SPf66 malaria vaccine is safe and immunogenic in malaria naive adults in Thailand.

In preparation for an efficacy trial of malaria vaccine SPf66 in Thailand, a series of overlapping Phase I trials were conducted of US-manufactured SPf66. Here, two clinical lots were evaluated for safety and immunogenicity in a combined open-label trial. Eleven healthy, malaria naive, 18-44 year-old Thai men and women received three doses by subcutaneous injection in alternate arms at 0, 1 and 6 months. Safety was assessed by monitoring local and systemic reactogenicity and laboratory parameters. Common side effects were mild erythema, induration and tenderness at the site of injection which resolved within 24-48 h. At third immunization, two volunteers developed acute bilateral reactions with induration, erythema and pruritus limited to the sites of the second and third immunizations. Eight of 11 volunteers sero-converted by ELISA, six of whom would be classified as high responders by Colombian standards. Eight of 11 volunteers developed a lymphoproliferative response to the SPf66 antigen. Side effects were more common and antibody and lymphoproliferative responses greatest, among the four female volunteers. This initial study of SPf66 malaria vaccine in Asia constitutes an essential link between the initial Phase I study in the US and subsequent field studies in a semi-immune population in a malaria endemic area of Thailand. This study further establishes comparability of US-manufactured SPf66 with that of Colombian provenance and substantiates the validity of the subsequent negative efficacy results of SPf66 in a field trial in Thailand.

Complete development of the liver stage of Plasmodium falciparum in a human hepatoma cell line.

Plasmodium falciparum parasites develop in the liver before being released into the bloodstream, where they exert the potentially lethal effects characteristic of malaria. Our understanding of the hepatic phase of the life cycle is limited by the parasite's requirement for fresh human liver cells in which to mature. In this work, liver parasites completed their development within a Thai human hepatoma cell line (HHS-102), and the presence of ring-form parasites in erythrocytes overlying the liver cell culture confirmed that an entire liver cycle was completed, culminating in the production of viable blood-stage parasites. The HHS-102 cell line allows investigation of the undefined liver stage of falciparum malaria previously unavailable in the laboratory.

Quinine with tetracycline for the treatment of drug-resistant falciparum malaria in Thailand.

Reports of deteriorating quinine efficacy prompted us to investigate the ability of quinine-tetracycline to clear parasites and fever from patients with multiple drug-resistant Plasmodium falciparum infections. Past and present treatment results were compared at two study sites along the Thai-Cambodian border. In northeastern Thailand, quinine-tetracycline cleared parasites more quickly in 1990 than in 1987 (mean 3.4 and 4.0 days, respectively; P = 0.006). In southeastern Thailand, there were no significant differences between 1990 (n = 26) and 1981-1983 (n = 42) in the time taken to clear either parasites (median 96 and 93 hr, respectively; P = 0.35) or fever (mean 74 and 66 hr, respectively; P = 0.30). In vitro drug sensitivity testing revealed a two-fold decrease in susceptibility to quinine between 1983 and 1990 in isolates from the southeastern Thai-Cambodian border (mean inhibitory concentration 166 ng/ml and 320 ng/ml, respectively; P less than 0.001). We conclude that oral quinine-tetracycline continues to reliably clear parasites and fever from falciparum malaria patients infected in eastern Thailand. Periodic re-evaluations are warranted, however, since the decrease in vitro susceptibility to quinine may be followed by an in vivo decay in the treatment response.

Ciprofloxacin treatment of drug-resistant falciparum malaria.

A randomized, open study of high-dose ciprofloxacin (750 mg every 12 h) in uncomplicated falciparum malaria was conducted in Thailand. No patient completed the planned 1-week treatment course. Because of rising parasitemia (threefold higher at 36 h than on admission) and deterioration of clinical status, three individuals required quinine treatment 36 h after commencing ciprofloxacin; a fourth was given quinine at 54 h. The study was terminated early for safety reasons after only four ciprofloxacin and four control patients had been enrolled. Ciprofloxacin was well absorbed and efficiently entered erythrocytes; median plasma and red cell concentrations 90 min after the first dose were 4.0 (range, 3.7-6.8) and 5.1 (3.8-6.0) micrograms/ml, respectively. However, 50% inhibition of parasite growth in vitro required 6.6 micrograms/ml, (5.6-9.6). Ciprofloxacin should not be used alone to treat chloroquine-resistant falciparum malaria.

Comparison of antibody responses to the circumsporozoite protein repeat region and to intact sporozoites during acute falciparum malaria.

Most acute falciparum malaria patients mount an antibody response to the circumsporozoite (CS) protein which contains a dominant B-cell epitope. In order to investigate whether antibodies against other epitopes on the sporozoite surface may be important during a particular phase of infection or convalescence, we longitudinally studied the antibody responses of 13 Thai patients with acute falciparum malaria. Antibody comparisons were made using intact Plasmodium falciparum sporozoites in an indirect fluorescent antibody test and the recombinant peptide, R32tet32, as capture antigen in an enzyme-linked immunosorbent assay. Antibody response curves derived using the 2 methods were similar, and adsorption with R32tet32 greatly (greater than 95%) diminished anti-sporozoite activity in sera. Thus, peptide constructs containing the CS repeat region epitope, (NANP)n, can be used with confidence to assay anti-sporozoite antibodies, independent of both the time of infection and prior malaria history.

Lymphocyte responsiveness to a candidate malaria sporozoite vaccine (R32tet32) of individuals with naturally acquired Plasmodium falciparum malaria.

Lymphocyte proliferative responses to the candidate malaria sporozoite vaccine antigen R32tet32 were evaluated in 29 patients with acute Plasmodium falciparum malaria, 20 convalescent patients, 11 nonimmune individuals, and 22 healthy residents of two endemic malarious areas in Thailand. The results indicate that 14 of 20 (70%) convalescent patients and 14 of 22 (64%) residents of endemic areas responded to the R32tet32 antigen. However, only 8 of 29 (28%) patients with acute P. falciparum malaria responded. When 4 of the convalescent patients who remained in a malaria-free area were restudied 5-10 months after the acute infection, they were either not responsive or their responses had greatly diminished. These findings show that sensitization to R32tet32 occurs following a natural P. falciparum infection, but the cellular immune response to sporozoite antigens may be short-lived and may be suppressed during acute P. falciparum malaria.

Malaria: treatment efficacy of halofantrine (WR 171,669) in initial field trials in Thailand.

Halofantrine (WR 171,669) hydrochloride was administered orally to 82 patients infected with Plasmodium falciparum malaria on the Thai-Kampuchean border between June 1982 and December 1983 in a randomized double-blind treatment trial which compared the efficacy of halofantrine with that of mefloquine. Halofantrine was curative with oral treatment on a single day in 65% of patients (13/20) who received 1000 mg followed 6 hours later by an additional 500 mg, and in 88% of patients (53/60) who received 500 mg every 6 hours for 3 doses. Mefloquine was curative in 88% of patients (22/25) given a single oral dose of 1000 mg and in 97% of patients (38/39) given a single oral dose of 1500 mg. The difference in cure rates between the 3-dose halofantrine regimen and either of the mefloquine regimens was not significant. The mean parasite clearance time for all regimens ranged from 75 to 84 hours. The mean fever clearance time for all four treatment groups was in the range 50-60 hours, with no significant differences between groups. Post-dosing side-effects in patients treated with halofantrine consisted of nausea, vomiting, abdominal pain and diarrhoea and were not significantly different from those treated with mefloquine. Halofantrine therefore appeared to be of comparable efficacy to mefloquine in the treatment of multidrug-resistant P. falciparum malaria.

Polymorphism of proteins in malaria parasites following mefloquine treatment.

Proteins in malaria parasites (Plasmodium falciparum) isolated from a patient in Thailand before treatment, and after recrudescence of infection subsequent to mefloquine treatment, were compared by two dimensional polyacrylamide gel electrophoresis (2D-PAGE) analysis. Nine 'pre-treatment' and six 'recrudescent' clones were studied. Variants of the enzyme glucose phosphate isomerase were also noted and mefloquine susceptibility of each clone was measured by in vitro tests. The 'pre-treatment' isolate was found to contain at least four genetically distinct clones, all sensitive to mefloquine, while the 'recrudescent' isolate contained at least two other types of clone, both showing increased tolerance to mefloquine. These two more tolerant types of clone differed from all the sensitive ones studied in regard to several different protein variants as shown by 2D-PAGE analysis. It is concluded that at least two (and probably more) genetically distinct clones of parasites with increased tolerance to mefloquine were present in the parasite population before mefloquine treatment was given, and were selected under mefloquine pressure.

Cloning and characterization of mefloquine-resistant Plasmodium falciparum from Thailand.

Resistance to mefloquine in Plasmodium falciparum has begun to occur along the border of Thailand and Kampuchea. As a means of assessing the natural occurrence of mefloquine resistance, the admission and post-treatment parasite isolates from a mefloquine treatment failure were cloned and characterized. Clones from the admission isolate were susceptible to mefloquine in vitro (ID50 of 3.4 [2-5], G [95% CI] ng/ml) and showed a mixture of isozyme types for glucose phosphate isomerase (GPI types I and II). The post-treatment clones were resistant to mefloquine in vitro (ID50 of 17.3 [13-23] ng/ml) with only one isozyme (GPI type I) detected. These observations suggest that under mefloquine pressure a resistant parasite population was selected in the patient, indicating that the potential for mefloquine resistance already exists in the indigenous P. falciparum gene pool. In addition, the mefloquine-resistant clones showed decreased susceptibility in vitro to halofantrine suggesting possible cross-resistance to this new antimalarial drug currently under development.

Antimalarial drug susceptibility testing of Plasmodium falciparum in Thailand using a microdilution radioisotope method.

Antimalarial activity of chloroquine, quinine, mefloquine and halofantrine against 33 strains of P. falciparum isolated from naturally acquired malaria infections in Thailand was determined using a radioisotope microdilution method. A microtitration procedure was used to test isolates of P. falciparum against the 4 drugs simultaneously. The mean ID50 for chloroquine and quinine reflected known resistance to those drugs in Thailand. The mean ID50 for mefloquine and halofantrine showed susceptibility to these drugs. Four isolates of P. falciparum however had markedly decreased susceptibility to mefloquine (ID50 greater than 15 ng/ml); one case of which was confirmed as the first case of RII resistance for mefloquine in Thailand. Several parasite isolates were also observed to have decreased susceptibility to the new drug, halofantrine. These studies strongly recommend that in vitro testing be done in conjunction with field evaluation of new antimalarial drugs.

Deficiency of Con A-induced suppressor cell activity in peripheral blood mononuclear cells from Thai adults naturally infected with Plasmodium falciparum and Plasmodium vivax.

Con A-pretreated mononuclear (MNC) cells from Thai adults with naturally acquired P. falciparum or P. vivax malaria were significantly less effective in suppressing the responsiveness of autologous or normal allogeneic responder cells to mitogenic lectins or allogenic stimulator cells than pretreated cells from healthy donors. Serial studies of three patients demonstrated that reduced suppressor cell activity was present early in malaria infection but returned to normal soon after treatment. These studies demonstrate that the loss of T cells previously observed in patients with malaria, in part may functionally represent a loss of suppressor T cells.

Cold-reactive immunoglobulin M antilymphocyte antibodies directed against B cells in Thai children with dengue hemorrhagic fever.

Antilymphocyte antibodies were found in 51 of 83 serum specimens from Thai children with dengue hemorrhagic fever (DHF). The lymphocytotoxic activity was complement dependent, and cytotoxicity was detected in the 19S immunoglobulin M-associated serum fractions at a temperature optimum of 15 degrees C. Sera with lymphocytotoxic activity were cytotoxic to autologous as well as allogeneic lymphocytes from patients and healthy adult donors and were directed primarily against B cells, with some T cell cross-reactivity. This study suggests that infection with DHF induces predominately cold-reactive antilymphocyte antibodies in DHF patients that could potentially interact with peripheral blood cells of patients and modulate the humoral immune responses of patients during infection.

Subpopulations of T cells (Tg and Tm) in patients with malaria.

In the present study we utilized rosetting techniques to enumerate the putative suppressor (Tg) and helper (Tm) T-cell subpopulations in the peripheral blood of adult Thais with malaria. A lower percentage of both Tg and Tm subpopulations and a lower number and percentage of total T cells was found in these patients during the acute period of infection than in the peripheral blood of healthy donors. However, the percentages of total T, Tg and Tm cells were higher during the convalescent period and were comparable to the values found in the peripheral blood of healthy donors. The significance of these findings are discussed. No correlations were found between the percentage of these T-cell subpopulations and the level of parasitemia or the hematocrit.

Characterization of cold reactive lymphocytotoxic antibodies in malaria.

Characterization of cold reactive lymphocytotoxic antibodies present in sera from Thai adults with malaria revealed that the antibodies are predominantly 19S (IgM), directed against both autologous and allogeneic mononuclear cells, complement-dependent, present in titres ranging from 1:2 to 1:16, and exhibit greater lymphocytotoxic activity during the acute stage of malarial infection than during the convalescent stage. The lymphocytotoxic antibodies were primarily directed against B cell targets or both B as well as T cell targets. In addition some sera were reactive with enriched monocyte/macrophage indicator cells at 15 degrees C, but not 37 degrees C. Antibodies directed against B cell targets were lymphocytotoxic both at 15 degrees C as well as 37 degrees C. The results indicate that IgM lymphocytotoxic antibodies in the sera of patients with malaria are directed primarily against B cells with reactivity to a lesser extent against T cells and macrophages and thus may play an immunoregulatory function in the humoral immune response to malaria infection.

Deficient spontaneous cell-mediated cytotoxicity and lectin-induced cellular cytotoxicity by peripheral blood mononuclear cells from Thai adults naturally infected with malaria.

To assess general cytotoxic effector cell capabilities by peripheral blood mononuclear cells from patients with active malaria infections, we examined antibody-dependent cellular cytotoxicity, spontaneous cell-mediated cytotoxicity, and lectin-induced cellular cytotoxicity by using human and chicken erythrocyte, Chang cell line, and K562 cell line targets. By using human erythrocyte and Change cell line targets, we found that Thai adults naturally infected with malaria had significantly impaired lectin-induced cellular cytotoxicity. In addition, spontaneous cell-mediated cytotoxicity was deficient with K562 but not with Chang cell line targets. Finally, no change in antibody-dependent cellular cytotoxicity was observed when chicken erythrocyte or Chang cell line targets were used. These observations, coupled with our previous observations of a physical loss of peripheral blood T cells, the presence of lymphocytotoxic serum antibodies, and defective T suppressor cell generation in patients with malaria, indicate that major alterations in the cellular immune system occur in patients with active malaria infections.

Effect of anti-coagulants on cold-reactive anti-lymphocyte activity in the blood of patients with malaria.

The effect of three different anti-coagulants on the level of cold-reactive anti-lymphocyte activity (ALA) in the peripheral blood (PB) of malarious individuals was assessed to determine if plasma could be substituted for serum in assays designed to characterize ALA. Results show that plasma obtained by treating PB with acid-citrate dextrose or ethylenediamine tetraacetic acid can be used instead of serum in these assays but that plasma obtained from heparin-treated blood cannot.

Suppression of mitogenic lectin-induced blast transformation of human peripheral blood mononuclear cells by pyrimethamine.

The anti-malarial drug pyrimethamine suppresses in vitro mitogenic lectin-induced blast transformation by human peripheral blood mononuclear cells (MNC) when the drug is added to cells (1 X 10(-5) M/culture). Sulphadoxine, a second widely used anti-malarial drug has no suppressive effect on the MNC. MNC responsiveness in the mixed leucocyte reaction and cellular viability are not altered by either pyrimethamine or sulphadoxine. In addition, no significant suppression is found when serum obtained from individuals on pyrimethamine-sulphadoxine chemoprophylaxis is added to MNC in the assays. The data, however, do not totally rule out any clinically significant suppressive effect by the anti-malarial drugs on human cellular immune responses.