The American Journal of Tropical Medicine and Hygiene - Volume 47, Issue 5, November 1992

Prevention and Control. Programs aimed at the eradication of a specific disease on a national or even international scale have received a very mixed reception among health professionals. The complex and hugely expensive effort to eradicate human malaria must ultimately be termed a failure. This experience tended to make health planners leery of such seemingly grandiose undertakings. Then came the remarkable success of the global campaign to eradicate smallpox and the enthusiasm for such a final solution was rekindled. Now we have another such effort that has garnered the support of a large number of countries, programs, and individuals. The possibility that Guinea worm disease or dracunculiasis can be eradicated from all endemic foci has engendered a remarkable level of international cooperation that may bring about this laudable goal within the foreseeable future. The first paper in this issue (see page 529) provides some interesting and valuable insights into the process involved in the development of the Nigerian program to eradicate dracunculiasis.

The transformation of dracunculiasis from an obscure and neglected rural disease to the highly visible target of a national eradication campaign in Nigeria is described in this report. This process progressed through four overlapping stages: documentation of the extent and nature of the disease as a national problem, demonstration in Nigeria that dracunculiasis could be effectively prevented by targeted provision and use of protected rural water supplies, mobilization for community participation in, and political support of, the eradication effort, and implementation of interventions nationwide. The conduct of the first national village-by-village search for cases and documentation of the adverse socioeconomic impact of the disease (e.g., on rice production) in Nigeria were the key elements used to solicit greater attention to the problem and mobilize support for its eradication. The critical role of the mass media in this effort and other benefits of this mobilization strategy are also highlighted.

A clinicoepidemiologic survey of Chagas' disease was conducted in the remote rural village of Tabacal in southcentral Cochabamba, Bolivia. In June and July 1988, we interviewed and examined 153 of 160 villagers > five years old for signs and symptoms of Chagas' disease. All participants had electrocardiograms (EKGs) and serologic analysis performed, and 20 villagers underwent xenodiagnosis. All 40 houses in the village were examined for triatomes, and house construction materials and defects were recorded. Seventy-four percent of all villagers had serologic evidence of Chagas' disease, and were defined as cases. Cases were three and one-half times more likely to have signs and symptoms of heart failure than non-cases (P = 0.2) and were nine times more likely to have EKG conduction abnormalities than non-cases (P = 0.02). Thirty-three percent of all EKG conduction defects occurred in individuals < 35 years of age. All dwellings had evidence of triatome infestation; 72% of the triatomes collected were positive for metacyclic trypanosomes. We conclude that Trypanosoma cruzi infection is highly prevalent in Tabacal and is a common cause of morbidity in that region.

Malaria transmission was studied in a newly irrigated area of the Mahaweli project in the dry zone of Sri Lanka. Observations were performed for a three-month period following the northeast monsoon. Parasitemia in the population varied from 20.2% in February to 7% in May, and infection was due to both Plasmodium falciparum and P. vivax. Night catches of mosquitoes collected with human bait included a high proportion of Anopheles annularis. Mosquitoes containing sporozoites in the salivary glands were identified by an enzyme-linked immunosorbent assay. Anopheles culicifacies, An. annularis, and An. aconitus were all implicated as vectors in the area. The highest entomologic inoculation rate, 0.12 infected bites/hr, was observed with An. annularis and P. vivax in March. We suggest that a change in the ecosystem from dry zone forest to irrigated cultivated land is the cause of the increased prevalence of An. annularis in this area and its emergence as a major vector of malaria.

We have investigated seroreactivity against Plasmodium falciparum crude parasite antigens, the P. falciparum ring-infected erythrocyte surface antigen (Pf155/RESA), as well as against two synthetic peptides (EENV)6 and (EENVEHDA)3 that represent important epitopes of Pf155/RESA. The study population consisted of 421 children and adult Thais living in an area with moderate malaria transmission. We related these serologic findings to some important epidemiologic baseline data collected in the study area. The parasite rate in study subjects was 18.76%. Sixty-two percent were seropositive to crude P. falciparum antigens, 30.3% to the Pf155/RESA antigen, 23.05% to (EENV)6, and 20.17% to (EENVEHDA)3. Antibody responses to crude P. falciparum antigens and to Pf155/RESA were age dependent and increased with exposure. There was evidence that Pf155/RESA antibodies might play a role in protective immunity in this population. Since Pf155/RESA is a potential vaccine candidate antigen, the information obtained from these field studies will provide some seroepidemiologic baseline data for subsequent vaccine trials.

Mosquitoes collected from coastal, inland valley, and alpine locations in California were evaluated for their experimental vector competence for two viruses in the California serogroup (Bunyaviridae: Bunyavirus). Aedes squamiger, a coastal salt marsh mosquito, was an efficient vector of a California encephalitis (CE)-like virus isolated from its habitat (89% of the pledget-fed females became infected and 61% transmitted virus). Aedes dorsalis, a coastal mosquito, and Ae. melanimon, an inland valley mosquito, were competent vectors of prototype CE virus (98% and 100% of the pledget-fed females became infected and 56% and 30%, respectively, transmitted virus). Aedes squamiger and Ae. dorsalis transmitted both viruses vertically to one or more of 20 of their progeny. Culiseta inornata was susceptible to infection with both viruses, but 5% or less transmitted virus perorally. Alpine mosquitoes, Ae. cataphylla, Ae. increpitus, and Ae. tahoensis, became infected with both CE and CE-like viruses, but 3% or less transmitted virus. All species of mosquitoes were more efficient vectors of both viruses following intrathoracic inoculation than following pledget feeding, suggesting the presence of mesenteronal barriers.

A series of experiments were done to study the effect of simulated summer and winter temperatures on the development of Phlebotomus perniciosus (Diptera:Psychodidae) and on the survival of Toscana virus in transovarially infected insects. Sand flies maintained at 28°C developed relatively fast, with adults emerging from 40 to 55 days after initial oviposition. Similar results were obtained with insects reared at 25°C. In contrast, sand flies maintained at 15°C developed slowly up to the fourth larval instar; at that point, further development ceased and the insects entered diapause. Diapause could be terminated by increasing the ambient temperature to 25°C. The ambient temperatures at which the immature forms were reared (15°C, 25°C, and 28°C) had no effect on the subsequent F1 adult filial infection rates with Toscana virus (49.1%, 47.5%, and 46.5%, respectively). The results of these experiments provide a model of how Toscana virus survives the winter in endemic areas by maintenance in diapausing P. perniciosus larvae. In another experiment, venereal transmission of Toscana virus was shown from transovarially infected males to non-infected virgin females. This is the first demonstration of sexual transmission of a phlebovirus by sand flies. If venereal transmission occurs in nature, it would provide an alternative method of virus amplification in the vector population, in the absence of viremic vertebrates.

We studied the prevalence of Cryptosporidium in 29 patients with acquired immunodeficiency syndrome (AIDS) from Zulia State, Venezuela. They ranged in age from five months to 46 years. Two were children and 27 were adults, of which six were women. Of the 21 men, 66.6% reported homosexual behavior. Three stool samples from each patient were examined, and modified Ziehl-Neelsen carbolfuchsin staining of formalinether stool concentrates was used to identify Cryptosporidium oocysts. To detect the presence of other intestinal parasites, direct wet mounts and iron-hematoxylin-stained smears were examined. Cryptosporidium was found in 12 (41.3%) of the patients and was identified as a single parasitic infection in seven of the 12 patients (58.3%). Other pathogenic parasites encountered were Giardia lamblia (3 of 12, 25%), Entamoeba histolytica (1 of 12, 8.3%), Ascaris lumbricoides, Trichuris trichiura, and Strongyloides sterocoralis (each 1 of 12, 8.3%). Blastocystis hominis, an organism with an uncertain taxonomic position and pathogenicity, was observed in three of 12 patients (25%). An inflammatory exudate was observed in 10 of 12 patients infected with Cryptosporidium. Most of the patients with this infection presented with chronic watery diarrhea and weight loss. Our results suggest that Cryptosporidium is very common in AIDS patients with diarrhea in Venezuela. However, the role of this parasite as an enteropathogen in these patients is uncertain.

Lymph node involvement by Leishmania during human cutaneous leishmaniasis was reported more than 90 years ago, but the importance of certain Leishmania strains in such dissemination remains largely speculative. We have examined 36 consecutively untreated cutaneous leishmaniasis patients early in their disease; 66.7% had enlarged lymph nodes. Patients with enlarged lymph nodes had higher anti-Leishmania immune responses than patients without such involvement, both at the IgG antibody level (mean ± SD optical density at 492 nm = 0.163 ± 0.089 versus 0.098 ± 0.086; P = 0.009) and in skin test responses (12.4 ± 1O.2 mm versus 5.7 ± 7.3; P = 0.03). Thirteen (62%) of 21 lymph node cultures and 16 (53%) of 30 cultures from cutaneous sites were positive for Leishmania. Eleven of 13 isolates from lymph nodes were characterized by a panel of monoclonal antibodies, and all were typed as L. braziliensis. Our findings stress the importance of L. braziliensis as an agent involved in the early invasion of the lymphatic system.

The effect of the three main Brazilian polyspecific antivenoms on venom clearance was assessed in 118 moderately envenomed victims of bites by Bothrops species (mainly B. jararaca) in Sao Paulo State, Brazil. Serum samples taken from patients at intervals during their stay in the hospital and at followup approximately four weeks later were tested by enzyme immunoassay for the presence of whole venom and therapeutic antivenom. Results indicated that in patients treated with the standard regimen of either four (40 ml) or eight (80 ml) ampules of each antivenom, venom was cleared from the circulation within four days of antivenom administration. However, high concentrations of antivenom persisted for approximately 10 days and remained detectable until 30–50 days after administration. This suggests that patients may be being treated with excessive amounts of antivenom in Brazil. This practice increases the national cost of antivenom therapy and may contribute to the high frequency of antivenom reactions. Clinically, there was no obvious difference in the efficacy between the three antivenoms.

The evolution of Lyme borreliosis was examined in genetically resistant C.B.-17 and susceptible C3H/He(C3H) mice homozygous for the severe combined immune deficiency (scid) gene, or their immunocompetent counterparts. The C.B-17, C.B-17-scid, C3H, and C3H-scid mice were inoculated intradermally with 104 Borrelia burgdorferi and examined on days 14, 21, 30, 45, and 60 after inoculation. Spirochetemia was detected through 30 days, but was cleared in all groups by 45 days. Kidney and brain were inconsistently culture positive, but spleen and ear punch samples were positive in most mice. Immunocompetent C.B-17 and C3H mice seroconverted with equivalent IgG titers to B. burgdorferi, while C.B-17-scid and C3H-scid mice did not seroconvert. Arthritis occurred in nearly all joints examined in all genotypes on day 14, was of equal severity among C.B-17, C.B-17-scid, and C3H mice, but was more severe in C3H-scid mice. By days 30 and 45, arthritis began to resolve in immunocompetent mice, with C3H mice having more severe disease than C.B-17 mice. Arthritis persisted in C.B-17-scid and C3H-scid mice. Carditis occurred to an equal degree in all groups on day 14, remained active in scid mice, but regressed in immunocompetent mice at later intervals. Many spirochetes were visualized with silver stain in inflamed synovial tissues of scid mice, and were present in other tissues in smaller numbers. These studies show that specific immunity is not involved in arthritogenesis or genetically determined susceptibility to arthritis, but is involved in arthritis and carditis regression.

Renal specimens from Aotus monkeys were studied by light microscopy and immunohistochemistry to examine pathologic changes following vaccination with synthetic peptides corresponding to the 35-kD, 55-kD, and 83-kD asexual blood stage antigens of Plasmodium falciparum. The monkeys were vaccinated and later challenged with P. falciparum. In the monkeys vaccinated with Centers for Disease Control peptides (group I), specimens from four of six postvaccinated animals had mild to severe mesangial proliferation and two had diffuse interstitial nephritis. Specimens from three monkeys vaccinated with Colombia peptides (group II) had mild to severe mesangial proliferation and one had interstitial nephritis. In the hybrid polymer-vaccinated monkeys (group III), specimens from three animals had mild to moderate mesangial proliferation and one had severe interstitial nephritis. On the other hand, the control group immunized with bovine serum albumin (group IV) showed that specimens from three animals had mild to severe mesangial proliferation and two had severe interstitial nephritis. In the nonimmunized group (group V), specimens from three animals had moderate to severe mesangial proliferation and two had severe and mild interstitial nephritis. Immunohistochemical analysis using the peroxidase-antiperoxidase method revealed mesangial deposits of P. falciparum antigens in 11 of 14 vaccinated monkeys and in five of 10 unvaccinated controls. These results show that treatment of monkeys with prospective malaria vaccines does not increase the frequency of occurrence or of the severity of renal lesions. These data thus provide a baseline for assessing the safety of synthetic malarial vaccines in the future.

Plasmodium falciparum-infected erythrocytes (PfE) were collected from acutely infected children in The Gambia and Tanzania and cultured for more than 30 hr until the parasites were mature trophozoites. Sera collected from these countries, other African countries, Asia, and South America were used in the PfE microagglutination test to determine whether PfE from East and West Africa share surface antigens. From the patterns of agglutination reactivity, we identified extensive antigenic diversity in surface antigens, but obtained no evidence for greater differences between isolates from East or West Africa and those within one region. The majority of sera from immune adults from The Gambia, Tanzania, Sudan, Nigeria, or Ghana were pan-agglutinating, and agglutinated all PfE isolates from The Gambia and Tanzania. Some sera from immune adults of Irian Jaya also agglutinated each of the seven African isolates, while others agglutinated many but not all of the isolates, similar to sera from immune adults of Flores, Indonesia. In contrast, sera from nonimmune adults from Colombia agglutinated few of the African isolates. It was remarkable, however, that sera from nonimmune Colombians agglutinated any African isolates. Our results are consistent with the following conclusions: some PfE surface antigen(s) are very diverse; this diversity is a feature of the parasite worldwide; the repertoire of isolate-specific surface antigens, although large, includes antigens that are either identical or antigenically cross-reactive in geographically very distant parasite populations; and African adults have pan-agglutinating antibodies that may contribute to protective immunity. Such pan-agglutinating antibodies could reflect the accumulation of a large repertoire of isolate-specific antibodies. The contribution of antibody against any shared PfE surface antigen to the pan-agglutinating reactivities is unknown and awaits development of the appropriate reagents.

Experimental cerebral malaria was recently found to occur in the squirrel monkey Saimiri sciureus when infected with the human malaria parasite Plasmodium falciparum. This report is concerned with the existence of spontaneous rosette formation ex vivo (infected blood samples) and in vitro (cultured parasites) between red blood cells (RBC) infected with squirrel monkey-adapted P. falciparum isolates and normal squirrel monkey RBC. Transfer of P. falciparum with high rosette formation tendencies (90–100 R+) from one donor monkey to several recipients gave rise to parasites that varied extensively in their ex vivo rosette formation capacity (4–96% R+). However, all individual parasites readily form rosettes after 24 hr of in vitro culture (60–95% R+). Host factors may be involved in the modulation of rosette formation, although it is found to occur both in splenectomized and spleen-intact animals. Cross-rosette formation is seen between parasitized human RBC and normal squirrel monkey RBC and vice versa, and rosettes formed by RBC of the two hosts are similarly affected by pH, temperature, EDTA, trypsin, as well as squirrel monkey and African human hyperimmune IgG. These characteristics of rosette formation are preserved after long-term in vitro culture in human RBC. Rosettes formed by some isolates are highly sensitive to heparin while others are not, suggesting at least two distinct mechanisms of rosette formation. This idea is also supported by the observation that specific squirrel monkey antisera to heparin-sensitive strains does not dissociate rosettes formed by a heparin-resistant strain. The results suggest that rosettes and anti-rosette formation antibodies formed by squirrel monkeys and humans exhibited similar characteristics, and that the squirrel monkey is therefore a good experimental model to study erythrocyte rosette formation and cerebral malaria.

The pathologic changes in placentae of pregnant rats infected with Plasmodium berghei at different stages of gestation were studied using light and electron microscopy and immunohistochemistry. The major changes observed were thickening and duplication of the trophoblastic basement membrane, and accumulation of parasitized erythrocytes and occasional mononuclear cells in the maternal blood space. Immunohistochemical examination of nine placentae revealed that six stained positively for IgG, two for IgM, and four for P. berghei antigen. No C3 deposition was detected. The findings in this study indicate that the variable parasitologic-clinical course from benign to fatal of P. berghei infection in pregnant rats makes it a potentially valuable model of human gestational malaria infection.

Improvements were made in the immunodetection of anti-galactocerebroside (anti-GalC) antibody in sera of patients with human African trypanosomiasis by thin-layer chromatography, enzyme-linked immunosorbent assay, and immunoadsorption. Rabbit anti-GalC antibodies were used to standardize these techniques and demonstrate their specificity. Anti-GalC antibodies were found in the sera of 42.8% of 63 patients with human African trypanosomiasis. Thirty-four control subjects living in the same endemic area were also tested. Anti-GalC levels were higher in human African trypanosomiasis patients with neurologic disturbances compared with patients without such disturbances. These antibodies were distributed mainly between the IgG and IgM classes, but 28% of the patients with human African trypanosomiasis had increased IgA levels without anti-GalC antibody activity.

A monoclonal antibody, MAb H24, recognized a Plasmodium falciparum antigen with a relative molecular mass (Mr) of 52 kD that appeared to be a rhoptry component by immunofluorescence microscopy. The antigen is synthesized during both ring and schizont stages, but pulse-chase experiments showed that it is not carried through to the next ring stage after reinvasion. It was not labeled by 3H-glucosamine. The purified MAb failed to inhibit parasite invasion in vitro. The antigen was isolated using affinity chromatography, and used to produce a monospecific polyclonal antibody (PAb H24) in mice. Polyclonal antibody H24 recognized the same antigen as MAb H24 as judged by both immunofluorescence microscopy and immunoprecipitation followed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and was markedly inhibitory in vitro.

In tropical countries, concomitant infections are a continuous problem. In the Rufiji Delta, an area of Tanzania that is holoendemic for malaria, there were outbreaks of influenza A, measles, and pertussis in 1986 and 1987. Significantly lower parasitic prevalences and mean densities of malaria parasites were found in children up to nine years of age who had measles or influenza than in asymptomatic control children. In contrast, children with pertussis had a higher prevalence and mean density than controls. The clinical courses of measles, influenza, or pertussis infections did not appear to be significantly affected by concomitant malaria infections. The reasons for the suppression of Plasmodium falciparum parasitemia during these viral infections are unclear. This effect could not be explained by the presence of fever.

The hybrid synthetic protein SPf(66), which contains small fragments of the 83-kD, 55-kD, 35-kD, and circumsporozoite antigens of Plasmodium falciparum, was studied to determine its protective capacity against malaria infection in Aotus lemurinus monkeys. Two groups of six monkeys each were immunized six times with this polymer, which was mixed with either Freund's adjuvant or aluminum hydroxide. Two groups of five animals each were used as controls and immunized with saline solution mixed with the same adjuvants. Neither antipeptide nor antimalarial antibodies developed after the six immunization doses. Regardless of this fact, the monkeys were challenged intravenously with 105 P. falciparum blood stage parasites, and the resultant parasitemia was followed daily on blood smears. Only one monkey from each of the groups immunized using Freund's adjuvant (both experimental and control) was protected. In those immunized using aluminum hydroxide, one animal was protected in the experimental group, but none were protected in the control group. Anti-parasite antibodies developed during the infection, but did not correlate with protection and failed to recognize SPf(66) peptide in an enzyme-linked immunosorbent assay. Immunization with the polymer did not boost natural antibodies present in two of the monkeys before the experiment. Low levels of gamma-interferon were produced in some animals, but were not correlated with protection.

Midguts of two strains of the mosquito vector Culex tarsalis were examined by light and electron microscopy following infection with western equine encephalomyelitis virus. Infection of the highly susceptible Knight's Landing strain with high-titered blood meals resulted in pathologic changes in the midgut epithelium after 2–4 days of incubation; lesions included sloughing of epithelial cells into the lumen and necrosis of cells in situ. Infection of Knight's Landing strain mosquitoes with low-titered blood meals and infection of the less susceptible Fort Collins strain with high-titered blood meals did not result in a significant increase in detached luminal cells, with respect to uninfected controls. Sloughing of infected cells into the midgut lumen may contribute to modulation of the mosquito infection. Lesions in the midgut of Cx. tarsalis are inconsistent with traditional views that regarded arbovirus infections of mosquito vectors as non-pathologic. These findings demonstrate that mosquito pathology is not an oddity limited to the previously described interaction between Culiseta melanura and eastern equine encephalomyelitis virus, and suggest that alphaviruses in general may adversely affect their mosquito vectors in nature.