. It is therefore not possible to deduce from this study whether the pattern of ocular onchocerciasis in south Sierra Leone is of the forest type, or a pattern on its own.

Onchocerca volvulus DNA probe classification correlates with epidemiologic patterns of blindness

Onchocerciasis, or river blindness, results from infection with Onchocerca volvulus. The parasite is endemic to West Africa, in both rain forest and savanna bioclimes. Several lines of evidence suggest that different strains of the parasite exist in the rain forest and savanna. Furthermore, epidemiologic evidence indicates that ocular onchocerciasis is most severe in savanna regions. This has led to the hypothesis that there is a strain association with ocular pathology. To test this hypothesis, parasites from villages in which severe and mild onchocerciasis were endemic were classified with two strain-specific DNA probes. A strong correlation (P less than .001) was found between disease severity and probe recognition, supporting the hypothesis that pathogenicity is strain related. The results suggest that pFS-1 and pSS-1BT may be used to predict the pathogenic potential of parasite populations throughout much of West Africa.

Importance of migrants infected with Onchocerca volvulus in west African river valleys protected by 14 to 15 years of Simulium control

A study was done to determine the importance of human migration from non-controlled endemic onchocerciasis foci to the river valleys that have been protected for the past 14 to 15 years by the vector control operations of the Onchocerciasis Control Programme in West Africa. The aim of the study was to assess the contribution of migrants to the prevalence and intensity of infection in villages from 5 major river valleys and their potential role in causing relapse of transmission once the vector is allowed to return. In Burkina Faso the migrant population varied from 0.0% to 18.1% of the village population, and averaged 4.9%. Migrants accounted only for 0.6% of the population in Ghanaian and Ivorian villages along the Black Volta river. The prevalence of infection was significantly higher in migrants (8.2%) than in non migrants (1.1%) in the surveyed villages in Burkina Faso, and 1.5% of migrants had infections with more than 16 microfilariae per snip as against 0.2% of non migrants. Nearly all infected migrants came from the south of the Côte d'Ivoire. The study shows that human migration has caused the importation of Onchocerca volvulus from non-controlled areas. However, the epidemiological importance of this phenomenon is limited because of the very small number of infected migrants per village while two-third of the infected migrants are believed to be infected with the less pathogenic forest strain of the parasite. Because migration patterns changes geographically and over time similar studies will be continued on a regular basis.

Onchocerciasis infection in children born during 14 years of Simulium control in West Africa

The incidence of onchocerciasis infection in children born since the start of vector control is one of the indicators used in the epidemiological evaluation of the Onchocerciasis Control Programme in West Africa (OCP). Though initially of littel value, after a decade of control it has become a sensitive indicator of residual transmission. The results of 14 years of control are reported. In 179 villages parasitological surveys were undertaken at intervals of 3-4 years. 15,286 children were examined and 110 were found to be infected, compared to an expected number of 2467 infected had there been no control. There was considerable geographical variation in the results. In the large central OCP area the results were excellent. Of 12,172 children examined in 127 villages, only 23 were found to be infected compared to an expected number of 1960 without control. This suggests that larviciding had achieved a 99% reduction in the incidence of infection in children. Additional surveys in 2 foci in the central OCP area where transmission had relapsed showed that these problems were very localized. Most villages with infected children were found in OCP border areas in the east and west, which had been reinvaded by infective vectors from elsewhere, and in the intermediate area between forest and savanna in Côte d'Ivoire where there had been partial control failures because of resistance. The incidence of infection in children was reduced by an estimated 68% in the eastern reinvaded area, by 87% in the western reinvaded area, and by 84% in the intermediate area.

Changes in ocular onchocerciasis after two rounds of community-based ivermectin treatment in a holo-endemic onchocerciasis focus

In a longitudinal study to determine the effect of annual community-based treatment of ocular onchocerciasis with ivermectin, the population living in the 3 most affected villages in the holo-endemic onchocerciasis focus of Asubende in Ghana were re-examined 16 and 24 months after initiating treatment. Ocular microfilarial loads had decreased to very low levels in nearly all of the 334 examined persons who were treated twice. Only very few subjects had ocular loads of 32 microfilariae or more in the anterior chamber of the eye, but this was not associated with deterioration of ocular lesions. Important regression of both early and advanced lesions of the anterior segment of the eye was observed, which was highly statistically significant with respect to iridocyclitis. Lesions of the posterior segment of the eye remained stable. Though no systematic change in the visual acuity of the population was observed, 3 new cases of blindness occurred in persons who already had eye lesions at such an advanced stage that ivermectin treatment could no longer affect the outcome. The results suggest that annual ivermectin treatment is adequate to control onchocercal ocular disease even in populations with very high endemicity levels.

The reproductive lifespan of Onchocerca volvulus in West African savanna

The epidemiological model ONCHOSIM--a model and computer simulation program for the transmission and control of onchocerciasis--has been used to determine the range of plausible values for the reproductive lifespan of Onchocerca volvulus. Model predictions based on different lifespan quantifications were compared with the results of longitudinal skin-snip surveys undertaken in 4 reference villages during 13 to 14 years of successful vector control in the Onchocerciasis Control Programme in West Africa. Good fits between predicted and observed trends in skin microfilarial loads could be obtained for all villages. It is concluded that the reproductive lifespan of the savanna strain of O. volvulus lies between 9 and 11 years, and that 95% of the parasites reach the end of reproduction before the age of 13 to 14 years.

The risk and dynamics of onchocerciasis recrudescence after cessation of vector control

Using a computer simulation study, we have investigated the risk and dynamics of onchocerciasis recrudescence after stopping vector control, in order to provide guidelines for operational decision-making in the Onchocerciasis Control Programme in West Africa (OCP). For this purpose, we used the microsimulation model ONCHOSIM to predict for periods of 9-15 years of vector control the ensuing risk and dynamics of recrudescence in an onchocerciasis focus. The model was quantified and validated using OCP evaluation and field research data. A range of plausible values was determined for important confounding parameters, i.e., vector biting rate, variation in exposure between individuals, parasite life span, and the relation between skin microfilarial load and vector infection. Different model quantifications were used in order to take account of the possible confounding effect of these parameters on the prediction of recrudescence. In the absence of immigration of infected humans or invasion by infected flies, the model predicts that 14 years of full-scale vector control are required to reduce the risk of recrudescence to less than 1%. The risk depends, in particular, on the vector biting rate, and this has implications for the planning of post-larviciding surveillance. Recrudescence will be a relatively slow process, and its rate will depend on the duration of vector control. Even if vector control were stopped too early, i.e., after 12-13 years in a highly endemic area, it would take more than 20 years before the intensity of infection in the community would reach levels of public health importance.

Onchocerciasis distribution and severity in five West African countries

The Onchocerciasis Control Programme in West Africa recently extended its operation to Guinea, Guinea-Bissau, the western part of Mali, Senegal and Sierra Leone. To estimate the number of people infected and blinded by the disease and to determine its distribution and severity in the extension area, 215 villages were selected, using a stratified random sampling procedure, and surveyed. All the relevant entomological information available at the time was used in the sampling procedure and in the selection of 92 non-representative villages that were surveyed to confirm the findings. In addition, the populations of 608 villages were examined to map out in detail the distribution of onchocerciasis in the areas at a high risk of onchocercal blindness. The study estimated that 1,475,367 people were infected and 23,728 were blinded from onchocerciasis out of a rural population of 4,464,183. The northern and western part of the study area and the lower Niger basin presented a low or no risk of onchocercal blindness. The upper Niger basin, the south-central part of Sierra Leone, and three small foci in the Gambia, Bakoye, and lower Niger river basins were areas with a high risk of onchocercal blindness. The other parts of the study area presented a medium risk of onchocercal blindness. By detecting the communities at risk of onchocercal disease this study permits the selection of populations for disease control based on mass distribution of ivermectin, a microfilaricide.

Detailed epidemiological mapping of three onchocerciasis foci in West Africa

Detailed epidemiological mapping of three isolated foci of hyperendemic blinding onchocerciasis was undertaken in three West African countries as part of community trials of ivermectin, a new microfilaricide for the treatment of human onchocerciasis. The results show that the geographical distribution of the prevalence and intensity of onchocerciasis infection in the community can be very different from what was expected on the basis of demographic and entomological information. The technique of detailed epidemiological mapping is an important tool for the identification of target populations for large scale ivermectin treatment of onchocerciasis. It is being used extensively in the Onchocerciasis Control Programme in West Africa.

Ocular onchocerciasis and intensity of infection in the community. III. West African rainforest foci of the vector Simulium sanctipauli

The community pattern of ocular onchocerciasis is described for 11 villages from the forest area in Côte d'Ivoire where S. sanctipauli is the princial vector. An analytical method is applied which relates indices of ocular onchocerciasis with the Community Microfilarial Load (CMFL) and compares the results with the ocular onchocerciasis pattern found in the West African savanna. In spite of high transmission levels as estimated by entomological indices, the CMFLs were relatively low which complicated the characterization of the ocular disease pattern. Nevertheless, it could be shown that ocular onchocerciasis is less severe in the Sanctipauli forest than in the savanna, even after correction for differences in CMFL. The prevalence of onchocercal eye lesions and blindness were low and advanced sclerosing keratitis was completely absent. The differences are explained by presuming strain differences of the parasite Onchocerca volvulus. For given CMFLs the mean microfilarial loads in the eye were significantly lower than in the savanna which suggests that the parasite strain in the Sanctipauli forest is less invasive to the eye. Ocular microfilarial loads were too low to determine if the parasite is also less pathogenic to the eye, as has been concluded previously for foci of S. yahense, but this possibility cannot be excluded.

Changes in ocular onchocerciasis four and twelve months after community-based treatment with ivermectin in a holoendemic onchocerciasis focus

The impact of ivermectin mass treatment on ocular onchocerciasis was studied in a holoendemic focus of blinding onchocerciasis in Ghana. A cohort of 417 persons, 369 of whom were treated, was followed up at 4 and 12 months after treatment. The mean ocular microfilarial load in the anterior chamber of the eye and in the cornea of treated persons was reduced to less than 20% and 10% of the pretreatment levels respectively at the 4 months follow-up but had increased significantly by 12 months. Lesions of the eye at the advanced stage of development remained stable. There was significant regression of early lesions of the anterior segment of the eye, particularly iridocyclitis, after ivermectin treatment. In view of the substantial increase of ocular microfilarial loads after 12 months, 6-monthly treatment may be indicated in such highly endemic foci. However, long-term observation is needed to give a correct estimate of the full benefit to be derived from mass treatment with ivermectin.

A community trial of ivermectin in the onchocerciasis focus of Asubende, Ghana. I. Effect on the microfilarial reservoir and the transmission of Onchocerca volvulus

A community trial of the microfilaricide ivermectin was undertaken in an isolated focus of hyperendemic savanna onchocerciasis in Ghana. One of the objectives was to determine the effect of mass treatment on the microfilarial reservoir and on the transmission of Onchocerciasis volvulus. Since 1978 the focus has been under entomological surveillance. This was intensified from 1 September 1987 till 11 February 1988 with daily vector collection and dissection of over 30,000 flies. A total of 14,991 people were treated with ivermectin on 7-10 October 1987. Skin snip surveys were done pre-treatment, and at two and four months after treatment. The mean skin microfilarial load in treated persons had fallen by more than 96% two months after treatment. During the next two months there was an increase in microfilaria loads which appeared to be faster than reported in the clinical trials. The total reservoir of skin microfilariae available for transmission had been reduced by an estimated 68%-78% two months after treatment. This was consistent with the entomological results which indicated a reduction in transmission of 65%-85% during the first three post-treatment months. The present study has shown for the first time that mass chemotherapy can significantly reduce onchocerciasis transmission. However, the remaining level of transmission was still unacceptably high and further studies are required to predict the long term impact of repeated mass treatment.

A community trial of ivermectin in the onchocerciasis focus of Asubende, Ghana. II. Adverse reactions

A community trial of the microfilaricide ivermectin undertaken in an hyperendemic focus of blinding onchocerciasis in Ghana. One objective was to investigate the safety of this new drug when used in mass treatments. 14,911 persons (61.5% of the census population) were treated with ivermectin. Of these, 15% reported with adverse reactions which were generally similar to those reported in the clinical trials. However, cutaneous reactions were relatively less frequent while brawny oedema of the limbs and inguinal gland pain were important. The severe reactions consisted of 37 cases of Severe Symptomatic Postural Hypotension (SSPH), 13 cases of severe fever and two cases of severe dyspnoea. The latter two cases represented life threatening situations, but there was no evidence that they were complications of ivermectin treatment. Only four of the SSPH cases required treatment. All severe adverse reactions were managed successfully and recovered within one day, usually within a few hours. The incidence of adverse reactions was highest the first day after treatment. Thirteen cases of delayed reactions were reported during a four-week follow-up. There was a highly significant relationship between incidence of adverse reactions and intensity of infection but no relation with ivermectin dosage within the range of 130-200 mcg/kg. The results suggest that ivermectin is sufficiently safe to be used in mass treatments. However, mass distribution of this drug should not be undertaken without adequate monitoring.

Ocular onchocerciasis and intensity of infection in the community. I. West African savanna

A method is introduced for the analysis of community patterns of ocular onchocerciasis in relation to the intensity of infection as measured by the Community Microfilarial Load (CMFL). Specific features of this method are the clear definition of ocular lesions and their separation into early and advanced stages, and the estimation of the prevalence of onchocercal blindness after exclusion of other causes of blindness. The method is applied to the ophthalmological and parasitological data from 33 villages from the West African savanna in order to obtain a reference pattern for subsequent analyses of ocular onchocerciasis patterns from other bioclimatic zones. In the savanna, there exists a clear linear relationship between most indices of ocular onchocerciasis and the CMFL. Mean ocular microfilarial loads, prevalences of the advanced lesions of the anterior and posterior segment of the eye and prevalences of different classifications of blindness show a high degree of correlation with the CMFL, as does also early sclerosing keratitis. The correlation is poor for the other early ocular lesions. All relationships are similar for the two sexes with the exception of posterior segment lesions which remain more common in males after correction for intensity of infection. The CMFL is superior to the prevalence of microfilariae in the skin as an index of endemicity. It allows a good prediction of the severity of onchocercal ocular disease in savanna communities using parasitological information only.

Ocular onchocerciasis and intensity of infection in the community. II. West African rainforest foci of the vector Simulium yahense

A novel method of analysis was used to describe community patterns of ocular onchocerciasis in relation to the intensity of infection in West African forest villages where S. yahense is the sole vector. The pattern is completely different from that found in the savanna, even after correction for the intensity of infection as measured by the Community Microfilarial Load (CMFL). Lesions of the anterior segment of the eye as well as onchocercal blindness either do not occur or occur only sporadically with increasing CMFL in the Yahense forest whilst a steep linear relation exists between the prevalence of these lesions and the CMFL in the savanna. Lesions of the posterior segment of the eye are also less common in the Yahense forest. For a given skin microfilarial load, the ocular microfilarial load is lower in the Yahense forest. For a given ocular microfilarial load, a lower prevalence of eye lesions is found in the Yahense forest compared to the savanna. It is concluded that microfilariae of Onchocerca volvulus in the Yahense forest are less eye invasive than microfilariae from the savanna. Furthermore, they appear to be also less pathogenic to the eye. These findings explain why ocular onchocerciasis is relatively mild in the Yahense forest, in spite of the high intensities of O. volvulus infection in the community.

The third ribosomal tRNA-binding site, the E site, is occupied in native polysomes

The nucleic acids of Escherichia coli cells were uniformly labelled with 32P by growing the cells in [32P]orthophosphoric acid for about four generations. The cells were harvested in the logarithmic phase, resuspended in a buffer containing 6 mM Mg2+, 150 mM NH4+ and polyamines and incubated for 3 min at 37 degrees C in the presence of 3H-labelled amino acids. This procedure preferentially labels growing peptidyl chains. Polysomes were isolated, the fraction in the post-translocational state was assessed by a puromycin reaction and the tRNA content/70S ribosome was quantified in comparison to the amount of 5S rRNA determined after separation by gel electrophoresis. The data revealed that at least 75% of post-translocational ribosomes in isolated native polysomes carry a tRNA in their E site. The results are consistent with the allosteric three-site model for the elongation cycle but disagree with the two-site model.

Adverse reactions after large-scale treatment of onchocerciasis with ivermectin: combined results from eight community trials

Eight community trials were carried out by the Onchocerciasis Control Programme in West Africa to determine the safety of the new microfilaricide ivermectin during large-scale treatment of onchocerciasis. The trial areas were located in eight different countries and varied greatly in endemicity level; a total of 50,929 persons were treated and monitored for 72 hours. Overall treatment coverage was 60% of the census population, the main reasons for non-treatment being the exclusion criteria. Of those treated, 9% reported with adverse reactions, 2.4% with moderate reactions, and 0.24% with severe reactions. Most reactions were reported during the first day of follow-up, the most frequent severe reaction being severe symptomatic postural hypotension (in 49 cases). Three cases of severe dyspnoea were life-threatening but their relationship with ivermectin treatment is uncertain. The incidence of adverse reactions was directly related to skin microfilarial load and was highest in the foci with the highest endemicity levels. Treatment resulted in 98% reductions in mean microfilarial loads at all endemicity levels. The benefit of treatment largely compensated for the discomfort due to adverse reactions, which were all transient and managed successfully. Ivermectin thus appears to be sufficiently safe for large-scale treatment but monitoring by resident nurses for at least 36 hours is recommended.

Population dynamics of Onchocerca volvulus after 7 to 8 years of vector control in West Africa

In an attempt to describe the changing population dynamics of Onchocerca volvulus during a period of vector control, nodulectomies were undertaken in 256 patients from ten villages in the Onchocerciasis Control Programme (OCP) and in 74 patients from two villages in an area with ongoing transmission. A total of 1198 nodules were excised and 4350 adult worms were isolated and examined for viability and productivity. In the OCP villages, the worm population is ageing and dying without replacement by new generations of parasites and various findings signal a breakdown of the worm population after about 12 years interruption of transmission. The sexual activity of the worms was significantly reduced. A Productivity Index was developed to measure the microfilariae production at the nodule level. The reduction in this index for the OCP villages correlates closely with the decline over the control period in the community microfilarial loads in the skin. The results show that it is not only the longevity of the parasite which will determine the duration of vector control, but that the reduced productivity of the ageing parasite population is of equal importance.

[Role of children in the evaluation of the Onchocerciasis Control Program in West Africa]

Incidence of onchocercal infections is studied in children borne since the start of the larvicidal treatments of the Onchocerciasis Control Programme in West Africa (OCP). A total of 8088 children, originating from 155 villages widely distributed throughout the initial area of the OCP were examined for microfilariae of O. volvulus. 37 were found infected. If there had not been control measures, 652 children would normally have become infected in such a sample. It is considered that in the centre of the OCP area which constitutes approximately 90% of the total, transmission has been interrupted (1 child infected among 5,886 examined in the centre). The remaining 36 cases are spread over two quite distinct marginal zones of the OCP where transmission persisted because of reinvasion by blackflies coming from untreated areas, or because of insecticide vector resistance, or because of occasional treatment failures. The entomological indices confirm perfectly the epidemiological findings in the central region as well as in the marginal zones.

A force-of-infection model for onchocerciasis and its applications in the epidemiological evaluation of the Onchocerciasis Control Programme in the Volta River basin area

A simple force-of-infection model for onchocerciasis has been developed for a study of the age-specific epidemiological trends during a period of vector control in the Onchocerciasis Control Programme in the Volta River basin area (OCP). The most important factors included in the model are the longevity of an infection, the aspect of super-infection, age-specific exposure, and the intensity of transmission during the pre-control period. The aim of the study was to determine the most appropriate statistics for the epidemiological evaluation in the OCP. There was generally good agreement between the epidemiological trends, predicted by the model, and the observed trends in the prevalence and mean load of microfilariae in skin snips taken from a cohort population from 23 villages in an area with 8 years of successful vector control in the OCP. It is concluded that the epidemiological trends during the control period are not uniform but depend on the initial age and the initial endemicity level of the population. The epidemiological indices for cohorts of children, born before the start of control, will not show a decrease during the first 8 years of interruption of transmission. The prevalence is too insensitive to be useful for the evaluation in hyperendemic villages during most of the control period. The most sensitive and meaningful statistic for a comparative analysis and for the assessment of epidemiological changes is the geometric mean microfilarial load in a cohort of adults. This index, which is called the Community Microfilarial Load (CMFL), is now routinely used in the OCP. The new analytical methodology has enabled a much better appreciation of the significant epidemiological impact of 8 years of vector control in the OCP. Several related aspects of the pre- and post-control dynamics of onchocerciasis infection are also discussed and priorities are formulated for further work on applied modelling of onchocerciasis.

The properties of the complex between ribosomal protein L2 and tRNA

Escherichia coli ribosomal protein L2 interacts with fMet-tRNAfMet and NacPhe-tRNAPhe in solution, protecting their 3'-ends from enzymatic degradation. At the same time L2 enhances the rate of spontaneous hydrolysis of the ester bonds between terminal riboses and amino acyl moieties of these two peptidyl-tRNA analogues. L2 has, however, only a slight effect on the rate of spontaneous deacylation of aminoacyl-tRNAs. We suggest that the role of L2 is in the fixation of the aminoacyl stem of tRNA to the ribosome at its P-site, and speculate that this protein is directly involved in the peptidyl transferase (PT) reaction.

The force of measles infection in East Africa

Catalytic models were applied to age-specific incidence data from two East African studies in order to study the force of measles infection in relation to age. The results are compared with the pattern observed in England and Wales. In East Africa the force of measles infection appears to be independent of age, probably as a result of sociocultural factors. Consequently the incidence of measles is highest in the second half of the first year of life and decreases with increasing age. Major vaccination efforts will raise the average age of measles attack, but the peak incidence will remain in the first year of life. This complicates the decision on the optimal age for vaccination and the need for incidence surveillance is stressed. The simple catalytic model, which is based on the assumption of an age-independent force of infection may play an important role in measles surveillance. With this model simple and economic surveillance studies could be designed which use cross-sectional data only.

Ribosomal protein L16 binds to the 3'-end of transfer RNA

Escherichia coli 50 S ribosomal subunits were reconstituted with and without protein L16 present. The latter particles, although active in puromycin reaction, were unable to use CACCA-Phe as an acceptor substrate. We also found that L16 interacts directly with this oligonucleotide and, in the complex with tRNA, protects its 3'-end from pancreatic ribonuclease digestion. We suggest that the role of L16 is in the fixation of the aminoacyl stem of tRNA to the ribosome at its A-site.

Current measles control in Tanzania

Measles is one of the major public health problems in Tanzania and is recognized as such by the population. Since 1975 measles vaccination has been given as part of the national expanded immunization program. On the basis of the findings of measles surveys and a vaccination trial, the policy of vaccination at six months of age has been changed to that of vaccination at nine months of age, and malnourished children are now vaccinated. Vaccination coverage is unsatisfactory because many villages are too far from health units and because measles vaccination has low credibility. The epidemiology of measles appears to be changing as a result of vaccination, and the age of vaccination may have to be modified in the future. A policy of vaccinating each child twice is being considered as well as one of vaccinating sick children who are attending maternal and child health clinics. At present eradication of measles is not a realistic target for countries such as Tanzania.

The interaction of ribosomal protein L16 and its fragments with tRNA

Two large proteolytic fragments of Escherichia coli 50 S ribosomal subunit protein L16 were generated by limited hydrolysis with chymotrypsin (missing 9 N-terminal amino acids) and trypsin (missing 16 N-terminal amino acids). It was found that while intact L16 and its chymotryptic fragment both interact with tRNA (Kd = 5.4 x 10(-7) M), the tryptic fragment does not. These results are interpreted in terms of possible significance of the residues 10-16 in the peptidyl transferase activity.

Hairy cell leukaemia. Clinical features and effect of splenectomy

Hairy-cell leukaemia (leukaemic reticuloendotheliosis) is a well-defined clinical entity. Most of the recent reports are almost entirely concerned with the pathological and functional aspects of the disease. In the present retrospective study the clinical features and laboratory data of 12 patients were analyzed together with a series of 123 adequately clinically documented cases from the literature. The Hb level and the sex of the patient proved to be the only parameters having some prognostic value for the survival time after diagnosis. The effect of splenectomy was assessed in two comparable groups of 24 splenectomized and 51 non-splenectomized patients. The operation seemed to be beneficial, but after 2 years the difference was not significant(.05 less than P less than .10). Analysis of subgroups showed that splenectomy was definitely beneficial in women, in patients with a Hb level over 8.0 g/dl or a platelet level above 50 X 10(9)/1, in patients with leucocytes below 3 X 10(9/1, , and also in patients with hepatomegaly (P less than .05 in all cases). These findings suggest that splenectomy is beneficial in cases where anaemia and thrombocytopenia are not very severe; in severe cytopenia the operation does not increase the life expectancy.