The American Journal of Tropical Medicine and Hygiene - Volume 72, Issue 2, February 2005

Schistosoma japonicum has been related to anemia, but the mechanisms mediating this relationship remain unresolved. The primary objective of this study was to assess the role of occult blood loss in mediating S. japonicum-associated anemia after adjusting for age, sex, socioeconomic status (SES), and other helminth infections. The secondary objective was to identify intensity categories of risk for occult blood loss for Trichuris and hookworm after adjustment for the presence of other helminth infections. The role of occult blood loss in mediating S. japonicum-associated anemia was studied cross-sectionally in 729 individuals 8–30 years old in Leyte, The Philippines. Three stool specimens were examined in duplicate for helminth eggs. Hemoglobin, fecal occult blood loss, and anemia were measured and related to the presence and intensity of helminths. Multivariate models were made to adjust for confounding by other helminths and SES. In multivariate models, hemoglobin significantly decreased with increasing infection intensity of S. japonicum, hookworm, and T. trichuria (P < 0.0031, P < 0.0001, and P < 0.0001, respectively). Individuals with higher intensities S. japonicum and T. trichuria were significantly more likely to be fecal occult positive (odds ratio [OR] = 3.54; P = 0.008 and OR = 2.68; P = 0.013, respectively), although this was not true for individuals with hookworm. Additionally, individuals with higher intensities of S. japonicum, hookworm, and T. trichuria were all more likely to be anemic (OR = 3.7, P = 0.0002; OR = 5.3, P = 0.0003; and OR = 1.6, P = 0.021, respectively). It is likely that occult blood loss plays a role only at heavier intensity S. japonicum infections and some other mechanism, such as anemia of inflammation, may be contributing to anemia.

This trial investigated the anti-schistosomal activity of mirazid in comparison with that of praziquantel in Schistosoma mansoni-infected Egyptian patients. The sample population was composed of 1,131 individuals (459 school children and 672 household members). Screening for S. mansoni was conducted using the standard Kato Katz technique. Four slides from a single stool sample were examined before treatment, and four slides per sample from stool samples obtained on three consecutive days were examined post-treatment. All positive eligible subjects were randomly assigned into two groups, the first received mirazid at a dose of 300 mg/day for three consecutive days, and the second received praziquantel at a single dose of 40 mg/kg. All treated subjects were examined 4–6 weeks post-treatment. Mirazid showed low cure rates of 9.1% and 8.9% in S. mansoni-infected school children and household members, respectively, compared with cure rates of 62.5% and 79.7%, respectively, in those treated with praziquantel. Therefore, we do not recommend mirazid as an agent to control schistosomiasis.

Alterations in the immunologic response induced by human T cell lymphotrophic virus type I (HTLV-I) predispose the development of disseminated strongyloidiasis. We report a case of an atypical clinical presentation of strongyloidiasis in a patient co-infected with HTLV-I causing scrotal and perineal pain and infertility. Strongyloides stercoralis was found in the analysis of the sperm and specific therapy for strongyloidiasis was associated with disappearance of the symptoms.

A recombinant protein, rLdccys1, which was produced by expression of the gene encoding a 30 kDa cysteine proteinase from Leishmania (Leishmania) chagasi, was used for detection of antibodies in sera from patients with active visceral leishmaniasis (VL) in enzyme-linked immunosorbent assays. Analysis of the predicted amino acid sequence of rLdccys1 showed that it contains all the characteristics of a cysteine proteinase. The ability of the protein to react with sera from humans with VL was also shown by Western blotting. The sensitivity for detection of specific antibodies to L. (L.) chagasi bodies using rLdccys1, L. (L.) chagasi promastigote lysates, and amastigote lysates was 80%, 98%, and 99%, respectively. No cross-reactivity between rLdccys1 and Chagas disease was observed, and there was little positive reactivity with sera from patients with cutaneous leishmaniasis and tuberculosis, compared with promastigote and amastigote extracts. Our findings indicate that rLdccys1 from L. (L.) chagasi constitutes a potential tool for the diagnosis of American VL.

Pentamidine was compared with meglumine antimoniate (Glucantime) for 80 patients with cutaneous leishmaniasis due to Leishmania braziliensis in Peru. Of the 40 patients administered Glucantime (20 mg of antimony [Sb]/kg/day intravenously for 20 days), 31 cured (78%), 6 failed (15%), of which 5 were due to relapse, and 3 were lost to follow-up (7%). Of the 40 patients administered pentamidine (2 mg/kg every other day for seven injections), 14 were cured (35%), 23 failed (58%), and 3 were lost to follow-up (7%). Five pentamidine failures were due to relapse, and 14 failures were due to the presence of parasites two weeks after therapy. Both regimens were well tolerated. Gastrointestinal, musculoskeletal, and total adverse events were not statistically different in either group. Elevations in levels of liver enzymes and pancreatic enzymes were statistically higher in the Glucantime group, but no patient terminated therapy prematurely. In this study, Glucantime was more effective than pentamidine for treatment of L. braziliensis cutaneous leishmaniasis in Peru based on parasitologic as well as clinical criteria.

Leishmaniasis caused by Leishmania infantum is a complex zoonotic disease, resulting in cutaneous and visceral manifestations in both dogs and humans. The present study involved a published Taqman fluorogenic real-time polymerase chain reaction (PCR) assay for surveillance of Leishmania sp. parasites among sand flies trapped in two provinces in Sicily, Catania and Agrigento, during the summer and fall of 2003. Only male specimens were identified to species level, while females were used to evaluate Leishmania sp. infection by PCR testing. The two most prevalent sand fly species found were Phlebotomus perfiliewi and P. perniciosus. Of the female sand flies tested, 2.9% were positive for Leishmania sp. DNA by the PCR.

Congenital toxoplasmosis is an obstetric problem in Mexico, but its actual frequency is unknown. Using a network for screening of non-infectious disorders, we performed a pilot study to determine the frequency of IgM antibodies to Toxoplasma gondii in 1,003 infants (53.1% male, mean ± SD age = 18.3 ± 13.0 days, birth weight = 3.116 ± 0.453 kg) in Mexico City from March to April 2003. Blood samples embedded in filter paper were assayed for IgM antibodies using a capture enzyme-linked immunosorbent assay and results were confirmed by Western blot. Two asymptomatic newborns, one of them premature, had IgM and IgG antibodies in a serum sample taken from both the infant and the mother and were clinically followed. Our data suggest a frequency of approximately two cases of congenital T. gondii infection per 1,000 newborns in Mexico City.

Tungiasis (caused by the sand flea Tunga penetrans) is hyperendemic in many resource-poor communities in Brazil. To understand transmission dynamics of this parasitic skin disease in a typical endemic area, a longitudinal study was carried out in a slum in Fortaleza in northeastern Brazil. In a door-to-door survey, the population of a randomly selected area (n = 1,460) was examined on four occasions for the presence of embedded sand fleas. Prevalence rates were 33.6% in March (rainy season), 23.8% in June (end of the rainy season), 54.4% in September (peak of the dry season), and 16.8% in January (begin of the rainy season). Tungiasis was more common in males than in females. The intensity of infestation was correlated with the prevalence. The study shows that prevalence of tungiasis and parasite burden vary significantly during the year with a peak in the dry season. These findings have important consequences for the design of control measures.

Clinical presentation of Plasmodium falciparum malaria reflects a continuum from asymptomatic to multi-organ manifestation and death. Severe malaria is defined by the World Health Organization as a qualitative variable. We used the multi-organ dysfunction score (MODS) as a quantitative approach for severity in 29 patients with severe and complicated P. falciparum malaria to test its usefulness in discriminating different severity levels. The MODS on admission was highly correlated with the duration of symptoms after admission (r = 0.73, P < 0.001) and the serum level of tumor necrosis factor alpha (r = 0.41, P = 0.03). In addition, the simplified MODS, based mainly on clinical findings, was also correlated with liver and renal dysfunction during hospitalization (alanine transaminase, r = 0.42, P = 0.02; blood urea nitrogen, r = 0.45, P = 0.015). A score ≥ 16 was associated with significantly longer disease duration (P = 0.018). Thus, this score might provide a predictive value for morbidity in P. falciparum malaria.

Single nucleotide polymorphisms (SNPs) in the Plasmodium falciparum dihydrofolate reductase (dhfr), and dihydropteroate synthetase (dhps), and chloroquine resistance transporter (Pfcrt) genes are used as molecular markers of P. falciparum resistance to sulfadoxine/pyrimethamine and chloroquine. However, to be a practical tool in the surveillance of drug resistance, simpler methods for high-throughput haplotyping are warranted. Here we describe a quick and simple technique that detects dhfr, dhps, and Pfcrt SNPs using polymerase chain reaction (PCR)– and enzyme-linked immunosorbent assay (ELISA)–based technology. Biotinylated PCR products of dhfr, dhps, or Pfcrt were captured on streptavidin-coated microtiter plates and sequence-specific oligonucleotide probes (SSOPs) were hybridized with the PCR products. A stringent washing procedure enabled detection of remaining bound SSOPs and distinguished between the SNPs of dhfr, dhps, and Pfcrt with high specificity. The SSOP-ELISA compared well with a standard PCR–restriction fragment length polymorphism procedure, and gave identical positive results in more than 90% of the P. falciparum slide-positive samples tested. The SSOP-ELISA of all dhfr, dhps, or Pfcrt SNPs on 88 samples can be performed in a single day and provides quick and reproducible results. The system can potentially be modified to detect SNPs in other genes.

The extensive data on the relationship between parasite genotype and susceptibility to antifolate drugs can now be coupled with pharmacokinetic information to allow construction of models of the selection and spread of antifolate-resistant Plasmodium falciparum. In this report, we have modeled the effect on resistance selection processes of combinations of antifolate antimalarial drugs with artesunate and with amodiaquine under a variety of conditions that can be defined by the user. The model is intended to assist policymakers in forecasting the useful therapeutic life (UTL) for a range of potential combination treatments. The model is especially designed for use by African malaria programs so that the interactions of key variables can be explored and appropriate combinations of drugs can be chosen for field testing. The model provides some important general conclusions: 1) for optimal extension of UTL, combination therapy must be deployed before either constituent drug is used as monotherapy; 2) even short periods of monotherapy can severely limit the usefulness of subsequent combination therapy; and 3) that adding a second drug to rescue an antifolate antimalarial that is overtly failing is an inappropriate and ultimately wasteful exercise.

The extent of gene polymorphisms associated with resistance to chloroquine and sulfadoxine-pyrimethamine was examined in field isolates of Plasmodium falciparum from Indonesia. Eight malaria-endemic areas, representing a broad region of the western and eastern Indonesian Archipelago were surveyed. Blood from 20–50 patients was collected at each site, DNA was isolated, and the sequences of four different genes (dihydrofolate reductase [dhfr], dihydropteroate synthase [dhps], P. falciparum multidrug resistance 1 [pfmdr1], and P. falciparum chloroquine resistance transporter [pfcrt]) were analyzed using polymerase chain reaction and restriction fragment length polymorphisms to detect polymorphisms previously shown to be associated with resistance. This analysis identified polymorphisms in dhfr at 108-Asn/Thr, 16-Val, and 59-Arg. Polymorphisms in dhps were found less frequently, either 437-Gly alone or paired with 540-Glu. The pfcrt 76-Thr polymorphism was fixed in all parasite populations and pfmdr1 86-Tyr polymorphisms in all populations except in the most eastern regions. The pfmdr1 1042-Asp polymorphism occurred less frequently. These findings indicate that polymorphisms in genes associated with drug resistance in P. falciparum are found across a broad region of Indonesia.

Recent findings indicating a low level of polymorphism in the Plasmodium falciparum genome have led to the hypothesis that existent polymorphisms are likely to have functional significance. We tested this hypothesis by developing a map of the polymorphism in the P. falciparum multidrug resistance 1 (pfmdr1) gene 5′ upstream region and assaying its correlation with drug resistance in a sample of field isolates from Dakar, Senegal. A comparison of six geographically diverse laboratory strains showed that the 1.94-kb 5′-untranslated region is highly monomorphic, with a total of four unique single nucleotide polymorphisms (SNPs) being identified. All of the mutations were localized to a 462-basepair region proximal to the transcription start point. Analysis of this region in field isolates shows the prevalence of one SNP throughout the entire population of parasites, irrespective of drug resistance status. The SNP frequency of the pfmdr1 upstream region is lower than that found in the noncoding region of other genes.

We conducted a randomized, double-blind, phase III yellow fever (YF) vaccine trial among 1,107 healthy children in Sullana in northern Peru. The safety and efficacy (by measurement of geometric mean neutralizing antibody titer responses) were determined for two YF vaccines, ARILVAX™ (n = 738) and YF-VAX® (n = 369). Serocon-version rates were higher (94.9%) in ARILVAX™ than in YF-VAX® (90.6%) recipients. The two-sided 95% confidence interval (YF-VAX®–ARILVAX™) was (-12.8% to -2.5%), indicating that the higher seroconversion rate for Arilvax™ was significant. Post-vaccination (30-day) mean log10 neutralization indices were found to be similar for both products: 1.32 for ARILVAX™ and 1.26 for YF-VAX® (P = 0.1404, by analysis of variance). A similar number of subjects in each group reported at least one adverse event (AE); 441 (59.8%) for ARILVAX™ versus 211 (59.9%) for YF-VAX®. Most (591; 96.7%) of these were of a mild nature and resolved without treatment. There were no treatment-related serious AEs. This is the first randomized, double-blind comparison of two YF vaccines in a pediatric population; both vaccines were shown to be highly immunogenic and well-tolerated.

A study was undertaken in villages endemic for Japanese encephalitis (JE) in Kerala in southern India during the period 1998–2001 to determine the host-feeding pattern of Culex tritaeniorhynchus, the major vector of JE in southeast Asia. A total of 3,067 blood-engorged Cx. tritaeniorhynchus were tested and 2,553 (82.2%) of the samples could be identified. Culex tritaeniorhynchus had fed mainly (56.6%) on cattle. Pig feeding accounted 6.3% of the total samples. Some samples (n = 980, 38.3%) were of serologic mixed origin. Of 980 mixed blood-fed mosquitoes, 975 (99.5%) had imbibed blood from two distinct hosts and 5 (0.5%) imbibed blood from three distinct hosts. Mixed blood meals were mostly (96.7%) from cattle and goats. The epidemiologic implications of multiple feeding of Cx. tritaeniorhynchus on dampening (dead-end) hosts such as cattle and goats in the transmission of JE virus is discussed.

Spatial patterns of and risk factors for seropositivity of dengue infection were studied in three sites in northern Thailand. A survey was conducted in 2001 among 1,750 persons. Potential risk factors for dengue infection were measured by questionnaire and IgM antibodies against dengue were detected by an enzyme-linked immunosorbent assay. The role of landscape as a risk factor was studied using land cover maps and a geographic information system. Logistic regression identified risk factors for dengue seropositivity. Spatial patterns of seropositive cases were determined by cluster analyses. Six percent of the study population was seropositive. Risk factors for dengue seropositivity differed per site, demonstrating variation in local infection patterns. In the periurban site, seropositivity depended on human behavior and factors related to housing quality rather than environmental factors. In both rural sites, older persons had a higher risk of seropositivity and persons living in houses surrounded by natural and agricultural land covers had a lower risk of seropositivity.

Knowledge of mosquito dispersal is critical for vector-borne disease control and prevention strategies and for understanding population structure and pathogen dissemination. We determined Aedes aegypti flight range and dispersal patterns from 21 mark-release-recapture experiments conducted over 11 years (1991–2002) in Puerto Rico and Thailand. Dispersal was compared by release location, sex, age, season, and village. For all experiments, the majority of mosquitoes were collected from their release house or adjacent house. Inter-village movement was detected rarely, with a few mosquitoes moving a maximum of 512 meters from one Thai village to the next. Average dispersal distances were similar for males and females and females released indoors versus outdoors. The movement of Ae. aegypti was not influenced by season or age, but differed by village. Results demonstrate that adult Ae. aegypti disperse relatively short distances, suggesting that people rather than mosquitoes are the primary mode of dengue virus dissemination within and among communities.

To better understand the clinical characteristics of concurrent bacteremia (dual infection) in patients with dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) and identify predictive risk factors for dual infection, 100 patients with DHF/DSS (7 with a dual infection and 93 with DHF/DSS alone [controls]) were enrolled in this study. A patient with DHF/DSS who lacked three or more of the five most frequently observed manifestations other than fever in controls or showed disturbed consciousness was defined as one with unusual dengue manifestations. Patients with a dual infection were older, and tended to have prolonged fever, higher frequencies of acute renal failure, gastrointestinal bleeding, altered consciousness, unusual dengue manifestations, and DSS. Acute renal failure (odds ratio [OR] = 51.45, P = 0.002), and prolonged fever (> 5 days) (OR = 26.07, P = 0.017) were independent risk factors for dual infection. Clinicians should be alert to the potential for concurrent bacteremia when treating patients with DHF/DSS who are at risk for dual infection and manage them accordingly.