Mapping, monitoring, and surveillance of neglected tropical diseases: towards a policy framework.

As national programmes respond to the new opportunities presented for scaling up preventive chemotherapy programmes for the coadministration of drugs to target lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma, possible synergies between existing disease-specific policies and protocols need to be examined. In this report we compare present policies for mapping, monitoring, and surveillance for these diseases, drawing attention to both the challenges and opportunities for integration. Although full integration of all elements of mapping, monitoring, and surveillance strategies might not be feasible for the diseases targeted through the preventive chemotherapy approach, there are opportunities for integration, and we present examples of integrated strategies. Finally, if advantage is to be taken of scaled up interventions to address neglected tropical diseases, efforts to develop rapid, inexpensive, and easy-to-use methods, whether disease-specific or integrated, should be increased. We present a framework for development of an integrated monitoring and evaluation system that combines both integrated and disease-specific strategies.

The elimination of Trypanosoma brucei gambiense? Challenges of reservoir hosts and transmission cycles: Expect the unexpected.

The World Health Organisation has set the goal for elimination of Human African Trypanosomiasis (HAT), caused by Trypanosoma brucei gambiense (gHAT), as a public health problem for 2020 and for the total interruption of transmission to humans for 2030. Targeting human carriers and potential animal reservoir infections will be critical to achieving this ambitious goal. However, there is continuing debate regarding the significance of reservoir host animals, wild and domestic, in different epidemiological contexts, whilst the extent and duration of the asymptomatic human carrier state is similarly undefined. This paper reviews the status of the knowledge of latent infections in wild and domestic animal reservoir hosts towards the goal of better understanding their role in the transmission dynamic of the disease. Focus areas include the transmission cycles in non-human hosts, the infectivity of animal reservoirs to Glossina palpalis s.l., the longevity of infection and the stability of T. b. gambiense biological characteristics in antelopes and domestic animals. There is compelling evidence that T. b. gambiense can establish and persist in experimentally infected antelopes, pigs and dogs for a period of at least two years. In particular, metacyclic transmission of T. b. gambiense has been reported in antelope-G.p.palpalis-antelope and pig-G.p.gambiensis-pig cycles. Experimental studies demonstrate that the infectiveness of latent animal reservoir infections with T. b. gambiense is retained in animal-Glossina-animal cycles (antelopes and pigs) for periods of three years and human infectivity markers (human serum resistance, zymodeme, DNA) are stable in non-human hosts for the same period. These observations shed light on the epidemiological significance of animal reservoir hosts in specific ecosystems characterized by presently active, as well as known "old" HAT foci whilst challenging the concept of total elimination of all transmission by 2030. This target is also compromised by the existence of human asymptomatic carriers of T. b. gambiense often detected outside Africa after having lived outside tsetse infested areas for many years - sometimes decades. Non-tsetse modes of transmission may also play a significant but underestimated role in the maintenance of foci and also preclude the total elimination of transmission - these include mother to child transmission and sexual transmission. Both these modes of transmission have been the subject of case reports yet their frequency in African settings remains to be ascertained when the context of residual foci are discussed yet both challenge the concept of the possibility of the total elimination of transmission.

Chronic clinical manifestations related to Wuchereria bancrofti infection in a highly endemic area in Kenya.

Clinical examinations were conducted in an effort to provide baseline data for a pilot filariasis elimination programme implemented in a Wuchereria bancrofti-endemic focus in Malindi district, Kenya. Of 186 males aged 15 years and above examined, 64 individuals (34.4%) had hydrocele, and the prevalence of the manifestation in those above 40 years old was 55.3%. The prevalence of leg lymphoedema in persons aged 15 years and above was 8.5%, with a higher rate in males (12.6%) than in females (5.7%). The overall prevalence of inguinal adenopathy was 8.6%, and males had a significantly higher (12.9%) prevalence of adenopathy than females (5.1%) (P<0.001). The data in the present study provided support for consideration of filarial infection as a possible cause of inguinal lymphadenopathy in bancroftian filariasis-endemic areas. The results of this study also indicate that lymphatic filariasis is a serious public health problem in the northern coastal areas and morbidity control programmes should be implemented to alleviate the suffering of those affected.

A comparison of selected immunological techniques used to detect anti-leishmanial antibodies in the sera of two reptile species.

European green lizards (Lacerta viridis) and spiny-tailed agamids (Agama caudospinosum) were obtained from areas endemic for human leishmaniasis. Serum antibody titres against Leishmania agamae, a reptilian leishmanial species, in normal lizards and lizards injected with Leishmania agamae promastigotes were measured by 5 immunological methods commonly used in the serodiagnosis of the human and mammalian leishmaniasis viz. immobilisation test (IMM), direct agglutination (DA), complement-fixation test (CFT), indirect haemagglutination (IHA) and enzyme-linked immunosorbent assay (ELISA). Correlation coefficients (r) were determined for comparisons between each method and linear regression equations calculated to convert antibody titres by one method to those by another. In each lizard species, the IMM test gave the lowest values while the highest were obtained with ELISA. The highest mean titre obtained by ELISA was between 2 and 10 times that obtained by the other methods for both control and immune sera. The methods of preparing the leishmanial antigen extracts affected the IHA and ELISA titres, while the source of complement was critical in obtaining good CFT values. Correlations ranging from 3% to 77% were found for the control animals but higher values ranging from 65% to 96% were obtained with the immunised lizards. Overall, the best correlation was with IHA and ELISA (r greater than 0.82) and with ELISA values for different antigen preparations compared with each other for both control (r greater than 0.67) and immune (r greater than 0.90) sera. ELISA thus appears the most sensitive method for detection and quantitation of anti-flagellate antibodies in normal lizard serum and for the determination of titres in immune serum. ELISA is the most applicable technique for screening reptiles and other lower vertebrates for anti-parasite immunoglobulins, and for screening potential carriers or reservoirs of infective flagellates in epidemiological studies aimed at disease control, especially in areas where human infections are prevalent.

Antigen distribution and humoral response in the lizard, Agama caudospinosum, after injection with Leishmania agamae.

The response of the spiny-tailed agamid lizard, Agama caudospinosum, to administration of Leishmania agamae promastigotes was investigated. Lizards given a single injection of promastigotes showed no signs of clinical infection. Neither promastigotes nor amastigotes were found in blood and tissue impression smears, nor in blood and selected body organ cultures. However, parasite antigens were demonstrated by an immunoenzyme method only in the liver, small intestine, stomach, spleen and kidney. Non-precipitating serum antibodies with gamma-electrophoretic mobility were detected by enzyme-lined immunosorbent assay 1 week post-injection and a maximum titre was reached after 6 weeks. The mean immune serum protein concentration increased significantly (P less than 0.005) about two-fold over the controls after injection. Decreases occurred in the beta-globulin region of anti-L. agamae sera (P less than 0.01) whilst the gamma-globulin fraction was increased (P less than 0.005) following electrophoresis on cellulose acetate membranes. C-reactive protein was not detected in any of the sera. These data show that although A. caudospinosum failed to become infected by L. agamae promastigotes, which had been isolated from agamids, it did exhibit antigen distribution and a humoral response similar to other reptiles.

Vector-borne parasitic diseases--an overview of recent changes.

This paper summarises the impact of different changes (environmental, ecological, developmental) on the one hand, with the impact of control measures on the other. The former group of changes have tended to exacerbate the incidence and prevalence of vector-borne parasitic diseases while the reduced public funds available for the health sector have reduced disease surveillance systems. However, some vector control/eradication programmes have been successful. Vector control in onchocerciasis and Chagas' disease and immediate host control in Guinea worm have reduced the public health importance of these disease. This contrasts, with malaria, where the complexity of different ecological situations and the variable vector ecology have made control difficult and epidemics frequent and unpredictable. Advances in our knowledge of how to implement and sustain insecticide-impregnated bednets which reduce morbidity and mortality in under 5-year olds will be a key issue for the coming years. In African trypanosomiasis and leishmaniasis, where control is dependent on effective diagnosis and surveillance followed by high-cost drug treatment, the health services are faced with major challenges--lack of drug availability and diagnostics no vector control--the diseases in some areas assuming epidemic status yet health services are unable to respond. Human African trypanosomiasis and visceral leishmaniasis are fatal if untreated, and require an emergency response approach. Changing vector distribution of Glossina is related to the ability of riverine flies of Glossina palpalis group to adapt to new vegetation patterns. In leishmaniasis changes have occurred in the distribution of the disease associated with development impact, urbanisation, civil unrest and changed agroforestry practice.

Effects of haemagglutination (lectin) inhibitory sugars on Theileria parva infection in Rhipicephalus appendiculatus.

We have previously described the presence of haemagglutinins in tissues of the tick, Rhipicephalus appendiculatus and determined their sugar specificities by inhibition experiments. In this study, haemagglutination inhibitory sugars are shown to have an effect in vivo on the abundance of Theileria parva infected salivary gland acini in Rhipicephalus appendiculatus. A significant increase (P < 0.05) was observed in T. parva acinar infection rates in the salivary glands of R. appendiculatus fed on ears of rabbits infused with melibiose and raffinose. In contrast, mannose and turanose (non-haemagglutination inhibitory sugars) did not cause elevation of T. parva acinar infection rates. The effect of melibiose in elevating acinar infections was observed when used only during T. parva maturation in the salivary glands but not during parasite pick-up from an infected bovine host. Stabilates produced from ticks with elevated acinar infections did not differ from control stabilates in infectivity to cattle, by comparison of prepatent periods to pyrexia, or parasitosis, or in the severity of reactions.

Effects of gamma irradiation on the midgut ultrastructure of Glossina palpalis subspecies.

In the sterile insect technique, insects are sterilized prior to release in areas where they are pests. The sterile males compete for and with fertile wild individuals for mates, thus reducing the population's reproductive rate. Tsetse fly (Glossina spp.) populations have been eradicated after release of laboratory-bred flies sterilized by gamma irradiation. However, no studies exist on radiation-induced damage to the midgut morphology and function of the radiation-sterilized insects. After G. palpalis palpalis and G. p. gambiensis were subjected to 130 Gy gamma radiation, their midgut damage and recovery were monitored by electron microscopy. The first sign of damage was atrophy and loss of the microvillous border from epithelial cells. The rate of cell degeneration increased, with young as well as old cells being affected and cellular debris filling the ectoperitrophic space. Muscle cells were destroyed, patches of basal lamina were left bare, intracellular virus- and rickettsia-like organisms became more frequent, and many replacement cells became unusually large. Partial recovery occurred from the 10th day postirradiation. Such changes in midgut ultrastructure and the corresponding inhibition of functions may increase the susceptibility of the fly to trypanosome infection.

Transformation, development, and transmission of axenically cultured amastigotes of Leishmania mexicana in vitro and in Lutzomyia longipalpis.

Axenic cultures of Leishmania mexicana amastigotes were transformed to promastigotes in vitro and in vivo in Lutzomyia longipalpis. In vitro, both exponential phase and stationary phase amastigotes were capable of transforming and growing as promastigotes, but exponential phase amastigotes completed this transition more quickly. In vivo, both populations were capable of establishing infections in sand flies by membrane feeding and could be transmitted to BALB/c mice via bite. A variety of morphologic forms could be observed in vivo, including putative metacyclic promastigotes. Infection rates in sandflies with axenic amastigotes were comparable with those achieved with lesion-derived amastigotes, supporting the use of these cultured forms in studies of parasite biology.

Vector-borne infections in the tropics and health policy issues in the twenty-first century.

Over the past 2 decades scientific advances and evolving strategies have significantly contributed to improved tools for control of vector-borne infections. These are: diagnostics--rapid assessment methods, non-invasive or minimally so yet sensitive and specific; new chemotherapeutics; pyrethroid insecticides and biological insecticidal products; refined strategies, such as combination therapy, rotation of insecticides for resistance management, community-directed treatment, standardized monitoring and evaluation to define programme progress; better epidemiological knowledge through improved identification of parasites and vectors; GIS, remote sensing and climate models which provide tools for epidemic prediction, planning control programmes and permit effective policy analysis; greater involvement of NGDOs (non-governmental development organizations) and CSOs (civil society organizations) in control; advent of donation programmes which involve community-based or directed mass drug distribution. Future problems could be: (1) the over-emphasis on inflexible financing by the insistence of donors on SWAps (sector-wide investment), (2) the over-reliance on pyrethroid pesticides, (3) the over-expectation that basic research will provide new drugs and vaccines for resource-poor settings in the necessary time scales, and (4) the failure to recognize that biological processes have an inherent capacity for change which outstrips the capacity of health services to respond. Malaria is a paradigm of an 'emerging disease'. (5) The challenge of implementing a 'vertical' approach to disease control within national health programmes, in the face of significant donor opposition to such programmes is a challenge even when such approaches will secure a 'public good'.

Development of Trypanosoma brucei in suckling mouse brain following intracerebral injection.

Intracerebral inoculation of Trypanosoma b. brucei and T. b. rhodesiense into suckling mice produced infection of brain tissue which subsequently gave rise to an infection of the blood and other tissues, in which a normal histopathological picture was observed. Treatment of other intracerebrally infected sucklings with 5 mg/kg diminazene aceturate (Berenil) to clear the infection from the blood permitted a study of the course of the infection in the brain without interference from pathological processes induced by bloodstream infections. There was rapid multiplication and migration of trypanosomes throughout the brain of mice. Pathological processes normally seen in experimental central nervous system infections were absent, except in a single mouse treated earlier with Berenil which developed meningo-encephalitis with trypanosomes present in the choroid plexus. The possible use of such a model system in chemotherapeutic studies is discussed.

Identification of the vectors of lymphatic filariasis in the Lower Shire Valley, southern Malawi.

An investigation of lymphatic filariasis vectors in Malawi is reported. Anopheles funestus, A. arabiensis, and A. gambiae sensu stricto had high rates of filarial infection (2.2-3.1%) and carried infective larvae. Anopheles funestus was the predominant species collected (77.6%) and was the primary vector during the study period of April to May 2002.

Pathogenicity of Crithidia fasciculata in the haemocoele of Glossina.

The mosquito flagellate Crithidia fasciculata produces intense haemocoelic infections following intrahaemocoelic inoculation into 5 species of Glossina--G. austeni, G. fuscipes fuscipes, G. morsitans morsitans, G. palpalis gambiensis and G. tachinoides. All Glossina inoculated with C. fasciculata died between days 4 and 9. Neither Trypanosoma brucei procyclics nor Leishmania hertigi promastigotes similarly inoculated into Glossina species, at the same dose, multiplied within the haemocoele and no deaths were recorded during the first 10 days post-injection. No mortalities amongst sham-injected controls occurred over the 10-day period.

Tsetse movement in wind fields: possible epidemiological and entomological implications for trypanosomiasis and its control.

This paper presents evidence that tsetse flies (Glossina) can be dispersed by wind. This dispersal in West Africa is suggested to be along a south-west north-east axis. The implications of wind dispersal of Glossina for chemical and genetic control operations is discussed. Field experiments necessary to test this hypothesis are recommended. A study of human trypanosomiasis foci in West Africa has revealed that foci are orientated in roughly parallel lines in a south-west north-east direction. This directionally was significant when compared with 7 other compass points. It is proposed that foci could be populated by infected flies dispersed from the south west, where denser populations exist, on the prevailing winds in the late dry/early rainy season. The significance of these ideas in relation to the epidemiology of Trypanosoma brucei rhodesiense in Ethiopia and T. evansi are discussed.

Mechanoreceptor--trypanosome interactions in the labrum of Glossina: fluid mechanics.

The fluid mechanics of the flow of blood through the labrum of Glossina is described in uninfected and trypanosome infected flies. The flow is characterised by the Reynolds number, and a frequency parameter for the pulsating flow and non-newtonian viscosity effects are considered. The effects of colonies of trypanosomes on the flow rate in the labrum and the interactions between colonies of Trypanosoma (Nannomonas) congolense and Trypanosoma (Trypanozoon) brucei and mechanoreceptors in the proximal third of the labrum are described. The direct association between trypanosomes and mechanoreceptors and the reduction in flow rate imposed by trypanosome colonies in the food canal distal to the mechanoreceptors will impair detection of stimuli by them. The epidemiological implications of these and earlier observations are discussed.

Trypanosoma (megatrypanum) melophagium in the sheep ked, Melophagus ovinus. A scanning electron microscope (SEM) study of the parasites and the insect gut wall surfaces.

A description of the different stages of Trypanosoma (M.) melophagium in different regions of the gut of the sheep ked (Melophagus ovinus) as observed by the SEM is presented. The extensive pile carpet or palisade colonization of the midgut and pylorus is described. The method of attachment and the relationship of the parasites to the microvilli in the midgut and the cuticle of the pylorus and ileum observed by other methods are confirmed. The micro-structure of the surfaces themselves in the regions of the gut to which parasites attach are described. The use of the technique for the study of other similar systems is discussed.

Fluid mechanics of bloodmeal uptake by Leishmania-infected sandflies.

The fluid mechanics of blood flow in the pharynx and cibarium of Phlebotomus papatasi are described using a simple static model. The flow is characterized as viscous laminar. The Hagen-Poiseuille equation is used to assess the effects of attached parasites in the foregut of Leishmania-infected sandflies on blood flow. The reductions in flow rate imposed by parasite colonization of the pharynx and cibarium will reduce the ability of an infected fly to take a bloodmeal, thus encouraging further probing, enhancing transmission. Regurgitation of the contents of the foregut is also possible. This will aid the deposition of infective forms from the foregut. Transmission by means of regurgitation of parasites from the midgut is considered unlikely.

Chitin derivatives as novel substrates for Trypanosoma brucei brucei attachment in vitro.

Procyclic trypomastigotes of Trypanosoma brucei brucei, cultured in Cunningham's medium with 20% heat-inactivated foetal calf serum at 27 degrees C, attached to chitosan and to gels of N-acetyl chitosan and glycol chitosan. Following attachment, epimastigotes, metacyclic-like trypomastigotes and multinucleate parasites appeared in the culture supernatant.

Anti-trypanosomal factor in the haemolymph of Glossina.

The motility of cultured procyclic forms of Trypanosoma brucei brucei ANTat serodeme derived from EATRO 1125 was greatly reduced when incubated in vitro with the haemolymph of Glossina morsitans morsitans at dilutions as low as 1:512 after incubation periods of 1-2 h at 27 degrees C. This effect was demonstrated in the haemolymph of male and female, teneral and non-teneral G.m. morsitans but was abolished by heat inactivation. A significant reduction in the motility of cultured forms of Trypanosoma (S.) dionisii was also observed when incubated in G.m. morsitans haemolymph but little effect was seen on culture forms of Crithidia fasciculata and Leishmania hertigi. An anti-trypanosomal factor was also demonstrated in the haemolymph of Glossina austeni, G. palpalis gambiensis and G. tachinoides.

Separation of Psychodopygus carrerai carrerai and P. yucumensis (Diptera: Psychodidae) by gas chromatography of cuticular hydrocarbons.

Specimens of two species of sandfly, Psychodopygus carrerai carrerai and P. yucumensis, vectors of Leishmania braziliensis braziliensis in the subandean lowlands of Bolivia, were subjected to cuticular hydrocarbon analysis to ascertain if the technique could separate the females. A high degree of separation (87%) was obtained based on significant differences in the cuticular hydrocarbon composition of these two species. Statistical treatment of the data shows that these species, initially identified by the colour of the mesonotum, can also be distinguished by their hydrocarbons.