A review of five years' experience with rubella vaccine in the United States.

National morbidity figures show a decline in reported rubella and congenital rubella syndrome since 1969, concurrent with widespread use of rubella vaccine. In addition, no nationwide outbreak, such as the 1963-1964 epidemic, has occurred, though on the basis of long-term secular trends, one would be expected between 1970 and 1974. Recent rubella outbreaks have occurred in unimmunized students in high schools and universities, and there appears to have been a slight upward shift in the age-specific incidence of rubella in the United States since the beginning of widespread immunization. Currently available vaccines have provided durable protection to date, and, although reinfection is known to occur following vaccination, it has not proven a risk to the pregnant woman. There is a small but significant incidence of adverse reactions and a potential risk to the woman who is vaccinated during pregnancy. These data indicate that rubella vaccines are safe and effective. They also imply that rubella vaccines, as they are currently applied, have been successful in reducing the morbidity of congenital rubella syndrome, although continued surveillance will be necessary to confirm this trend.

Vector density, parasite prevalence, and transmission of Onchocerca volvulus in Guatemala.

Transmission of Onchocerca volvulus at 4 locations with different prevalences of human onchocerciasis in the Atitlán region of Guatemala is described in relation to vector density and infection rates. The percentages of residents with skin biopsies positive for microfilariae of O. volvulus at these locations were 13.8%, 33.3%, 65.4%, and 89.6%. The following variables associated with transmission were calculated from our observations (the values are presented in an order that corresponds with the above prevalence rates): frequency of third-stage larvae (calculated on an annual basis) in parous Simulium ochraceum, 0, 0.004, 0.005, and 0.004; estimated daily biting density of S. ochraceum, 23, 24, 254, and 1,509 flies per day; and estimated annual infective biting density (based on S. ochraceum), 0, 18, 185, and 1,101 potentially infective bites per year. The frequencies of third-stage larvae are very small compared with those observed in Africa, and suggest that transmission of O. volvulus in Guatemala depends on high vector density. Locations with low, and perhaps tolerable, levels of onchocerciasis (less than 15% of female residents with skin biopsies positive for microfilariae) have mean daily biting densities for S. ochraceum of less than or equal to 24 flies, and infected residents normally have mean microfilarial densities of less than or equal to 3 microfilariae per mg of skin. Stratification of prevalence rates by age group proved useful for assessing current transmission within a village.

Onchocerciasis in Guatemala. Epidemiology in fincas with various intensities of infection.

To provide quantitative information on the epidemiology of infection with Onchocerca volvulus and to define the association between indicators of infection and onchocercal eye disease, skin snips were obtained and skin and ocular examinations were performed on 892 persons living on seven Guatemalan coffee plantations. Skin-snip positivity and the density of microfilariae in the skin increased with age, reaching highest levels at 15-19 years, and both were greater in males than females. A history of nodulectomy was given by 67% of long-term residents and this percentage also increased with age. Over 90% of skin-snip positive subjects and 39% of skin-snip negative subjects had previous or present nodules. Microfilariae were detected in the cornea of 35.1% and in the anterior chamber of 18.9% of all persons examined and the frequencies increased with age, reaching peak levels at 10-19 years. Onchocercal eye lesions were found in 52 persons, causing bilateral blindness in six. Skin-snip positivity, microfilarial skin density, number of nodules, eye infection, and onchocercal eye lesions all correlated significantly with each other. Onchocercal blindness in one or both eyes was found only on fincas with a high prevalence (greater than 80%) and intensity of infection (greater than 22 microfilariae/mg skin).

In vitro susceptibility of Plasmodium falciparum isolates from Jilore, Kenya, to antimalarial drugs.

Twenty-six Plasmodium falciparum isolates obtained during a prophylaxis study at Jilore primary school, Malindi, Kenya, were adapted to in vitro culture and their susceptibility to 13 antimalarial drugs was tested by a modified radioisotopic method. Pyrimethamine, chloroquine, amodiaquine, cycloguanil, chlorcycloguanil, quinine, quinidine and sulfadoxine, and the experimental compounds MB 35769, mefloquine, WR 184806, parvoquone, and menoctone were used. The isolates could be divided into two groups with significantly different susceptibility to pyrimethamine, shown by a 755-fold difference in the mean ID50 values (2.77 +/- 1.98 x 10(-10) mol/l and 2.09 +/- 1.64 x 10(-7) mol/l). The mean susceptibility of the two groups differed 7.7-fold for chlorcycloguanil and 14.6-fold for cycloguanil, but were not significantly different for the other drugs. All isolates were more sensitive to amodiaquine than to chloroquine in vitro. The ratio of the geometric mean ID50 values of chloroquine to amodiaquine was 3.13. The ratio for the chemically related compounds parvoquone to menoctone was 5.63, quinine to quinidine was 5.58, and mefloquine to WR 184806 was 12.16.

Age-specific prevalence of antibody to a synthetic peptide of the circumsporozoite protein of Plasmodium falciparum in children from three villages in Kenya.

The presence of antibody to the repeating epitope of the circumsporozoite protein of Plasmodium falciparum was determined in children 1 month to 10 years old from three villages in western Kenya using the synthetic peptide (PNAN)5 in an enzyme-linked immunosorbent assay. The percentage of antibody-positive children increased with age and differed in the three villages. The village with the lowest percentage of antibody-positive children had the lowest percentage of infections as determined by detection of blood stage parasites. The villages also differed in the age at which antibody first appeared. In one village, only 12% of the children had antibody by the age of 5; while in the other two villages, 60% and 73% had antibody by 4 years of age.

Parasitological diagnosis of onchocerciasis: comparisons of incubation media and incubation times for skin snips.

Tissue culture fluid NCTC 135 (Hank's base) was compared to water and to saline as incubation media for the detection of microfilariae of Onchocerca volvulus in skin snips. NCTC 135 allowed detection of significantly more positive persons than did water (P less than 0.001) or saline (P less than 0.05) when two snips per person were incubated for periods of 0.5 or 24 hours. In addition, snips containing microfilariae were incubated in NCTC 135 or in saline and the number of emerged microfilariae was determined at various intervals of time up to 24 hours. After incubation, snips were either fixed in 10% formalin, serially sectioned, and the microfilariae counted, or they were digested in collagenase solution to free unemerged microfilaire. Of the total number of microfilariae present in the snips, 43.9% +/- 18.5, 80.2% +/- 22.2, 83.0% +/- 19.5, and 85.3% +/- 18.0 had emerged by 0.5, 4, 8, and 24 hours of incubation, respectively. Of the microfilariae that remained in the skin after incubation, most were located deep in the dermis.

Comparison of DNA probe and cytogenetic methods for identifying field collected Anopheles gambiae complex mosquitoes.

A recently developed DNA probe method was compared with the standard cytogenetic method for identifying the species of individual mosquitoes in the Anopheles gambiae complex. The complex consists of 6 morphologically indistinguishable sibling species that include the major African malaria vectors. Half-gravid, field collected mosquitoes were split into 2 portions: the abdomen was preserved for ovarian nurse cell cytotaxonomy and the head/thorax portion was desiccated for DNA extraction. Cytogenetic examination of the Kenya specimens showed 88 An. gambiae and 108 An. arabiensis. The Zimbabwe specimens consisted of 6 An. gambiae and 55 An. Quadriannulatus. All samples of the 3 species were polymorphic for the major chromosomal inversions previously recorded in field specimens from eastern and southern Africa, indicating that the collections reflected natural levels of intraspecific variation in the field populations sampled. Approximately 97% of the cytologically identified mosquitoes were also identified to species by the DNA probe method, and in every case the DNA probe and cytogenetic methods of species identification produced concordant results.

Detection of antibodies in human sera to the repeating epitope of the circumsporozoite protein of Plasmodium falciparum using the synthetic peptide (NANP)3 in an enzyme-linked immunosorbent assay (ELISA).

An enzyme-linked immunosorbent assay (ELISA) was developed to detect antibody in human sera to a synthetic peptide, Asn-Ala-Asn-Pro (NANP)3, derived from the repeating amino acid sequence found in the surface circumsporozoite protein of Plasmodium falciparum sporozoites. One hundred four sera from U.S. residents were used to determine a cut-off value for reactivity. Test sera were considered reactive when the absorbance was greater than that at the 95th percentile of the control sera. Sera from 112 Kenyans living in an area of holoendemic malaria transmission were tested. Of the total number of sera, 65% had detectable antibody to (NANP)3. The percentage of reactive sera increased from 41% in sera from children under 4 years of age to 85% in sera from adults 20 to 39 years of age. The high exposure to malaria parasites of the Kenyans was reflected in indirect fluorescent antibody assay titers to blood stage P. falciparum parasites. All of the Kenyan sera had antibody present at titers greater than 1:256.

Plasmodium falciparum infection rates in Anopheles gambiae, An. arabiensis, and An. funestus in western Kenya.

Mosquitoes collected monthly for 1 year from human habitations in the Kisumu area of western Kenya were identified by morphological characters as Anopheles gambiae Giles sensu lato (An. gambiae s.l.) or An. funestus. Of the mosquitoes collected, 7,244 (67%) of the An. gambiae s.l. and 8,511 (87%) of the An. funestus were tested by enzyme-linked immunosorbent assay (ELISA) for the presence of Plasmodium falciparum circumsporozoite (CS) protein. ELISA positivity rates were 8.2% for An. gambiae s.l. and 6.1% for An. funestus. Both An. gambiae and An. arabiensis were detected among 432 ELISA-positive and 668 ELISA-negative An. gambiae s.l. identified to species with a ribosomal DNA probe. The species-specific infection rates were calculated to be 9.6% for An. gambiae and 0.4% for An. arabiensis. These results confirm that An. gambiae and An. funestus are the primary malaria vectors in western Kenya and that An. arabiensis is a relatively minor vector.

Permethrin-impregnated curtains and bed-nets prevent malaria in western Kenya.

The effectiveness of permethrin-impregnated (0.5 g/m2) bed-nets and curtains as malaria control measures was evaluated in Uriri, Kenya in 1988. One hundred five families were randomly assigned to 1 of 3 study groups (control, bed-net, or curtain). All participants were cured of parasitemia with pyrimethamine/sulfadoxine. Selective epidemiologic and entomologic parameters were measured weekly, while knowledge, attitude, and practices surveys were conducted at the beginning and end of the 15 week study. Plasmodium falciparum infections per person week at risk were significantly higher in the control group than in either the curtain group (5.42 vs. 2.35 cases/100 person weeks risk) or the bed-net group (5.42 vs. 3.77 cases/100 person weeks risk). The curtain group had fewer infections per person week at risk than the bed-net group (2.35 vs. 3.77 cases/100 person weeks risk). A difference was found in clinical malaria among the groups: 45% of persons in the bed-net and curtain groups vs. 30% of those in the control group reported no episodes of fever and chills (chi 2, P less than 0.05). Indoor resting Anopheles gambiae or An. funestus were found on 94 occasions in the control houses, but only twice in the treated houses during weekly visits to each house over the study period (chi 2 P less than 0.001). The pyrethrum knockdown method produced similar results with a total of 195, 23, and 3 An. gambiae and An. funestus collected in the control, bed-net, and curtain houses during the same period, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of a synthetic DNA probe for Plasmodium falciparum in African blood specimens.

Synthetic DNA oligomers homologous to 21-base long repetitive sequences of Plasmodium falciparum DNA were labeled with 32P using T4 kinase, and were hybridized with purified DNA and with processed blood samples from Africa. The sequence PFR1, its antiparallel oligomer PFR1R, and PFR1 covalently attached to biotin hybridized similarly to P. falciparum DNA. One-microliter aliquots of blood from Zaire spotted on prewet nylon filters and hybridized with PFR1 gave detectable autoradiogram signals from samples with parasitemias as low as 1,000 parasites/mm3. Blood lysis and protein digestion followed by alkylation allowed dot-blot processing of larger aliquots of blood. After hybridization with PFR 1 and autoradiography, 26 samples were scored positive visually, compared with 34 scored positive by microscopy. The effective sensitivity for processed 10-microliter samples was about 500 parasites/mm3. Signals from hybridized probes were quantitated by liquid scintillation counting and densitometry, and were proportional to the amounts of purified P. falciparum DNA applied to the filter. Autoradiogram signals also were roughly proportional (correlation coefficient, r = 0.77) to the number of parasites/mm3 of blood from field samples as determined by microscopic examination.

Identification of malaria species by ELISA in sporozoite and oocyst infected Anopheles from western Kenya.

Enzyme-linked immunosorbent assays (ELISAs) for the circumsporozoite (CS) antigens of Plasmodium falciparum, P. malariae, and P. ovale were used to identify species of sporozoite and oocyst infections detected by dissection in Anopheles gambiae s.1. and An. funestus collected in western Kenya. ELISAs identified 92.5% of 1,113 salivary gland infections; Plasmodium species infections included 79.4% P. falciparum, 3.2% P. malariae, 1.7% P. ovale, and 2 or more Plasmodium species were detected in 15.7% of the Anopheles in which the species of parasite was identified. Identification was more likely with greater numbers of sporozoites observed in dissections, increasing from 65% ELISA positivity in mosquitoes with 1-10 sporozoites in their salivary glands to 96% in mosquitoes with over 1,000 sporozoites. ELISAs detected CS antigen in 66% of 294 Anopheles that by dissection had oocysts but uninfected salivary glands. Of 112 Anopheles with a single species of Plasmodium detected in the salivary glands, 29 (25.9%) had 1 or more additional species detected in the midgut, indicating a high potential for multiple infections. Similar proportions of Plasmodium species were found in An. gambiae s.1. and An. funestus.

Distribution of microfilariae in Guatemalans with onchocerciasis.

Ten Simulium ochraceum were allowed to feed at 10 different sites on 12 Guatemalans with onchocerciasis, and skin snips were taken from six of these sites. Numbers of microfilariae (mff) ingested by the flies and mff emerging from skin snips were highly correlated and showed that concentrations were greatest on the torso and decreased peripherally. S. ochraceum ingested the number of mff present in 1.0 mg or under 1.5 mm2 of skin. Numbers of mff in skin snips from the head, shoulder and upper arm correlated with over-all levels of infection but were frequently negative in subjects with light infections. Two or more skin snips were best able to detect and quantify infections.

Failure of erythromycin to improve chloroquine treatment of Plasmodium falciparum malaria in Kenya.

58 children aged 1 to 10 years who had pure Plasmodium falciparum infections acquired on the coast of Kenya were treated with chloroquine 25 mg/kg given over 3 d and erythromycin 10 mg/kg 4 times a day given for 7 d. After 4 weeks follow-up, 62% had recurrent infections and 11% failed to clear their parasitaemia (1 had an RIII pattern of resistance). Of 38 children treated with chloroquine 25 mg/kg alone, 55% had recurrences and 21% failed to clear (including 1 RIII). In vitro microtests classified 74% of isolates from initial infections and 91% of isolates from recurrent infections as resistant. Erythromycin does not improve chloroquine treatment in children with infections due to P. falciparum having low to moderate levels of chloroquine resistance.

The reservoir of Plasmodium falciparum malaria in a holoendemic area of western Kenya.

The reservoir of infectious Plasmodium falciparum gametocytes in a population living in an area of holoendemic malaria in western Kenya was estimated by directly feeding mosquitoes on volunteers. Resulting mosquito infections were assessed both by midgut examination for oocysts and by enzyme-linked immunosorbent assay for P. falciparum circumsporozoite antigen. Calculations based on the age structure of the population and the resulting rates of mosquito infections indicated that children under 10 years of age were responsible for 72% of mosquito infections, individuals between 10 and 21 years of age contributed 12%, and those over 21 years of age accounted for 16%. No infection resulted in mosquitoes fed on infants less than 1 year of age.

Chlorproguanil/dapsone for the treatment of non-severe Plasmodium falciparum malaria in Kenya: a pilot study.

Chlorocycloguanil, the active metabolite of chlorproguanil, was synergistic in vitro with dapsone against 2 culture-adapted Plasmodium falciparum isolates from Kenya; maximal synergy occurred at lower concentrations that it did with pyrimethamine and sulfadoxine. 48 children with asymptomatic P. falciparum infections were treated with chlorproguanil (at a target dose of 1.2 mg/kg) and dapsone (target dose of 1.2 or 2.4 mg/kg); all were free of parasitaemia by day 7. The following numbers had recurrences on days 14, 21, and 28, respectively: 1 of 48, 7 of 47, and 7 of 40. All 39 children treated with pyrimethamine (target dose 1.2 mg/kg) and sulfadoxine (target dose 24 mg/kg) were cleared of infection, while the following had recurrences on days 14, 21, and 28: 1 of 39, 2 of 38, and 2 of 36. The rate of decrease in parasitaemia was the same in the 2 groups, and there was no change in haematocrit or haemoglobin during the follow-up. The rate of recurrence in the children receiving chlorporguanil/dapsone was higher, probably because these drugs have a much shorter clearance time than pyrimethamine/sulfadoxine. Chlorproguanil/dapsone is an effective combination for treating P. falciparum malaria and deserves further study.

Chloroquine treatment of falciparum malaria in an area of Kenya of intermediate chloroquine resistance.

106 children aged 1-10 years who had pure Plasmodium falciparum infections and temperatures greater than or equal to 38 degrees C were treated with chloroquine base, 25 mg/kg body weight. 29% of the infections were sensitive in vivo, 41% recurred within 4 weeks (RI), 26% were RII resistant, and 4% were RII resistant. Rieckmann micro in vitro tests were successful in 64% of isolates obtained from these children; 63% were resistant to chloroquine. In 58 paired isolates obtained before and after treatment, the level of chloroquine sensitivity was lower in the parasites persisting or recurring after treatment. All children except 2 of the 4 with RIII resistance became afebrile an average of 1.4 d after starting treatment and their other symptoms resolved in an average of 1.8 d. By day 28, 57% of the children with RI resistance and 78% of those with RII resistance had recurrence of fever and other symptoms, compared with 19% of children with sensitive infections. No relationship was observed between the clinical or parasitological response and age, nutritional status, haematocrit, splenomegaly, presence of sickle-cell trait, or seropositivity to malaria by enzyme-linked immunosorbent assay. The study demonstrates that, in most children with malaria in an area of intermediate chloroquine resistance, fever and other symptoms resolve at least temporarily when treated with chloroquine.

Serological reactivity to the ring-infected erythrocyte surface antigen and circumsporozoite protein in gravid and nulligravid women infected with Plasmodium falciparum.

To investigate potential mechanisms for pregnancy-associated alterations in the immune response to malaria, we tested plasma samples from Plasmodium falciparum-infected nulligravida (42), primigravida (23) and multigravida (38) Kenyan women for reactivity to the ring-infected erythrocyte surface antigen (RESA) by a modified indirect fluorescent antibody assay and to synthetic peptides derived from amino acid sequences of RESA and the circumsporozoite (CS) protein of P. falciparum by an enzyme-linked immunosorbent assay. Reactivity to RESA showed the lowest titres in primigravid women, intermediate titres in nulligravid women and the highest titres in multigravid women (loge mean antibody = 3.28, 4.64, and 5.28, respectively, P less than 0.03), but was not associated with initial parasite density or response to chloroquine treatment. No relationship in antibody reactivity to the 3 synthetic peptides of the RESA molecule was observed by gravidity (0, 1, or greater than or equal to 2), age, initial parasite density or response to treatment. Levels of antibody to the synthetic peptides of the CS protein increased with age and were higher in gravid than in nulligravid women in the 15-19 year age group. The increased malaria prevalence and parasite density and the decreased response to antimalarial treatment in pregnant women is not explained by lower levels of antibody to RESA or CS protein during pregnancy.

Safety and immunogenicity of a Plasmodium falciparum sporozoite vaccine: boosting of antibody response in a population with prior natural exposure to malaria.

Recombinant sporozoite vaccine or placebo were administered once to 25 volunteers from an area endemic for malaria. Antibody to R32tet32 rose in 9 of 15 receiving vaccine and remained elevated in 6 for 6 months. Mean absorbance increase was 0.43 +/- 0.40 with vaccine, 0.01 +/- 0.23 with placebo, and 0.72 +/- 0.19 in responders. Six non-responders had significantly lower pre-immunization levels (0.07 +/- 0.05) than responders (0.39 +/- 0.25). There was an association between an increase in immunofluorescence (n = 4) and an increase in absorbance (n = 9) among vaccine recipients (n = 15). Vaccine-induced increase in antibody to natural circumsporozoite antigen was indicated by increases in immunofluorescence and by increases in circumsporozoite precipitation score in 2 of the 5 responders with highest antibody increase measured by enzyme-linked immunosorbent assay. Response to subunit sporozoite vaccine paralleled response to prior natural sporozoite exposure and was significant and prolonged in a population with prior natural exposure to malaria.