Influence of Intermittent Preventive Treatment on Antibodies to VAR2CSA in Pregnant Cameroonian Women

Anna Babakhanyan Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Yeung L. Tutterrow Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Naveen Bobbili Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Ali Salanti Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Andrew Wey Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Josephine Fogako Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Robert J. Leke Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Rose G. F. Leke Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Diane Wallace Taylor Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii; Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon

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Intermittent preventive treatment (IPT) and insecticide-treated bed nets are the standard of care for preventing malaria in pregnant women. Since these preventive measures reduce exposure to malaria, their influence on the antibody (Ab) response to the parasite antigen VAR2CSA was evaluated in pregnant Cameroonian women exposed to holoendemic malaria. Ab levels to full-length VAR2CSA (FV2), variants of the six Duffy binding like (DBL) domains, and proportion of high avidity Ab to FV2 were measured longitudinally in 92 women before and 147 women after IPT. As predicted, reduced exposure interfered with acquisition of Ab in primigravidae, with 71% primigravidae being seronegative to FV2 at delivery. Use of IPT for > 13 weeks by multigravidae resulted in 26% of women being seronegative at delivery and a significant reduction in Ab levels to FV2, DBL5, DBL6, proportion of high avidity Ab to FV2, and number of variants recognized. Thus, in women using IPT important immune responses were not acquired by primigravidae and reduced in a portion of multigravidae, especially women with one to two previous pregnancies. Longitudinal data from individual multigravidae on IPT suggest that lower Ab levels most likely resulted from lack of boosting of the VAR2CSA response and not from a short-lived Ab response.

Author Notes

* Address correspondence to Diane Wallace Taylor, Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, 651 Ilalo Street, BSB 320, Honolulu, HI 96813. E-mail: dwtaylor@hawaii.edu
† Deceased.

Financial support: The work was supported by grants from NIAID, NIH, UO1AI43888 (pre-intervention samples) and RO1AI071160 (post-intervention samples) (Diane Wallace Taylor, Rose G. F. Leke) and FP7/2007-2013 grant agreement no. 200889 (STOPPAM) (Ali Salanti), IMPM (Rose G. F. Leke).

Authors' addresses: Anna Babakhanyan, Center for Global Health and Diseases, Case Western Reserve University, Cleveland, OH, E-mail: axb784@case.edu. Yeung L. Tutterrow, Naveen Bobbili, Andrew Wey, and Diane Wallace Taylor, Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, E-mails: yltutterrow@gmail.com, bobbili@hawaii.edu, awey@hawaii.edu, and dwtaylor@hawaii.edu. Ali Salanti, Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark, and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark, E-mail: salanti@sund.ku.dk. Josephine Fogako and Rose G. F. Leke, The Biotechnology Center, Faculty of Medicine and Biomedical Research, University of Yaoundé I, Yaoundé, Cameroon, E-mail: roseleke@yahoo.com.

  • 1.

    Dellicour S, Tatem AJ, Guerra CA, Snow RW, ter Kuile FO, 2010. Quantifying the number of pregnancies at risk of malaria in 2007: a demographic study. PLoS Med 7: e1000221.

  • 2.

    McGregor IA, 1984. Epidemiology, malaria and pregnancy. Am J Trop Med Hyg 33: 517–525.

  • 3.

    Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, Brabin B, Newman RD, 2007. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis 7: 93–104.

  • 4.

    Brabin BJ, Premji Z, Verhoeff F, 2001. An analysis of anemia and child mortality. J Nutr 131: 636S–645S; discussion 646S–648S.

  • 5.

    Brabin BJ, 1983. An analysis of malaria in pregnancy in Africa. Bull World Health Organ 61: 1005–1016.

  • 6.

    Rogerson SJ, Pollina E, Getachew A, Tadesse E, Lema VM, Molyneux ME, 2003. Placental monocyte infiltrates in response to Plasmodium falciparum malaria infection and their association with adverse pregnancy outcomes. Am J Trop Med Hyg 68: 115–119.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Salanti A, Dahlback M, Turner L, Nielsen MA, Barfod L, Magistrado P, Jensen AT, Lavstsen T, Ofori MF, Marsh K, Hviid L, Theander TG, 2004. Evidence for the involvement of VAR2CSA in pregnancy-associated malaria. J Exp Med 200: 1197–1203.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Srivastava A, Gangnard S, Round A, Dechavanne S, Juillerat A, Raynal B, Faure G, Baron B, Ramboarina S, Singh SK, Belrhali H, England P, Lewit-Bentley A, Scherf A, Bentley GA, Gamain B, 2010. Full-length extracellular region of the var2CSA variant of PfEMP1 is required for specific, high-affinity binding to CSA. Proc Natl Acad Sci USA 107: 4884–4889.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Ferreira MU, da Silva Nunes M, Wunderlich G, 2004. Antigenic diversity and immune evasion by malaria parasites. Clin Diagn Lab Immunol 11: 987–995.

  • 10.

    Newbold C, Craig A, Kyes S, Rowe A, Fernandez-Reyes D, Fagan T, 1999. Cytoadherence, pathogenesis and the infected red cell surface in Plasmodium falciparum. Int J Parasitol 29: 927–937.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Fried M, Nosten F, Brockman A, Brabin BJ, Duffy PE, 1998. Maternal antibodies block malaria. Nature 395: 851–852.

  • 12.

    Staalsoe T, Shulman CE, Bulmer JN, Kawuondo K, Marsh K, Hviid L, 2004. Variant surface antigen-specific IgG and protection against clinical consequences of pregnancy-associated Plasmodium falciparum malaria. Lancet 363: 283–289.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Barfod L, Dobrilovic T, Magistrado P, Khunrae P, Viwami F, Bruun J, Dahlback M, Bernasconi NL, Fried M, John D, Duffy PE, Salanti A, Lanzavecchia A, Lim CT, Ndam NT, Higgins MK, Hviid L, 2010. Chondroitin sulfate A-adhering Plasmodium falciparum-infected erythrocytes express functionally important antibody epitopes shared by multiple variants. J Immunol 185: 7553–7561.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Duffy PE, Fried M, 2003. Antibodies that inhibit Plasmodium falciparum adhesion to chondroitin sulfate A are associated with increased birth weight and the gestational age of newborns. Infect Immun 71: 6620–6623.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Staalsoe T, Megnekou R, Fievet N, Ricke CH, Zornig HD, Leke R, Taylor DW, Deloron P, Hviid L, 2001. Acquisition and decay of antibodies to pregnancy-associated variant antigens on the surface of Plasmodium falciparum-infected erythrocytes that protect against placental parasitemia. J Infect Dis 184: 618–626.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    O'Neil-Dunne I, Achur RN, Agbor-Enoh ST, Valiyaveettil M, Naik RS, Ockenhouse CF, Zhou A, Megnekou R, Leke R, Taylor DW, Gowda DC, 2001. Gravidity-dependent production of antibodies that inhibit binding of Plasmodium falciparum-infected erythrocytes to placental chondroitin sulfate proteoglycan during pregnancy. Infect Immun 69: 7487–7492.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Feng G, Aitken E, Yosaatmadja F, Kalilani L, Meshnick SR, Jaworowski A, Simpson JA, Rogerson SJ, 2009. Antibodies to variant surface antigens of Plasmodium falciparum-infected erythrocytes are associated with protection from treatment failure and the development of anemia in pregnancy. J Infect Dis 200: 299–306.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    WHO, 2004. A Strategic Framework for Malaria Prevention and Control during Pregnancy in the African Region. AFR/MAL/04/01. Geneva, Switzerland: World Health Organization.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    WHO, 2012. Updated WHO Policy Recommendation: Intermittent Preventive Treatment of Malaria in Pregnancy Using Sulfadoxine-Pyrimethamine (IPTp-SP). Geneva, Switzerland: WHO Press.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    van Eijk AM, Hill J, Larsen DA, Webster J, Steketee RW, Eisele TP, ter Kuile FO, 2013. Coverage of intermittent preventive treatment and insecticide-treated nets for the control of malaria during pregnancy in sub-Saharan Africa: a synthesis and meta-analysis of national survey data, 2009–11. Lancet Infect Dis 13: 1029–1042.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Staalsoe T, Shulman CE, Dorman EK, Kawuondo K, Marsh K, Hviid L, 2004. Intermittent preventive sulfadoxine-pyrimethamine treatment of primigravidae reduces levels of plasma immunoglobulin G, which protects against pregnancy-associated Plasmodium falciparum malaria. Infect Immun 72: 5027–5030.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Aitken EH, Mbewe B, Luntamo M, Kulmala T, Beeson JG, Ashorn P, Rogerson SJ, 2012. Antibody to P. falciparum in pregnancy varies with intermittent preventive treatment regime and bed net use. PLoS One 7: e29874.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Aitken EH, Mbewe B, Luntamo M, Maleta K, Kulmala T, Friso MJ, Fowkes FJ, Beeson JG, Ashorn P, Rogerson SJ, 2010. Antibodies to chondroitin sulfate A-binding infected erythrocytes: dynamics and protection during pregnancy in women receiving intermittent preventive treatment. J Infect Dis 201: 1316–1325.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Diouf I, Tine RC, Ndiaye JL, Sylla K, Faye B, Mengue ML, Faye O, Dieng Y, Gaye A, Gaye O, 2011. Effect of intermittent presumptive treatment with sulfadoxine-pyrimethamine on the acquisition of anti-VAR2CSA antibodies in pregnant women living in a hypoendemic area in Senegal [in French]. Bull Soc Pathol Exot 104: 277–283.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Serra-Casas E, Menendez C, Bardaji A, Quinto L, Dobano C, Sigauque B, Jimenez A, Mandomando I, Chauhan VS, Chitnis CE, Alonso PL, Mayor A, 2010. The effect of intermittent preventive treatment during pregnancy on malarial antibodies depends on HIV status and is not associated with poor delivery outcomes. J Infect Dis 201: 123–131.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Tutterrow YL, Salanti A, Avril M, Smith JD, Pagano IS, Ako S, Fogako J, Leke RG, Taylor DW, 2012. High avidity antibodies to full-length VAR2CSA correlate with absence of placental malaria. PLoS One 7: e40049.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Tutterrow YL, Avril M, Singh K, Long CA, Leke RJ, Sama G, Salanti A, Smith JD, Leke RG, Taylor DW, 2012. High levels of antibodies to multiple domains and strains of VAR2CSA correlate with the absence of placental malaria in Cameroonian women living in an area of high Plasmodium falciparum transmission. Infect Immun 80: 1479–1490.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Ndam NT, Denoeud-Ndam L, Doritchamou J, Viwami F, Salanti A, Nielsen MA, Fievet N, Massougbodji A, Luty AJ, Deloron P, 2015. Protective antibodies against placental malaria and poor outcomes during pregnancy, Benin. Emerg Infect Dis 21: 813–823.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Leke RF, Bioga JD, Zhou J, Fouda GG, Leke RJ, Tchinda V, Megnekou R, Fogako J, Sama G, Gwanmesia P, Bomback G, Nama C, Diouf A, Bobbili N, Taylor DW, 2010. Longitudinal studies of Plasmodium falciparum malaria in pregnant women living in a rural Cameroonian village with high perennial transmission. Am J Trop Med Hyg 83: 996–1004.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    WHO, 2005. Summary Country Profile for HIV/AIDS Treatment Scale-Up. Geneva, Switzerland: World Health Organization.

  • 31.

    Snounou G, Pinheiro L, Goncalves A, Fonseca L, Dias F, Brown KN, do Rosario VE, 1993. The importance of sensitive detection of malaria parasites in the human and insect hosts in epidemiological studies, as shown by the analysis of field samples from Guinea Bissau. Trans R Soc Trop Med Hyg 87: 649–653.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Avril M, Hathaway MJ, Cartwright MM, Gose SO, Narum DL, Smith JD, 2009. Optimizing expression of the pregnancy malaria vaccine candidate, VAR2CSA in Pichia pastoris. Malar J 8: 143.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Fouda GG, Leke RF, Long C, Druilhe P, Zhou A, Taylor DW, Johnson AH, 2006. Multiplex assay for simultaneous measurement of antibodies to multiple Plasmodium falciparum antigens. Clin Vaccine Immunol 13: 1307–1313.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Babakhanyan A, Leke RG, Salanti A, Bobbili N, Gwanmesia P, Leke RJ, Quakyi IA, Chen JJ, Taylor DW, 2014. The antibody response of pregnant Cameroonian women to VAR2CSA ID1-ID2a, a small recombinant protein containing the CSA-binding site. PLoS One 9: e88173.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Wood S, 2006. Generalized Additive Models: An Introduction with R. Chapman and Hall/CRC Press.

  • 36.

    Benjamini Y, Hochberg Y, 1995. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Statist Soc B 57: 298–300.

  • 37.

    Tonga C, Kimbi HK, Anchang-Kimbi JK, Nyabeyeu HN, Bissemou ZB, Lehman LG, 2013. Malaria risk factors in women on intermittent preventive treatment at delivery and their effects on pregnancy outcome in Sanaga-Maritime, Cameroon. PLoS One 8: e65876.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Mbu RE, Takang WA, Fouedjio HJ, Fouelifack FY, Tumasang FN, Tonye R, 2014. Clinical malaria among pregnant women on combined insecticide treated nets (ITNs) and intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine in Yaounde, Cameroon. BMC Womens Health 14: 68.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Salanti A, Resende M, Ditlev SB, Pinto VV, Dahlback M, Andersen G, Manczak T, Theander TG, Nielsen MA, 2010. Several domains from VAR2CSA can induce Plasmodium falciparum adhesion-blocking antibodies. Malar J 9: 11.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Nielsen MA, Pinto VV, Resende M, Dahlback M, Ditlev SB, Theander TG, Salanti A, 2009. Induction of adhesion-inhibitory antibodies against placental Plasmodium falciparum parasites by using single domains of VAR2CSA. Infect Immun 77: 2482–2487.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Clausen TM, Christoffersen S, Dahlback M, Langkilde AE, Jensen KE, Resende M, Agerbaek MO, Andersen D, Berisha B, Ditlev SB, Pinto VV, Nielsen MA, Theander TG, Larsen S, Salanti A, 2012. Structural and functional insight into how the Plasmodium falciparum VAR2CSA protein mediates binding to chondroitin sulfate A in placental malaria. J Biol Chem 287: 23332–23345.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Fernandez P, Viebig NK, Dechavanne S, Lepolard C, Gysin J, Scherf A, Gamain B, 2008. Var2CSA DBL6-epsilon domain expressed in HEK293 induces limited cross-reactive and blocking antibodies to CSA binding parasites. Malar J 7: 170.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Magistrado PA, Minja D, Doritchamou J, Ndam NT, John D, Schmiegelow C, Massougbodji A, Dahlback M, Ditlev SB, Pinto VV, Resende M, Lusingu J, Theander TG, Salanti A, Nielsen MA, 2011. High efficacy of anti DBL4varepsilon-VAR2CSA antibodies in inhibition of CSA-binding Plasmodium falciparum-infected erythrocytes from pregnant women. Vaccine 29: 437–443.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Fried M, Avril M, Chaturvedi R, Fernandez P, Lograsso J, Narum D, Nielsen MA, Oleinikov AV, Resende M, Salanti A, Saveria T, Williamson K, Dicko A, Scherf A, Smith JD, Theander TG, Duffy PE, 2013. Multilaboratory approach to preclinical evaluation of vaccine immunogens for placental malaria. Infect Immun 81: 487–495.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Lambert LH, Bullock JL, Cook ST, Miura K, Garboczi DN, Diakite M, Fairhurst RM, Singh K, Long CA, 2014. Antigen reversal identifies targets of opsonizing IgGs against pregnancy-associated malaria. Infect Immun 82: 4842–4853.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Teo A, Hasang W, Randall LM, Unger HW, Siba PM, Mueller I, Brown GV, Rogerson SJ, 2015. Malaria preventive therapy in pregnancy and its potential impact on immunity to malaria in an area of declining transmission. Malar J 14: 215–223.

    • PubMed
    • Search Google Scholar
    • Export Citation
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