The American Journal of Tropical Medicine and Hygiene - Volume 67, Issue 5, November 2002

Despite its diminishing efficacy because of increased resistance, chloroquine remains the primary antimalarial agent in many endemic areas. Evidence is mounting that point mutations on the Pfcrt and possibly the Pfmdr1 genes are conferring plasmodial resistance to chloroquine. In 1998, atypically strong rainfalls led to an increased activity of falciparum malaria in Mauritania that affected non-endemic regions bordering the Saharan desert. An in vivo study on chloroqine resistance was combined with studies for molecular markers of drug resistance. Detection of Pfmdr1-76-tyrosine showed an increased odds ratio (2.91) for resistance (P = 0.0195). However, by use of this codon alone, sensitivity for detection of resistance was 60.6%, and specificity was 65.3%. In comparison, detection of the K76T mutation at Pfcrt showed a very high sensitivity (100%) while specificity remained relatively low (65.4%). For the combination of mutations on both genes, the odds ratio for detection of resistance increased to 5.31 (P = 0.0005). Here, sensitivity was again decreased to 60.6% while specificity increased to 76.9%. The results of this study suggest that detection of Pfcrt T76 can be applied for predicting chloroquine resistance in epidemiologic settings with sufficiently high sensitivity to make it an attractive alternative to time- and labor-consuming in vivo trials. Additional testing for Pfmdr Y76 provides increased specificity to this approach.

Aotus monkeys were infected with a strain of Plasmodium vivax from Panama to determine its potential for the testing of malarial vaccines. After sporozoite inoculation, 3 splenectomized Aotus nancymai that had been infected previously with Plasmodium falciparum and P. vivax had prepatent periods of 13, 15, and 15 days with maximum parasite counts of 12,726/microl, 5,310/microl, and 9,180/microl. Three other A. nancymai previously infected with P. falciparum only had prepatent periods of 17, 15, and 15 days with maximum parasite counts of 44,460/microl, 31,500/microl, and 42,660/microl. One monkey with no previous history of infection had a prepatent period of 14 days after sporozoite inoculation, and a maximum parasite count of 100,000/microl; detectable parasitemia persisted for almost 500 days with 13 recognizable peaks in the parasite count. Anopheles dirus, Anopheles freeborni, Anopheles stephensi, and Anopheles quadrimaculatus mosquitoes were readily infected with the Panama strain.

Although most of the Papua New Guinea highlands are too high for stable malaria transmission, local epidemics are a regular feature of the region. Few detailed descriptions of such epidemics are available, however. We describe the investigation of a malaria epidemic in the Obura Valley, Eastern Highlands Province, Papua New Guinea. Of the 244 samples examined by microscopy, 6.6% were positive for Plasmodium falciparum only, 9.4% were positive for Plasmodium vivax only, and 1.2% were mixed infections. MSP2 and MSP3alpha genotyping and AMA1 sequencing were used to determine the genetic variation present in a sample of P. falciparum and P. vivax infections. The P. vivax infections were found to be genetically highly diverse. In contrast, all P. falciparum samples were of a single genotype. This striking difference in genetic diversity suggests endemic, low-level local transmission for P. vivax but an outside introduction of P. falciparum as the most likely source of the epidemic.

The combination of artesunate and mefloquine is currently one of the most effective treatments against multidrug-resistant Plasmodium falciparum malaria. To improve patient compliance to such a combination, the two agents have been combined in a prepacked single blister. Patients were instructed to simultaneously co-administer the drugs once a day for three days. In the present randomized, double-blind, parallel group, comparative, single center study in Thailand, this concept was investigated in 204 adults and children with acute, uncomplicated P. falciparum malaria. Patients were randomized into two treatment groups and received once a day over a three-day period the following: Group A received artesunate, 4-5 mg/kg/day, and mefloquine, total dose = 25 mg/kg, approximately 8.5 mg/kg/day, simultaneously. Group B received artesunate, 4-5 mg/kg/day, and mefloquine, total dose = 25 mg/kg, sequentially (i.e., no mefloquine dose on the first day, 15 mg/kg on the second day, and 10 mg/kg on the third day). Both treatment groups showed no relevant differences in baseline demographic and clinical characteristics. Intent-to-treat analysis revealed a cure rate at day 28 (primary endpoint) of 100% in group A and 99% in group B (difference not significant). The secondary endpoints of mean time to fever clearance (group A = 34 hours, group B = 31 hours) and mean time to parasite clearance (group A = 44 hours group B = 48 hours) were similar between groups (both differences not significant). Tolerability was good in both treatment groups, with no difference in the overall incidence of adverse events. There was a low incidence of nausea/vomiting (4.9% in both groups) and central nervous system side effects (4.9% in group A versus 8.8% in group B). These were comparable between groups and generally of a mild nature. The three-day combination of artesunate and mefloquine (Artequin, Mepha, Ltd., Aesch, Switzerland) with the introduction of mefloquine on day 1 offers a practical dosing regimen that is highly effective and well tolerated in patients of different ages with uncomplicated P. falciparum malaria. It is likely that the prepacked blister approach translates clinically into a better patient compliance, thereby contributing to limit the development of drug resistance.

Previously, we described a direct inhibitory effect of sodium artesunate on sodium chloride transport in the thick ascending limb of Henle's loop, indicating that artesunate acts as a diuretic agent. Here we present 2 cases of falciparum malaria treated with 4 intravenous 60-mg doses of sodium artesunate. Neither diuretics nor vasoactive drugs were administered. A rise in diuresis (6 L/24 hours) was accompanied by an increase in natriuresis, and both declined at the end of the treatment. This diuretic effect has not been reported previously in patients and may modify the course of renal failure and respiratory distress syndrome, both of which complicate severe malaria.

To assess the degree of skin disease in Simulium neavei s.s.-transmitted onchocerciasis, 72 patients infected with Onchocerca volvulus in the Kabarole district of Uganda were studied. They were clinically and parasitologically evaluated. Onchocercal skin lesions were determined using a modified Murdoch skin assessment, and skin scores were calculated. The chronic skin score (4.0) was associated with age, and the acute skin score (8.5) was significantly higher in males. The burden of onchocercal skin lesions was found to be high in most patients. The number of nodules (median number 1.9) and the microfilarial load (geometric mean of microfilaria 11.5) were not determinants for the burden of onchocercal skin disease in infected individuals. The study concludes that onchodermatitis is a serious medical condition in Kigoyera Parish and needs to be considered in all efforts to control onchocerciasis.

Gaining a better understanding of the spatial population structure of infectious agents is increasingly recognized as being key to their more effective mapping and to improving knowledge of their overall population dynamics and control. Here, we investigate the spatial structure of bancroftian filariasis distribution using geostatistical methods in an endemic region in Southern India. Analysis of a parasite antigenemia prevalence dataset assembled by sampling 79 villages selected using a World Health Organization (WHO) proposed 25 x 25 km grid sampling procedure in a 225 x 225 km area within this region was compared with that of a corresponding microfilaraemia prevalence dataset assembled by sampling 119 randomly selected villages from a smaller subregion located within the main study area. A major finding from the analysis was that once large-scale spatial trends were removed, the antigenemia data did not show evidence for the existence of any small-scale dependency at the study sampling interval of 25 km. By contrast, analysis of the randomly sampled microfilaraemia data indicated strong spatial contagion in prevalence up to a distance of approximately 6.6 kms, suggesting the likely existence of small spatial patches or foci of transmission in the study area occurring below the sampling scale used for sampling the antigenemia data. While this could indicate differences in parasite spatial population dynamics based on antigenemia versus microfilaraemia data, the result may also suggest that the WHO recommended 25 x 25 km sampling grid for rapid filariasis mapping could have been too coarse a scale to capture and describe the likely local variation in filariasis infection in this endemic location and highlights the need for caution when applying uniform sampling schemes in diverse endemic regions for investigating the spatial pattern of this parasitic infection. The present results, on the other hand, imply that both small-scale spatial processes and large-scale factors may characterize the observed distribution of filariasis in the study region. Our preliminary analysis of a mountain range associated large-scale trend in the antigenemia data suggested that a nonlinear relationship of infection prevalence with elevation might be a factor behind such observed global spatial patterns. We conclude that geostatistic methods can provide a powerful framework for carrying out the empirical investigation and analysis of parasite spatial population structure. This study shows that their successful application, however, will crucially depend on our gaining a more thorough understanding of the appropriate geographic scales at which spatial studies should be carried out.

Among acute respiratory infections (ARIs), respiratory syncytial virus (RSV) is an important pathogen, especially in infants and preschool children. This study focused on RSV epidemiology in a region of southeastern Brazil with a tropical climate. A total of 406 nasopharyngeal secretion samples were taken from children less than five years of age with ARIs. Of these, 114 (28%) were RSV-positive. These samples were found in all age groups, but showed a higher prevalence in newborns. Infection with RSV was identified in 10 of the 12 months of the study period, but the majority (88.5%) of cases occurred from late summer to mid-fall.

Mosquitoes and wild birds were collected from three sites near locations in the New York City metropolitan area where single, West Nile (WN) virus-positive dead birds were found early in the 2000 transmission season. The mosquitoes were tested for the presence of infectious virus with a Vero cell culture assay and for WN viral RNA by using reverse transcriptase-polymerase chain reaction (RT-PCR) protocols. Serum samples from wild birds were tested for the presence of neutralizing antibodies against WN virus. Infectious WN virus and WN viral RNA were found in Culex species adult mosquitoes from each of the three sites, and a seropositive hatch-year house sparrow (Passer domesticus) was found in one of the three sites. Molecular techniques used to identify the species in the positive mosquito pools found that most of the pools contained a combination of Culex pipiens and Cx. restuans. The minimum infection rate in Culex species mosquitoes from the sites ranged from 0.2 to 6.0 per 1,000 specimens tested. The results demonstrated that, at least early in the transmission season, detection of a WN virus-positive dead bird indicates a local WN virus transmission cycle. This information is valuable in focusing subsequent surveillance and vector management programs. In addition, the RT-PCR procedure for detecting WN viral RNA in mosquito pools detected more positive pools than did the Vero cell plaque assay.

We compared the performance of 2 commercially available dipstick assays, 2 enzyme-linked immunosorbent assays (ELISAs), and an indirect immunofluorescent antibody (IFA) assay for the diagnosis of scrub typhus, using the indirect immunoperoxidase (IIP) test as the reference standard. The dipstick assays were the Integrated Diagnostics (Baltimore, MD) Dip-S-Ticks Scrub Recombinant (r56) dipstick test (INDX assay) and the PanBio (Brisbane, Australia) Scrub Typhus IgM and IgG Rapid Immunochromatographic test (PanBio assay). One of the ELISAs used pooled cell lysates of Karp, Kato, and Gilliam strain Orientia tsutsugamushi as antigen (pooled-antigen ELISA), and the other used a recombinant r56 protein as the antigen (recombinant ELISA). With a panel of 123 positive and 227 negative sera, sensitivity and specificity of the assays were as follows: INDX assay, IgG, 60% and 95%, IgM, 60% and 97%; PanBio assay, IgG, 94% and 96%, IgM, 83% and 93%; IFA (1:400 cutoff), IgG, 91% and 96%, IgM, 85% and 98%; pooled-antigen ELISA, IgG (1:1600 cutoff), 97% and 89%, IgM (1:400 cutoff), 94% and 91%; recombinant ELISA, IgG (1:1600 cutoff), 97% and 92%, IgM (1:400 cutoff), 93% and 94%. Because of its excellent performance and use of a standardized, commercially available antigen, the recombinant ELISA is suitable for use in a diagnostic laboratory, where it may be able to replace the IFA and IIP assays. In contrast, the PanBio dipstick assay was easy to perform and did not require sophisticated equipment, making it suitable for use in rural areas where more sophisticated diagnostic tests such as the ELISA and IFA may not be available.

We analyzed the 5S (rrf)-23S (rrl) intergenic spacer amplicon gene of Lyme disease spirochetes (Borrelia burgdorferi sensu lato) for the first time in Taiwan. The genetic identities of these Taiwan isolates (TWKM1-7) were clarified by comparing their restriction fragment length polymorphism patterns and sequence similarities of the polymerase chain reaction-amplified intergenic spacer amplicon genes with 3 major genospecies of Lyme disease spirochetes. Amplified-spacer DNAs were purified further and subjected to the cleavage by nuclease DraI or MseI. Differential fragment patterns in relation to different genospecies of Lyme disease spirochetes were observed among tested Borrelia isolates, and all of these Taiwan isolates were closely related to the genospecies of B. burgdorferi sensu stricto. The phylogenetic analysis also revealed that the sequence similarity of polymerase chain reaction-amplified spacer genes of these Taiwan isolates was highly homogeneous (95.7-100%) within the genospecies of B. burgdorferi sensu stricto and can be distinguished clearly from other genospecies of Lyme disease spirochetes with a 4.1% sequence divergence. Based on the differential fragment patterns and sequence similarity among these Taiwan isolates, the genetic identity of these Taiwan isolates should be classified into the genospecies of B. burgdorferi sensu stricto.

One explanation proposed for the widespread failure to control zoonotic visceral leishmaniasis by culling infected domestic dogs is that wild canids or humans play significant roles in transmission. The aim of this study was to determine the importance of domestic dogs as the reservoir hosts of visceral leishmaniasis in northwest Iran. A random sample of 3,872 children and 199 dogs in 38 villages was surveyed by the direct agglutination test. Dog ownership details among these households were collected by questionnaire. Parasites isolated from 16 patients and 12 dogs were characterized as Leishmania infantum MON-1. Average seroprevalence in dogs (21.6%) was much higher than in children (7%). Child seropositivity increased significantly with village dog density in absolute terms (P < 0.001) and in relation to dog/human ratios (P = 0.028). Dog ownership within villages also was a significant risk factor for child seropositivity (P = 0.003).

Ecologic niche modeling has allowed numerous advances in understanding the geographic ecology of species, including distributional predictions, distributional change and invasion, and assessment of ecologic differences. We used this tool to characterize ecologic differentiation of Triatoma brasiliensis populations, the most important Chagas' disease vector in northeastern Brazil. The species' ecologic niche was modeled based on data from the Fundação Nacional de Saúde of Brazil (1997-1999) with the Genetic Algorithm for Rule-Set Prediction (GARP). This method involves a machine-learning approach to detecting associations between occurrence points and ecologic characteristics of regions. Four independent "ecologic niche models" were developed and used to test for ecologic differences among T. brasiliensis populations. These models confirmed four ecologically distinct and differentiated populations, and allowed characterization of dimensions of niche differentiation. Patterns of ecologic similarity matched patterns of molecular differentiation, suggesting that T. brasiliensis is a complex of distinct populations at various points in the process of speciation.

Chronic Trypanosoma cruzi infection can reactivate in patients with immunosuppression related to human immunodeficiency virus (HIV) infection, resulting in severe meningoencephalitis or myocarditis and high parasitemia. The effects of T. cruzi on HIV infection are unknown. We describe an HIV-infected patient with chronic Chagas' disease who experienced an asymptomatic T. cruzi reactivation characterized by the finding of the parasite in direct microscopic examination of blood. The patient's HIV viral load had increased simultaneously with the exacerbation of T. cruzi parasitemia and decreased to previous levels after successful antiparasitic treatment. This otherwise unexplained finding suggests that T. cruzi infection might up-regulate HIV replication, which may affect HIV disease progression. Asymptomatic reactivation of Chagas' disease has not been reported before. This could mean that the severe clinical manifestations related to the reactivation of trypanosomiasis are just the tip of the iceberg.

Hepatic hydatid cysts are extremely rare in Taiwan. We report a case of complicated, multivesicular, hydatid cysts in the liver and a secondary infection with Klebsiella pneumoniae. The cysts were detected in an early stage by ultrasonography and computed tomography and treated successfully with radical resection.

A total of 415 wild 9-banded armadillos from the East Atchafalaya River Levee (Point Coupee, LA) were collected over 4 years to estimate the incidence and prevalence of Mycobacterium leprae and Trypanosoma cruzi and to discern any relationship between the 2 agents. M. leprae infections were maintained at a high steady prevalence rate year to year averaging 19%. T. cruzi antibody prevalence remained relatively low, averaging 3.9%, and varied markedly between years. Prevalence rates were independent, with only 3 armadillos coinfected with both agents. M. leprae incidence density ranged from 0.47 to 3.5 cases per 1,000 animal-days, depending on case definition, confirming active intense transmission of M. leprae among armadillos. No incident T. cruzi cases were found. These infections seem to occur independently and may be used in comparisons to understand better factors that may influence transmission of these agents.

Campylobacter is a leading cause of traveler's diarrhea in Thailand. Since resistance to quinolones is high among Campylobacter isolates, empiric therapy with quinolones for traveler's diarrhea may be ineffective in this region. We conducted an observational study among 169 U.S. military personnel with acute diarrhea and compared their microbiologic findings to those of 77 asymptomatic personnel deployed to Thailand in May 1998. Of 146 pathogenic bacterial isolates, the most common were nontyphoidal Salmonella (n = 31), enterotoxigenic Escherichia coli (n = 24), and C. jejuni/coli (n = 23). Campylobacter was strongly associated with disease (odds ratio = 5.9; 95% confidence interval = 1.3-37.3), with a more severe clinical presentation, and with a reduced functional ability at presentation (P = 0.02). In vitro resistance to ciprofloxacin was observed in 96% of the Campylobacter isolates. Sub-optimal treatment response to ciprofloxacin was observed in 17% of the cases of Campylobacter infection versus 6% due to other causes. These results highlight the importance of Campylobacter as a cause of severe traveler's diarrhea in Thailand and illustrates the ongoing problem with antibiotic-resistant strains and associated treatment problems.

The prevalence and risk factors associated with canine gastrointestinal parasitic zoonoses and the role of dogs in the mechanical transmission of human Ascaris infection was examined in three tea estates in Assam, India. Nearly all (99%) dogs harbored one or more zoonotic species of gastrointestinal parasites, with hookworm infection being most common (94%). Parasitic stages presumed to be host-specific for humans such as Ascaris spp. (31%), Trichuris trichiura (25%), and Isospora belli (2%) were also recovered from dog feces. A polymerase chain reaction-linked restriction fragment length polymorphism technique was used to differentiate the species of Ascaris eggs in dog feces. The results of this study demonstrate the role of the dog as a significant disseminator and environmental contaminator of Ascaris lumbricoides in communities where promiscuous defecation by humans occurs.

We report a case of a chronic infiltrate of the intestinal wall of the transverse colon by the eggs of Enterobius vermicularis in a man who had immigrated to Taiwan from mainland China 50 years ago. During surgery for suspected transverse colon carcinoma, histologic examination of the tumor mass revealed eggs of E. vermicularis embedded in granulation tissue in the submucosa of the transverse colon. Results of a stool examination were negative for eggs but strongly positive for occult blood. The mass in the transverse colon was completely removed during surgery. At the present time, the patient remains asymptomatic.

Taiwan initiated a nationwide program in 1986 to have all 15-year-old schoolgirls vaccinated against rubella and another program in 1992 to encourage all women of childbearing age to receive rubella vaccination. To assess the immunity among women after the implementation of these programs, we conduct a serosurvey. We recruited women who were 15-44 years old and received pre-employment health examinations at the clinic of an industrial park from January 1 to June 30, 2000. Anti-rubella antibody titers were determined by enzyme-linked immunoassays. All 1,087 women who fit the selection criteria agreed to participate, and the overall susceptible (seronegative) rate was 5.7%. The susceptible rate was much lower among women who were covered by both programs than women who were not (4% versus 23%, P < 0.001). The nationwide vaccination programs were effective, but a substantial proportion of childbearing-age women were still susceptible and need booster vaccination.