Dose-ranging study for trials of therapeutic infection with Necator americanus in humans.

Epidemiological studies suggest that a hookworm infection producing 50 eggs/gram of feces may protect against asthma. We conducted a dose-ranging study to identify the dose of hookworm larvae necessary to achieve 50 eggs/gram of feces for therapeutic trials of asthma. Ten healthy subjects without asthma or airway hyperresponsiveness to inhaled methacholine received 10, 25, 50, or 100 Necator americanus larvae administered double blind to an area of skin on the arm. Subjects were seen weekly for 12 weeks and were then treated with mebendazole. Skin itching at the entry site and gastrointestinal symptoms were common at higher doses. Lung function did not change. Levels of blood eosinophils and IgE increased transiently, and levels of IgG increased progressively. All doses resulted in at least 50 eggs/gram of feces in the eight subjects who completed the study. Infection with 10 N. americanus larvae is well tolerated, elicits a modest host eosinophil response, and is potentially suitable for use in preliminary clinical therapeutic trials.

Cuticle preparations from Necator americanus and their immunogenicity in the infected host.

Cuticle samples have been prepared from the human parasitic nematode Necator americanus using detergent solubilisation with sodium dodecyl sulphate and subsequent reduction of disulphide bonds using 2-beta-mercaptoethanol. It would appear that N. americanus, like many other nematodes, relies on relatively small collagenous proteins, linked by disulphide bonds, to maintain the integrity of its cuticle. These molecules are normally hidden from the immune system during the course of infection but are potentially immunogenic. It is suggested that waves of antibodies, firstly with specificity against superficial cuticular epitopes followed by antibodies against deeper lying, structural elements, should be induced during vaccination to effectively destroy the nematode at the cuticular level.

Identification of hookworm (Necator americanus) antigens and their translation in vitro.

During in vitro culture adult (day 35) Necator americanus synthesise a wide range of protein species many of which are excreted or secreted into the culture medium. Both post infection (day 117) hamster sera and sera from infected humans precipitate antigens of 15, 30, 33, 44, 46 and 69 kDa although individual human sera exhibit some variability in absolute specificity. In immunoblotting experiments antigens of 33 kDa are routinely recognised by human sera although two-dimensional gel analysis suggests that more than one polypeptide is involved. RNA isolated from adult worms direct the in vitro synthesis of numerous polypeptides possessing antigenic determinants recognised by sera from infected hamsters and humans. Post-translational modification of N. americanus encoded polypeptides is not, therefore, a prerequisite for antigenicity.

The clinical and immunologic responses of normal human volunteers to low dose hookworm (Necator americanus) infection.

Five normal human volunteers were exposed to approximately 50 infective larvae of Necator americanus and were observed for the development of clinical signs or symptoms and for changes in blood eosinophil levels, IgG antibody titers, total and parasite-specific IgE, and lymphocyte blastogenic responses for 6-10 weeks. Bronchoalveolar lavage was performed on four subjects prior to infection and at times when larval migration through the pulmonary tree was likely. Eggs were demonstrated in the stools of four volunteers who remained untreated for more than 6 weeks; one volunteer had to be treated at day 40 because of severe gastrointestinal symptoms. All others also complained of abdominal pain and flatulence between days 35-40. All volunteers developed marked blood eosinophilia which peaked between days 38-64 and ranged from 1,350-3,828 eosinophils/mm3. Small increases in total and parasite-specific IgE and IgG were noted in some volunteers. One volunteer showed a significant lymphocyte blastogenic response. With the exception of mucosal erythema, bronchoalveolar lavage results were unremarkable. Our data indicate that a single small inoculum of hookworm larvae is capable of producing significant transient gastrointestinal morbidity and marked blood eosinophilia but does not induce other prominent T cell- and B cell-dependent immune responses.

Evaluation of the skin test for hookworm as an epidemiological tool.

The usefulness of a skin test with larval Necator americanus antigen for assessment of hookworm prevalence was evaluated in an endemic area of Costa Rica. In comparison with standard coprologic techniques employed to survey the population, the skin test detected 83% of infections, showing a fairly satisfactory sensitivity. The overall specificity of the test was 50%, i.e., random. No correlation was found between skin reactivity and hookworm burden. The sensitivity of the test increased moderately with age, but its specificity decreased significantly at the same time. False positive reactions were more numerous among persons formerly infected with hookworm who had been negative for as long as 5 years. There was an indication of cross reactivity with intestinal nematodes other than hookworm. The test was used to detect hookworm infected persons in the community for selective treatment, in comparison with mass treatment of all the people in another village. The selective administration of an anthelminthic drug to only skin test positive persons did not achieve the same drop in community hookworm prevalence as did the indiscriminate treatment of the whole population.

Antibody responses in self-infections with Necator americanus.

Antibody responses were measured in a volunteer infected four times with Necator americanus over a 27-month period. The main source of antigen was culture fluid in which living adult N. americanus had been maintained for several days. Antibodies to worm acetylcholinesterase and IgE antibodies were detected only with this material, but antibodies were identified by the enzyme-linked immunosorbent (ELISA) assay, with either adult worm secretions or extracts of third-stage infective larvae. The total serum IgE level fell after the first infection, but although it then increased during subsequent infections, it never rose above 600 U per ml. None of the antibody responses suppressed the rat of worm development to maturity, or reduced the fecundity of the parasites. However, it is suggested that the development of the immune response may be associated with the waning of the severe gastro-intestinal symptoms which were experienced in this infection, and which are frequently characteristic of hookworm infections.

Variation in delayed hypersensitivity in onchocerciasis.

Soluble antigen preparations were made from Onchocerca volvulus adults recovered from subcutaneous nodules, and from Necator americanus third-stage larvae. Intradermal skin tests were carried out on a total of 100 individuals clinically classified as having either the generalized form of onchocerciasis (86 cases, or the localized sowda form (14 cases). 91 of the people studied produced immediate reactions to the onchocercal antigen, but only those with sowda showed delayed reactions, though one person with generalized disease showed a doubtful delayed reaction. Reactions to N. americanus antigen, both immediate and delayed, were seen in both forms of the disease. The lack of delayed skin reaction in the generalized form of onchocerciasis is discussed, and a comparison is made with other diseases. Preliminary evidence for the existence of a true spectrum of clinical and immunological forms of onchocerciasis is suggested by one case in this study.

Necator americanus in neonatally infected hamsters. The time-course of infection and antibody response to the surface antigens of L4 and adult worms.

Neonatal hamsters were infected with a hamster-adapted strain of Necator americanus, and the time-course of infection was followed by worm and faecal egg counts. Parasite eggs were first recorded during the 6th week of infection, increasing rapidly thereafter to peak in weeks 7-10. Male hamsters excreted more eggs than females, but both sexes were equally susceptible to infection and harboured comparable worm burdens. Faecal egg counts declined from week 10 onwards and this was associated with a loss of worms from animals with heavy infections. Low level infections were stable over the first 114 d of infection but worm fecundity nevertheless still declined over this period. Both hamster sexes responded similarly to surface antigens on adult worms, the antibody levels rising from week 5 onwards to reach a plateau in weeks 6-7, which persisted until the experiments were terminated. The major antigens recognised on the surface of adult worms had molecular masses corresponding to 25 kDa, 32 kDa, a doublet with the heaviest polypeptide resolving at 46 kDa, and a triplet with the heaviest at 67 and 93kDa. In contrast L4 had only 2 major cuticular antigens resolving at 41 and 93kDa. The 93kDa molecule on L4 and adult worms may be antigenically related.

Antigenic cross-reactivity between Necator americanus and Ascaris lumbricoides in a community in Papua New Guinea infected predominantly with hookworm.

Sero-epidemiological data are presented in which antigenic cross-reactivity between Necator americanus and Ascaris lumbricoides has been investigated in a community in Papua New Guinea infected predominantly with N. americanus. It is our contention that the antigenic cross-reactivity which undoubtedly exists between these species accounted for (i) a peak in antibody levels against N. americanus in 10-13 years old children (driven by infection with A. lumbricoides), and (ii) the maintenance of apparent antibody levels against A. lumbricoides in older age groups (driven by infection with N. americanus in the absence of overt infection with A. lumbricoides). Cross-reactivity was analysed further, and apparently N. americanus-specific epitopes identified, by immunoblotting. These observations could have considerable bearing on the interpretation of data from sero-epidemiological studies which failed to take account of concurrent infection with these parasites.

Site of resistance to Necator americanus in hamsters.

Resistance to the development of human hookworm, Necator americanus was examined in 3- to 6-week-old young adult hamsters. Only 3% of N. americanus infective third stage larvae (NaL3) reached maturity in the intestines of young adults as opposed to as many as 60% in 2-day-old baby hamsters. This seemingly effective resistance prevailing in young adults was investigated in some detail. The skin, the first site of contact for the invading NaL3, was bypassed during the infection process. Completely in vitro exsheathed NaL3 (ExNaL3) were used, and young adult hamsters were infected parenterally, by-passing the skin. Even after exsheathing the larvae artificially before infection and by-passing the skin, no improvement was seen in the development of N. americanus in the intestines of young adults. Higher infection doses also did not increase the worm burden. Some of the factors limiting the development of parasites in young adults were examined. N. americanus were monitored in lungs and intestines during various intervals after infection. Similar parasite burdens were apparent in lungs of baby as well as young adult hamsters. In the intestines, a significantly lower burden of N. americanus was seen during various intervals in young adults compared to the baby hamsters. Moreover, N. americanus were expelled soon after reaching the intestine. This comparative monitoring revealed the intestine as the seat of resistance against the establishment of N. americanus in young adult hamsters.

Adherence of human eosinophils to infective filariform larvae of Necator americanus in vitro.

Eosinophilia is common in hookworm infection but the interaction between eosinophils and the larval stage of the parasite is poorly understood. The present study was conducted to test the ability of the eosinophils to adhere to infective filariform larvae of Necator americanus in vitro. Adherence of eosinophils to the larvae was found to be serum dependent. Antibody facilitated eosinophil adherence but this was maximal in the presence of complement. The adherence was greatly diminished by EGTA treated normal human serum (NHS) and was completely abolished when NHS was treated with either EDTA or heat-inactivation, suggesting that the process can be facilitated through complement activation via the alternative pathway. As with other nematodes, the surface of hookworm larvae appeared to be both antigenic and complement-activating. Although it is not known whether eosinophil adherence has any larvicidal effect, the present study demonstrated for the first time a definite interaction between human eosinophils and hookworm filariform larvae.

The detection of antibodies to hookworm larva in patients by immunofluorescence: a preliminary report.

Using the fluorescent antibody technique 84% of patients with severe hookworm infection and 74% of Nigerian blood donors have detecable antibodies that react with surface antigen of hookworm larvae. On the other hand only 24% of Nigerian medical students and 20% of Caucasians (Canadians) have such antibodies in their sera. It is suggested that while the results of tests on students may be due to the relatively infrequent contact with hookworm the antibody positivity in the Caucasians may be due to cross reaction with other related helminths. The titre of antibody produced in the hookworm infected patients was similar to that of the blood donors but differed from other groups. Lower positivity rates were observed with further dilution of sera in the hookworm infected patients. This may be due to their relative incapacity to produce potent hookworm antibody. Further work on this aspect is required as well as improvement of the specificity of the technique.

Antigen expression during development of the human hookworm, Necator americanus (Nematoda).

The accumulated and de novo synthesized antigens expressed by L3, L4 and adult Necator americanus, recognized by both the natural host, man, and the experimental host, the hamster, were identified by immunoblotting and immunoprecipitation analysis. Following infection of neonatal hamsters serum samples were taken on days 17, 35 and 117. Only serum taken 117 days after infection showed significant reactivity in immunoblotting experiments, recognizing adult epitopes of 30,000, 33,000, 48,000 and 69,000 mol. wt thereby suggesting that few accumulated antigens are shared between developmental stages. By contrast, immunoprecipitation analysis of metabolically labelled proteins suggested that L3 and in particular L4 larvae synthesize some antigens which comigrate with those synthesized and accumulated by adult worms. In addition, L4 larvae synthesize a 41,000 mol. wt excretory/secretory (ES) stage specific antigen. Parallel experiments using serum samples from infected humans, demonstrated that hamsters and man recognize many antigens of identical molecular weight. Notable in this respect are accumulated adult antigens of 30,000, 33,000, 48,000 and 69,000 and de novo synthesized antigens of 30,000, 33,000, 44,000, 46,000 and 69,000 mol. wt. Some individual human sera mainly recognized L3 antigens of 47,000-69,000 mol. wt in immunoblotting experiments whilst others simultaneously recognized adult epitopes. This differential recognition of developmental stages by individual human sera suggests that genetic or epidemiological factors are operative and warrants further study. Overall, these studies confirm the pronounced immunogenicity of Necator americanus in both man and an animal model and pave the way for analysis of the relevance of these antigens to field situations.

Homology between roundworm (Ascaris) and hookworm (N. americanus) antigens detected by human IgE antibodies.

Utilizing the techniques of radioallergosorbent test (RAST), inhibition of RAST and isoelectric focusing on polyacrylamide gels, antigenic cross-reactivity has been shown between extracts of Ascaris lumbricoides. Ascaris suum and Necator americanus (hookworm). Antigenic homology is extensive between the two Ascaris preparations. The antigens common to hookworm and Ascaris, while representing a minor component of Ascaris body fluid, are nonetheless potent stimulators of IgE antibody production in subjects infected only with hookworm larvae. These shared antigens appear to have a pI of less than 5.1. The hookworm specific antigens also have a pI of less than 5.1, whereas those specific to Ascaris have pI values in the ranges of 5.0 to 6.0 and 7.0 to 8.6. These latter antigens, i.e. those with pI between 7.0 and 8.6, apparently elicit an immune response only during an active infection with Ascaris.

The recognition of antigens on the surface of adult and L4 Necator americanus by human and hamster post-infection sera.

The surface antigens of adult Necator americanus were recognized by post-infection hamster sera and resolved at molecular weight 93,000, 67,000, 46,000, 43,000, 32,000 and 25,000. L4 larvae in contrast had one major surface antigen, resolving at 93,000. These antigens were also recognized by a range of human sera, although on a differential basis. This suggests that the human sera tion. However, the results do indicate that the hamster model might be of immunological relevance to the human disease state, in that infected hamster recognized the full cuticular antigen spectrum of adult Necator. This, at least, gives the experimenter a convenient reference point from which to conduct further experiments incorporating parameters such as re-infection, anthelmintic treatment and genetic variability to study the effect of these modifications on the serological response.

The action of a mast cell protease on the cuticular collagens of Necator americanus.

Collagen-like proteins, thought to be responsible for maintaining the structural integrity of the nematode cuticle, were isolated from adult Necator americanus and shown to be susceptible to digestion by purified mast cell proteases. Although these collagens would appear normally to be masked by superficially expressed (surface) antigens, it is suggested that a sufficiently avid and specific immune response could remove this potentially protective coat, rendering the structurally important underlying layers open to immune attack.