The Synaptic Leap

The Lancet Infectious Diseases, Vol. 10, No. 9. (September 2010), pp. 603-611.

Summary Background Schistosomiasis is an important parasitic disease in Kenya. Decreasing susceptibility of schistosomes to praziquantel, the major drug used to reduce disease morbidity, has made assessment of new antischistosomal drugs a priority. We aimed to assess the safety and efficacy of an artesunate-based combination drug in the treatment of schistosomiasis. Methods In this open-label randomised trial in Rarieda district of western Kenya, we enrolled school children (aged 6–15 years) who had Schistosoma mansoni infection according to duplicate Kato-Katz thick smears from a stool sample. Computer-generated block randomisation was used to assign children (1:1) to receive artesunate (100 mg) with sulfalene (also known as sulfamethoxypyrazine; 250 mg) plus pyrimethamine (12·5 mg) as one dose every 24 h for 3 days or one dose of praziquantel (40 mg/kg per day). The primary efficacy endpoint was the number of participants cured 28 days after treatment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01054651. Results Between October and December, 2009, 212 children were enrolled and assigned to receive artesunate with sulfalene plus pyrimethamine (n=106) or praziquantel (n=106). 69 patients (65%) were cured in the praziquantel treatment group compared with 15 (14%) in the artesunate with sulfalene plus pyrimethamine treatment group (p<0·0001). Adverse events were less common in patients taking artesunate with sulfalene plus pyrimethamine than in those taking praziquantel (22% [n=23] vs 49% [n=52], p<0·0001), and no drug-related serious adverse events occurred. Interpretation The standard treatment with praziquantel is more effective than artesunate with sulfalene plus pyrimethamine in the treatment of children with S mansoni infection in western Kenya. Whether artemisinin-based combination therapy has a role in the treatment of schistosomiasis is unclear. Funding Dafra Pharma, Belgium.
Charles Obonyo, Erick Muok, Pauline Mwinzi

The Lancet Infectious Diseases (10 August 2010)

Summary Schistosomiasis is a major neglected tropical disease, with more than 200 million people infected and close to 800 million at risk. The disease burden is estimated to exceed 70 million disability-adjusted life-years. The anthelmintic drug praziquantel is highly effective in killing adult schistosome worms, but it is unable to kill developing schistosomes and so does not prevent reinfection. As a result, current praziquantel-based control programmes in Asia and sub-Saharan Africa are not effective or sustainable in the long term. The control of neglected tropical diseases, including schistosomiasis, is a funding priority for several donor agencies, with over US$350 million committed until 2013. Here we put forward an argument that donor funds would be more effectively spent on the development of a multi-faceted, integrated control programme, which would have a greater and longer lasting effect on disease transmission than the current chemotherapy-based programmes. The development of a transmission-blocking vaccine is also of great importance. A multi-faceted integrated control programme that incorporates a vaccine, even if only partly effective, has the potential to eliminate schistosomiasis. This integrated-approach model has the potential to improve the health of a billion of the world's poorest people and its effect cannot be underestimated.
Darren Gray, Donald McManus, Yuesheng Li, Gail Williams, Robert Bergquist, Allen Ross

Diagnostic Microbiology and Infectious Disease, Vol. 67, No. 4. (August 2010), pp. 337-345.

The pathogenesis of schistosomiasis is mainly caused by egg-induced granuloma formation and subsequent fibrosis. If Schistosoma japonicum infections could be detected in the early stage, especially before the egg deposition in the host tissues, the development of severe pathologic lesions might be prevented efficiently. The present study identified and characterized S. japonicum Sjp40, a potential antigen candidate for the early diagnosis of schistosomiasis. From the S. japonicum cercariae cDNA library, a clone encoding Sjp40 was identified by screening with the pooled rabbit sera collected on day 21 postinfection. Then, the recombinant Sjp40 protein (rSjp40) and monoclonal antibodies (McAbs) anti-rSjp40 were developed. The expression profiles of Sjp40 at 3 stages of S. japonicum , including egg, cercariae, and adult, were also determined at both mRNA and protein level, which displayed that the expression pattern of Sjp40 varied at different stages. Quantification of circulatory anti-Sjp40 IgG in the infected mice sera by time-resolved fluoroimmunoassay showed a statistically significant increase on days 21, 28, 35, and 42 postinfection compared with the mice sera prior to infection and the control mice. It was further confirmed by Western blot that all 8 clones of anti-rSjp40 McAbs could react specifically with the native antigen in S. japonicum cercariae, and rSjp40 could be recognized by the pooled infected mouse sera on days 21, 28, 35, and 42 postinfection as well as the pooled patient sera with acute schistosomiasis japonica. These findings indicated that Sjp40 and its antibodies are detectable from the host at a relatively early phase (day 21 postinfection with S. japonicum ) and suggested that Sjp40 is a potential antigen candidate for the early diagnosis of schistosomiasis.
Xiao-Hong Zhou, Jin-Ya Wu, Xiao-Qin Huang, Santhosh Kunnon, Xing-Quan Zhu, Xiao-Guang Chen

Parasitology, Vol. 136, No. 13. (November 2009), pp. 1683-1693.

Beginning in 1970, the potential of remote sensing (RS) techniques, coupled with geographical information systems (GIS), to improve our understanding of the epidemiology and control of schistosomiasis in Africa, has steadily grown. In our current review, working definitions of RS, GIS and spatial analysis are given, and applications made to date with RS and GIS for the epidemiology and ecology of schistosomiasis in Africa are summarised. Progress has been made in mapping the prevalence of infection in humans and the distribution of intermediate host snails. More recently, Bayesian geostatistical modelling approaches have been utilized for predicting the prevalence and intensity of infection at different scales. However, a number of challenges remain; hence new research is needed to overcome these limitations. First, greater spatial and temporal resolution seems important to improve risk mapping and understanding of transmission dynamics at the local scale. Second, more realistic risk profiling can be achieved by taking into account information on people's socio-economic status; furthermore, future efforts should incorporate data on domestic access to clean water and adequate sanitation, as well as behavioural and educational issues. Third, high-quality data on intermediate host snail distribution should facilitate validation of infection risk maps and modelling transmission dynamics. Finally, more emphasis should be placed on risk mapping and prediction of multiple species parasitic infections in an effort to integrate disease risk mapping and to enhance the cost-effectiveness of their control.
C Simoonga, J Utzinger, S Brooker, P Vounatsou, CC Appleton, AS Stensgaard, A Olsen, TK Kristensen

Parasitology Research (6 July 2010)

Abstract  Immunodiagnostic tests are commonly used in the diagnosis for schistosomiasis japonica in field situation. Their diagnostic effect, however, has never been evaluated in a systematic way. We set out to review the value of tests including enzyme-linked immunosorbent assay (ELISA) and indirect hemagglutination assay (IHA) in the diagnosis of schistosomiasis japonica. A comprehensive search was conducted in order to identify all possible studies achieving the inclusion criteria. We undertook a meta-analysis of diagnostic ability that compared ELISA with IHA for the diagnosis of schistosomiasis japonica. Original articles were searched in Pubmed, Science Citation Index Expanded, Cochrane Library, Proquest and China National Knowledge Infrastructure. Data extractions were conducted independently by two reviewers. Summary receiver operating characteristic curves were used to summarize overall test performance. Funnel plot was used to analyze publication bias. Finally, 16 studies met inclusion criteria. In all studies combined, the diagnostic odds ratio (DOR) for IHA was 8.689 (95%CI 7.671 to 9.842) and ELISA was 3.691 (95%CI 3.018 to 4.515). The DOR for IHA was better than that for ELISA. IHA demonstrated TPR* = 0.721 and ELISA showed TPR* = 0.633. IHA performance was superior to that of ELISA. Nevertheless, difference of the accuracy between the two methods for diagnosis of schistosomiasis japonica has no statistical significance as shown by the result of Z test. We found that both IHA and ELISA can be used to rule in or rule out the diagnosis.
HuiPing Zhu, ChuanHua Yu, Xin Xia, GuoYing Dong, Jie Tang, Long Fang, Yukai Du

Epidemiologic Perspectives & Innovations, Vol. 7 (14 July 2010), 3.

Background: Schistosomiasis infection, contracted through contact with contaminated water, is a global public health concern. In this paper we analyze data from a retrospective study reporting water contact and schistosomiasis infection status among 1011 individuals in rural China. We present semi-parametric methods for identifying risk factors through a comparison of three analysis approaches: a prediction-focused machine learning algorithm, a simple main-effects multivariable regression, and a semi-parametric variable importance (VI) estimate inspired by a causal population intervention parameter. Results: The multivariable regression found only tool washing to be associated with the outcome, with a relative risk of 1.03 and a 95% confidence interval (CI) of 1.01-1.05. Three types of water contact were found to be associated with the outcome in the semi-parametric VI analysis: July water contact (VI estimate 0.16, 95% CI 0.11-0.22), water contact from tool washing (VI estimate 0.88, 95% CI 0.80-0.97), and water contact from rice planting (VI estimate 0.71, 95% CI 0.53-0.96). The July VI result, in particular, indicated a strong association with infection status - its causal interpretation implies that eliminating water contact in July would reduce the prevalence of schistosomiasis in our study population by 84%, or from 0.3 to 0.05 (95% CI 78%-89%). Conclusions: The July VI estimate suggests possible within-season variability in schistosomiasis infection risk, an association not detected by the regression analysis. Though there are many limitations to this study that temper the potential for causal interpretations, if a high-risk time period could be detected in something close to real time, new prevention options would be opened. Most importantly, we emphasize that traditional regression approaches are usually based on arbitrary pre-specified models, making their parameters difficult to interpret in the context of real-world applications. Our results support the practical application of analysis approaches that, in contrast, do not require arbitrary model pre-specification, estimate parameters that have simple public health interpretations, and apply inference that considers model selection as a source of variation.
Sylvia Sudat, Elizabeth Carlton, Edmund Seto, Robert Spear, Alan Hubbard

Parasitology International (08 July 2010)

Oxidative stress is a common mechanism contributing to hepatic damage and fibrogenesis in a variety of liver disorders. The liver is the target organ for many parasitic infections, hence there is a great demand for the development of novel treatment strategies. In the present study conducted on mice infected with larval stage of Mesocestoides vogae , we investigated effects of therapy with praziquantel (PZQ) alone and in combination with silymarin on liver GSH content, lipid peroxidation and larval reduction. Proliferation of liver cells by means of BrdU incorporation into DNA and production of superoxide anions by peritoneal adherent cells was measured to assess the antioxidant activity of silymarin. Drugs administration was carried on from day 15 post infection (p.i.) for ten consecutive days and examination was performed during 20 days of follow up the therapy. Larval M. vogae infection caused liver damage and triggered extensive oxidative stress, resulting in the abolishment of GSH redox balance and ROS-induced lipid peroxidation. PZQ administration caused short-term decline of GSH levels in healthy mice. Low GSH levels in infected mice were elevated gradually in response to the drug, but respiratory burst in cells was not reduced. Silymarin in combination with PZQ showed strong direct antioxidant capacity and stimulated the larvicidal effect of praziquantel. Treatment with PZQ and silymarin downregulated the generation of superoxide anions, prevented lipid peroxidation, stimulated GSH synthesis and proliferation of hepatocytes in infected livers. These findings demonstrated that silymarin can markedly decrease the liver injury and its co-administration with PZQ potentiate effect of therapy, probably due to the downregulation of fibrogenesis.
Samuel Velebný, Gabriela Hrčkova, Alžbeta Königová

Parasitology International (08 July 2010)

Oxidative stress is a common mechanism contributing to hepatic damage and fibrogenesis in a variety of liver disorders. The liver is the target organ for many parasitic infections, hence there is a great demand for the development of novel treatment strategies. In the present study conducted on mice infected with larval stage of Mesocestoides vogae , we investigated effects of therapy with praziquantel (PZQ) alone and in combination with silymarin on liver GSH content, lipid peroxidation and larval reduction. Proliferation of liver cells by means of BrdU incorporation into DNA and production of superoxide anions by peritoneal adherent cells was measured to assess the antioxidant activity of silymarin. Drugs administration was carried on from day 15 post infection (p.i.) for ten consecutive days and examination was performed during 20 days of follow up the therapy. Larval M. vogae infection caused liver damage and triggered extensive oxidative stress, resulting in the abolishment of GSH redox balance and ROS-induced lipid peroxidation. PZQ administration caused short-term decline of GSH levels in healthy mice. Low GSH levels in infected mice were elevated gradually in response to the drug, but respiratory burst in cells was not reduced. Silymarin in combination with PZQ showed strong direct antioxidant capacity and stimulated the larvicidal effect of praziquantel. Treatment with PZQ and silymarin downregulated the generation of superoxide anions, prevented lipid peroxidation, stimulated GSH synthesis and proliferation of hepatocytes in infected livers. These findings demonstrated that silymarin can markedly decrease the liver injury and its co-administration with PZQ potentiate effect of therapy, probably due to the downregulation of fibrogenesis.
Samuel Velebný, Gabriela Hrčkova, Alžbeta Königová

Chinese Annals of Mathematics - Series B (21 June 2010)

Abstract  A dynamic model of schistosoma japonicum transmission is presented that incorporates effects of the prepatent periods of the different stages of schistosoma into Barbour’s model. The model consists of four delay differential equations. Stability of the disease free equilibrium and the existence of an endemic equilibrium for this model are stated in terms of a key threshold parameter. The study of dynamics for the model shows that the endemic equilibrium is globally stable in an open region if it exists and there is no delays, and for some nonzero delays the endemic equilibrium undergoes Hopf bifurcation and a periodic orbit emerges. Some numerical results are provided to support the theoretic results in this paper. These results suggest that prepatent periods in infection affect the prevalence of schistosomiasis, and it is an effective strategy on schistosomiasis control to lengthen in prepatent period on infected definitive hosts by drug treatment (or lengthen in prepatent period on infected intermediate snails by lower water temperature).
Yu Yang, Dongmei Xiao

The Journal of Infectious Diseases, Vol. 202, No. 3. (15 August 2010), pp. 399-405.

doi: 10.1086/653828 Background.  Age prevalence curves for areas in which schistosomiasis is endemic suggest that humans develop partial immunity to reinfection beginning in early adolescence. We conducted a 2‐year longitudinal study to determine whether children infected with Schistosoma mansoni develop protection‐related immune responses after treatment with praziquantel and whether the development of these immune responses is accelerated by frequent treatment after reinfection. Methods.  Children (8–10 years old) were tested for S. mansoni every 4 months and treated with praziquantel when positive (arm A; $n=68$ ) or were tested and treated at the end of the 2‐year follow‐up period (arm B; $n=49$ ). Results.  Children in arm A who remained free of infection during follow‐up had significantly higher baseline levels of schistosome‐specific immunoglobulin E (IgE) than did children with ⩾2 repeat diagnoses of S. mansoni infection. Children with ⩾2 repeat diagnoses of S. mansoni infection had significantly increased levels of anti‐schistosome IgE and CD23+ B cells after receiving ⩾3 praziquantel treatments over the course of follow‐up. No increase in either parameter was seen in children who received only the baseline praziquantel treatment. Conclusions.  B cell activation and anti‐schistosome IgE are associated with resistance to S. mansoni in children, and these immunological parameters can be increased by multiple rounds of infections and praziquantel‐induced cures.
Carla Black, Erick Muok, Pauline Mwinzi, Jennifer Carter, Diana Karanja, Evan Secor, Daniel Colley

Acta Tropica (01 June 2010)

Considering the decrease of disease burden caused by intestinal schistosomiasis in many endemic settings, more sensitive diagnostic methods are needed to plan and monitor control measures. We conducted a cross-sectional survey in a rural community in northeast Brazil (317 inhabitants). A combined approach including repeated faecal examinations and ELISA testing was applied. In a first round, single stool samples were collected from 305 (96.2%) participants. Three Kato-Katz (KK) smears were prepared from each sample, and IgG ELISA was performed from serum samples. In the 85 cases of negative KK smears, but positive ELISA results, three additional faecal samples were collected in a second round, and another five KK smears prepared. In the first round of KK analysis, 11/287 (3.8%; 95% confidence interval; 1.92–6.75) were positive. After examining up to eight smears per individual (second round), prevalence of schistosomiasis increased to 8.7% (95% confidence interval: 5.9–12.5). In total, 96/287 (33.4%, 95% confidence interval: 28.0–39.2) samples were positive by ELISA testing. There were no false negative ELISA results. Specificity, positive and negative predictive values of ELISA as compared to up to eight KK smears from three stool samples (reference diagnosis) were 72.9%, 26.0% and 100%, respectively. A single KK smear detected only 12% of the 25 infections; this increased to 44% (three smears, one stool sample), 84% (five smears, three stool samples) and 96% (six smears, four stool samples). We conclude that in low-endemic areas in Brazil the use of KK continues being an important tool. The additional benefit of preparing more than six KK smears from repeated stool samples is negligible. ELISA may be useful for screening populations, with subsequent confirmation of diagnosis by KK or other more sensitive, but highly specific methods.
Sabrina Frota, Teiliane Carneiro, José Queiroz, Lúcia Alencar, Jorg Heukelbach, Fernando Bezerra

Experimental Parasitology (26 May 2010)

The extracellular loop 2 of a Tetraspanin from S. japonicum (Sj-TSP-2) is homologous to S. mansoni TSP-2. In our initial study, Sj-TSP-2 is an identical antigen against schistosomiasis caused by S. japonicum. Through the pET32 vector system and nickel (Ni)-absorbed chelating Sepharose, Sj-TSP-2 was expressed and purified as a soluble fusion constructed with an N-terminal thioredoxin-His 6 -EK protease site tag (Trx-TSP-2). In phosphate buffer (PB) with a low concentration of imidazole, the Trx-TSP-2 fusion protein was efficiently cleaved by enterokinase (EK). Sj-TSP-2 was isolated and enriched using Cobalt (Co)-absorbed chelating Sepharose and HiTrap SP column. Character of the protein was analyzed via animal experiments and then clinical trials. The purification approach yielded pure Sj-TSP-2, which will provide feasible advices for discovering vaccines against schistosomiasis.
Chuang Yuan, Yi-jie Fu, Jie Li, Yu-fei Yue, Lu-lu Cai, Wen-jing Xiao, Jian-ping Chen, Li Yang

Journal of immunology (Baltimore, Md. : 1950), Vol. 184, No. 11. (1 June 2010), pp. 6438-6446.

Alternatively activated macrophages prevent lethal intestinal pathology caused by worm ova in mice infected with the human parasite Schistosoma mansoni through mechanisms that are currently unclear. This study demonstrates that arginase I (Arg I), a major product of IL-4- and IL-13-induced alternatively activated macrophages, prevents cachexia, neutrophilia, and endotoxemia during acute schistosomiasis. Specifically, Arg I-positive macrophages promote TGF-beta production and Foxp3 expression, suppress Ag-specific T cell proliferation, and limit Th17 differentiation. S. mansoni-infected Arg I-deficient bone marrow chimeras develop a marked accumulation of worm ova within the ileum but impaired fecal egg excretion compared with infected wild-type bone marrow chimeras. Worm ova accumulation in the intestines of Arg I-deficient bone marrow chimeras was associated with intestinal hemorrhage and production of molecules associated with classical macrophage activation (increased production of IL-6, NO, and IL-12/IL-23p40), but whereas inhibition of NO synthase-2 has marginal effects, IL-12/IL-23p40 neutralization abrogates both cachexia and intestinal inflammation and reduces the number of ova within the gut. Thus, macrophage-derived Arg I protects hosts against excessive tissue injury caused by worm eggs during acute schistosomiasis by suppressing IL-12/IL-23p40 production and maintaining the Treg/Th17 balance within the intestinal mucosa.
De'broski Herbert, Tatyana Orekov, Amanda Roloson, Monica Ilies, Charles Perkins, William O'Brien, Stephen Cederbaum, David Christianson, Nives Zimmermann, Marc Rothenberg, Fred Finkelman

Molecular and Biochemical Parasitology (12 May 2010)

The ATP-binding cassette (ABC) superfamily of proteins comprises several ATP-dependent efflux pumps involved in transport of toxins and xenobiotics from cells. These transporters are essential components of normal physiology, and a subset is associated with development of multidrug resistance. P-glycoprotein (Pgp) and the multidrug resistance-associated proteins (MRPs) represent two classes of these multidrug resistance (MDR) transporters. MRP1 is one type of mammalian MRP, which preferentially transports anionic compounds and compounds detoxified by cellular enzymes such as glutathione-S-transferase. It also transports signaling molecules, including immunomodulators. In schistosomes, both Pgp and MRP substrates localize to the excretory system, a potentially attractive target for new antischistosomals. We have previously shown that expression of schistosome Pgp (SMDR2) is altered in worms exposed to praziquantel (PZQ), the current drug of choice against schistosomiasis, and is expressed at higher levels in worms from isolates with reduced PZQ susceptibility. We have also shown that PZQ interacts directly with SMDR2. Here, we examine the relationship between PZQ and SmMRP1, a Schistosoma mansoni homolog of mammalian MRP1. SmMRP1 RNA is differentially expressed in adult males and females, and levels increase transiently following exposure of adult worms to sub-lethal concentrations of PZQ. A corresponding, though delayed, increase in anti-MRP1 immunoreactive protein also occurs following exposure to PZQ. PZQ-insensitive juvenile worms express higher levels of both SmMRP1 and SMDR2 RNA than mature adults, consistent with the hypothesis that increases in levels of schistosome multidrug transporters may be involved in development or maintenance of reduced susceptibility to PZQ.
Ravi Kasinathan, William Morgan, Robert Greenberg

Molecular and Biochemical Parasitology (12 May 2010)

The ATP-binding cassette (ABC) superfamily of proteins comprises several ATP-dependent efflux pumps involved in transport of toxins and xenobiotics from cells. These transporters are essential components of normal physiology, and a subset is associated with development of multidrug resistance. P-glycoprotein (Pgp) and the multidrug resistance-associated proteins (MRPs) represent two classes of these multidrug resistance (MDR) transporters. MRP1 is one type of mammalian MRP, which preferentially transports anionic compounds and compounds detoxified by cellular enzymes such as glutathione-S-transferase. It also transports signaling molecules, including immunomodulators. In schistosomes, both Pgp and MRP substrates localize to the excretory system, a potentially attractive target for new antischistosomals. We have previously shown that expression of schistosome Pgp (SMDR2) is altered in worms exposed to praziquantel (PZQ), the current drug of choice against schistosomiasis, and is expressed at higher levels in worms from isolates with reduced PZQ susceptibility. We have also shown that PZQ interacts directly with SMDR2. Here, we examine the relationship between PZQ and SmMRP1, a Schistosoma mansoni homolog of mammalian MRP1. SmMRP1 RNA is differentially expressed in adult males and females, and levels increase transiently following exposure of adult worms to sub-lethal concentrations of PZQ. A corresponding, though delayed, increase in anti-MRP1 immunoreactive protein also occurs following exposure to PZQ. PZQ-insensitive juvenile worms express higher levels of both SmMRP1 and SMDR2 RNA than mature adults, consistent with the hypothesis that increases in levels of schistosome multidrug transporters may be involved in development or maintenance of reduced susceptibility to PZQ.
Ravi Kasinathan, William Morgan, Robert Greenberg