Molecular approaches to epidemiology and clinical aspects of malaria

Malaria is a problem of global importance, responsible for 1-2 million deaths per year, mainly in African children, as well as considerable morbidity manifested as severe anaemia and encephalopathy in young children. Fundamental to the development of new tools for malaria control in humans is an increased understanding of key features of malaria infection, such as the diversity of outcome in different individuals, the understanding of different manifestations of the disease and of the mechanisms of immunity that allow clinical protection in the face of ongoing low-grade infection (concomitant immunity or premunition). Here, Graham Brown and colleagues review some of the ways in which molecular approaches might be used to increase our understanding of the epidemiology and clinical manifestations of malaria, as discussed at the Molecular Approaches to Malaria conference (MAM2000), Lorne, Australia, 2-5 February 2000.     

Molecular approaches to malaria: seeking the whole picture

This year, Australia hosted its first major international conference on malaria - Molecular Approaches to Malaria in Lorne, Victoria, 2-5 February 2000 (MAM2000). The worldwide research effort toward a better understanding of the pathogenesis and control of malaria in the post-genomic era was discussed and debated by over 250 researchers from 18 countries during four days packed with molecular biology, cell biology, genomics, vaccines and pathogenic mechanisms. This special malaria edition of Parasitology Today is an attempt to capture and summarize the quality and breadth of work presented at the conference and place this in the context of the current global malaria research effort; eight of the nine Reviews in this issue have been written by session chairs or presenters at MAM2000.     

Malaria vaccines

Although the possibility of a live attenuated malaria vaccine has been considered, current malaria vaccine development activities are dominated by attempts to develop a subunit vaccine. Hence, it is entirely appropriate that a session of the Molecular Approaches to Malaria conference, Lorne, Australia, 2-5 February 2000, was devoted to vaccine development. The oral presentations in this session and the relevant poster presentations are outlined here by Robin Anders and Allan Saul.     

Advancements in transfection technologies for Plasmodium

Malaria is a global problem that affects millions of people annually. A relatively poor understanding of the malaria parasite biology has hindered vaccine and drug development against this disease. Robust methods for genetic analyses in Plasmodium have been lacking due to the difficulties in its genetic manipulation. Introduction of transfection technologies laid the foundation for genetic dissection of Plasmodium and recent years have seen the development of novel tools for genetic manipulation that will help us delineate the intriguing biology of this parasite. This review focuses on such recent advances in transfection technologies for Plasmodium that have improved our ability to carry out more thorough genetic analyses of the biology of the malaria parasite.     

An Open Source Business Model for Malaria

Greater investment is required in developing new drugs and vaccines against malaria in order to eradicate malaria. These precious funds must be carefully managed to achieve the greatest impact. We evaluate existing efforts to discover and develop new drugs and vaccines for malaria to determine how best malaria R&D can benefit from an enhanced open source approach and how such a business model may operate. We assess research articles, patents, clinical trials and conducted a smaller survey among malaria researchers. Our results demonstrate that the public and philanthropic sectors are financing and performing the majority of malaria drug/vaccine discovery and development, but are then restricting access through patents, ‘closed’ publications and hidden away physical specimens. This makes little sense since it is also the public and philanthropic sector that purchases the drugs and vaccines. We recommend that a more “open source” approach is taken by making the entire value chain more efficient through greater transparency which may lead to more extensive collaborations. This can, for example, be achieved by empowering an existing organization like the Medicines for Malaria Venture (MMV) to act as a clearing house for malaria-related data. The malaria researchers that we surveyed indicated that they would utilize such registry data to increase collaboration. Finally, we question the utility of publicly or philanthropically funded patents for malaria medicines, where little to no profits are available. Malaria R&D benefits from a publicly and philanthropically funded architecture, which starts with academic research institutions, product development partnerships, commercialization assistance through UNITAID and finally procurement through mechanisms like The Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S.’ President’s Malaria Initiative. We believe that a fresh look should be taken at the cost/benefit of patents particularly related to new malaria medicines and consider alternative incentives, like WHO prequalification.     

Opportunities, problems and perspectives for malaria control in sub-Saharan Africa

Environments conducive to high malaria transmission and widespread poverty are at the roots of the 'malaria giant', which affects 46 countries in Africa. The recent interest in and momentum of work on malaria, in endemic countries and the international community, is unprecedented and opens new perspectives for controlling the disease. Significant steps included: (i) the allocation of US$20 million by WHO for accelerated implementation of malaria control in 34 African countries in 1997-98; (ii) the Declaration on Malaria by the Heads of States of the Organization of African Unity and the establishment of the African Initiative for Malaria Control in 1997; (iii) the concomitant mobilisation of the research community in the Multilateral Initiative on Malaria; (iv) the G8 Summit in 1998 in Birmingham asking for higher commitment to malaria control, particularly in Africa; and (v) the Roll Back Malaria initiative set as a WHO priority project in 1998. However, experiences have proved the alarming 'resilience' of the malaria system in Africa, showing devastating consequences when malaria returns to the original levels after intensive control is interrupted. Effective malaria control in Africa requires long-term action, firmly rooted in the social development of the country.     

South American Plasmodium falciparum after the malaria eradication era: clonal population expansion and survival of the fittest hybrids

Malaria has reemerged in many regions where once it was nearly eliminated. Yet the source of these parasites, the process of repopulation, their population structure, and dynamics are ill defined. Peru was one of malaria eradication's successes, where Plasmodium falciparum was nearly eliminated for two decades. It reemerged in the 1990s. In the new era of malaria elimination, Peruvian P. falciparum is a model of malaria reinvasion. We investigated its population structure and drug resistance profiles. We hypothesized that only populations adapted to local ecological niches could expand and repopulate and originated as vestigial populations or recent introductions. We investigated the genetic structure (using microsatellites) and drug resistant genotypes of 220 parasites collected from patients immediately after peak epidemic expansion (1999-2000) from seven sites across the country. The majority of parasites could be grouped into five clonal lineages by networks and AMOVA. The distribution of clonal lineages and their drug sensitivity profiles suggested geographic structure. In 2001, artesunate combination therapy was introduced in Peru. We tested 62 parasites collected in 2006-2007 for changes in genetic structure. Clonal lineages had recombined under selection for the fittest parasites. Our findings illustrate that local adaptations in the post-eradication era have contributed to clonal lineage expansion. Within the shifting confluence of drug policy and malaria incidence, populations continue to evolve through genetic outcrossing influenced by antimalarial selection pressure. Understanding the population substructure of P. falciparum has implications for vaccine, drug, and epidemiologic studies, including monitoring malaria during and after the elimination phase.     

Plasmodium post-genomics: an update

The concept behind the first Molecular Approaches to Malaria meeting, held 1-5 February 2000 in Lorne, Australia, was ahead of its time; to convene a meeting of malaria researchers, database developers and genomics scientists, and to discuss how genomic sciences and their relevant disciplines could be applied to solve important problems in malaria research. The success of the second Molecular Approaches to Malaria meeting, held 1-5 February 2004 in the same place, together with the influence of genomics on malaria research, is testament to the vision that the organizers had at the first meeting. This review attempts to capture some of the current efforts in the post-genomics era of malaria research and highlights the approaches discussed at the Molecular Approaches to Malaria 2004 meeting.     

Malaria: therapy, genes and vaccines

Malaria kills over 3,000 children each day. Modern molecular and biochemical approaches are being used to help understand and control Plasmodium falciparum, the parasite that causes this deadly disease. New drugs are being invented for both chemoprophylaxis and therapeutic treatments and their use is discussed along side that of the more commonly used treatments. Classical genetic crosses coupled with molecular analysis of gene loci are use to explain the genetics behind the development of specific drug resistances that the parasites have naturally developed. Rapid advances in DNA sequencing techniques have allowed the compete sequencing of the P. falciparum and several other rodent malaria parasite genomes. Proteomics and computational analysis of these vast databanks are being used to model and investigate the three-dimensional structure of many key malaria proteins in an attempt to facilitate drug design. Recombinant protein expression in bacteria and yeast coupled with cGMP purification technologies and conditions have lead to the recent availability of several dozen malaria protein antigens for human-use Phase I and Phase II vaccine trials. Drug companies, private foundations, and key government agencies have contributed to the coordinated efforts needed to test these antigens, adjuvants and delivery methods in an effort to find an effective malaria vaccine that will prevent infection and disease.     

Medicines for Malaria Venture: sustaining antimalarial drug development

The Medicines for Malaria Venture (MMV) is committed to discovering, developing and delivering new drugs for malaria. Founded in 1999 as a nonprofit organization bringing private sector management methods to bear on a global public health problem, MMV is today recognized as a leader among the public-private partnerships working on diseases for the developing world. Together with its many partners, MMV manages the world's largest malaria research and development portfolio, covering the innovation spectrum from basic drug discovery to late-stage development.     

Comparative proteomic analysis of metabolically labelled proteins from Plasmodium falciparum isolates with different adhesion properties

Background

Malaria is a huge public health problem in Africa that is responsible for more than one million deaths annually. In line with the Roll Back Malaria initiative and the Abuja Declaration, Eritrea and other African countries have intensified their fight against malaria. This study examines the impact of Eritrea's Roll Back Malaria Programme: 2000–2004 and the effects and possible interactions between the public health interventions in use.

Methods

This study employed cross-sectional survey to collect data from households, community and health facilities on coverage and usage of Insecticide-Treated Nets (ITNs), Indoor Residual Spraying (IRS), larvicidal activities and malaria case management. Comparative data was obtained from a similar survey carried out in 2001. Data from the Health Management Information System (HMIS) and reports of the annual assessments by the National Malaria Control Programme was used to assess impact. Time series model (ARIMA) was used to assess association.

Results

In the period 2000–2004, approximately 874,000 ITNs were distributed and 13,109 health workers and community health agents were trained on malaria case management. In 2004, approximately 81% households owned at least one net, of which 73% were ITNs and 58.6% of children 0–5 years slept under a net. The proportion of malaria cases managed by community health agents rose from 50% in 1999 to 78% in 2004. IRS coverage increased with the combined amount of DDT and Malathion used rising from 6,444 kg, in 2000 to 43,491 kg, in 2004, increasing the population protected from 117,017 to 259,420. Drug resistance necessitated regimen change to chloroquine plus sulfadoxine-pyrimethamine. During the period, there was a steep decline in malaria morbidity and case fatality by 84% and 40% respectively. Malaria morbidity was strongly correlated to the numbers of ITNs distributed (β = -0.125, p < 0.005) and the amount (kg) of DDT and Malathion used for IRS (β = -2.352, p < 0.05). The correlation between malaria case fatality and ITNs, IRS, population protected and annual rainfall was not statistically significant.

Conclusion

Eritrea has within 5 years attained key Roll Back Malaria targets. ITNs and IRS contributed most to reducing malaria morbidity.     

Current scenario of malaria in India

The Indian National Malaria Eradication Programme (NMEP) is reporting 2.5 to 3 million malaria cases, and about 1,000 malaria deaths annually. Malaria in the northeastern states is stable and in the peninsular India unstable. There are six major and three minor malaria vectors, of which Anopheles culicifacies transmits malaria in rural areas and An. stephensi in the towns. Other vectors are of local importance. Plasmodium vivax is the dominant infection and accounts for 60-65% cases whereas P. falciparum contributes 30-35% cases. Field operations to control malaria are impeded by resistance and/or exophilic vector behavior, parasite resistance to antimalarial drugs, operational problems in spraying, failure to search breeding of mosquitoes at weekly intervals, staff shortages and financial constraints. Resurgent malaria invaded new ecotypes created by green revolution, industrial growth and urban development resulting in paradigm shift towards man-made malaria. NMEP has launched a world bank-assisted enhanced malaria control project with primary emphasis to protect 62.2 million high risk population in 7 states.     

Glucose-6-phosphate metabolism in Plasmodium falciparum

Malaria is still one of the most threatening diseases worldwide. The high drug resistance rates of malarial parasites make its eradication difficult and furthermore necessitate the development of new antimalarial drugs. Plasmodium falciparum is responsible for severe malaria and therefore of special interest with regard to drug development. Plasmodium parasites are highly dependent on glucose and very sensitive to oxidative stress; two observations that drew interest to the pentose phosphate pathway (PPP) with its key enzyme glucose-6-phosphate dehydrogenase (G6PD). A central position of the PPP for malaria parasites is supported by the fact that human G6PD deficiency protects to a certain degree from malaria infections. Plasmodium parasites and the human host possess a complete PPP, both of which seem to be important for the parasites. Interestingly, there are major differences between parasite and human G6PD, making the enzyme of Plasmodium a promising target for antimalarial drug design. This review gives an overview of the current state of research on glucose-6-phosphate metabolism in P. falciparum and its impact on malaria infections. Moreover, the unique characteristics of the enzyme G6PD in P. falciparum are discussed, upon which its current status as promising target for drug development is based.     

Effects of artemisinins on reticulocyte count and relationship to possible embryotoxicity in confirmed and unconfirmed malarial patients

Rat studies suggest that artemisinin-induced decreases in reticulocyte count are a marker for embryotoxicity (in one study, r = 0.82; p < 0.05). In clinical studies, therapeutic doses of artemisinins induced decreases in reticulocyte count that were larger in five of six groups of healthy volunteers (mean decreases of 47-75%) than in 12 groups of patients with malaria (mean decreases of 0-34% and incidences of low reticulocyte count of 0.6-18%). Malaria causes hypoferremia and drug concentrates in infected red cells so, among the explanations for the lesser decreases in patients, is that malaria protects against artemisinin-induced decreases in reticulocyte count by reducing the target tissue levels of active drug and/or ferrous iron which activates the drug to toxic free radicals. The disease could also protect against embryotoxicity in which case pregnant women without malaria would be at greater risk of artemisinin-induced embryotoxicity. Malaria protection against artesunate toxicity has been observed in rats. No artemisinin-induced embryotoxicity has been identified in limited numbers of women with confirmed malaria in the first trimester. However, in large parts of tropical Africa, malaria treatment is based on fever rather than confirmation of parasitemia and many pregnant women without malaria are exposed to antimalarials. No clinical studies have been conducted on uninfected women for whom pregnancy was identified and then an artemisinin was administered subsequently. Testing in rats and/or humans is needed to determine if malaria protects against reticulocytopenia and embryotoxicity and whether the parasite is a more or less sensitive target than the embryo and reticulocyte.     

Malaria in the whole world and in Romania

Malaria is the world's most important tropical parasitic disease. Malaria is a public health problem today in more than 90 countries. Worldwide prevalence of the disease is estimated to be in the order of 300-500 million clinical cases each year. Malaria is endemic in a total of 101 countries and territories. In Romania, malaria does not represent an important public health problem. In 1999, there were reported a total number of 32 malaria cases in Romanian people. 78% from these recognized as etiological agent Pl. falciparum. The malaria cases imported from Turkey (5) have had as etiological agent Pl. vivax. The most affected age group is between 21-50 years and a distribution by profession shows that sailor personnel accounts for 65.6% of all cases. Africa remains the most important endemic region from where the malaria cases in Romanian people are imported. An adequate chemoprophylaxis is not, yet, easy to obtain for Romanian people who are travelling abroad in endemic countries because of the lack of specific drugs (especially for resistant forms of Pl. falciparum). Even if the Romanian Ministry of Health had elaborated orders regarding malaria and Cloroquine is the usual drug administered, as chemoprophylaxis, to Romanian people who travel abroad, in each year in our country appears around 30-60 imported malaria cases. That is the cause why Romanian Ministry of Health wants to solve this problem which is the major cause of the malaria cases in Romanian people.     

Performance of ¿VIKIA Malaria Ag Pf/Pan¿ (IMACCESS®), a new malaria rapid diagnostic test for detection of symptomatic malaria infections

ABSTRACT: BACKGROUND: Recently, IMACCESS[REGISTERED SIGN] developed a new malaria test (VIKIA Malaria Ag Pf/Pan[TRADE MARK SIGN]), based on the detection of falciparum malaria (HRP-2) and non-falciparum malaria (aldolase). METHODS: The performance of this new malaria rapid diagnostic test (RDT) was assessed using 1,000 febrile patients seeking malaria treatment in four health centres in Cambodia from August to December 2011. The results of the VIKIA Malaria Ag Pf/Pan were compared with those obtained by microscopy, the CareStart Malaria[TRADE MARK SIGN] RDT (AccessBio[REGISTERED SIGN]) which is currently used in Cambodia, and real-time PCR (as "gold standard"). RESULTS: The best performances of the VIKIA Malaria Ag Pf/Pan[TRADE MARK SIGN] test for detection of both Plasmodium falciparum and non-P. falciparum were with 20--30 min reading times (sensitivity of 93.4% for P. falciparum and 82.8% for non-P. falciparum and specificity of 98.6% for P. falciparum and 98.9% for non-P. falciparum) and were similar to those for the CareStart Malaria[TRADE MARK SIGN] test. CONCLUSIONS: This new RDT performs similarly well as other commercially available tests (especially the CareStart Malaria[TRADE MARK SIGN] test, used as comparator), and conforms to the World Health Organization's recommendations for RDT performance. It is a good alternative tool for the diagnosis of malaria in endemic areas.     

Malaria parasites require TLR9 signaling for immune evasion by activating regulatory T cells

Malaria is still a life-threatening infectious disease that continues to produce 2 million deaths annually. Malaria parasites have acquired immune escape mechanisms and prevent the development of sterile immunity. Regulatory T cells (Tregs) have been reported to contribute to immune evasion during malaria in mice and humans, suggesting that activating Tregs is one of the mechanisms by which malaria parasites subvert host immune systems. However, little is known about how these parasites activate Tregs. We herein show that TLR9 signaling to dendritic cells (DCs) is crucial for activation of Tregs. Infection of mice with the rodent malaria parasite Plasmodium yoelii activates Tregs, leading to enhancement of their suppressive function. In vitro activation of Tregs requires the interaction of DCs with parasites in a TLR9-dependent manner. Furthermore, TLR9(-/-) mice are partially resistant to lethal infection, and this is associated with impaired activation of Tregs and subsequent development of effector T cells. Thus, malaria parasites require TLR9 to activate Tregs for immune escape.     

Bilayer Effects of Antimalarial Compounds

Because of the perpetual development of resistance to current therapies for malaria, the Medicines for Malaria Venture developed the Malaria Box to facilitate the drug development process. We tested the 80 most potent compounds from the box for bilayer-mediated effects on membrane protein conformational changes (a measure of likely toxicity) in a gramicidin-based stopped flow fluorescence assay. Among the Malaria Box compounds tested, four compounds altered membrane properties (p< 0.05); MMV007384 stood out as a potent bilayer-perturbing compound that is toxic in many cell-based assays, suggesting that testing for membrane perturbation could help identify toxic compounds. In any case, MMV007384 should be approached with caution, if at all.     

Helminth-infected patients with malaria: a low profile transmission hub?

The scale-up of malaria control efforts in recent years, coupled with major investments in malaria research, has produced impressive public health impact in a number of countries and has led to the development of new tools and strategies aimed at further consolidating malaria control goals. As a result, there is a growing need for the malaria policy setting process to rapidly review increasing amounts of evidence. The World Health Organization Global Malaria Programme, in keeping with its mandate to set evidence-informed policies for malaria control, has convened the Malaria Policy Advisory Committee as a mechanism to increase the timeliness, transparency, independence and relevance of its recommendations to World Health Organization member states in relation to malaria control and elimination. The Malaria Policy Advisory Committee, composed of 15 world-renowned malaria experts, will meet in full twice a year, with the inaugural meeting scheduled for 31 January to 2 February 2012 in Geneva. Policy recommendations, and the evidence to support them, will be published within two months of every meeting as part of an open access Malaria Journal thematic series. This article is a prelude to that series and provides the global malaria community with the background and overview of the Committee and its terms of reference.