Epidemiological evidence for an association between chloroquine resistance of Plasmodium falciparum and its immunological properties

The appearance of chloroquine-resistant genotypes o f Plasmodium falciparum has thwarted the goal of global eradication of malaria. Although much effort has been put into understanding the molecular mechanisms of chloroquine resistance, many questions about its distribution remain open: Why, some 30 years after the emergence o f chloroquine resistance, have resistant genotypes not taken over the population? Why have many parasites remained sensitive? Why, after its first appearance in Africa, has chloroquine resistance spread so rapidly through sub-Saharan Africa? In this paper Jacob Koella reviews epidemiological data that suggest that an answer to these questions may involve an association between chloroquine resistance and immunological properties o f malaria parasites.     

Malaria invasion of human erythrocytes

The invasion of human red blood cells (RBC) by plosmodiol merozoites is a key event during malaria infection, and the inhibition o f invasion is regarded as a crucial goal of malaria vaccine development. For Plasmodium falciparum it has been suggested that the red cell sialoglycoproteins, glycophorins A, B and C, are receptors for invasion and that O-linked or N-linked carbohydrate structures may be involved as receptor sites(1-3). However, recent evidence suggests that the role o f these sialoglycoproteins and carbohydrates may have been overestimated. In this article, Peter Hermentin discusses the contradictory findings and presents a revised model for the invasion process.     

A strain theory of malaria transmission

Does the fact that the risk o f getting malaria is high in most endemic areas mean that it will be impossible to control through vaccination? Not if malaria is composed of several mildly transmissible strains, and what we are measuring as the high risk is the probability of being infected by any one of the several strains circulating independently within the same area. In this article, Sunetra Gupta and Karen Day discuss a strain theory of malaria transmission that fits both recent serological and molecular observations and more conventional epidemiological data on age distributions of infection and disease. Their analyses suggest that the transmissibility of malaria has been grossly overestimated, and that the control of malaria through vaccination may be far easier than previously assumed.     

What can the residents of malaria endemic countries do to protect themselves against malaria?

The incidence of malaria may vary substantially between adjacent communities and within an individual community, even in areas of high malaria transmission. Analysis of the factors responsible for these local variations in the incidence of malaria may identify potential control measures. Factors shown to be associated with local protection against malaria in some situations include house position, house design, the use of insect repellents and mechanical barriers such as bednets and curtains. The efficacy of insecticide treated nets and curtains in preventing mortality and morbidity from malaria, at least in the short-term, has been demonstrated convincingly. However, other measures of personal protection have not been evaluated in large trials which have clinical malaria as their endpoint. Such trials are needed to see if new malaria control tools can be identified that will assist current international efforts to improve malaria control, especially in Africa. The millions of non-immune travellers who visit malaria endemic areas each year need to protect themselves against malaria and the ways in which they can do this most effectively have been studied extensively. However, less attention has been paid to the local population of malaria endemic areas. What steps can they adopt to provide personal protection against malaria and how effective are these measures? Clues to which measures might be effective can come from study of the reasons for local variations in the incidence of malaria.     

Capacity strengthening in malaria research: the Gates Malaria Partnership

The Gates Malaria Partnership (GMP) includes five African and four European partner institutions. Its research programme has five priority areas involving an extensive range of field-based studies. GMP research has contributed significantly to the development of new research consortia investigating strategies for improving means of malaria control, and has already had an impact on policy and practice. A substantial investment in innovative training activities in malaria has enhanced knowledge and practice of malaria control at all levels from policy making to local community involvement. Capacity development, notably through a PhD programme, has been an underlying feature of all aspects of the programme.     

Segregation analysis detects a major gene controlling blood infection levels in human malaria.

The profound influence that the genetic makeup of the host has on resistance to malaria infection has been established in numerous animal studies. This genetic heterogeneity is one of the main causes of the difficulties in developing an effective malaria vaccine. Segregation analysis is the first step in identifying the nature of genetic factors involved in the expression of human complex diseases, as infectious diseases. To assess the role of host genes in human malaria, we performed segregation analysis of blood parasite densities in 42 Cameroonian families by using both the unified mixed model and the class D regressive model of analysis. The results provide clear evidence for the presence of a recessive major gene controlling the degree of infection in human malaria. Parameter estimates show a frequency of .44-.48 for the deleterious allele, indicating that about 21% of the population is predisposed to high levels of infection.     

Did medicated salt hasten the spread of chloroquine resistance in Plasmodium falciparum?

With acknowledged difficulties in achieving satisfactory compliance rates for the large-scale delivery of many antiporositic drugs, the use of medicated salt has often been seen as a useful way to improve the level o f treatment in target populations. Iodinated salt is said to have contributed to a decline in endemic goitre, and salt medicated with chloroquine and/or other antimalorials, or with diethylcarbomazine, has been widely used in public health programmes against malaria and filariosis respectively. In this article, however, David Payne suggests that chloroquinized salt programmes may have been a major factor in promoting chloroquine resistance in Plasmodium falciparum.     

Why do Plasmodium falciparumm-infected erythrocytes form spontaneous erythrocyte rosettes?

Plasmodium falciparum malaria is one o f the most widespread o f human parasitic diseases and is responsible for the deaths of several million people in subtropical and tropical regions o f the world. The interaction o f malarial merozoites with erythrocytes and the adherence o f infected erythrocytes to the endothelium are among the cellular interactions extensively studied to define candidate antigens for a blood stage vaccine. However, the exact mechanisms underlying the invasion o f erythrocytes by P. falciparum merozoites and their subsequent binding to endothelium are not yet understood. Here Mats Wahlgren, Johan Carlson, Rachonee Udomsangpetch and Peter Perlmonn discuss a novel cytoodherence phenomenon which may be o f great importance in this context, that is, the spontaneous binding o f uninfected erythrocytes to those infected with late-stage parasites (trophozoites/schizonts).     

HIV and malaria: a lesson in immunology?

HIV is now common in many areas of Africa that are also highly endemic for malaria. In this article, Geoff Butcher summarizes the available data on the possible interaction o f HIV and malaria, and shows that the course of falciparum malaria is virtually unaffected by the presence of HIV. This raises significant questions for our understanding of immunity to the asexual blood stages of human malaria and the use of animal models in malaria research.     

The role of Kupffer cells in the clearance of malaria sporozoites from the circulation

In the past decade, one of the most intriguing subjects in understanding the mechanism of malaria infection has been explanation of the role of Kupffer cells. These liver cells, which play an important part in the body's defense against infection, seemed to have on essential supportive role in the homing o f sporozoites. Do Kupffer cells favor the establishment of primary malaria infection? Extensive research has revealed much, but still not everything we need to know about the sporozoite-Kupffer cell affair.     

Human T-cell responses to malaria: mostly forgotten or committed to memory?

T cells have been implicated in both malaria immunity and malaria disease and factors controlling the maintenance of T-cell responses over time may alter the clinical outcome o f infection. Michael Good and Janine Bilsborough have compared the T-cell responses to epitopes from the Plasmodium vivax and P. falciparum circumsporozoite proteins and here discuss the issue of T-cell memory as it applies to malaria.     

Insecticide resistance gene frequencies in Anopheles sacharovi populations of the Çukurova plain, Adana Province, Turkey

In Turkey, the mosquito Anopheles sacharovi has been under field selection pressure sequentially with DDT, dieldrin, malathion and pirimiphosmethyl over a period of 30 years for the purpose of malaria control. In 1984, the field population of An.sacharovi in the malarious Cukurova plain of Adana Province contained an altered acetylcholinesterase-based resistance gene giving broad spectrum resistance against organophosphorus and carbamate insecticides. The cross-resistance spectrum from this mechanism conferred resistance to malathion but not to the organophosphorus insecticide pirimiphos-methyl. Over the 6 years that pirimiphos-methyl has been applied for malaria vector control in this area, the frequency of the altered acetylcholinesterase resistance gene has declined, although in 1989 and 1990 it was still present at measurable frequencies in An.sacharovi from Cukurova. In addition to the acetylcholinesterase resistance mechanism there is evidence of an increased level of glutathione S-transferase in some of the An.sacharovi populations tested. This is known to be correlated with DDT resistance in other anophelines. In Turkish An.sacharovi, DDT resistance and elevated glutathione S-transferase occur in the same populations at similar frequencies. The continued prevalence of resistance to DDT and dieldrin, long after the 1971 cessation of DDT spraying for malaria control in Turkey, suggests that the DDT resistance gene has insufficient reduced fitness associated with it to have been lost from the field population during the past two decades. The implications of the slow decline in resistance gene frequencies in this field population are discussed in relation to mathematical models for managing resistance.     

Sphingolipid synthesis and membrane formation by Plasmodium

Plasmodium falciparum is a protozoan parasite that causes the most virulent o f human malarias. The asexual blood-stage organism invades and multiplies in a vacuole in the mature erythrocyte. During intravacuolar growth, it induces the formation of a novel network o f tubovesicular membranes, the TVM, that is not present in uninfected red blood cells. Recent data suggest that sphingomyelin biosynthesis by the parasite is an essential requirement for the assembly o f the TVM. Furthermore, sphingolipid synthesis as well as the formation and function o f the TVM may provide new targets for chemotherapy against malaria parasites.     

Secretory transport in Plasmodium

The asexual blood stage of the human malaria parasite Plasmodium falciparum resides within the mature erythrocyte - a cell that has no intracellular organelles and few biosynthetic activities. However, Plasmodium, as on actively growing and dividing cell, has numerous requirements for the uptake o f nutrients and expulsion of waste. Hence, the parasite must extensively remodel the erythrocyte to facilitate its survival, not only by exporting numerous proteins, but also by providing the requisite machinery for their .trafficking. In this review, Heidi Elmendorf and Kastun Haldar propose a model for secretion in P. falciparum.     

Combining zooprophylaxis and insecticide spraying: a malaria-control strategy limiting the development of insecticide resistance in vector mosquitoes

Strategies to eradicate the vector-borne infectious diseases (e.g. malaria and Japanese encephalitis) are often directed at controlling vectors with insecticides. Spraying insecticide, however, opens the way for the development of insecticide resistance in vectors, which may lead to the failure of disease control. In this paper, we examine whether the combined use of insecticide spray and zooprophylaxis can limit the development of insecticide resistance in mosquitoes. Zooprophylaxis refers to the control of vector-borne diseases by attracting vectors to domestic animals in which the pathogen cannot amplify (a dead-end host). The human malaria parasite Plasmodium spp. has a closed transmission cycle between humans and mosquitoes, and hence cattle can serve as a dead-end host. Our model reveals that, by a suitable choice of insecticide spraying rate and cattle density and location, malaria can, in some situations, be controlled without mosquitoes developing insecticide resistance.     

Ethical,legal and social aspects of the approach in Sudan

The global malaria situation, especially in Africa, and the problems frequently encountered in chemical control of vectors such as insecticide resistance, emphasize the urgency of research, development and implementation of new vector control technologies that are applicable at regional and local levels. The successful application of the sterile insect technique (SIT) for the control of the New World screwworm Cochliomyia hominivorax and several species of fruit flies has given impetus to the use of this method for suppression or elimination of malaria vectors in some areas of Africa including Northern State of Sudan. The research and development phase of the Northern State feasibility study has been started. Sudanese stakeholders are working side-by-side with the International Atomic Energy Agency in the activities of this important phase. Several ethical, legal and social issues associated with this approach arose during this phase of the project. They need to be seriously considered and handled with care. In this paper, these issues are described, and the current and proposed activities to overcome potential hurdles to ensure success of the project are listed.     

The role of vector control in stopping the transmission of malaria: threats and opportunities

Malaria control, and that of other insect borne diseases such as dengue, is heavily dependent on our ability to control the mosquito populations that transmit these diseases. The major push over the last decade to reduce the global burden of malaria has been driven by the distribution of pyrethroid insecticide-treated bednets and an increase in coverage of indoor residual spraying (IRS). This has reduced malaria deaths by a third. Progress towards the goal of reducing this further is threatened by lack of funding and the selection of drug and insecticide resistance. When malaria control was initially scaled up, there was little pyrethroid resistance in the major vectors, today there is no country in Africa where the vectors remain fully susceptible to pyrethroids. The first pyrethroid resistance mechanisms to be selected produced low-level resistance which had little or no operational significance. More recently, metabolically based resistance has been selected, primarily in West Africa, which in some mosquito populations produces more than 1000-fold resistance. As this spreads the effectiveness of pyrethroid-based bednets and IRS will be compromised. New public health insecticides are not readily available. The pipeline of agrochemical insecticides that can be re-purposed for public health dried up 30 years ago when the target product profile for agricultural insecticides shifted from broad spectrum, stable, contact-acting insecticides to narrow spectrum stomach poisons that could be delivered through the plant. A public–private partnership, the Innovative Vector Control Consortium, was established in 2005 to stimulate the development of new public health pesticides. Nine potential new classes of chemistry are in the pipeline, with the intention of developing three into new insecticides. While this has been successfully achieved, it will still take 6–9 years for new insecticides to reach the market. Careful management of the resistance situation in the interim will be needed if current gains in malaria control are not to be reversed.     

Temperature and malaria trends in highland East Africa

There has been considerable debate on the existence of trends in climate in the highlands of East Africa and hypotheses about their potential effect on the trends in malaria in the region. We apply a new robust trend test to mean temperature time series data from three editions of the University of East Anglia's Climatic Research Unit database (CRU TS) for several relevant locations. We find significant trends in the data extracted from newer editions of the database but not in the older version for periods ending in 1996. The trends in the newer data are even more significant when post-1996 data are added to the samples. We also test for trends in the data from the Kericho meteorological station prepared by Omumbo et al. We find no significant trend in the 1979-1995 period but a highly significant trend in the full 1979-2009 sample. However, although the malaria cases observed at Kericho, Kenya rose during a period of resurgent epidemics (1994-2002) they have since returned to a low level. A large assembly of parasite rate surveys from the region, stratified by altitude, show that this decrease in malaria prevalence is not limited to Kericho.     

Fever as a cause of hypophosphatemia in patients with malaria

Hypophosphatemia occurs in 40 to 60% of patients with acute malaria, and in many other conditions associated with elevations of body temperature. To determine the prevalence and causes of hypophosphatemia in patients with malaria, we retrospectively studied all adults diagnosed with acute malaria during a 12-year period. To validate our findings, we analyzed a second sample of malaria patients during a subsequent 10-year period. Serum phosphorus correlated inversely with temperature (n = 59, r = -0.62; P<0.0001), such that each 1 degrees C increase in body temperature was associated with a reduction of 0.18 mmol/L (0.56 mg/dL) in the serum phosphorus level (95% confidence interval: -0.12 to -0.24 mmol/L [-0.37 to -0.74 mg/dL] per 1 degrees C). A similar effect was observed among 19 patients who had repeat measurements of serum phosphorus and temperature. In a multiple linear regression analysis, the relation between temperature and serum phosphorus level was independent of blood pH, PCO2, and serum levels of potassium, bicarbonate, calcium, albumin, and glucose. Our study demonstrates a strong inverse linear relation between body temperature and serum phosphorus level that was not explained by other factors known to cause hypophosphatemia. If causal, this association can account for the high prevalence of hypophosphatemia, observed in our patients and in previous studies of patients with malaria. Because hypophosphatemia has been observed in other clinical conditions characterized by fever or hyperthermia, this relation may not be unique to malaria. Elevation of body temperature should be added to the list of causes of hypophosphatemia.