Imported malaria in Montagnard refugees settling in North Carolina: implications for prevention and control.

In the winter of 1992, some 402 Southeast Asian refugees were resettled in North Carolina. They received very limited medical screening before immigration and many arrived in the United States with significant health problems, including several tropical infectious diseases. These refugees had lived for many years in remote areas along the Vietnam-Cambodia border, where there is intense transmission of malaria, including Plasmodium falciparum resistant to most antimalarial drugs available in the United States. Of 322 refugees screened after arrival in North Carolina, 187 (58%) were infected: 33% with P. falciparum, 23.5% with P. vivax, 23.5% with P. malariae, and 2.1% with P. ovale. Most infected persons were asymptomatic and infections with multiple species were common. Because of the documented high infection prevalence and the probable presence of many subpatent infections, all nonpregnant refugees were treated with halofantrine; those with P. vivax or P. ovale infections were given primaquine as well. This group accounted for the largest cluster of malaria cases reported in the United States in the last 50 years. Their rapid relocation, with minimal medical screening prior to arrival, resulted in a significant burden to the refugees and to the health-care system. Coordination between immigration agencies, the public health community, and medical workers in communities where the refugees are settled is critical for U.S.-based management of imported tropical diseases.

Parasitized erythrocyte membrane antigens of Plasmodium brasilianum: relationships with the ring-infected erythrocyte surface antigen of Plasmodium falciparum.

An antigen, designated here as the parasitized erythrocyte membrane antigen (PEMA), is present in the erythrocyte membrane surrounding all intraerythrocytic stages of Plasmodium brasilianum. An antibody specific for PEMA appeared in 21 (50%) of 42 antisera from Saimiri sciureus monkeys naturally infected with P. brasilianum. Of these 42 sera, nine (21.4%) contained antibody to the ring-infected erythrocyte membrane antigen (RESA); of these nine sera, six did not react with PEMA. Sera of humans infected with P. malariae reacted with PEMA and RESA in a similar pattern; i.e., of 83 antisera, 71 (85.5%) reacted with PEMA and 30 (36%) reacted with RESA. Only one of these latter 30 sera were not reactive with PEMA. Of 167 sera from humans infected with P. falciparum but not P. malariae, 133 (79.6%) reacted with RESA; of these, 43 (25.7% of the total) reacted with PEMA but not RESA. Although PEMA was demonstrated with P. brasilianum and RESA with P. falciparum, neither PEMA or RESA could be demonstrated with P. malariae. Interactions of PEMA and RESA and the corresponding antibodies offer a method whereby the two morphologically similar quartan species, P. malariae and P. brasilianum, can be readily distinguished from each other and may furnish clues to genetic separation of the two and the mechanisms of interaction of quartan malaria and P. falciparum where they are coendemic.

Protective immunity induced in squirrel monkeys with recombinant apical membrane antigen-1 of Plasmodium fragile.

Saimiri sciureus boliviensis monkeys were immunized with the Plasmodium fragile form of the merozoite apical membrane antigen-1 produced using the baculovirus expression system and combined with Montanide ISA 720 adjuvant. Following three immunizations, monkeys were challenged with 10,000 P. fragile trophozoite parasites. Antibody titers determined by fluorescence microscopy indicated an enhanced response following the second immunization. Four of five control animals had parasite counts > 5% 18-26 days following challenge. Four of five immunized monkeys had reduced levels of maximum parasitemia or delays in accumulated parasite counts, suggestive of protection. Rechallenge of the animals with P. falciparum resulted in three of four adjuvant control animals developing patent parasitemia whereas none of five immunized animals were infected, suggesting some level of heterologous protection.

Immunologic cross-reactivity between structural proteins of human T-cell lymphotropic virus type I and the blood stage of Plasmodium falciparum.

To determine the serologic cross-reactivity between human T-cell lymphotropic virus type I (HTLV-I) and parasite antigens, we measured antibody responses against HTLV-I, Plasmodium falciparum, Plasmodium vivax, and Brugia malayi in serum specimens obtained from regions where malaria (n = 482) and filariasis (n = 101) are endemic. Analysis of immune reactivity to HTLV-I antigens showed that specimens from regions where malaria is endemic had significantly higher rates of enzyme immunoassay (EIA) reactivity (76 of 482 [15.8%] than those from regions where filariasis is endemic (0 of 101 [0%]). Western blot (immunoblot) analysis of the HTLV-I EIA-reactive specimens demonstrated predominant Gag reactivity (HTLV-Iind). Only two specimens each from Indonesia and Brazil and four specimens from Papua New Guinea had Env reactivity by radioimmunoprecipitation analysis. Furthermore, a positive correlation between HTLV-EIA and titers of antibody to the blood stage of P. falciparum (rs = 0.24, P < 0.005) was discerned; no correlation was observed between antibodies to the blood stage or the circumsporozoite protein of P. vivax and the circumsporozoite protein of P. falciparum. In addition, P. falciparum-infected erythrocyte lysate specifically abrogated binding of Gag-specific antibodies in HTLV-Iind specimens from regions where malaria is endemic without affecting binding in HTLV-I-seropositive specimens, suggesting that the immunologic cross-reactivity between HTLV Gag proteins and malaria parasites is restricted to the blood-stage antigens of plasmodia in specimens from regions where malaria is endemic. However, HTLV-seroindeterminate specimens from the United States did not demonstrate serologic cross-reactivity, suggesting that antigenic mimicry of HTLV proteins extends to other nonplasmodial antigens as well.

Role of adjuvants in the modulation of antibody isotype, specificity, and induction of protection by whole blood-stage Plasmodium yoelii vaccines.

Mice were immunized with whole killed blood stage Plasmodium yoelii parasites in 15 adjuvant formulations then boosted and challenged with parasitized blood. Five of six groups immunized with the Ag in oil-in-water emulsions or formulations without oil were protected. Formulations that induced protection contained saponin, pertussis, copolymer P1004, and detoxified RaLPS. In contrast, none of nine groups of animals immunized with Ag in water-in-oil emulsions were protected. Ineffective adjuvants included CFA and water-in-squalene emulsions with copolymer L141 plus detoxified RaLPS, dimethyldioctadecyl ammonium bromide, and mycobacterial cell wall skeletons. Antibody was measured by ELISA against disrupted parasites and by indirect fluorescent antibody (immunofluorescence) using intact parasites. Protection was associated with antibody of the IgG2a isotype detected by immunofluorescence but not with other isotypes detected by immunofluorescence or any type antibody detected by ELISA. The water-in-oil adjuvants induced high titers by ELISA but low titers by immunofluorescence. These results, together with Western blot analyses, suggested that adjuvant vehicles control the specificity of antibody and that this, in turn, is essential for induction of protective immune responses in this model.

Spleen in sickle cell anemia: comparative studies of Nigerian and U.S. patients.

Anecdotal reports have attributed persistent splenomegaly in African sickle cell anemia (SS) patients to the effects of malaria. However, no comparative studies of patients in malarial and nonmalarial regions have been conducted, and few studies of malaria antibody titers have been reported. In the present study, age- and sex-matched Nigerian patients (n = 310), while it was found only in 8% of U.S. patients (n = 100) from Georgia. There was significant linear correlation between spleen size and Hb levels and with serum immunoglobulins in the Nigerian group. However, serum complement levels (C3 and C4) were not affected by spleen size. In both groups, patients with splenomegaly had fewer circulating pitted red cells than their counterparts without splenomegaly. The mean +/- SE of IgG-specific malaria antibody titer among the Nigerian patients without palpable spleens was 9,386 +/- 2,036; 9,334 +/- 2,980 in those with spleens between 1 and 5 cm, 16,201 +/- 4,502 in those with spleens between 6 and 10 cm, and 22,445 +/- 8,456 in those with spleens above 10 cm. Coexistent alpha-thalassemia did not influence the prevalence of splenomegaly among the Nigerian SS patients. This study provides additional evidence that malaria plays a significant role in the persistence of splenomegaly in African patients.

Immunogenicity of the Plasmodium falciparum asexual blood-stage synthetic peptide vaccine SPf66.

The immunogenicity of the cocktail vaccine SPf66 against Plasmodium falciparum was investigated in rabbits, monkeys, and human volunteers. This polymerized peptide vaccine incorporates a portion of each of the 35-kD, 55-kD, and 83-kD blood-stage proteins, linked by an amino acid sequence reproducing one repeat from the circumsporozoite protein of P. falciparum. Results from this study show that vaccination with this vaccine molecule elicited high titers of antibodies to SPf66 and its constituents, but these antibodies did not correlate with regular or sensitive indirect fluorescent antibody (IFA) titers to blood-stage malaria parasites. However, rabbits injected with individual peptides produced antibodies with low affinity to indefinite parasite structures by immunoelectron microscopy, and rabbits injected with SPf66 had high antibody titers against the peptide (NANP)40. Consequently, these anti-SPf66 serum samples recognized P. falciparum sporozoites in the IFA. Such reactivity was not observed in monkeys or human volunteers vaccinated with SPf66. In addition, SPf66 components were recognized by antibodies induced by natural infection in humans and by laboratory-monitored infections in Aotus monkeys. These results suggest that this vaccine candidate merits further developmental work to better define immune response elicited by the copolymer to the parasite.

Malaria and pregnancy in Cameroonian women. Naturally acquired antibody responses to asexual blood-stage antigens and the circumsporozoite protein of Plasmodium falciparum.

Antibody responses to Plasmodium falciparum antigens in women during pregnancy were investigated in Mfou, a rural community in Cameroon. The study consisted of cross-sectional analyses involving 225 pregnant women and 75 non-pregnant controls. Blood samples were collected from each woman to determine serological reactivity to intraerythrocytic malarial antigens, ring-infected erythrocyte surface antigen (RESA) and circumsporozoite (CS) repeat peptide (NANP)5 by the indirect fluorescent antibody assay, modified immunofluorescent antibody assay, and enzyme-linked immunosorbent assay, respectively. Reactivity to intraerythrocytic asexual blood-stage antigens and to the CS repeat region was similar in both pregnant and non-pregnant women, and no correlation with parasitaemia was found. In contrast, anti-RESA antibody levels were significantly lower in pregnant than in non-pregnant women (P = 0.02) and in primigravidae than in multigravidae (P = 0.002), and were inversely correlated with parasitaemia (r = -0.36; P < 0.01). These data suggest that the increased susceptibility to malarial infection in pregnant women may be explained in part by their lower reactivity to RESA.

Epstein-Barr virus transformation of Saimiri sciureus (squirrel monkey) B cells and generation of a Plasmodium brasilianum-specific monoclonal antibody in P. brasilianum-infected monkeys.

The new-world monkeys Saimiri sciureus (squirrel monkeys) are currently used as a model to test the efficacy of vaccines against human malaria. To improve our knowledge on this model, we tested the susceptibility of S. sciureus B cells to Epstein-Barr virus (EBV) infection. B-lymphoblastoid cell lines were obtained from six of six healthy animals after infection with the B95-8 source of EBV. The frequency distributions of spleen B cells clonally committed to the production of immunoglobulins M and G, as measured by limiting dilution analysis, were from 1 in 179 to 1 in 1,085 and from 1 in 45 to 1 in 60, respectively, in three monkeys naturally infected with Plasmodium brasilianum. In the same three animals, the frequency of spleen B cells committed to the production of P. brasilianum-specific antibody ranged from 1 in 2,211 to 1 in 9,099. One B-lymphoblastoid cell line producing anti-P. brasilianum-specific antibody was cloned twice, and the immunoglobulin G produced was purified. This monoclonal antibody recognized a parasite component of 197 kDa and was specific for Plasmodium malariae and P. brasilianum parasites. These data document that squirrel monkey B cells naturally primed by an infectious agent can be efficiently used to produce monospecific antibodies against the infectious agent.

Antibodies to the ring-infected erythrocyte surface antigen of Plasmodium falciparum elicited by infection with Plasmodium malariae.

The ring-infected erythrocyte surface antigen (RESA) of Plasmodium falciparum (RESA-P), found in the membrane of erythrocytes infected with young asexual stages of P. falciparum, is a promising vaccine candidate. Antibodies to RESA-P were inducible by infection with another human malaria species, P. malariae. Of 298 serum samples from inhabitants of three isolated localities in Peru where P. vivax and P. malariae were endemic and P. falciparum had never been reported, 26% had anti-RESA-P antibodies as evidenced by a modified immunofluorescent-antibody assay and confirmed by Western blot (immunoblot) analysis. These seroepidemiologic observations were corroborated by the fact that of six chimpanzees infected with P. malariae, three developed anti-RESA-P antibodies after infection. The modified immunofluorescent-antibody-reactive antibodies, purified by adsorption and elution on monolayers of glutaraldehyde-fixed and air-dried P. falciparum-infected erythrocytes, reacted in an immunofluorescent-antibody assay with both parasite structures and erythrocyte membrane in P. falciparum antigen preparations, but only with parasite structures in P. malariae antigen preparations. This serologic cross-reactivity between P. falciparum and P. malariae is of interest in view of the importance of RESA-P as a vaccine candidate and because the two species are coendemic in many areas.

Assessment of a synthetic DNA probe for Plasmodium falciparum in African blood specimens.

Synthetic DNA oligomers homologous to 21-base long repetitive sequences of Plasmodium falciparum DNA were labeled with 32P using T4 kinase, and were hybridized with purified DNA and with processed blood samples from Africa. The sequence PFR1, its antiparallel oligomer PFR1R, and PFR1 covalently attached to biotin hybridized similarly to P. falciparum DNA. One-microliter aliquots of blood from Zaire spotted on prewet nylon filters and hybridized with PFR1 gave detectable autoradiogram signals from samples with parasitemias as low as 1,000 parasites/mm3. Blood lysis and protein digestion followed by alkylation allowed dot-blot processing of larger aliquots of blood. After hybridization with PFR 1 and autoradiography, 26 samples were scored positive visually, compared with 34 scored positive by microscopy. The effective sensitivity for processed 10-microliter samples was about 500 parasites/mm3. Signals from hybridized probes were quantitated by liquid scintillation counting and densitometry, and were proportional to the amounts of purified P. falciparum DNA applied to the filter. Autoradiogram signals also were roughly proportional (correlation coefficient, r = 0.77) to the number of parasites/mm3 of blood from field samples as determined by microscopic examination.

Indirect immunofluorescence test for human Babesia microti infection: antigenic specificity.

An indirect immunofluorescence (IIF) test was performed with human sera to detect cross-reactivity of Babesia microti antibodies with other species of Babesia parasites, with other blood and tissue parasites, and with various tick-borne organisms. Antisera to B. microti cross reacted with other Babesia species, but at lower dilutions than with the homologous antigens, and occurred most often during the acute phase of the disease. Cross-reactions with antibodies to malaria, Colorado tick fever, and a variety of other parasitic diseases were uncommon. However, acute and convalescent phase sera from 4 patients with suspected or confirmed Rocky Mountain spotted fever showed a rise in titer to B. microti antigen. In addition, 6 of 185 serum samples from children on an Indian reservation in North Carolina had IIF titers of greater than or equal to 1:256, suggesting a possible focus of B. microti infections in humans.

Evaluation of serological cross-reactivity between antibodies to Plasmodium and HTLV-III/LAV.

Serum samples from 460 patients with existing or previous Plasmodium infections, high antimalarial antibody titres, and no apparent risk of exposure to human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) were assayed for HTLV-III/LAV antibody; only 1 sample, from a 21-year-old African woman, was strongly reactive by enzyme-linked immunosorbent assay (ELISA) and positive by western blot. Conversely, no sample from 100 HTLV-III/LAV-positive American homosexual men was strongly reactive for antibodies to the four Plasmodium species that infect human beings by an indirect fluorescent antibody technique, or for antibodies to Plasmodium falciparum by an ELISA technique. Thus, exposure to Plasmodium does not result in HTLV-III/LAV seropositivity, and HTLV-III/LAV antibodies are not strongly cross-reactive with malarial antigens.

An oocyst-transmitted outbreak of toxoplasmosis: patterns of immunoglobulin G and M over one year.

Sera from 32 patients who became ill after jungle combat training were tested for antibodies to Toxoplasma gondii using the indirect immunofluorescence test. Swift rises of both IgG and IgM antibodies occurred within 2 weeks of infection. Reduction in IgM titers, due to competitive suppression by IgG antibody, occurred in most but not all cases. Suppression of IgM reaction by IgG antibody could be prevented by adsorption of serum with Staphylococcus aureus containing protein A. Antibody of the IgM class could be detected at greater than or equal 1:256 level in many sera at 6-month and 1-year intervals after exposure. In groups with exposures such as were experienced in this study, the presence of IgM antibody titers in single serum specimens cannot be used to indicate recent exposure. Both IgG and IgM antibody may rise together to high levels very rapidly after infection; IgM did not precede IgG antibody in our 32 subjects.

Computer-assisted multiple categorization of absorbance values in ELISA through pictorial emulation of 96-well plates.

A simple algorithm is proposed by which multiple categorization of absorbance values from ELISA plates is performed under a microcomputer control. The printed output is a pictorial emulation of a 96-well plate with the color intensities represented for each reaction. Although the method is presented as a colorimeter computer interfaced system, a provision for manual entry of absorbance values via keyboard is also included. Simulation is based solely on the magnitude of absorbance values. Therefore, it is possible to utilize any enzyme/substrate combination within the range of filters of the colorimeter. We have tested the present system for titration of anti-malarial antibodies in human serum and for the screening of mouse hybridoma culture supernatants.

Diagnosis of acute acquired toxoplasmosis with the enzyme-labelled antigen reversed immunoassay for immunoglobulin M antibodies.

The reversed enzyme-labelled antigen immunoassay (R-EIA), based on the capture of serum immunoglobulin M antibodies (IgM) and subsequent addition of Toxoplasma gondii soluble antigen tagged with peroxidase and substrate, was evaluated comparatively with the IgM-indirect immunofluorescence test (IgM-IIF) for the detection of anti-toxoplasma IgM antibodies in sera from individuals with diagnosed acute acquired toxoplasmosis. Additional serum groups from normal healthy individuals and sera presenting possible nonspecific reactivities were also evaluated. Complete specificity of R-EIA was shown. There was no correlation between the magnitude of R-EIA results and IgM-IIF titers, but a positive (although not linear) correlation was found between R-EIA and the IgM-IIF titers obtained after adsorption of sera with Staphylococcus aureus protein A. Direct labelling of the antigen by a simple coupling technique facilitated the assay standardization and improved its signal-to-noise ratio.