Old and new targets for innovative antimalarial compounds: the different strategies of the Italian Malaria Network.

Clinical treatment-failures to affordable drugs encouraged new investigation for discovery and development of new prophylactic and therapeutic interventions against malaria. The Drug Discovery Cluster (DDcl) of the Italian Malaria Network gathers several highly integrated and complementary laboratories from different Italian Institutions to identify, synthesise, screen in vitro and in vivo new antimalarial molecules directed against the intraerythrocytic stage of P. falciparum parasites and/or with transmission blocking activity to select lead compounds for further development. Complementary research activities, both in vitro and in the clinics, aim at investigating the pathogenetic mechanisms of severe malaria anaemia and the different manifestations of the disease in malaria-HIV co-infected patients to identify new therapies and improve survival.

Effects of a neem extract on blood feeding, oviposition and oocyte ultrastructure in Anopheles stephensi Liston (Diptera: Culicidae).

Secondary metabolites of the neem tree (Azadirachta indica A. Juss., Meliaceae) exhibit a wide range of biological activities in insects. However, few studies have addressed the effects of neem extracts or compounds in arthropods of medical importance. In this study, a laboratory strain of Anopheles stephensi was used to assess the effects of a commercial formulation (Neem Azal) (NA)), containing azadirachtin A at 34%, on blood feeding, oviposition and oocyte ultrastructure. Oral administration of Neem Azal) to A. stephensi females through artificial blood meals did impair blood intake and oviposition in a concentration dependent manner. Similar results were obtained on females, which had consumed Neem Azal) in sucrose solution before taking a blood meal of plain blood. Neem treated females displayed a delay in oocyte development in both the phase of vitellogenesis and the phase of choriogenesis. The ultrastructural studies on ovaries from Neem Azal) treated females revealed distinct structural modifications indicative of: (i) a complete block of oogenesis, (ii) impairment of vitellogenesis and vitelline envelope formation, (iii) a severe degeneration of follicle cells. In agreement with results obtained in other insects, this study indicates that Neem Azal) impairs hormone control of oogenesis and exerts a cytotoxic effect on both follicular cells and oocytes of the Asian malaria vector A. stephensi.

Host preferences of phlebotomine sand flies at a hypoendemic focus of canine leishmaniasis in central Italy.

A survey was carried out on phlebotomine sand flies and their feeding habits at a hypoendemic focus of Leishmania infantum in Macerata province, central Italy. During two consecutive years (2000-2001), 1465 sand fly specimens (42.5% of which were males) were collected from a variety of diurnal resting sites in the municipality of Camerino. The most prevalent species was Phlebotomus perniciosus (76.6%), followed by P. papatasi (10.4%), Sergentomyia minuta (9.1%), Phlebotomus perfiliewi (3.3%) and P. mascittii (0.5%). Among the 842 females collected, 578 (68.6%) were blood-fed. Based on the results of blood meal analyses, P. perniciosus fed on man, dogs, equines, sheep and birds; P. perfiliewi on dogs, equines, sheep and birds; P. papatasi on dogs, equines and birds. Two specimens of P. mascittii fed on equines. Forage ratios (FRs) and host selectivity indices gave different results for the large domestic animals. More than 95% of the specimens collected inside a stable, dog kennel, sheep pen and chicken house were found to have fed on the animals housed in the respective shelters. In addition, at one collecting site where almost all the hosts mentioned above were present simultaneously, both P. perniciosus and P. perfiliewi were found to have fed on all five species, indicating that host choice was probably related to its availability (i.e. number and size) rather than specific attractiveness. The feeding habits of the two Leishmania vectors may have implications for the epidemiology of leishmaniasis in urban and peri-urban areas, where sand fly females deprived of other vertebrate hosts (particularly the larger species) may begin to bite humans and dogs more frequently.

An estimation of Toxocara canis prevalence in dogs, environmental egg contamination and risk of human infection in the Marche region of Italy.

The human risk of infection with larvae of Toxocara canis was estimated in people from the Marche region of Italy. This region includes both urban and rural areas and its inhabitants frequently keep dogs for company, hunting, as guardians or shepherds. T. canis infection was diagnosed in 33.6% out of 295 dogs examined. Nearly half of the dogs (48.4%) living in rural areas were found T. canis positive, compared to about one-quarter of the dogs (26.2%) from urban areas. Analysis by provenance and role revealed the highest infection rate in rural hunting dogs (64.7%) and the lowest in urban companion dogs (22.1%). According to questionnaire data, the peridomestic environment, i.e. gardens and dog pens, is the most important defecation site in both rural and urban areas. Since over 40% of the dogs who defecate in dog pens are infected and 24% of urban and 47% of rural dogs who leave their droppings in the house surroundings harbour the parasite, it is clear that these environments may constitute sites of zoonotic risk. Our analysis of soil samples from 60 farms confirmed the high contamination level, revealing positive soil samples in more than half of the farms. Substantial egg contamination was also found in urban areas, as 3/6 parks examined were Toxocara spp. positive. Finally, our serological findings indicate that human infection actually occurs in the area: 7 out of 428 adults examined (1.6%) had very high levels of antibodies to T. canis antigen, suggesting a previous contact with the Larva migrans of the nematode.

Insecticide-treated materials, mosquito adaptation and mass effect: entomological observations after five years of vector control in Burkina Faso.

Insecticide-treated bednets and curtains have been shown to be successful in reducing malaria transmission and child mortality in Africa over periods of up to 2 years. A major concern relating to this approach is that, in time, it will be compromised by the selection of mosquito genotypes that are resistant at the biochemical or behavioural level. We report entomological data from a large area in Burkina Faso where insecticide-treated curtains have been in use for up to 5 years. Longitudinal indoor and outdoor CDC light-trap catches were performed in 4 sentinel villages. In addition cross-sectional surveys using indoor spray catches and outdoor CDC light-trap catches were performed each September in a larger number of villages, including 8 located outside the intervention area. We found no evidence of the selection of mosquito phenotypes that might compromise the intervention. Indoor and outdoor vector densities remained very low after 5 years of intervention, both compared with pre-intervention levels and with concurrent levels outside the intervention area. We found no evidence of a switch to outdoor rather than indoor biting. The proportion of blood meals taken on humans may have decreased but our data are inconclusive on this point. We observed higher vector densities and sporozoite rates at the periphery of the intervention zone than at the centre, which may reflect re-invasion of peripheral villages by mosquitoes from outside the intervention area. In 'real life' programmes, with perhaps patchy, less than optimal coverage, the protection against malaria transmission provided to individuals using insecticide-treated materials may be less than that achieved in the randomized controlled trials which demonstrated an impact of insecticide-treated materials on child mortality.

Insecticide-treated curtains reduce the prevalence and intensity of malaria infection in Burkina Faso.

A large, randomized controlled trial to investigate the impact of insecticide-treated curtains (ITC) on child mortality was conducted in an area of seasonal, holoendemic malaria in Burkina Faso. 158 communities totalling some 90,000 people were censused and grouped into 16 geographical clusters, 8 of which were randomly selected to receive ITC in June-July 1994, just prior to the rainy season. In September-October 1995, at the peak period of malaria transmission, a cross-sectional survey was conducted in 84 of the villages. A random sample of 905 children aged 6-59 months was identified and visited. 763 children (84%) were present at the time of the visit and recruited into the study. Mothers were asked about fever in the past 24 h, the child's temperature was taken, and a sample of blood collected to identify and quantify malaria infections and to measure haemoglobin (Hb) levels. Children protected by ITC were less likely to be infected with Plasmodium falciparum (risk ratio = 0.92; 95% CI 0.86, 0.98) or P. malariae (risk ratio = 0.42, 95% CI 0.19, 0.95). The mean intensity of P. falciparum infections was lower among children protected by ITC (899 vs. 1583 trophozoites/microliter; P < 0.001), while the mean Hb level was 0.4 g/dl higher (P < 0.001). While we found no evidence that ITC had an impact on the prevalence of malaria-associated fever episodes, the confidence intervals around our estimates of the impact of ITC on malaria morbidity were wide. We conclude that widespread implementation of ITC in this area of high malaria transmission led to a modest reduction in the prevalence of malaria infection and to a more substantial reduction in the intensity of these infections which caused increased Hb levels. We were unable to demonstrate any impact of ITC on malaria morbidity, but the wide confidence intervals around our point estimates do not preclude the possibility of a substantial impact.

Widespread distribution of insecticide-impregnated curtains reduces child mortality, prevalence and intensity of malaria infection, and malaria transmission in rural Burkina Faso.

The results of the first two years of implementation of a large scale trial of insecticide-treated curtains in Burkina Faso are summarised in this presentation. The trial was conducted in a highly malarious area and involved a population of slightly less than 100,000, distributed in 158 villages over an area of almost 1000 km2. A remarkable impact on entomological parameters (Anopheles density, sporozoite rate, entomological inoculation rate) was accompanied by a relatively modest reduction of parasitological indices (prevalence and density of Plasmodium falciparum). All-cause mortality in children 0.5 to 5 year old showed over two years a 15% decline. The authors believe that the wide surface of the protected zone and the almost total coverage achieved in the intervention villages were the major determinants of the observed reduction of transmission. A conclusive interpretation of the mortality results requires a further follow-up of the study population.

Wide-scale installation of insecticide-treated curtains confers high levels of protection against malaria transmission in a hyperendemic area of Burkina Faso.

In a region of Sudanese savannah in Burkina Faso, insecticide-treated curtains were installed in 8 out of 16 zones, each covering an area of about 50 km2. Longitudinal entomological monitoring using CDC light traps was performed in 4 villages (2 intervention, 2 control) over a period of 3 years (including 1 year prior to intervention). In the 3rd year a cross-sectional entomological survey using spray catches was performed in 84 villages (40 intervention). Indoor vector densities in protected houses showed large reductions (P = 0.01). The available data were also consistent with an impact on outdoor and unprotected indoor densities. The proportion of mosquitoes carrying sporozoites was 4.1% in protected villages compared with 11.5% in unprotected villages (P = 0.07). Entomological inoculation rates fell substantially (P = 0.01), reflecting these reductions. The impact of this intervention on mosquito survival appears to have been greater than those in similar trials conducted in the Gambia, Ghana and Kenya in which the intervention was applied over smaller areas.

Do insecticide-treated curtains reduce all-cause child mortality in Burkina Faso?

To evaluate whether insecticide-treated netting (ITN) reduces child mortality in different epidemiological settings, 4 large, randomized, controlled trials were conducted in Africa. Here we report the findings from the trial in Burkina Faso, in an area of hyperendemic and markedly seasonal malaria transmission. The trial involved 158 villages, with a total population of some 90,000, grouped into 16 geographical clusters. Ascertainment of mortality among children aged 6-59 months began in early 1993. In June/July 1994, 8 of the clusters, randomly selected, received permethrin-treated curtains. Follow-up of children and ascertainment of mortality continued until May 1996. A 15% reduction in all-cause mortality among children aged 6-59 months was observed over the 2-year period following the installation of the curtains (95% c.i. -4% to 30%). In the first year, post-intervention mortality was substantially lower in the clusters receiving curtains compared with the control clusters (rate ratio = 0.74; 95% c.i. 0.57, 0.95) but in the second year, there was no difference between mortality in the two groups (rate ratio = 0.99). The overall two-year impact of the intervention is consistent with the impacts observed in other trials which have demonstrated reductions in child mortality of from 17% to 33%. However, the year-by-year analysis raises some concerns about the long-term effect of ITN. Further follow-up of this population is warranted.

Comparison of two methods for assessing child mortality in areas without comprehensive registration systems.

We compared the effectiveness of 2 approaches to assessing child deaths in a rural area of Burkina Faso, West Africa. Censuses, repeated yearly, identified 410 child deaths in the age range 6-59 months. Surveillance using community informants identified only 319 deaths. The estimated sensitivities of the 2 systems were 97% and 76%, respectively. Both systems appeared less effective at detecting child deaths before 6 months of age (sensitivities 74% and 57%). Most of the deaths missed by the census were of children born since the previous census. The cost of one year's surveillance was twice that of a single census. The marginal cost of the surveillance system per additional child death identified between 6 and 59 months was about US$ 1500. Thorough annual censuses may be sufficient to ascertain almost all child deaths over 6 months of age. In studies wishing to identify child deaths before 6 months of age, such an approach is unlikely to be adequate. In such situations, our data indicated that the use of unpaid community informants can improve assessment of deaths. Where accurate assessment of early infant death rate is required, regular visits to each household by members of the study team are likely to be the only reliable approach.

Localization of HLA-A2.1-restricted T cell epitopes in the circumsporozoite protein of Plasmodium falciparum.

Localization of human MHC class I-restricted T cell epitopes in the circumsporozoite (CS) protein of the human parasite Plasmodium falciparum is an important objective in the development of antimalarial vaccines. To this purpose, we synthesized a series of overlapping synthetic 20-mer peptides, spanning the entire sequence of the 7G8 CS molecule except for the central repeat B cell domain. The P.f.CS peptides were first tested for their ability to bind to the human MHC class I HLA-A2.1 molecule on T2, a human cell line. Subsequently, the use of a series of shorter peptide analogues allowed us to determine the optimal A2.1 binding sequence present in several of the 20-mers. Binding P.f.CS peptides were further tested for their capacity to activate PBL from HLA-A2.1+ immune donors living in a malaria-endemic area. Specific IFN-gamma production was detected in the supernatant of cultures of PBL from exposed individuals. Cytotoxic T cell lines and clones were derived from the PBL of one responder, and their activity was shown to be HLA-A2.1-restricted and specific for the peptide 334-342 of the CS protein. In addition, double transgenic HLA-A2.1 x human beta 2-microglobulin mice were immunized with peptide 1-10 of the CS protein. T cells derived from immune lymph nodes displayed a peptide-specific HLA-A2.1-restricted cytolytic activity after one in vitro stimulation.

In vitro immune recognition of synthetic peptides from the Plasmodium falciparum CS protein by individuals naturally exposed to different sporozoite challenge.

The impact of duration and intensity of sporozoite challenge on the in vitro cell immune response to synthetic peptides of the circumsporozoite (CS) protein of Plasmodium falciparum was investigated in residents of a malaria endemic area in Burkina Faso (West Africa). Lymphocyte proliferation and interferon-gamma (IFN-gamma) production were used to assess immune recognition of synthetic peptides corresponding to the polymorphic Th2R and Th3R regions, to the conserved CS.T3 sequence and to NANP and degenerate NVDP repeats. Immune responses were measured in adults and children from a village where they received more than 100 sporozoite inoculations per year and in adults living in a town, exposed to a 10-100 times lower challenge. A lifetime intense exposure apparently increased the ability to proliferate in response to most peptides in the rural adults, who all produced antibodies to NANP repeats. Surprisingly, cell cultures from these subjects seldom contained appreciable levels of IFN-gamma. In the urban adults, possibly due to the moderate challenge they are exposed to, significant differences in the proliferative potentials of the peptides could be detected. The highest stimulation indices were obtained with the genetically unrestricted CS.T3 peptide. Remarkably, proliferative responses to Th2R and Th3R appeared to be correlated with the humoral response to the CS protein, indicating a T helper significance of the epitopes. The differing proliferative potential of the polymorphic epitopes in the urban adults suggests that polymorphism might delay the development of immune responsiveness under conditions of sporadic transmission. The children from the highly malarious village displayed the lowest proliferative scores, accompanied by a high prevalence of antibodies to NANP repeats. On the basis of these findings, the hypothesis is proposed that a pure B cell reactivity to NANP repeats could ontogenetically precede the mounting of a conventional T-B cooperative immune response.

Detecting malaria sporozoites in live, field-collected mosquitoes.

A method is described for identifying malaria-infected mosquitoes, without killing them or hampering their fitness. Individual mosquitoes were induced to salivate on coverslips, and sporozoites, deposited on the glass surface, were visualized by Giemsa staining. Of 21 mosquitoes found to contain sporozoites by salivary gland dissection, 13 had delivered sporozoites on coverslips. A positive correlation was found between the amount of saliva expelled and ejection of sporozoites, indicating that the sensitivity of the method may be increased by improving the probing behaviour of the mosquitoes. The procedure described may be suitable for selecting infected mosquitoes which are able to eject sporozoites during probing. Being applicable to wild Anopheles and to large numbers of mosquitoes, the method lends itself for use in field studies on malaria.

Multiple antigen peptides for specific detection of antibodies to a malaria antigen in human sera.

Multiple antigen peptides (MAP), consisting of a number of peptide copies synthesized on a branching lysyl core, offer a novel approach for rendering small peptides immunoreactive in solid-phase immunoassays. An octameric MAP, carrying 6 repeats of the sequence -N-A-A-G-, tandem repeated in the immunodominant region of the circumsporozoite (CS) protein of Plasmodium malariae, was used as a model to evaluate the suitability of the MAP system in an indirect enzyme-linked immunosorbent assay (ELISA) for detecting antibodies against a parasite antigen in individuals exposed to natural infection. The reaction of endemic sera in ELISA on MAP8-(NAAG)6 was related to that obtained in immunofluorescence on sporozoites, indicating the specificity of the antibody-MAP interaction. The reactivity of immune sera was found to be directed only against the (NAAG)6 moiety of the MAP and not against the lysyl core, since antibody binding to MAP8-(NAAG)6 was completely inhibited by (NAAG)6-NA monomer, but remained uninfluenced when lysyl core was used as competing ligand. The levels of antibodies to MAP8-(NAAG)6, in two groups of individuals naturally exposed to malaria infection, appeared to be related to their respective exposure to the parasite.

Waiting for the vaccine: sporozoite vaccine research entails important progress in malaria epidemiology.

The research efforts aimed at developing a vaccine against malaria, although failing thus far in their main objective, have produced molecular tools of great utility for epidemiological studies. For example, monoclonal antibodies directed against the repeats of Plasmodium circumsporozoite (CS) protein allowed the 2-site assay for detecting sporozoites in mosquitoes to be established. This immunoassay is advantageous compared with the conventional method of salivary gland dissection and microscopic examination, for it makes the identification of the sporozoite species possible, thanks to species-specific aminoacid sequences of the CS repeats. Other examples of vaccine research-derived tools are synthetic peptides reproducing the repetitive part of the CS protein, which allow antibodies to sporozoites, in individuals exposed to malaria, to be detected. Antibodies to the CS repeats of Plasmodium (Laverania) falciparum proved to be a reliable indicator of the intensity of malaria transmission and, therefore, were suitable for monitoring the impact of malaria control programmes. Finally, a project is outlined that, relying on the application of these tools, will aim at characterizing the transmission of Plasmodium (Plasmodium) malariae and at unveiling the possible relationship among different species thriving in the same distribution area, an issue which may become of relevance in view of the likely introduction of a vaccine directed against a single species.

Permethrin-impregnated curtains in malaria control.

The impact of permethrin-impregnated curtains on the incidence of malaria episodes, parasitaemia and splenomegaly was assessed during a 22 month period in 2 groups of children aged 0.5-6 years. One group lived in houses where permethrin-impregnated curtains had been installed, the other group lived in houses without curtains. A significant reduction of incidence of malaria episodes, mean parasite density, parasite prevalence and splenomegaly was consistently observed in the intervention group towards the end of the period of moderate transmission, whereas no clear-cut impact could be demonstrated during the high transmission period. The influence of malaria pressure and community utilization on the protective efficiency of curtains is discussed. Because of their acceptability and the ease of reimpregnation, curtains proved to be a suitable technique for integration into primary health care.

Intraerythrocytic administration of a synthetic Plasmodium antigen elicits antibody response in mice, without carrier molecules or adjuvants.

The synthetic peptide (NANP)40, reproducing the tandem-repeated epitope of the circumsporozoite protein of Plasmodium (Laverania) falciparum, was entrapped into murine, autologous erythrocytes by a hypotonic dialysis method. Mice immunized intravenously with minute amounts of encapsulated peptide produced considerable antibody titres. This result indicates that intraerythrocytic antigen administration may have a potential as an immunization system for humans, since it dispenses with adjuvants and carrier molecules.

Evaluation of an ELISA kit for epidemiological detection of antibodies to Plasmodium falciparum sporozoites in human sera and bloodspot eluates.

Antibodies to Plasmodium falciparum sporozoites represent a serological transmission indicator, which can be applied in epidemiological studies to estimate the intensity of malaria transmission. An ELISA method has been developed as an industrial kit to detect these antibodies, using a chemically synthesized (NANP)40 peptide as antigen. The results obtained with this kit are compared in the present paper with those obtained by an ELISA test already applied in epidemiological studies. In testing sera from individuals living in endemic areas, a high diagnostic concordance (92.1%) was obtained between the two assays. The absorbances of these sera correlated well, as shown by a correlation coefficient r = 0.877. Sera from individuals never exposed to malaria gave very low absorbances with the kit. This minimum non-specific binding increases the probability of comparable results in different studies. When the two ELISAs were evaluated for analytical sensitivity and precision, similar satisfactory results were achieved. The test can be performed not only with sera but also with eluates from filterpaper bloodspots. Modifications of the kit to reduce its cost and suggestions regarding distribution and funding are also proposed.

Immunotechniques for epidemiology of malaria: appropriate tools for integration of primary health care with malaria research and control.

Community-based malaria control with integrated primary health care appears to be the most feasible approach for endemic countries in their struggle against malaria. To plan and implement personal protection and vector control measures, there is the need for comprehensive information about local modes of transmission. Experience with insecticide-based vector control programmes and entomological data accumulated over the years has revealed vector systems of extraordinary heterogeneity, creating multifaceted transmission situations. The primary health care-system offers an appropriate structure to collect and evaluate microepidemiological information countrywide. Community and health workers trained and supervised by qualified personnel could be involved in the assessment of clinical, parasitological and entomological indices. Community participation is facilitated if personnel are taught the use of immunotechniques. Tests can be performed on dried material which allows samples to be stored for months without refrigeration, so that transport to and processing in a central laboratory are not subject to time constraints. This paper describes and discusses enzyme-linked immunosorbent assays to determine if antibodies to sporozoites are present in blood collected as dried spots and to identify the origin of bloodmeals using dried mosquito abdomens.