Differential non-responsiveness in humans of candidate Plasmodium falciparum vaccine antigens.

Synthetic subunit vaccines to sporozoites, merozoites, and gametes are being developed for malaria. The vaccine strategy assumes that the population to be immunized will respond favorably to these vaccine antigens. Using sera of 35 adults and 50 children from the The Gambia, West Africa, where Plasmodium falciparum is highly endemic, we examined the humoral immune response to candidate malaria vaccine antigens from sporozoites, merozoites, and gametes. We observed widespread restricted immunogenicity to defined parasite antigens in children and adults. HLA typing of adult lymphocytes demonstrated a marked diversity in HLA haplotypes in this population. Our results and those from our studies in mice suggest that genetic factors may partly explain the immunological non-responsiveness. This may necessitate re-evaluation of the malaria vaccine strategy.

A simple model of the build-up of resistance to mixtures of anti-malarial drugs.

In an organism with a life-cycle modelled on that of Plasmodium two separate resistance genes are assumed, each protecting against one of two unrelated drugs. The model was used to compare the rates of build-up of resistance in a population where the two drugs are used either as a mixture or in sequence. The model suggests that the use of a mixture would be advantageous if: both resistances are initially rare; there is recombination between the genes; a large proportion of the parasite population is unexposed to the drugs.

A national survey of the prevalence of chloroquine resistant Plasmodium falciparum malaria in The Gambia.

In The Gambia, 760 children less than 10 years of age with Plasmodium falciparum malaria were treated with chloroquine (25 mg/kg) and followed-up 2 and 9 d after the start of treatment. 700 children (92.1%) completed the study. The level of in vivo resistance to chloroquine varied by area from 0.4% to 16.4%. Of the 28 children found to have chloroquine resistant malaria, none was ill when seen at the 9 d follow-up and only 3 (10.3%) required further treatment with alternative antimalarials because of persistent high levels of parasitaemia. However, the fact that 30.4% of the children who completed the study had chloroquine in their urine at presentation may have masked the true level of resistance and led to underestimation of the clinical significance of these findings. The blood film at day 2 did not usefully predict resistance. 67 isolates were tested in vitro for chloroquine sensitivity. The mean EC50 was 15.5 nmol/litre, an eight-fold decrease in sensitivity from that of isolates tested in 1982. 8 (11%) of the isolates had EC50s above the WHO reference value for sensitive isolates of 18.3 nmol/litre, with values ranging from 22 to 65 nmol/litre of culture medium. Gambian isolates were sensitive to quinine (mean EC50 = 49.6 nmol/litre).

Immunity to malaria in young Gambian children after a two-year period of chemoprophylaxis.

A cohort of 48 Gambian children was protected against malaria by fortnightly administration of Maloprim (pyrimethamine and dapsone) for 2 years between their 3 and 5 birthdays. A matched cohort of 47 children received placebo. During the year following the termination of prophylaxis there was no increase in the frequency of clinical attacks of malaria in the protected children compared with the control children. Antibody levels to circumsporozoite protein were measured by a radioimmunoassay and that to blood-stage antigens by a variety of techniques including an ELISA to whole blood-stage Plasmodium falciparum antigen, immunofluorescent assays (IFAT) to acetone fixed, glutaraldehyde fixed and unfixed parasites, a merozoite inhibition test and an opsonizing assay. Antibody levels were, in general, lower in protected than in control children and several differences between the two groups were statistically significant. When antibody levels were measured by ELISA and IFAT at the end of the following rainy season, when malaria transmission was intense, those in protected children had increased to comparable levels to those found in control children. Our findings suggest that chemoprophylaxis given for 2 years lowers malaria antibody levels but that it does not interfere with the development of protective immunity.

Cellular immune responses to Plasmodium falciparum antigens in children receiving long term anti-malarial chemoprophylaxis.

Fifty-two Gambian children who had received fortnightly chemoprophylaxis with maloprim, (pyrimethamine and dapsone), and 45 receiving placebo, were studied. Cellular immune responses to malaria antigens, measured by lymphoproliferative responses and interferon production, were higher in children who had received prophylaxis than in controls, although the anti-malarial antibody levels were lower. During a one-year period after termination of prophylaxis, there was no increase in the frequency of clinical episodes of malaria in the children who had received Maloprim. These results suggest that chemoprophylaxis for 3 years may lower malaria antibody levels, but does not interfere with the development of protective immunity, perhaps by enhancing cell-mediated immune responses to malaria in protected children.

Cellular immune responses to Plasmodium falciparum antigens in Gambian children during and after an acute attack of falciparum malaria.

Peripheral blood mononuclear cells from 63 Gambian children with acute Plasmodium falciparum malaria were examined for lymphoproliferation and interferon-gamma (IFN) production in response to stimulation by mitogens, malaria antigens and other soluble antigens. Mitogen or Candida-induced proliferation was not depressed during acute infection but was enhanced 2 to 4 weeks after treatment. Responses to partially purified soluble P. falciparum antigens were minimal or absent in all children in the acute phase but approximately 50% of the children responded by proliferation or IFN-gamma production during the 2 to 8 week convalescent period. These proliferative responses were severely depressed in the presence of the patient's own serum. Nine children with significant convalescent phase proliferative responses were re-examined several months after acute infection. Of these, four remained responsive for at least 8 months in the probable absence of reinfection.

Cell-mediated immune responses to Plasmodium falciparum antigens in adult Gambians.

Peripheral blood mononuclear cells from clinically immune Gambian adults were assayed for in vitro proliferation in response to crude and partially purified Plasmodium falciparum antigens. Lymphoproliferative responses to malaria antigens, lectin mitogens and Candida albicans were compared with those of control donors with no previous exposure to malaria. Cells of malaria-immune individuals were significantly more responsive to conconavalin A, and less responsive to phytohaemagglutinin, than cells from the control donors in both non-immune human serum and autologous serum. Cells from a proportion of immune donors proliferated in response to soluble malaria antigens but a substantial minority did not. Young adults and women were over-represented in the non-responding population. Responses to soluble malaria antigens were depressed in autologous serum compared with normal human serum. Both immune and control cells produced low levels of gamma-IFN when stimulated with crude P. falciparum schizont antigens. Approximately half the immune donors, and none of the controls, produced significant levels of gamma-IFN in response to purified soluble malaria antigen or malaria parasite culture supernatant. There was no direct correlation between lymphoproliferation and gamma-IFN production.