[Subsidized artemisinin based combination treatments for Africa]. / Associations à base d'artémisinine subventionnées pour l'Afrique.

Malaria-associated mortality and morbidity have increased in recent decades, with the worldwide spread of chloroquine and sulfadoxine-pyrimethamine resistant parasites. Artemisinin-based combination therapies (ACTs) have been proposed as an alternative to conventional antimalarial drugs. ACTs are effective against multidrug-resistant infections, work quickly, are safe and well tolerated, and seem to decrease transmission by inactivating gametocytes. The affordable medicines facility-malaria (AMFm) - an initiative aiming at increasing the availability of affordable ACTs through public and private practice - is trying to accelerate the large-scale use of ACT worldwide. This began with an initial pilot phase in a selected group of African countries. However, the epidemiology of malaria, the economic context, and healthcare infrastructure of African countries differ considerably from those prevailing in Asia, where ACTs were first implemented in the 1990s. ACT implementation in Africa must therefore be accompanied by control and operational measures to maintain the efficacy of ACT and to protect patients against misuse. We discuss the expected benefits of the AMFm initiative in Africa and stress the importance of dealing with operational issues before implementation in the field, focusing particularly on drug resistance.

A complement receptor-1 polymorphism with high frequency in malaria endemic regions of Asia but not Africa.

Complement receptor-1 (CR1) is a ligand for rosette formation, a phenomenon associated with cerebral malaria (CM). Binding is dependent on erythrocyte CR1 copy number. In Caucasians, low CR1 expressors have two linked mutations. We determined the Q981H and HindIII RFLP distribution in differing population groups to ascertain a possible role in adaptive evolution. We examined 194 Caucasians, 180 Choctaw Indians, 93 Chinese-Taiwanese, 304 Cambodians, 89 Papua New Guineans (PNG) and 366 Africans. PCR/RFLP used HindIII for CR1 expression and BstNI for the Q981H mutation. DNA sequencing and pyrosequencing were performed to resolve inconclusive results. Gene frequencies for the L allele were 0.15 in Africans, 0.16 in Choctaws, 0.18 in Caucasians, 0.29 in Chinese-Taiwanese, 0.47 in Cambodians and 0.58 in PNG. Allelic frequency for 981H were 0.07 in Africans, 0.15 in Caucasians, 0.18 in Choctaws, 0.29 in Chinese-Taiwanese, 0.47 in Cambodians and 0.54 in PNG. The Q981H polymorphism correlates with the HindIII RFLP in most groups except West Africans and appears to be part of a low CR1 expression haplotype. The gene frequency for the haplotype is highest in the malaria-endemic areas of Asia, suggesting that this haplotype may have evolved because it protects from rosetting and CM.

Association of severe malaria with a specific Plasmodium falciparum genotype in French Guiana.

Why severe Plasmodium falciparum malaria occurs in only a small percentage of patients is unclear. The possibility that specific parasite characteristics contribute to severity has been investigated in French Guiana, a hypoendemic area, where parasite diversity is low and all patients with severe cases are referred to a single intensive care unit. Parasite genotyping in geographically and temporally matched patients with mild and severe disease showed that the association of a specific msp-1 allele (B-K1) with a specific var gene (var-D) was overrepresented among patients with severe versus mild disease (47% vs. 3%, respectively; P<.001). Moreover, this genotype combination was consistently observed in the most severe clinical cases. Reverse-transcription polymerase chain reaction demonstrated programmed expression of var-D in vivo, which is consistent with its potential implication in severe disease. These results provide field evidence of an association of severe malaria with specific genetic characteristics of parasites and open the way for intervention strategies targeting key virulence factors of parasites.

Monkeys of the rainforest in French Guiana are natural reservoirs for P. brasilianum/P. malariae malaria.

Monkey blood samples were collected from 214 monkeys relocated as part of the wildlife rescue organized in French Guiana during the filling of the Petit Saut Dam on the Sinnamary River. These samples were tested for malaria parasites by microscopy of thick blood filsm and by nested PCR for small subunit rRNA genes (SSUrRNA). Parasitic blood forms similar to Plasmodium brasilianum were detected in 4 monkey species: Alouatta seniculus macconnelli, Saguinus midas midas, Pithecia pithecia and Ateles paniscus paniscus, with the highest prevalence in Alouatta monkeys. PCR was more sensitive than the conventional method for detecting low-grade parasitaemia in positive monkeys. The examination of blood films indicated that 5.6% of the animals carried parasites whereas the nested PCR for ribosomal DNA indicated a prevalence of 11.3%. The P. brasilianum SSUrRNA gene sequence was analysed and aligned with those from P. malariae, P. falciparum and P. vivax. This suggested that P. brasilianum and P. malariae are very closely related. Similar results were obtained from analysis of the sequences in P. malariae and P. brasilianum isolates of a polymorphic gene fragment analogous to the merozoite surface protein-1 (MSP-1) gene of P. falciparum. The P. brasilianum/P. malariae sequences were more similar to those of P. vivax than to those of P. falciparum, at least in the gene region examined. The high degree of DNA homology in the sequences of the SSUrRNA and msp1-like genes is consistent with other characterizations demonstrating a taxonomic relationship between P. brasilianum and P. malariae species. Our results provide further evidence that P. brasilianum and P. malariae are virtually identical and should probably be considered to be a single malaria species. This raises the question as to whether monkeys living in the rainforest are natural reservoirs for both simian and human malaria. These results have implications for the interpretation of the current epidemiological situation in French Guiana.

Plasmodium falciparum: population genetic analysis by multilocus enzyme electrophoresis and other molecular markers.

Abderrazak, S. B., Oury, B, Lal, A. A., Bosseno, M.-F., Force-Barge, P., Dujardin, J.-P., Fandeur, T., Molez, J.-F., Kjellberg, F., Ayala, F. J., and Tibayrenc, M. 1999. Plasmodium falciparum: Population genetic analysis by multilocus enzyme electrophoresis and other molecular markers. Experimental Parasitology 92, 232-238. The population structure of Plasmodium falciparum, the agent of malignant malaria, is uncertain. We have analyzed multilocus enzyme electrophoresis (MLEE) polymorphisms at 7-12 gene loci in each of four populations (two populations in Burkina Faso, one in Sudan, one in Congo), plus one "cosmopolitan" sample consisting of parasite cultures from 15 distant localities in four different continents. We have also performed random amplified polymorphic DNA analysis (RAPD) and restriction fragment length polymorphism (RFLP) and characterized gene varia tion at four antigen genes in the Congo population. All genetic assays show abundant genetic variability in all populations analyzed. With the isoenzyme assays, strong linkage disequilibrium is apparent in at least two local populations, the Congo population and one population from Burkina Faso, as well as in the cosmopolitan sample, and less definitely in the other Burkina Faso population. However, no linkage disequilibrium is detected in the Congo population with the molecular assays. We failed to detect any nonrandom association between the different kinds of genetic markers; that is, MLEE with RAPD or RFLP, RAPD with RFLP, and so on. Although isoenzyme data show statistical departures from panmictic expectations, these results suggest that in the areas under survey, P. falciparum populations do not undergo predominant clonal evolution and show no clear-cut subdivisions, un like Trypanosoma cruzi, Leishmania sp., and other major parasitic species. We discuss the epidemiological and taxonomical significance of these results.

Novel target antigens of the variant-specific immune response to Plasmodium falciparum identified by differential screening of an expression library.

A primary infection by the Plasmodium falciparum Palo Alto O and R antigenic variants induces a variant-specific immunity in the Saimiri sciureus monkey. We have shown that these variants express distinct PfEMP1 antigens and differ in their levels of expression of additional antigens, including two conserved erythrocyte membrane-associated proteins, HRP1 and PfEMP3. To identify the antigens eliciting a variant-specific response, we conducted a differential screening of a lambdagt11 library with variant-specific sera. We report here the analysis of the 46 anti-R-specific clones. Two specific targets of the anti-R response were identified: (i) PfEMP3, suggesting that immunogenicity of this antigen is modulated by its relative abundance in different variants, and (ii) Asn-rich motifs. Most anti-R-specific clones, derived from so-far-undescribed genes, were detected by a cross-reaction on poly(Asn) stretches, as indicated by elimination of the signal after absorption on Asn-rich sequences. Reverse transcription-PCR (RT-PCR) showed that expression of the gene defined by clone 13 was R specific. Pepscan analysis of clone 13 identified three Asn-rich polypeptides and one unique peptide reacting specifically with antibodies eluted from the R-infected erythrocyte surface. Antisera raised to the unique peptide reacted with an R-specific protein. Attempts to demonstrate that clone 13 was derived from a var gene by using PCRs combining clone 13 and var-derived primers were unsuccessful. The var genes expressed by O and R parasites were identified not by this strategy but by RT-PCR with var-specific primers. This work has provided novel insights into immunity to antigenic variants and has identified a novel gene switched on during antigenic variation.

Plasmodium falciparum parasites in French Guiana: limited genetic diversity and high selfing rate.

The genetic characteristics of Plasmodium falciparum isolates collected in French Guiana, where malaria transmission is low and occurs in isolated foci, were studied. Blood samples were collected from 142 patients with symptomatic malaria and typed using a polymerase chain reaction-based strategy for merozoite surface protein-(MSP-1) block 2, the MSP-2 central domain, and glutamate-rich protein (GLURP) repeat domain polymorphism. This showed that the parasite population circulating in French Guiana presented a limited number of allelic forms (4, 2, and 3 for MSP-1 block 2, MSP-1, and GLURP, respectively) and a small number of mixed infections, contrasting with the large genetic diversity of parasite populations and infection complexity reported for Africa, Asia, and other parts of South America. Two groups of isolates displaying identical 3 loci allele combinations were further studied for the Pf332 antigen, histidine-rich protein-1, thrombospondin-related anonymous protein, and Pf60 multigene family polymorphism. Within each group, most isolates were identical for all markers tested. This suggests a high rate of self-fertilization of P. falciparum parasites in French Guiana, resulting in homogenization of the population. The implications of these findings for malaria control in areas of low endemicity are discussed.

Variant- and strain-specific immunity in Saimiri infected with Plasmodium falciparum.

Variant- and strain-specific immunity to malaria in Saimiri monkeys infected with homologous O and R variants of the Palo Alto strain (FUPSP) of Plasmodium falciparum or by various heterologous divergent strains were studied. Following homologous reinfections, the primary immune response in monkeys was effective only against the same variant type but not against the other variant, which differed only by antigens exposed at the surface of the infected red blood cell. In contrast, after two successive inoculations with a single variant type, a variant transcending immunity developed to both O and R parasite populations. The immunity against FUPSP in monkeys repeatedly infected with various combinations of heterologous strains, including Sal I, Tanzania, Camp, FUPCP, FCH4, FVO, and FUPCDC parasites was less effective, resulting at best in protecting the monkey against fulminating infection. However, in several cases, previous or concomitant heterologous infections modified the course of virulent infection by FUPSP parasites, indicating a significant degree of cross-protection between the strains. Therefore, in this model, while variant- and strain-specific antigens are important components of acquired immunity to malaria, the monkey immune response to infection transcends phenotypic antigenic variation and strain diversity.

A modification in restriction pattern of the Plasmodium falciparum Pf60 multigene family associated with a specific antigenic variation switch in the Palo Alto line.

The wide occurrence of molecular rearrangements associated with expression of specific members within multigene families led us to investigate whether this also happens during antigenic variation of malaria parasites. We have investigated here the Pf60 multigene family restriction patterns of four distinct variants of the Plasmodium falciparum Palo Alto line propagated in Saimiri monkeys. The O and its cloned Oc variant both express the O serotype, while the R variant (derived from O parasites) and the Vc variant (derived from Oc parasites) express distinct serotypes. We show that a specific modification of the restriction pattern could be associated with antigenic switching in this line. The DNA of the variants which expressed the O serotype (O and Oc) had a specific 5.5 kb Hind III/Eco RI restriction fragment which was absent from the R or Vc parasite DNA, whereas both R and Vc DNA presented a 3.5 kb Hind III/Eco RI restriction fragment, which was absent from the O and Oc parasites. These results indicate that both expression and silencing of the O serotype were associated with specific restriction patterns, suggesting that some molecular rearrangement or some modification of the DNA might control expression of the variant surface antigen in malaria parasites.

Plasmodium falciparum: altered expressions of erythrocyte membrane-associated antigens during antigenic variation.

The O and R antigenic variants of the Plasmodium falciparum Palo Alto strain present differences in the morphology of the infected red blood cell membrane, in their adhesion properties, surface immunofluorescence, and agglutination specificities and importantly, induce a variant-specific protection after a primary infection in Saimiri sciureus monkeys. To identify potential targets of variant-specific immunity, we have compared the antigenic makeup of both variants by immunoblot. O-specific monkey sera generated similar profiles on both parasite types, while R-specific sera showed a consistent difference on a high-molecular-mass undefined antigen. Distinct antibody specificities were eluted from the surface of O- or R-infected erythrocytes, generating variant-specific agglutination, surface immunofluorescence, and immunoblot profiles. An antiserum raised to Pf60.1, predicted to cross-react with the cytoplasmic domain of PfEMP1, reacted with specific, SDS-soluble antigens in both variants. Antigens associated with the membrane of the infected red blood cells were further investigated using several specific antisera. The 85-kDa HRP1 gene product was more abundant in O than in R parasites, while the reverse was observed for the PfEMP3 protein. These data indicate that O and R parasites differ in the expression of several antigens associated with the membrane of the infected red blood cell.

Extensive genetic diversity of Plasmodium falciparum isolates collected from patients with severe malaria in Dakar, Senegal.

While some genetic host factors are known to protect against severe Plasmodium falciparum malaria, little is known about parasite virulence factors. We have compared the genetic characteristics of P. falciparum isolates collected from 56 severe malaria patients and from 30 mild malaria patients recruited in Hôpital Principal, Dakar, Senegal. All isolates were typed using polymerase chain reaction amplification of polymorphic genetic loci (MSP-1, MSP-2, HRP1, GLURP, CSP, RESA, and the multigene family Pf60). The complexity of infections was lower in severe than in mild malaria and the parasite genetic diversity in both groups was very large. No specific genetic make-up was associated with severity; there were, however, marked differences in allele frequencies in both groups, with a prevalence up to 60% of MSP-2 alleles specifically observed in the severe malaria isolates. In addition, the presence of MSP-1/RO33 alleles was significantly associated with a higher plasma level of tumour necrosis factor alpha receptor 1 (P < 0.05), a reported indicator of severity in human malaria. These results point to potential differences in the genetic characteristics of parasites inducing severe versus mild pathology.

Plasmodium falciparum: genetic diversity of several strains infectious for the squirrel monkey (Saimiri sciureus).

The squirrel monkey, Saimiri sciureus, is a useful experimental host for the human malaria parasite Plasmodium falciparum. Twelve strains of P. falciparum, including monkey-adapted strains, culture-derived strains, and one human isolate were injected into naive, splenectomized Saimiri monkeys of karyotype 14-7. Several parameters were recorded following inoculation such as parasitemia, body temperature, standard hematological parameters, gametocytemia, rosette formation, autoagglutination, as well as HRPI and PfEMP3 expression. Each strain was injected into two to four monkeys and induced a reproducible course of infection. Four distinct patterns of parasite development were observed. For each strain, a multilocus genotype was established by PCR using several polymorphic (Pf60, RESA, RESA2, MSA1, MSA2, Pf332, TRAP, GLURP, CSP, and HRPI) or conserved (EBA175, GARP, MDRI, and RNA POL III) markers. RFLP analysis was conducted for the Pf11.1 locus. This genotyping approach showed that 3 strains presented strictly similar patterns, typical of FUP/SP parasites. A group of 7 other strains presented a highly similar FUP/CP (FCR3-like) genetic background, while 4 other strains showed unique patterns. Infectiousness did not depend on a RESA deletion, as several strains developed successfully while present ng a wild-type RESA gene. Conversely, an interesting correlation was found between allelic diversity at the HRPI locus and the course of blood stage infection. The data presented here provide the first precise genotyping of several monkey-adapted strains, allowing a more rational approach in the study of the role of parasite diversity on host/parasite interactions.

Different genetic characteristics of Plasmodium falciparum isolates collected during successive clinical malaria episodes in Senegalese children.

A narrow epidemiologic survey was conducted during a four-month period of intense malaria transmission in Dielmo, a holoendemic Senegalese village. Longitudinal clinical and parasitologic follow-up indicate that clinical malaria episodes always occurred after an abrupt increase in parasite densities. Polymerase chain reaction analysis of Plasmodium falciparum parasites was carried out in blood samples collected longitudinally from 10 children who had experienced several clinical episodes during this period. Our data show that the genetic diversity of the parasites circulating in this village is very large. The successive clinical episodes experienced by each child were caused by genetically distinct parasite populations that were recently inoculated and multiplied in an apparently unrestricted manner. Importantly, the genetic characteristics of the parasite populations detected during phases of asymptomatic carriage differed from those causing a clinical episode, suggesting that the various factors that control of parasite growth in these children are strain-specific.

Rapid turnover of Plasmodium falciparum populations in asymptomatic individuals living in a high transmission area.

A polymerase chain reaction (PCR) typing technique, based on the amplification of polymorphic regions from the merozoite surface protein 1 (MSP-1) and MSP-2 Plasmodium falciparum genes, was used to characterize parasites collected in a longitudinal study of asymptomatic carriers of malaria parasites living in two distinct epidemiologic situations. Blood samples were collected from children and adults living in the village of Dielmo, Senegal, when malaria transmission was 3-6 infective bites/week/individual. For each individual, every sample collected at two-week intervals over a period of three months showed a specific PCR pattern. Changes involved both appearance and disappearance of specific alleles. Analysis of blood samples collected at a few-days interval showed that modifications of the PCR patterns occurred rapidly. Most alleles were detected over a period of 2-3 weeks, but some alleles could be detected only for a few days. The frequent modifications of the PCR patterns indicate significant changes in allelic balance over time, and importantly, this was observed both in children and adults. These results strongly contrast with the stability of the parasite types harbored by asymptomatic individuals living in Pikine, Senegal during a period in which malaria transmission was interrupted, and therefore suggest that the rapid turnover observed in Dielmo may reflect the introduction of new parasite populations by mosquitoes.

PCR typing of field isolates of Plasmodium falciparum.

We report on an analysis of the constraints of PCR typing of field Plasmodium falciparum isolates by using a few highly polymorphic markers, MSA-1, MSA-2, TRAP, and CS. We show that the reactions are specific for the P. falciparum species. The detection threshold (minimum number of parasites required to detect a visible band by ethidium bromide) differed from one marker to the other and, within one locus, from one primer combination to the other. Importantly, the various MSA-1 and MSA-2 reference alleles were amplified with the same efficiency. Amplification from reconstituted allele mixtures indicated that at certain allele ratios, the most abundant allele interfered with the amplification of the less abundant one. An analysis of nine isolates collected from patients with acute malaria in Dielmo, Senegal, during a transmission season when the inoculation rate was one infective bite every second night is presented and discussed. All samples contained more than one parasite type. A significant polymorphism was observed for the four markers. Novel TaqI restriction fragment length polymorphisms were found for the TRAP gene, and TRAP gene typing alone allowed a distinction between the various isolates. MSA-1 and MSA-2 gave multiple band patterns specific for each sample.

Immune pressure selects for Plasmodium falciparum parasites presenting distinct red blood cell surface antigens and inducing strain-specific protection in Saimiri sciureus monkeys.

The passive transfer of specific antibodies to a naive splenectomized Saimiri sciureus monkey infected with the Palo Alto FUP/SP strain of Plasmodium falciparum resulted in the emergence of parasites resistant to the transferred antibodies. Molecular typing indicated that the original and resistant parasites were isogenic. Saimiri monkeys primed with original parasites were fully susceptible to a challenge by the resistant ones, and vice versa. This absence of crossprotection indicates that strain-specific determinants would be the major targets of protective immunity developed in these monkeys. Phenotypic analysis showed that the surface of the infected red blood cells differed in both lines. Original parasites formed rosettes, autoagglutinated, presented characteristic knobs at the surface of the infected red blood cell, and did not agglutinate in the presence of a pool of human immune sera. In contrast, the resistant parasites did not form rosettes, did not spontaneously autoagglutinate, presented abnormal flattened knobs, and formed large aggregates in the presence of a pool of human immune sera. The presence of strain-specific determinants at the surface of the resistant parasites was confirmed by surface immunofluorescence and agglutination using homologous Saimiri serum. Neither the original nor the resistant parasites cytoadhered to an amelanotic melanoma cell line, suggesting that cytoadherence and agglutination can be dissociated. These results indicate that parasites that differ by the antigens exposed at the surface of the red blood cell induce strain-specific immunity. Furthermore they show that rosetting and nonrosetting parasites differ in their antigenic properties and do not crossprotect.

A large multigene family expressed during the erythrocytic schizogony of Plasmodium falciparum.

We report the identification of a large multigene family of Plasmodium falciparum using a clone isolated with a polyclonal antiserum raised to a Babesia divergens merozoite protein. The recombinant antigen reacted with human sera collected from individuals exposed to malaria. The deduced protein sequence contains a motif homologous to the consensus sequence of merozoite rhoptry proteins encoded by multigene families in several Babesia species. Antibodies raised to the recombinant protein reacted with a 60-kDa merozoite protein both on B. divergens and on P. falciparum immunoblots. The insert hybridized to a large number of fragments on P. falciparum Southern blots and to most chromosomes of the parasite. Specifically, approx. 3-kb RNAs were detected in 4-16-nucleus schizonts. Ten distinct cDNAs were isolated that differed in the size, position and number of restriction sites in the region homologous to the original genomic clone. With about 140 copies per haploid genome, this is the first large multigene family described in malaria parasites. The existence of a multigene family encoding proteins present in the invasive stage of malaria parasites suggests an important role in invasion and denotes a significant potential for generating diversity.