Evidence and strategies for malaria prevention and control: a historical analysis.

Public health strategies for malaria in endemic countries aim to prevent transmission of the disease and control the vector. This historical analysis considers the strategies for vector control developed during the first four decades of the twentieth century. In 1925, policies and technological advances were debated internationally for the first time after the outbreak of malaria in Europe which followed World War I. This dialogue had implications for policies in Europe, Russia and the Middle East, and influenced the broader international control agenda. The analysis draws on the advances made before 1930, and includes the effects of mosquito-proofing of houses; the use of larvicides (Paris Green) and larvivorous fish (Gambusia); the role of large-scale engineering works; and the emergence of biological approaches to malaria. The importance of strong government and civil servant support was outlined. Despite best efforts of public health authorities, it became clear that it was notoriously difficult to interrupt transmission in areas of moderately high transmission. The importance of combining a variety of measures to achieve control became clear and proved successful in Palestine between 1923 and 1925, and improved education, economic circumstances and sustained political commitment emerge as key factors in the longer term control of malaria. The analysis shows that the principles for many of the present public health strategies for malaria have nearly all been defined before 1930, apart from large scale usage of pesticides, which came later at the end of the Second World War. No single intervention provided an effective single answer to preventing transmission, but certainly approaches taken that are locally relevant and applied in combination, are relevant to today's efforts at elimination.

Dynamics of the Human Infectious Reservoir for Malaria Determined by Mosquito Feeding Assays and Ultrasensitive Malaria Diagnosis in Burkina Faso.

BACKGROUND: Plasmodium falciparum gametocytes are essential for malaria transmission. Malaria control measures that aim at reducing transmission require an accurate characterization of the human infectious reservoir. METHODS: We longitudinally determined human infectiousness to mosquitoes and P. falciparum carriage by an ultrasensitive RNA-based diagnostics in 130 randomly selected inhabitants of an endemic area. RESULTS: At least 1 mosquito was infected by 32.6% (100 of 307) of the blood samples; in total, 7.6% of mosquitoes (916 of 12 079) were infected. The proportion of infectious individuals and infected mosquitoes were negatively associated with age and positively with asexual parasites (P < .001). Human infectiousness was higher at the start of the wet season and subsequently declined at the peak of the wet season (adjusted odds ratio, 0.52; P = .06) and in the dry season (0.23; P < .001). Overall, microscopy-negative individuals were responsible for 28.7% of infectious individuals (25 of 87) and 17.0% of mosquito infections (145 of 855). CONCLUSIONS: Our study reveals that the infectious reservoir peaks at the start of the wet season, with prominent roles for infections in children and submicroscopic infections. These findings have important consequences for strategies and the timing of interventions, which need to include submicroscopic infections and be implemented in the dry season.

Robert Koch, malaria pioneer.

The role of Robert Koch in the early discoveries of the malaria lifecycle and the complex of diseases, the development of immunity, quinine prophylaxis and the mosquito theory has fallen into oblivion. As a mature and famous hygienist, Koch had travelled the Old World, where malaria was endemic. His first studies took place in Tanganyika, German East Africa (now Tanzania) in 1898 and thereafter in Italy and the East Asian archipelago. As malaria in Germany did not offer a sufficiently endemic situation, he chose the Istrian island of Brioni (Kroatia) to eliminate malaria. Because virtually all of Koch's publications are in German, his achievements on malaria never settled in the common memory of tropical medicine. Around the turn of the century the race to elucidate the transmission pathway through mosquitoes took place and though he hardly yielded any honour of priority, his research certainly determined the speed by which British and Italian contenders made their ways. His exertion and interference led to the awarding of the 2nd Nobel Prize in Medicine to Ronald Ross only, leaving Giovanni Battista Grassi to draw the blank. Proof of this intervention in the otherwise well-known quarrel at the start of modern malaria research shows once more how personal characters may clash or join forces.

Naturally acquired immune responses to Plasmodium falciparum sexual stage antigens Pfs48/45 and Pfs230 in an area of seasonal transmission.

Acquisition of immunity to Plasmodium falciparum sexual stages is a key determinant for reducing human-mosquito transmission by preventing the fertilization and the development of the parasite in the mosquito midgut. Naturally acquired immunity against sexual stages may therefore form the basis for the development of transmission-blocking vaccines, but studies conducted to date offer little in the way of consistent findings. Here, we describe the acquisition of antigametocyte immune responses in malaria-exposed individuals in Burkina Faso. A total of 719 blood samples were collected in a series of three cross-sectional surveys at the start, peak, and end of the wet season. The seroprevalence of antibodies with specificity for the sexual stage antigens Pfs48/45 and Pfs230 was 2-fold lower (22 to 28%) than that for an asexual blood stage antigen glutamate-rich protein (GLURP) (65%) or for the preerythrocytic stage antigen circumsporozoite protein (CSP) (54%). The youngest children responded at frequencies similar to those for all four antigens but, in contrast with the immune responses to GLURP and CSP that increased with age independently of season and area of residence, there was no evidence for a clear age dependence of responses to Pfs48/45 and Pfs230. Anti-Pfs230 antibodies were most prevalent at the peak of the wet season (P < 0.001). Our findings suggest that naturally acquired immunity against Pfs48/45 and Pfs230 is a function of recent exposure rather than of cumulative exposure to gametocytes.

The plasticity of Plasmodium falciparum gametocytaemia in relation to age in Burkina Faso.

BACKGROUND: Malaria transmission depends on the presence of gametocytes in the peripheral blood. In this study, the age-dependency of gametocytaemia was examined by microscopy and molecular tools. METHODS: A total of 5,383 blood samples from individuals of all ages were collected over six cross sectional surveys in Burkina Faso. One cross-sectional study used quantitative nucleic acid sequence based amplification (QT-NASBA) for parasite quantification (n = 412). The proportion of infections with concurrent gametocytaemia and median proportion of gametocytes among all parasites were calculated. RESULTS: Asexual parasite prevalence and gametocyte prevalence decreased with age. Gametocytes made up 1.8% of the total parasite population detected by microscopy in the youngest age group. This proportion gradually increased to 18.2% in adults (p < 0.001). Similarly, gametocytes made up 0.2% of the total parasite population detected by QT-NASBA in the youngest age group, increasing to 5.7% in adults (p < 0.001). This age pattern in gametocytaemia was also evident in the proportion of gametocyte positive slides without concomitant asexual parasites which increased from 13.4% (17/127) in children to 45.6% (52/114) in adults (OR 1.55, 95% CI 1.38-1.74, p < 0.001). CONCLUSIONS: The findings of this study suggest that although gametocytes are most commonly detected in children, the proportion of asexual parasites that is committed to develop into gametocytes may increase with age. These findings underscore the importance of adults for the human infectious reservoir for malaria.

Seasonal patterns of Plasmodium falciparum gametocyte prevalence and density in a rural population of Burkina Faso.

Gametocytes are the malaria parasite stages that secure the transmission from the human host to the mosquito. The identification of natural parameters that influence gametocyte carriage can contribute to a better understanding of the dynamics of the sexual stage parasites for transmission reducing strategies. A total of 3400 blood slide readings were done during four cross-sectional surveys (2002-2003) including all age groups to determine the effect of season on Plasmodium falciparum gametocytes in a seasonal malaria transmission area of Burkina Faso. Entomological data were collected to determine the malaria transmission intensity in relation to seasons. Transmission intensity was estimated by monthly EIRs, averaging 28 and 32 infective bites/person/month in the wet seasons of 2002 and 2003, respectively. The EIR in the dry seasons was below one infective bite/person/month. The gametocyte prevalence was significantly higher at the start and peak of the wet season compared to the dry season when corrected for asexual parasite density and age. Gametocyte density significantly increased during the wet season after correction for asexual parasite density and age. In this study, season appears to be an independent parameter that determines gametocyte prevalence and density and should be considered to be included in epidemiological studies on malaria transmission.

Age-dependent distribution of Plasmodium falciparum gametocytes quantified by Pfs25 real-time QT-NASBA in a cross-sectional study in Burkina Faso.

Sexual stages of Plasmodium falciparum play a key role in the transmission of malaria. Studies on gametocytes are generally based on microscopic detection, but more sensitive detection methods for P. falciparum gametocytes frequently detect sub-patent gametocytes. We used Pfs25 mRNA quantitative-nucleic acid sequence-based amplification (QT-NASBA) to quantify gametocytes in 412 samples from a cross-sectional study in Burkina Faso, covering all age groups, to determine age-related patterns in gametocyte carriage and gametocyte density. The more sensitive QT-NASBA technique gave estimates of gametocyte prevalence 3.3-fold higher than microscopy (70.1% versus 21.4%, respectively). Prevalence of gametocytes significantly decreased with age. Our data suggest that asexual parasite densities are primarily responsible for the age-related decrease of gametocyte prevalence, possibly because of developing asexual stage immunity. Gametocyte densities decrease also with age, primarily because of decreasing asexual parasite densities; only a small but significant age effect on gametocyte density may be caused by developing sexual stage-specific immunity.

[Treatment of syphilis with malaria or heat]. / Behandeling van syfilis met malaria of warmte.

Until the end of the Second World War, syphilis was a common sexually transmitted infection. This stigmatising infectious disease caused mental decline, paralysis and eventually death. The history of syphilis was given public attention because of 'malaria therapy', which had been applied from the First World War onwards in patients with paralytic dementia. In 1917, the Austrian physician Julius Wagner-Jauregg (1857-1940) induced fever in these patients by infecting them with malaria parasites; in 1927, he received the Nobel Prize for his discovery of the healing properties of malarial fever. One source, not cited anywhere, is an interview that the American bacteriologist and science writer/medical journalist Paul de Kruif conducted with Wagner-Jauregg in 1930. The reporting of this meeting, and De Kruif's later involvement in the mechanical heat treatment of patients with syphilis, form the inspiration for this article. When penicillin became available, both treatments became obsolete.

[Thijsse, teacher of nature, teacher of malaria]. / Roode kruistochten door polderland. Jac. P. Thijsse en de Nederlandse malariabestrijding.

The start of organised malaria control in The Netherlands originated from an epidemic that became apparent in 1919. Shortly thereafter the Commission for Malaria Control realised the need for involvement of the population in the endemic area of North-Holland province. Education and propaganda would make them alert to reduce the risk of infection and aware of the need for medical diagnosis and treatment. The commission called upon Dr. Jac. P. Thijsse, a professional educator who had just received an honorary doctor's degree at the University of Amsterdam for his excellent work on bringing nature and field biology to the attention of the general public. He had founded the Society for Nature Conservation. Thijsse was invited to write a book on malaria, for use at primary school level. The booklet was called 'About mosquitoes and malaria' and it was widely used by teachers and pupils. Thijsse was also instrumental in the making of a propaganda film on malaria and its control. It was acclaimed by visiting malariologists from abroad for its quality, and it was watched with astonishment by the people in rural North-Holland. Thijsse was a member of the scientific Malaria Commission for five years. His profound knowledge about flora and fauna made him an expert in predicting the chances of mosquito breeding in polder canals with fresh or brackish water. After his resignation he was nominated president for a committee to organise a contest for a new propaganda poster. He passed away in 1945, just before a new epidemic would strike the war-exhausted population of the coastal provinces. It would have been a disappointment to him, because he had strongly believed that the scientific and organising power of the Malaria Commission would be successful in bringing the fever curse to a halt. This epidemic was the last one, and whatever the cause, malaria had disappeared from the Netherlands in 1960.

Experimental, therapeutic and natural transmission of Plasmodium vivax tertian malaria: scientific and anecdotal data on the history of Dutch malaria studies.

When Plasmodium vivax tertian malaria was prevalent in The Netherlands, the use of therapeutic malaria for the treatment of neurosyphilis patients presented an opportunity for biological studies of the parasite's behaviour, in healthy volunteers. One unexplained phenomenon was the long latency between natural exposure to a single infected mosquito and the appearance of clinical signs (average 8 months). Dutch studies with volunteers and syphilis patients, suggested that hundreds of sporozoites transmitted by several mosquito bites were enough to provoke an early attack, known from tropical vivax-malaria. Sporozoites appeared to be programmed either to delay their pre-erythrocytic development or to proceed to an early attack within three weeks. The number of infectious bites also determined the relapse rate and the number of relapses after a primary attack. Analyses of primary cases and relapses from the previous year were used to predict the incidence for the next year. These historic findings fit well with recent studies on genotyping of blood stages during primary attacks and relapses. External factors (i.e. the milieu inside the human host) may trigger hypnozoites to reactivate, but predetermined periods of latency should also be considered.

Paradigm shifts in malaria study and control.

The history of the study of malaria, its parasites and vectors, and aspects of public health and control has shown some irregularities. Mostly the research was a steady accumulation of knowledge, but there were also deadlocks, fundamental disagreements and sometimes a drastic reorientation. In this article we follow the major events, some of the investigators involved, and how they promoted their ways of the fight against this disease. Every episode or moment is calibrated with the theory of science, developed by Thomas Kuhn. His idea of paradigms in science and sudden shifts is helpful for the understanding of what steered the various levels of malaria research. It also may keep investigators on the alert of dead ends and breakthroughs in future.

Duration of the mosquitocidal effect of ivermectin.

Background: Ivermectin (IVM) reduces the lifespan of malaria-transmitting mosquitoes after feeding on humans treated with IVM. If this effect is sufficiently long and strong, IVM could form part of a drug combination that not only treats malaria patients but also reduces onward transmission. Limited data are available on the exact duration of the mosquitocidal effect of IVM; daily mosquito feeding assays are required for this. Materials and Methods: We determined mortality rates of Anopheles stephensi mosquitoes that took a blood meal on Swiss mice, Wistar rats and Cynomolgus monkeys that received IVM orally at 200-400 µg/kg. Mosquito feeding assays were performed on five consecutive days after IVM administration. Mosquito mortality was determined in the first 72 hours after feeding. Results: Mosquito mortality was 70-100% when mosquitoes fed on any of the animals 1-2 days after the last IVM administration. After this time-point the mosquitocidal effect was still evident in some animals but became more variable. Conclusions: Our findings of a pronounced but short-lived mosquitocidal effect makes the timing of IVM administration crucial to form a useful addition to anti-malarial drugs.

Substantial contribution of submicroscopical Plasmodium falciparum gametocyte carriage to the infectious reservoir in an area of seasonal transmission.

BACKGROUND: Man to mosquito transmission of malaria depends on the presence of the sexual stage parasites, gametocytes, that often circulate at low densities. Gametocyte densities below the microscopical threshold of detection may be sufficient to infect mosquitoes but the importance of submicroscopical gametocyte carriage in different transmission settings is unknown. METHODOLOGY/PRINCIPAL FINDINGS: Membrane feeding experiments were carried out on 80 children below 14 years of age at the end of the wet season in an area of seasonal malaria transmission in Burkina Faso. Gametocytes were quantified by microscopy and by Pfs25-based quantitative nucleic acid sequence-based amplification assay (QT-NASBA). The children's infectiousness was determined by membrane feeding experiments in which a venous blood sample was offered to locally reared Anopheles mosquitoes. Gametocytes were detected in 30.0% (24/80) of the children by microscopy compared to 91.6% (65/71) by QT-NASBA (p<0.001). We observed a strong association between QT-NASBA gametocyte density and infection rates (p = 0.007). Children with microscopically detectable gametocytes were more likely to be infectious (68.2% compared to 31.7% of carriers of submicroscopical gametocytes, p = 0.001), and on average infected more mosquitoes (13.2% compared to 2.3%, p<0.001). However, because of the high prevalence of submicroscopical gametocyte carriage in the study population, carriers of sub-microscopical gametocytes were responsible for 24.2% of the malaria transmission in this population. CONCLUSIONS/SIGNIFICANCE: Submicroscopical gametocyte carriage is common in an area of seasonal transmission in Burkina Faso and contributes substantially to the human infectious reservoir. Submicroscopical gametocyte carriage should therefore be considered when implementing interventions that aim to reduce malaria transmission.

Early sporogonic development in local vectors of Plasmodium falciparum in rural Cameroon

In ongoing studies on experimental transmission of Plasmodium falciparum in the city of Yaounde gametocyte carriers are daily being identified among dispensary patients with malaria-like complaints. This species comprises 93 of all parasitemias and because of the selection criteria most patients have it as a recent infection. 17 of all P. falciparum-positives carry detectable gametocytes with little difference between youngsters and adults. Blood of adult carriers is taken and infection of Anopheles gambiae mosquitoes is attempted by membrane feeding; the establishment of infection is judged by the presence of oocysts.