Plasmodium falciparum incidence relative to entomologic inoculation rates at a site proposed for testing malaria vaccines in western Kenya.

Relationships between Plasmodium falciparum incidence and entomologic inoculation rates (EIRs) were determined for a 21-month period in Saradidi, western Kenya, in preparation for malaria vaccine field trials. Children, ranging in age from six months to six years and treated to clear malaria parasites, were monitored daily for up to 12 weeks to detect new malaria infections. Overall, new P. falciparum infections were detected in 77% of 809 children. The percentage of children that developed infections per two-week period averaged 34.7%, ranging from 7.3% to 90.9%. Transmission by vector populations was detected in 86.4% (38 of 44) of the two-week periods, with daily EIRs averaging 0.75 infective bites per person. Periods of intense transmission during April to August, and from November to January, coincided with seasonal rains. Relationships between daily malaria attack rates and EIRs indicated that an average of only 7.5% (1 in 13) of the sporozoite inoculations produced new infections in children. Regression analysis demonstrated that EIRs accounted for 74% of the variation in attack rates. One of the components of the EIR, the human-biting rate, alone accounted for 68% of the variation in attack rates. Thus, measurements of either the EIR or the human-biting rate can be used to predict corresponding attack rates in children. These baseline epidemiologic studies indicate that the intense transmission patterns of P. falciparum in Saradidi will provide excellent conditions for evaluating malaria vaccine efficacy.

Plasmodium falciparum gametocytemia in Kenyan children: associations among age, intensity of exposure to transmission, and prevalence and density of subsequent gametocytemia.

Recently, an association was described between the density of Plasmodium falciparum asexual parasitemia in Kenyan children and the entomologic inoculation rate (EIR) measured prior to measurement of asexual parasitemia. This study examined whether transmission pressure, as represented by the EIR, was associated with the prevalence or density of gametocytemia in Kenyan children. Each month for 19 months, a cohort of approximately 50 children was given a radical cure and enrolled in the study. Blood films were taken on days 0, 7, and 14. The EIR was calculated for the 28-day period ending 14 days prior to enrollment: the relationship between blood film data from day 7 and exposure variables was explored. We found that younger children were more likely to be gametocytemic than older children and, if gametocytemic, were more likely to have a dense gametocytemia. There was an inverse relationship between the number of infective bites per night received and prevalence but not density of gametocytemia, even after age adjustment. Concordance of gametocytemia prevalence on days 0 (64%), 7 (66%), and 14 (52%) was poor; 84% of the children were positive on at least one day. This indicates that in many subjects the detectable gametocytemia varied over the 14 days. Under these holoendemic transmission conditions, the EIR is inversely correlated with prevalence of gametocytemia, and point measurements of gametocytemia by conventional microscopy underestimate the number of infective donor hosts.

Plasmodium species identification by ELISA for sporozoites removed from dried dissection slides.

This study tested the feasibility of identifying salavary gland sporozoites to species by Plasmodium falciparum ELISA by drying them on slides or in vials. The glands were dissected from Anopheles gambiae Giles s.l. and An. funestus Giles collected in western Kenya. In 119 gland infections containing a geometric mean of 1,222 sporozoites, a mean of 72.5% of sporozoites were removed in 60 microliters saline from slides at the time of dissection. Each of the 119 samples was divided into three 18 microliters aliquots. Subsamples were stored at -70 degrees C, dried in vials, or dried on a microslide. When tested by Plasmodium falciparum ELISA, positive reactions were observed in 86.6% of frozen samples, 70.6% of samples held dry in vials, and 50.4% of samples held dry on microslides for 1 mo. Of 90 gland infections where coverslips were removed and slides were left to dry for 1 mo before adding blocking buffer, 81.1% were positive for P. falciparum. This was not significantly different from either frozen gland samples (where 85.5% of 392 infections were identified or frozen gland plus corresponding thorax samples where 86.2% of 160 samples were identified). In malaria field studies, where it is not always practical to freeze samples, sporozoites from dissected mosquitoes can be preserved adequately for ELISA identification by simply removing coverslips and drying dissection slides.

Characterization of malaria transmission by Anopheles (Diptera: Culicidae) in western Kenya in preparation for malaria vaccine trials.

Malaria transmission was studied for 33 mo in the villages of Kisian and Saradidi in western Kenya in preparation for field trials of malaria vaccines. Abundance estimates of Anopheles gambiae Giles sensu lato and Anopheles funestus Giles, which constituted over 99% of 26,645 anophelines collected, were compared for all-night biting collections inside houses, outdoors, and in tents. The overall numbers of Anopheles per man-night were 2.3 times greater in Kisian than in Saradidi. For the three types of collections, mean sporozoite rates by dissection ranged from 2.2 to 5.4% for 13,072 Anopheles in Kisian and from 9.9 to 13.6% for 7,058 Anopheles in Saradidi; greater than 90% of the infections were Plasmodium falciparum, either alone or mixed with P. malariae or P. ovale. Heaviest transmission from April to July coincided with the end of the long rainy season. Entomological inoculation rates (EIR) averaged 0.82 infective bites per man per night inside houses in Kisian and 0.65 in Saradidi. Outdoors, EIRs averaged 0.09 in Kisian and 0.52 in Saradidi. In tents, which were evaluated to identify methods for exposing nonindigenous volunteers during vaccine efficacy trials, EIRs were 3.3 and 2.5 times less than inside houses for Kisian (EIR = 0.25) and Saradidi (EIR = 0.26), respectively. Exposure in tents averaged one infective bite every 4.0 d in Kisian and every 3.8 d in Saradidi. The use of tents in vaccine efficacy trials should provide adequate exposure for nonindigenous volunteers. Malaria vaccine trials could be conducted efficiently in western Kenya, with timing dependent upon the intensity of transmission required by vaccine trial objectives.

Malaria sporozoite detection by dissection and ELISA to assess infectivity of afrotropical Anopheles (Diptera: Culicidae).

Malaria infection rates determined by dissection and Plasmodium falciparum enzyme-linked immunosorbent assay (ELISA) were compared for 26,935 Anopheles gambiae Giles sensu lato and 17,739 Anopheles funestus Giles collected during 20 mo in western Kenya. ELISA infection rates were about 43% higher than dissection sporozoite rates. In dissection-negative Anopheles, circumsporozoite (CS) protein was detected by ELISA in 5.2% of 10,017 salivary gland samples and in 12.2% of 237 thorax samples. The accuracy of dissection and ELISA techniques was compared by the following tests on a group of 352 field-collected Anopheles (held 10 d to ensure sporogonic development): salivary gland dissection, examination of Giemsa-stained dissection slides, ELISA tests on salivary gland and thorax body parts, and microscopic techniques for determining sporozoite loads. Respective infection rates were 9.9%, 10.8%, and 15.6% for dissection, stained slides, and ELISA. Sporozoite loads were associated significantly with ELISA absorbance values (r = 0.76). Compared with Giemsa-stained dissection slide results, the sensitivity of sporozoite detection was 92.1% for dissection compared with 78.9% for ELISA; specificity was 100.0% for dissection versus 92.0% for ELISA. Immunological detection of CS protein in head-thorax samples of Afrotropical vectors overestimated the proportion of infective Anopheles because the comparison of techniques indicated that 45.4% of the ELISA positive Anopheles did not contain salivary gland sporozoites.

Effect of human circumsporozoite antibodies in Plasmodium-infected Anopheles (Diptera: Culicidae).

Human circumsporozoite (CS) antibodies to Plasmodium falciparum were detected in blood meals from 45.0% of 1,547 field-collected Anopheles gambiae Giles sensu lato and Anopheles funestus Giles from western Kenya. Possible effects on malaria infections within the Anopheles host were investigated. Circumsporozoite antibodies were detected in blood meals up to 36 h after feeding. Antibodies crossing the midgut were detected experimentally in hemolymph from 4 to 36 h after feeding; human IgG also was present in hemolymph from fully gravid field-collected Anopheles. Ingestion of high-titer human CS antibodies or 2A10 monoclonal antibody to P. falciparum sporozoites by P. falciparum-infected An. gambiae, 10 d after feeding on an infected human, had no effect on oöcyst maturation, sporozoite rates, or sporozoite loads. Contact between CS antibodies and sporozoites in the hemocoel did not block sporozoite invasion of salivary glands. Human IgG antibodies were detected by an indirect fluorescent antibody technique on salivary gland sporozoites from 83.3% of 114 field-collected Anopheles. In 65.4% of 26 infections, antibodies persisted on sporozoites for at least three days. Thus, a high proportion of naturally infected An. gambiae s.l. and An. funestus in western Kenya transmit sporozoites that are bound with human IgG acquired during previous blood meals. The infectivity of such sporozoites needs to be determined in relation to natural transmission and to the potential use of malaria sporozoite vaccines.

Relative abundance and blood feeding behavior of nocturnally active culicine mosquitoes in western Kenya.

At 2 sites in western Kenya targeted for future malaria vaccine trials, adult culicine mosquitoes were sampled over one year by 5 collection techniques to assess human exposure to potential vectors of pathogens other than malaria. Collections included 20,910 females representing 19 species in Kisian and 4,312 females of 11 species in Saradidi. Common species in Kisian included Culex quinquefasciatus (71.4%), Mansonia uniformis (15.8%), Ma. africana (6.2%), Aedes mcintoshi (2.0%), Coquillettidia fuscopennata (1.9%) and Ae. ochraceus (1.8%). Common species in Saradidi included Cx. quinquefasciatus (92.7%), Cx. nebulosus (4.5%) and Ma. uniformis (1.0%). Human-bait collections identified 16 man-biting culicine species in Kisian and 9 in Saradidi. Man-biting rates at Kisian for the 5 most common species were 1.8, 14.6 and 13.5 times higher than at Saradidi for indoor, outdoor and tent collections, respectively. Exposure indoors was estimated to be 1,277 bites/man/year at Kisian and 720 at Saradidi. Blood meal identification for 1,083 mosquitoes confirmed that the common culicine species feed primarily on humans and cows.

Human resistance to Plasmodium falciparum increases during puberty and is predicted by dehydroepiandrosterone sulfate levels.

Immunity to Plasmodium falciparum develops slowly in areas of endemicity, and this is often ascribed to poorly immunogenic or highly variant parasite antigens. However, among populations newly exposed to malaria, adults acquire immunity more rapidly than children. We examined the relationship between pubertal development and resistance to P. falciparum. During two transmission seasons in western Kenya, we treated the same cohort of young males to eradicate P. falciparum and then obtained blood smears each week for 4 months. We determined pubertal development by Tanner staging and by levels of dehydroepiandrosterone sulfate (DHEAS) and testosterone in plasma. In multivariate and age-stratified analyses, we examined the effect of pubertal development on resistance to malaria. In both seasons (n = 248 and 144 volunteers, respectively), older males were less susceptible than younger males. Age-related decreases in the frequency and density of parasitemia were greatest during puberty (15- to 20-year-olds). DHEAS and testosterone were significant independent predictors of resistance to P. falciparum parasitemia, even after accounting for the effect of age. Fifteen- to 20-year-old males with high DHEAS levels had a 72% lower mean parasite density (P<0.01) than individuals with low DHEAS levels. Similarly, 21- to 35-year-old males with high DHEAS levels had a 92% lower mean parasite density (P<0.001) and 48% lower frequency of parasitemia (P<0.05) than individuals with low DHEAS levels. These data suggest that the long period needed to attain full immunity could be explained as a consequence of host development rather than as the requirement to recognize variant or poorly immunogenic parasite antigens.

ELISA absorbance cut-off method affects malaria sporozoite rate determination in wild Afrotropical Anopheles.

Malaria sporozoite infection rates in a mixed species group of 244 Anopheles gambiae Giles sensu lato and 115 An.funestus Giles wild female mosquitoes were compared using three methods to determine cut-off absorbance values for positivity of a Plasmodium falciparum Welch enzyme-linked immunosorbent assay (ELISA). Positive controls were based on P.falciparum circumsporozoite protein. As negative controls, four wild male Anopheles were included on each microtitre plate; tests were repeated on four consecutive days for each plate. Infection rates were estimated at 13.1-22.8% using the mean absorbance value of negative controls plus three standard deviations, 11.7-12.8% using double the mean and 12.5-13.6% using the fixed cut-off value of 0.20 (allowing for 20% variation in negative control absorbance values). Observed agreement for positivity or negativity among samples tested four times was 98.6% for the 2 x mean method, 97.2% for the fixed cut-off 0.20 value, but only 82.7% for the mean + 3 SD method. It was concluded that the 2x mean cut-off method is most reliable for field studies. P.falciparum sporozoite rates of 12.2% in An.funestus and 11.9% in An.gambiae s.l. were thus determined on the basis of the 2x mean cut-off method. This comparative evaluation demonstrates that vector infectivity rates can be seriously over-estimated from sporozoite ELISA tests, by as much as 87% in one case considered here, depending on the absorbance cut-off method applied for negative controls.

Mechanical transmission of Trypanosoma brucei rhodesiense by Glossina morsitans morsitans (Diptera:Glossinidae).

Interrupted feedings of teneral, laboratory-reared Glossina morsitans morsitans were used to study mechanical transmission of Trypanosoma brucei rhodesiense. Intervals between exposure of individual flies on parasitaemic rats and refeeding on clean rats were varied from five minutes to 24 hours. Direct transmissions were demonstrated at each interval up to 160 minutes after exposure. Proboscis dissections showed that active trypanosomes were present up to 320 minutes after exposure. No mechanical transmissions from bovine to bovine occurred in 39 attempts, when groups of 20-120 flies exposed on parasitaemic bovines were transferred immediately to uninfected cattle, but two of 40 individual flies exposed on parasitaemic bovines mechanically transmitted trypanosomes to clean rats. Proboscis dissections made immediately after flies were exposed to a bovine with a parasitaemia of 4.8 x 10(-4) trypanosomes/microliters of blood showed that 11 of 20 (55%) had active trypanosomes in the food canal. The mean number of trypanosomes per proboscis was 29.4 (+/- 20.5). Of 20 flies exposed on a bovine with a low parasitaemia, however, only one trypanosome was seen in proboscis dissections. The parasitaemia of the infected donor was an important factor in mechanical transmission. The mechanical transmission of trypanosomes from one host to another may largely depend on the infectivity threshold of the recipient host, and individual mechanically-infected tsetse flies may not transmit an infective dose.

Quantitation of malaria sporozoites in the salivary glands of wild Afrotropical Anopheles.

The number of malaria sporozoites in the salivary glands was determined microscopically for 1137 wild, naturally infected Anopheles from western Kenya. Infective Anopheles gambiae Giles sensu lato (n = 874) contained a geometric mean (GM) of 962 sporozoites and An.funestus Giles (n = 263) contained 812. No significant differences were detected in geometric mean numbers of sporozoites between species, collection techniques or sites. Of the infective An.gambiae, 1.7% (15/874) contained more than 41,830 sporozoites, the maximum observed for An.funestus. Microscopic techniques were found to be more sensitive than enzyme-linked immunosorbent assays (ELISA) for detecting low-grade sporozoite infections in salivary glands. Salivary gland sporozoites from 83.6% of the 1137 gland infections were identified by ELISA as either Plasmodium falciparum Welch (n = 910), P.ovale Stephens (n = 7), P.malariae Grassi & Feletti (n = 3) or mixed (n = 30). The 187 gland infections which could not be identified by ELISA contained significantly fewer sporozoites (GM = 242) than those which could be identified (GM = 1200).

Quantitation of malaria sporozoites transmitted in vitro during salivation by wild Afrotropical Anopheles.

The malaria transmission potential of wild, infective Anopheles from western Kenya was evaluated by determining the number of sporozoites transmitted in vitro by salivation when their mouthparts were inserted into capillary tubes containing either sucrose or blood. With sucrose, 86.6% of 102 infective Anopheles transmitted a geometric mean (GM) of 3.84 sporozoites (range 1-34). With blood, 23.1% of 104 infective Anopheles, tested on the day of collection, transmitted a GM of 2.30 sporozoites (range 1-117). For Anopheles held 5 days postcapture before testing with blood, 53.6% of 56 transmitted a GM of 6.04 sporozoites (range 1-420). Transmitting Anopheles contained significantly more salivary gland sporozoites than non-transmitters. No significant differences were detected between Anopheles gambiae Giles sensu lato and Anopheles funestus Giles in sporozoite transmission by individuals with sporozoites in their salivary glands. Sporozoites were detected microscopically in the salivary duct from heads in 80.3% of 117 infective Anopheles (GM = 11.2, range 1-71). Sporozoite detection in mosquito heads by ELISA was 25% less efficient than microscopic detection. Over 98% of the infective Anopheles transmitted less than twenty-five Over 98% of the infective Anopheles transmitted less than twenty-five sporozoites. Transmitted sporozoites represented only about 3% of the total sporozoites in the salivary glands suggesting that sporozoite transmission may be restricted to sporozoites in the salivary duct at the time of feeding. Results are discussed in relation to anti-sporozoite vaccine development.

Trypanosoma vivax: disseminated intravascular coagulation in cattle.

Five crossbred cattle infected with Trypanosoma vivax (Likoni) by Glossina morsitans developed capillary haemorrhages at the onset of parasitaemia, followed by the presence of occult blood in faecal samples and eventually melena. Two animals required treatment to survive, on days 13 and 38 respectively. The other three animals cleared their parasitaemias without treatment. Packed cell volume (PCV) levels decreased in all animals to levels ranging from 7.5 to 17%. Relapse in a treated animal initiated marked haemorrhage and a loss of 14 PCV units during a six-day period. Thrombocytopenia was common to all animals, and thrombocytes decreased to levels of 4000/microliters of blood. All animals developed increased levels of fibrinogen and fibrin monomer. Prolonged prothrombin times were found in all animals, and activated partial thromboplastin times were also extended in the two animals with high parasitaemias.

Dose- and time-dependent relations between infective Anopheles inoculation and outcomes of Plasmodium falciparum parasitemia among children in western Kenya.

Blood-stage level Plasmodium falciparum infection (parasitemia density) is generally elevated prior to, or at the time of, clinical presentation of severe pediatric malaria episodes. Intensity of exposure to infective Anopheles mosquito bites is a suspected determinant of higher density parasitemia. Analyses of entomologic and parasitologic data collected in 1986-1987 were conducted to investigate whether the dose of infective bites predicted the incidence or degree of P. falciparum parasitemia in Kenyan children < 6 years old. At 21 consecutive 30-day intervals, a new cohort (n approximately 50 each) was enrolled, cured of malaria parasites, and monitored over 84 days for recurrent parasitemia. Outcomes included time to parasitemia, time to parasitemia > or = 5,000/microliter, and parasitemia density. Ecologic and individual-level analyses were conducted. The mean infective bite exposure experienced by each cohort was significantly associated with the incidence of parasitemia (age-adjusted r2 = 0.38, p = 0.022) and more strongly associated with the incidence of parasitemia > or = 5,000/microliter (age-adjusted r2 = 0.72, p < 0.001). The infective bite dose, analyzed as a time-dependent covariate, was associated with a 2.8 times higher rate of parasitemia > or = 5,000/microliter among children exposed to > or = 1 infective bite per day as compared with the referent (rate ratio (RR) = 2.82, 95% confidence interval (CI) 2.24-3.56). Cumulative infective bite exposure, exposure duration, and age were significant predictors of recurrent parasitemia density in multiple linear regression analyses. The results support the contention that reductions in P. falciparum transmission intensity, in the absence of complete elimination, will reduce higher level parasitemia among African children.

PIP: Elevated numbers of asexual erythrocytic-stage Plasmodium falciparum parasites in the peripheral blood circulation is a known risk factor of the clinical severity of malaria episodes. The interrelationships among a continuum of sporozoite dose, duration of exposure, age, level of parasitemia at enrollment, village of residence, sex, and recurrent P. falciparum parasitemia were investigated in a 2-year (1986-87) study of 862 children 6 months to 6 years of age from six contiguous villages in Western Kenya. At 21 consecutive 30-day intervals, a new cohort was enrolled, cured, and monitored over 84 days for recurrent parasitemia. The mean cumulative dose was 23 inoculations, and there was a significant linear correlation between this variable and the incidence rate of first recurrent parasitemia, with even stronger associations for the incidence of higher density parasitemia. The overall 70-day cumulative incidence of first recurrent parasitemia was 88.5% (22.5% for high-density P. falciparum). The infective bite dose, analyzed as a time-dependent covariate, was associated with a 2.8 times higher rate of parasitemia equal to or above 5000/mcl among children exposed to one or more bites per day compared to the referent. Each one unit increase in the mean dose was associated with a 24% higher rate of recurrent parasitemia and a 26% higher rate of recurrent high-density parasitemia after adjustment for covariates. Multiple linear regression analyses indicated that parasitemia density was significantly positively associated with cumulative dose and inversely associated with duration of exposure and age. Approximately 36% of the variance in malaria incidence rates was explained by the mean cumulative dose of infective bites.

Impact of transmission intensity and age on Plasmodium falciparum density and associated fever: implications for malaria vaccine trial design.

To facilitate design of vaccine trials, malaria was studied in 6-month- to 6-year-old Kenyans during high (HI) and low intensity transmission seasons. During 84 days after cure, exposure to infected mosquitoes was 9-fold greater in the HI group, yet incidence of P. falciparum infection was increased only 2-fold, with no age effect. The density of recurrent P. falciparum was 14-fold greater in the HI group, and there was a striking association between age and parasitemia > or = 5000/microL. Fever was the only clinical manifestation attributable to parasitemia and only when the parasite density was > or = 5000/microL. Sixty-four percent of children with > or = 20,000 parasites/microL versus 10% with 1-4999/microL were febrile when parasitemic. Recurrent P. falciparum infection as a vaccine trial end point can be studied year-round among children < or = 6 years [corrected] in western Kenya. However, high-grade parasitemia (> or = 5000 or 20,000/microL) with or without elevated temperature will be optimally studied in the high transmission season among children < 2 years.