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1.  Prevalence of Cutaneous Leishmaniasis in Districts of High and Low Endemicity in Mali 
PLoS Neglected Tropical Diseases  2016;10(11):e0005141.
Historically the western sahelian dry regions of Mali are known to be highly endemic for cutaneous leishmaniasis (CL) caused by Leishmania major, while cases are rarely reported from the Southern savanna forest of the country. Here, we report baseline prevalence of CL infection in 3 ecologically distinct districts of Mali (dry sahelian, north savanna and southern savanna forest areas). We screened 195 to 250 subjects from 50 to 60 randomly selected households in each of the 6 villages (four from the western sahelian district of Diema in Kayes region, one from the central district of Kolokani and one from the southern savanna district of Kolodieba, region of Sikasso). The screening consisted of: 1] A Leishmanin Skin Test (LST) for detection of exposure to Leishmania parasites; 2] clinical examination of suspected lesions, followed by validation with PCR and 3] finger prick blood sample to determine antibody levels to sand fly saliva. LST positivity was higher in the western district of Diema (49.9%) than in Kolokani (24.9%) and was much lower in Kolondieba (2.6%). LST positivity increased with age rising from 13.8% to 88% in Diema for age groups 2–5 years and 41–65 years, respectively. All eight PCR-confirmed L. major CL cases were diagnosed in subjects below 18 years of age and all were residents of the district of Diema. Exposure to sand fly bites, measured by anti-saliva antibody titers, was comparable in individuals living in all three districts. However, antibody titers were significantly higher in LST positive individuals (P<0.0001). In conclusion, CL transmission remains active in the western region of Mali where lesions were mainly prevalent among children under 18 years old. LST positivity correlated to higher levels of antibodies to sand fly salivary proteins, suggesting their potential as a risk marker for CL acquisition in Mali.
Author Summary
It is generally assumed that neglected tropical diseases (NTDS) such as leishmaniasis are concentrated in poor populations. It affects as many as 12 million people, with 1.5 to 2 million new cases every year around the world. Depending on the species of Leishmania, the host can develop cutaneous leishmaniasis (CL) or visceral leishmaniasis. In Mali, CL caused by Leishmania major is transmitted through the bite of infected sand flies belonging to the species Phlebotomus duboscqi. The objectives of this study were to determine the baseline prevalence of LST positivity, a test of previous exposure to Leishmania parasites, the prevalence of CL lesions, and the level of anti-P. duboscqi salivary antibodies, indicative of exposure to vector bites, in populations living in western, central and southern Mali, three ecologically distinct study sites. LST positivity was higher in the western district of Diema (85.1%) than in Kolokani (24.6%) and was much lower in Kolondieba (2.7%). All eight PCR-confirmed L. major CL cases were diagnosed in subjects below 18 years of age and all were residents of the district of Diema. Exposure to sand fly bites, measured by anti-saliva antibody titers, was established in individuals living in these three districts and antibody titers were higher in LST positive individuals (P<0.0001). The finding of this study provides an update on the prevalence of CL in these regions.
PMCID: PMC5127506  PMID: 27898671
2.  Fleas and trypanosomes of peridomestic small mammals in sub-Saharan Mali 
Parasites & Vectors  2016;9:541.
Fleas are obligate blood-feeding ectoparasites and vectors of several bacterial zoonotic pathogens as well as trypanosomes that parasitize rodents and other small mammals. During investigations of tick- and rodent-borne diseases in Mali, West Africa, we included fleas and rodent-borne trypanosomes, both of which are poorly known in this country, but are attracting greater public health interest.
Small mammals were captured in 20 Malian villages from December 2007 to October 2011. Fleas were collected and identified to species, and thin blood smears were prepared, stained and examined microscopically for trypanosomes.
We captured 744 small mammals, 68 (9.1 %) of which yielded fleas. Two species of fleas, Xenopsylla cheopis and Xenopsylla nubica, were collected from six species of rodents and one species of shrew. Multimammate rats, Mastomys natalensis, were hosts for 58.5 % of all fleas collected. Xenopsylla cheopis was found in the moister southern savannah while X. nubica was mostly restricted to the drier Sahel. Trypanosomes were found in 3 % of 724 blood smears, although 91 % of parasitemic animals originated from two villages where black rats (Rattus rattus) and M. natalensis were the primary hosts and X. cheopis the dominant flea. The trypanosomes were morphologically consistent with the Trypanosoma (Herpetosoma) lewisi group, flea-borne hemoflagellates that parasitize domestic rats.
Xenopsylla cheopis and trypanosomes parasitize peridomestic rats that commingle with people in southern Mali. Given the increasing awareness of flea-borne trypanosomes as possible human pathogens, we hope our findings will stimulate future investigators to examine the potential public health significance of flea-borne trypanosomosis in West Africa.
Electronic supplementary material
The online version of this article (doi:10.1186/s13071-016-1818-5) contains supplementary material, which is available to authorized users.
PMCID: PMC5057378  PMID: 27724960
Siphonaptera; Rodents; Shrews; Trypanosomosis; West Africa
3.  Novel phenotypic assays for the detection of artemisinin-resistant Plasmodium falciparum malaria in Cambodia: in-vitro and ex-vivo drug-response studies 
The Lancet. Infectious diseases  2013;13(12):1043-1049.
Artemisinin resistance in Plasmodium falciparum lengthens parasite clearance half-life during artemisinin monotherapy or artemisinin-based combination therapy. Absence of in-vitro and ex-vivo correlates of artemisinin resistance hinders study of this phenotype. We aimed to assess whether an in-vitro ring-stage survival assay (RSA) can identify culture-adapted P falciparum isolates from patients with slow-clearing or fast-clearing infections, to investigate the stage-dependent susceptibility of parasites to dihydroartemisinin in the in-vitro RSA, and to assess whether an ex-vivo RSA can identify artemisinin-resistant P falciparum infections.
We culture-adapted parasites from patients with long and short parasite clearance half-lives from a study done in Pursat, Cambodia, in 2010 (registered with, number NCT00341003) and used novel in-vitro survival assays to explore the stage-dependent susceptibility of slow-clearing and fast-clearing parasites to dihydroartemisinin. In 2012, we implemented the RSA in prospective parasite clearance studies in Pursat, Preah Vihear, and Ratanakiri, Cambodia (NCT01736319), to measure the ex-vivo responses of parasites from patients with malaria. Continuous variables were compared with the Mann-Whitney U test. Correlations were analysed with the Spearman correlation test.
In-vitro survival rates of culture-adapted parasites from 13 slow-clearing and 13 fast-clearing infections differed significantly when assays were done on 0–3 h ring-stage parasites (10·88% vs 0·23%; p=0·007). Ex-vivo survival rates significantly correlated with in-vivo parasite clearance half-lives (n=30, r=0·74, 95% CI 0·50–0·87; p<0·0001).
The in-vitro RSA of 0–3 h ring-stage parasites provides a platform for the molecular characterisation of artemisinin resistance. The ex-vivo RSA can be easily implemented where surveillance for artemisinin resistance is needed.
Institut Pasteur du Cambodge and the Intramural Research Program, NIAID, NIH.
PMCID: PMC5015432  PMID: 24035558
4.  Cow-baited tents are highly effective in sampling diverse Anopheles malaria vectors in Cambodia 
Malaria Journal  2016;15(1):440.
The accurate monitoring and evaluation of malaria vectors requires efficient sampling. The objective of this study was to compare methods for sampling outdoor-biting Anopheles mosquitoes in Cambodia.
In the Cambodian provinces of Pursat, Preah Vihear, and Ratanakiri, six different mosquito trapping methods were evaluated: human landing collection (HLC), human-baited tent (HBT), cow-baited tent (CBT), CDC miniature light trap (LT), CDC miniature light trap baited with molasses and yeast (LT-M), and barrier fence (F) in a Latin square design during four or six consecutive nights at the height of the malaria transmission season.
Using all traps, a total of 507, 1175, and 615 anophelines were collected in Pursat, Preah Vihear, and Ratanakiri, respectively. CBTs captured 10- to 20-fold more anophelines per night than the other five sampling methods. All 2297 Anopheles mosquitoes were morphologically identified and molecularly typed using standard morphological keys and sequencing the rDNA ITS2 region to distinguish cryptic species, respectively. Overall, an extremely diverse set of 27 known Anopheles species was sampled. CBTs captured the same molecular species that HLCs and the other four traps did, as well as additional species. Nine specimens representing five Anopheles species (Anopheles hyrcanus, Anopheles barbirostris sensu stricto, Anopheles barbirostris clade III, Anopheles nivipes, and Anopheles peditaeniatus) were infected with Plasmodium falciparum and were exclusively captured in CBTs.
These data indicate that cow-baited tents are highly effective in sampling diverse Anopheles malaria vectors in Cambodia. This sampling method captured high numbers of anophelines with limited sampling effort and greatly reduced human exposure to mosquito bites compared to the gold-standard human landing collection.
Electronic supplementary material
The online version of this article (doi:10.1186/s12936-016-1488-y) contains supplementary material, which is available to authorized users.
PMCID: PMC5004278  PMID: 27577697
Anopheles; Cambodia; Trap; Outdoor transmission; Malaria; Vector
5.  Artemisinin-resistant Plasmodium falciparum clinical isolates can infect diverse mosquito vectors of Southeast Asia and Africa 
Nature communications  2015;6:8614.
Artemisinin-resistant Plasmodium falciparum parasites are rapidly spreading in Southeast Asia, yet nothing is known about their transmission. This knowledge gap, and the possibility that these parasites will spread to Africa, endangers global efforts to eliminate malaria. Here we produce gametocytes from parasite clinical isolates that displayed artemisinin resistance in patients and in vitro, and use them to infect native and non-native mosquito vectors. We show that contemporary artemisinin-resistant isolates from Cambodia develop and produce sporozoites in two Southeast Asian vectors, Anopheles dirus and An. minimus, and the major African vector, An. coluzzii (formerly An. gambiae M). The ability of artemisinin-resistant parasites to infect such highly diverse Anopheles species, combined with their higher gametocyte prevalence in patients, may explain the rapid expansion of these parasites in Cambodia and neighboring countries, and further compromise efforts to prevent their global spread.
PMCID: PMC4616032  PMID: 26485448
6.  Impact of red blood cell variants on childhood malaria in Mali: a prospective cohort study 
The Lancet. Haematology  2015;2(4):e140-e149.
Red blood cell (RBC) variants protect African children from severe Plasmodium falciparum malaria. Their individual and interactive impacts on mild disease and parasite density, and their modification by age-dependent immunity, are poorly understood.
We conducted a 4-year, prospective cohort study of children aged 0.5–17 years in Maliin 2008-2011. Exposures were haemoglobin S (HbS), HbC, α-thalassaemia, ABO blood groups, and glucose-6-phosphate dehydrogenase (G6PD)deficiency encoded by the X-linked A- allele. Primary and secondary outcomes were malaria incidence and parasite density. Incidence rate ratios (IRRs) were modeled with quasi-Poisson regression; parasite densities were analyzed with Generalized Estimating Equations.
We diagnosed 4091 malaria episodes in 1543 children over 2656 child-years of follow-up (cyfu). RBC variants were common: HbAS 14.2%, HbAC 6.7%, α-thalassaemia 28.4%, type O blood group 40.2%, and G6PD deficiency9.4% (boys) and 20.4% (girls). Malaria incidence was 1.54 episodes/cyfu, ranged from 2.78 at age 3 to 0.40 at age 16 years, was reduced 34% in HbAS vs HbAA children (adjusted IRR [aIRR] 0.66; 95% CI 0.59-0.75) and 49% in G6PD A-/A- vs A+/A+ girls (aIRR 0.51; 95% CI 0.29-0.90), but was increased 15% in HbAC children (aIRR 1.15; 95% CI 1.01-1.32). Parasite density was reduced in HbAS vs HbAA children (median 10,550 vs 15, 150 parasites/μL; p=0.0004). HbAS-associated reductions in malaria risk and parasite density were greatest in early childhood.
Individual and interactive impacts of HbAS, HbAC, and G6PD A-/A-on malaria risk and parasite density define clinical and cellular correlates of protection. Further identification of the molecular mechanisms of these protective effects may uncover novel targets for intervention.
Intramural Research Program, National Institute of Allergy and Infectious Diseases, National Institutes of Health.
PMCID: PMC4418020  PMID: 26687956
8.  Molecular Differentiation of Metastriate Tick Immatures 
Hard ticks, family Ixodidae, are divided into two groups, the Metastriata and the Prostriata, based on morphological differences. In the United States, there are four medically important genera of the Ixodidae: Ixodes, Amblyomma, Dermacentor, and Rhipicephalus. Ixodes is the only genus in and representative of the Prostriata, whereas the latter three genera are members of the Metastriata. All developmental stages of the Prostriata can be easily differentiated from the Metastriata using morphology. Similarly, the three Metastriate genera are highly identifiable as adults, yet as immatures, the discriminating characteristics can be difficult to use for differentiation, especially if the specimens are damaged or engorged with blood. All three Metastriate genera represent medically important vectors, thus accurate differentiation is necessary. To this end, we have developed a multiplexed-PCR diagnostic assay that, when combined with RFLP analysis will differentiate between the Metastriate genera—Amblyomma, Dermacentor, Rhipicephalus, and Haemaphysalis based on the length of the PCR amplicon and subsequent restriction digestion profile. The intended use for this diagnostic is to verify morphological identifications, especially of immatures, as well as to identify samples destroyed for molecular analysis, which will lead to more accurate field data as well as implication of vectors in disease transmission.
PMCID: PMC4152316  PMID: 15682516
Metastriate; Amblyomma; Dermacentor; Haemaphysalis; Rhipicephalus; diagnostic
9.  Mammal Diversity and Infection Prevalence in the Maintenance of Enzootic Borrelia burgdorferi along the Western Coastal Plains of Maryland 
The primary vector of Borrelia burgdorferi in North America, Ixodes scapularis, feeds on various mammalian, avian, and reptilian hosts. Several small mammal hosts; Peromyscus leucopus, Tamias striatus, Microtus pennsylvanicus, and Blarina spp. can serve as reservoirs in an enzootic cycle of Lyme disease. The primary reservoir in the northeast United States is the white-footed mouse, P. leucopus. The infection prevalence of this reservoir as well as the roles of potential secondary reservoirs has not been established in southern Maryland, a region of low to moderate Borrelia infection in humans. Intensive trapping at 96 locations throughout the western Coastal Plains of Maryland was conducted and we found that 31.6% of P. leucopus were infected with B. burgdorferi. Sequence and phylogenetic analysis revealed that only B. burgdorferi sensu stricto circulated in southern Maryland. Feral house mice and voles also were infected and may serve as secondary hosts. Peromyscus gender, age and month of capture were significantly associated with infection status. Larval I. scapularis were the dominant ectoparasite collected from captured rodents even though host seeking A. americanum and D. variabilis were collected in greater numbers across the sampling region. Our findings illustrate that the enzootic cycle of LD is maintained in the western Coastal Plains region of southern Maryland between I. scapularis and P. leucopus as the dominant reservoir.
PMCID: PMC4128254  PMID: 17187577
Lyme disease; Ixodes scapularis; Peromyscus leucopus; Borrelia burgdorferi
10.  Artemisinin-resistant Plasmodium falciparum clinical isolates can infect diverse mosquito vectors of Southeast Asia and Africa 
Nature Communications  2015;6:8614.
Artemisinin-resistant Plasmodium falciparum parasites are rapidly spreading in Southeast Asia, yet nothing is known about their transmission. This knowledge gap and the possibility that these parasites will spread to Africa endanger global efforts to eliminate malaria. Here we produce gametocytes from parasite clinical isolates that displayed artemisinin resistance in patients and in vitro, and use them to infect native and non-native mosquito vectors. We show that contemporary artemisinin-resistant isolates from Cambodia develop and produce sporozoites in two Southeast Asian vectors, Anopheles dirus and Anopheles minimus, and the major African vector, Anopheles coluzzii (formerly Anopheles gambiae M). The ability of artemisinin-resistant parasites to infect such highly diverse Anopheles species, combined with their higher gametocyte prevalence in patients, may explain the rapid expansion of these parasites in Cambodia and neighbouring countries, and further compromise efforts to prevent their global spread.
It is unknown whether artemisinin-resistant malaria parasites from Southeast Asia can infect any African species of Anopheles mosquitoes and thus spread to Africa. Here, St. Laurent et al. show that artemisinin-resistant isolates from Cambodia can indeed infect the major African vector, Anopheles coluzzii.
PMCID: PMC4616032  PMID: 26485448
11.  Leishmania major, the Predominant Leishmania Species Responsible for Cutaneous Leishmaniasis in Mali 
Leishmania major is the only species of Leishmania known to cause cutaneous leishmanisis (CL) in Mali. We amplified Leishmania DNA stored on archived Giemsa-stained dermal scraping slides obtained from self-referral patients with clinically suspected CL seen in the Center National d'Appui A La Lutte Contre La Maladie (CNAM) in Bamako, Mali, to determine if any other Leishmania species were responsible for CL in Mali and evaluate its geographic distribution. Polymerase chain reaction (PCR) amplification was performed using a Leishmania species-specific primer pair that can amplify DNA from L. major, L. tropica, L. infantum, and L. donovani parasites, possible causative agents of CL in Mali. L. major was the only species detected in 41 microscopically confirmed cases of CL from five regions of Mali (Kayes, Koulikoro, Ségou, Mopti, and Tombouctou). These results implicate L. major as the predominant, possibly exclusive species responsible for CL in Mali.
PMCID: PMC3592546  PMID: 23324218
12.  Chloroquine Remains Effective for Treating Plasmodium vivax Malaria in Pursat Province, Western Cambodia 
Antimicrobial Agents and Chemotherapy  2014;58(10):6270-6272.
Chloroquine (CQ) is used to treat Plasmodium vivax malaria in areas where CQ resistance has not been reported. The use of artemisinin (ART)-based combination therapies (ACTs) to treat CQ-sensitive P. vivax infections is effective and convenient but may promote the emergence and worsening of ART resistance in sympatric Plasmodium falciparum populations. Here, we show that CQ effectively treats P. vivax malaria in Pursat Province, western Cambodia, where ART-resistant P. falciparum is highly prevalent and spreading. (This study has been registered at under registration no. NCT00663546.)
PMCID: PMC4187907  PMID: 25049249
13.  Identification and characterization of microsatellite markers in the Chagas disease vector Triatoma dimidiata 
Triatoma dimidiata, one of the major vectors of Chagas disease in Central America, is found in both domestic and peri-domestic habitats. Questions concerning population boundaries, infestation rates, insecticide resistance, and geographic dispersal of triatomine bugs persist and may be resolved using genetic markers such as microsatellites. Microsatellites are short tandem repeats found dispersed throughout a genome and can be useful for genotypic identification. We developed a plasmid library from the genomic DNA isolated from a single T. dimidiata adult collected in Guatamala. Ten thousand clones were screened using a probe consisting of nine microsatellite oligonucleotides. Eight loci appear polymorphic among populations found in Guatemala, Honduras, and Mexico, and thus are potentially useful for population genetic applications.
PMCID: PMC4152310  PMID: 12798021
Chagas disease; Microsatellites; Triatoma
14.  Geographic Distribution and Genetic Characterization of Lassa Virus in Sub-Saharan Mali 
Lassa fever is an acute viral illness characterized by multi-organ failure and hemorrhagic manifestations. Lassa fever is most frequently diagnosed in Nigeria, Sierra Leone, Liberia, and Guinea, although sporadic cases have been recorded in other West African countries, including Mali. The etiological agent of Lassa fever is Lassa virus (LASV), an Arenavirus which is maintained in nature and frequently transmitted to humans by Mastomys natalensis. The purpose of this study was to better define the geographic distribution of LASV-infected rodents in sub-Saharan Mali.
Methodologies/Principal Findings
Small mammals were live-trapped at various locations across Mali for the purpose of identifying potential zoonotic pathogens. Serological and molecular assays were employed and determined LASV infected rodents were exclusively found in the southern Mali near the border of Côte d'Ivoire. Overall, 19.4% of Mastomys natalensis sampled in this region had evidence of LASV infection, with prevalence rates for individual villages ranging from 0 to 52%. Full-length genomic sequences were determined using high throughput sequencing methodologies for LASV isolates generated from tissue samples of rodents collected in four villages and confirmed the phylogenetic clustering of Malian LASV with strain AV.
The risk of human infections with LASV is greatest in villages in southern Mali. Lassa fever should be considered in the differential diagnosis for febrile individuals and appropriate diagnostic techniques need to be established to determine the incidence of infection and disease in these regions.
Author Summary
Lassa fever is an acute infection associated with hemorrhagic manifestations and multi-organ failure in West Africa. The etiological agent of Lassa fever is Lassa virus (LASV), a rodent-borne arenavirus, which is maintained in nature and transmitted to humans by the multimammate rat, Mastomys natalensis. Despite the ubiquitous nature of the rodent reservoir, LASV-infected animals are most commonly documented in Nigeria, Sierra Leone, Guinea and Liberia. These four countries represent the historic endemic region for Lassa fever, although there is increasing evidence of sporadic cases occurring in other West African nations including Mali. To better define the geographic distribution of LASV-infected rodents in Mali, we tested samples from small animals collected at 27 sites across the country. Although M. natalensis was the predominant rodent species in the majority of villages, evidence of LASV infection was exclusively found in southern Mali, where overall nearly 20% of rodents were positive. The full genomic sequence was determined for five isolates and confirmed LASV in Mali is closely related to strain AV. We conclude that there is a risk of human exposure to LASV in villages in southern Mali and Lassa fever should be considered in the differential diagnosis for acutely ill, febrile patients.
PMCID: PMC3855028  PMID: 24340119
15.  Artemisinin-resistant Plasmodium falciparum in Pursat province, western Cambodia: a parasite clearance rate study 
The Lancet infectious diseases  2012;12(11):851-858.
Artemisinin-resistant Plasmodium falciparum has been reported in Pailin, western Cambodia, detected as a slow parasite clearance rate in vivo. Emergence of this phenotype in western Thailand and possibly elsewhere threatens to compromise the effectiveness of all artemisinin-based combination therapies. Parasite genetics is associated with parasite clearance rate but does not account for all variation. We investigated contributions of both parasite genetics and host factors to the artemisinin-resistance phenotype in Pursat, western Cambodia.
Between June 19 and Nov 28, 2009, and June 26 and Dec 6, 2010, we enrolled patients aged 10 years or older with uncomplicated falciparum malaria, a density of asexual parasites of at least 10 000 per μL of whole blood, no symptoms or signs of severe malaria, no other cause of febrile illness, and no chronic illness. We gave participants 4 mg/kg artesunate at 0, 24, and 48 h, 15 mg/kg mefloquine at 72 h, and 10 mg/kg mefloquine at 96 h. We assessed parasite density on thick blood films every 6 h until undetectable. The parasite clearance half-life was calculated from the parasite clearance curve. We genotyped parasites with 18 microsatellite markers and patients for haemoglobin E, α-thalassaemia, and a mutation of G6PD, which encodes glucose-6-phosphate dehydrogenase. To account for the possible effects of acquired immunity on half-life, we used three surrogates for increased likelihood of exposure to P falciparum: age, sex, and place of residence. This study is registered with, number NCT00341003.
We assessed 3504 individuals from all six districts of Pursat province seeking treatment for malaria symptoms. We enrolled 168 patients with falciparum malaria who met inclusion criteria. The geometric mean half-life was 5.85 h (95% CI 5.54–6.18) in Pursat, similar to that reported in Pailin (p=0.109). We identified two genetically different parasite clone groups: parasite group 1 (PG1) and parasite group 2 (PG2). Non-significant increases in parasite clearance half-life were seen in patients with haemoglobin E (0.55 h; p=0.078), those of male sex (0.96 h; p=0.064), and in 2010 (0.68 h; p=0.068); PG1 was associated with a significant increase (0.79 h; p=0.033). The mean parasite heritability of half-life was 0.40 (SD 0.17).
Heritable artemisinin resistance is established in a second Cambodian province. To accurately identify parasites that are intrinsically susceptible or resistant to artemisinins, future studies should explore the effect of erythrocyte polymorphisms and specific immune responses on half-life variation.
Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health.
PMCID: PMC3786328  PMID: 22940027
16.  Ex Vivo Susceptibility of Plasmodium falciparum to Antimalarial Drugs in Western, Northern, and Eastern Cambodia, 2011-2012: Association with Molecular Markers 
Antimicrobial Agents and Chemotherapy  2013;57(11):5277-5283.
In 2008, dihydroartemisinin (DHA)-piperaquine (PPQ) became the first-line treatment for uncomplicated Plasmodium falciparum malaria in western Cambodia. Recent reports of increased treatment failure rates after DHA-PPQ therapy in this region suggest that parasite resistance to DHA, PPQ, or both is now adversely affecting treatment. While artemisinin (ART) resistance is established in western Cambodia, there is no evidence of PPQ resistance. To monitor for resistance to PPQ and other antimalarials, we measured drug susceptibilities for parasites collected in 2011 and 2012 from Pursat, Preah Vihear, and Ratanakiri, in western, northern, and eastern Cambodia, respectively. Using a SYBR green I fluorescence assay, we calculated the ex vivo 50% inhibitory concentrations (IC50s) of 310 parasites to six antimalarials: chloroquine (CQ), mefloquine (MQ), quinine (QN), PPQ, artesunate (ATS), and DHA. Geometric mean IC50s (GMIC50s) for all drugs (except PPQ) were significantly higher in Pursat and Preah Vihear than in Ratanakiri (P ≤ 0.001). An increased copy number of P. falciparum mdr1 (pfmdr1), an MQ resistance marker, was more prevalent in Pursat and Preah Vihear than in Ratanakiri and was associated with higher GMIC50s for MQ, QN, ATS, and DHA. An increased copy number of a chromosome 5 region (X5r), a candidate PPQ resistance marker, was detected in Pursat but was not associated with reduced susceptibility to PPQ. The ex vivo IC50 and pfmdr1 copy number are important tools in the surveillance of multidrug-resistant (MDR) parasites in Cambodia. While MDR P. falciparum is prevalent in western and northern Cambodia, there is no evidence for PPQ resistance, suggesting that DHA-PPQ treatment failures result mainly from ART resistance.
PMCID: PMC3811250  PMID: 23939897
17.  Multiple populations of artemisinin-resistant Plasmodium falciparum in Cambodia 
Nature genetics  2013;45(6):10.1038/ng.2624.
We describe an analysis of genome variation in 825 Plasmodium falciparum samples from Asia and Africa that reveals an unusual pattern of parasite population structure at the epicentre of artemisinin resistance in western Cambodia. Within this relatively small geographical area we have discovered several distinct but apparently sympatric parasite subpopulations with extremely high levels of genetic differentiation. Of particular interest are three subpopulations, all associated with clinical resistance to artemisinin, which have skewed allele frequency spectra and remarkably high levels of haplotype homozygosity, indicative of founder effects and recent population expansion. We provide a catalogue of SNPs that show high levels of differentiation in the artemisinin-resistant subpopulations, including codon variants in various transporter proteins and DNA mismatch repair proteins. These data provide a population genetic framework for investigating the biological origins of artemisinin resistance and for defining molecular markers to assist its elimination.
PMCID: PMC3807790  PMID: 23624527
18.  Effects of Age, Hemoglobin Type and Parasite Strain on IgG Recognition of Plasmodium falciparum–Infected Erythrocytes in Malian Children 
PLoS ONE  2013;8(10):e76734.
Naturally-acquired antibody responses to antigens on the surface of Plasmodium falciparum-infected red blood cells (iRBCs) have been implicated in antimalarial immunity. To profile the development of this immunity, we have been studying a cohort of Malian children living in an area with intense seasonal malaria transmission.
Methodology/Principal Findings
We collected plasma from a sub-cohort of 176 Malian children aged 3-11 years, before (May) and after (December) the 2009 transmission season. To measure the effect of hemoglobin (Hb) type on antibody responses, we enrolled age-matched HbAA, HbAS and HbAC children. To quantify antibody recognition of iRBCs, we designed a high-throughput flow cytometry assay to rapidly test numerous plasma samples against multiple parasite strains. We evaluated antibody reactivity of each plasma sample to 3 laboratory-adapted parasite lines (FCR3, D10, PC26) and 4 short-term-cultured parasite isolates (2 Malian and 2 Cambodian). 97% of children recognized ≥1 parasite strain and the proportion of IgG responders increased significantly during the transmission season for most parasite strains. Both strain-specific and strain-transcending IgG responses were detected, and varied by age, Hb type and parasite strain. In addition, the breadth of IgG responses to parasite strains increased with age in HbAA, but not in HbAS or HbAC, children.
Our assay detects both strain-specific and strain-transcending IgG responses to iRBCs. The magnitude and breadth of these responses varied not only by age, but also by Hb type and parasite strain used. These findings indicate that studies of acquired humoral immunity should account for Hb type and test large numbers of diverse parasite strains.
PMCID: PMC3790723  PMID: 24124591
19.  Relationship between Malaria Incidence and IgG Levels to Plasmodium falciparum Merozoite Antigens in Malian Children: Impact of Hemoglobins S and C 
PLoS ONE  2013;8(3):e60182.
Heterozygous hemoglobin (Hb) AS (sickle-cell trait) and HbAC are hypothesized to protect against Plasmodium falciparum malaria in part by enhancing naturally-acquired immunity to this disease. To investigate this hypothesis, we compared antibody levels to four merozoite antigens from the P. falciparum 3D7 clone (apical membrane antigen 1, AMA1-3D7; merozoite surface protein 1, MSP1-3D7; 175 kDa erythrocyte-binding antigen, EBA175-3D7; and merozoite surface protein 2, MSP2-3D7) in a cohort of 103 HbAA, 73 HbAS and 30 HbAC children aged 3 to 11 years in a malaria-endemic area of Mali. In the 2009 transmission season we found that HbAS, but not HbAC, significantly reduced the risk of malaria compared to HbAA. IgG levels to MSP1 and MSP2 at the start of this transmission season inversely correlated with malaria incidence after adjusting for age and Hb type. However, HbAS children had significantly lower IgG levels to EBA175 and MSP2 compared to HbAA children. On the other hand, HbAC children had similar IgG levels to all four antigens. The parasite growth-inhibitory activity of purified IgG samples did not differ significantly by Hb type. Changes in antigen-specific IgG levels during the 2009 transmission and 2010 dry seasons also did not differ by Hb type, and none of these IgG levels dropped significantly during the dry season. These data suggest that sickle-cell trait does not reduce the risk of malaria by enhancing the acquisition of IgG responses to merozoite antigens.
PMCID: PMC3610890  PMID: 23555917
20.  Differential salivary gland transcript expression profile in Ixodes scapularis nymphs upon feeding or flavivirus infection 
Ticks and Tick-Borne Diseases  2012;3(1):18-26.
Ixodid ticks are vectors of human diseases such as Lyme disease, babesiosis, anaplasmosis, and tick-borne encephalitis. These diseases cause significant morbidity and mortality worldwide and are transmitted to humans during tick feeding. The tick-host-pathogen interface is a complex environment where host responses are modulated by the molecules in tick saliva to enable the acquisition of a blood meal. Disruption of host responses at the site of the tick bite may also provide an advantage for pathogens to survive and replicate. Thus, the molecules in tick saliva not only aid the tick in securing a nutrient-rich blood meal, but can also enhance the transmission and acquisition of pathogens. To investigate the effect of feeding and flavivirus infection on the salivary gland transcript expression profile in ticks, a first-generation microarray was developed using ESTs from a cDNA library derived from Ixodes scapularis salivary glands. When the salivary gland transcript profile in ticks feeding over the course of 3 days was compared to that in unfed ticks, a dramatic increase in transcripts related to metabolism was observed. Specifically, 578 transcripts were up-regulated compared to 151 down-regulated transcripts in fed ticks. When specific time points post attachment were analyzed, a temporal pattern of gene expression was observed. When Langat virus-infected ticks were compared to mock-infected ticks, transcript expression changes were observed at all 3 days of feeding. Differentially regulated transcripts include putative secreted proteins, lipocalins, Kunitz domain-containing proteins, anti-microbial peptides, and transcripts of unknown function. These studies identify salivary gland transcripts that are differentially regulated during feeding or in the context of flavivirus infection in Ixodes scapularis nymphs, a medically important disease vector. Further analysis of these transcripts may identify salivary factors that affect the transmission or replication of tick-borne flaviviruses.
PMCID: PMC3275779  PMID: 22309855
Tick vector; Ixodes scapularis; Nymph; Salivary gland; Gene expression; Feeding; Flavivirus
21.  A Potential Role for Plasma Uric Acid in the Endothelial Pathology of Plasmodium falciparum malaria 
PLoS ONE  2013;8(1):e54481.
Inflammatory cytokinemia and systemic activation of the microvascular endothelium are central to the pathogenesis of Plasmodium falciparum malaria. Recently, ‘parasite-derived’ uric acid (UA) was shown to activate human immune cells in vitro, and plasma UA levels were associated with inflammatory cytokine levels and disease severity in Malian children with malaria. Since UA is associated with endothelial inflammation in non-malaria diseases, we hypothesized that elevated UA levels contribute to the endothelial pathology of P. falciparum malaria.
Methodology/Principal Findings
We measured levels of UA and soluble forms of intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), E-selectin (sE-Selectin), thrombomodulin (sTM), tissue factor (sTF) and vascular endothelial growth factor (VEGF) in the plasma of Malian children aged 0.5–17 years with uncomplicated malaria (UM, n = 487) and non-cerebral severe malaria (NCSM, n = 68). In 69 of these children, we measured these same factors once when they experienced a malaria episode and twice when they were healthy (i.e., before and after the malaria transmission season). We found that levels of UA, sICAM-1, sVCAM-1, sE-Selectin and sTM increase during a malaria episode and return to basal levels at the end of the transmission season (p<0.0001). Plasma levels of UA and these four endothelial biomarkers correlate with parasite density and disease severity. In children with UM, UA levels correlate with parasite density (r = 0.092, p = 0.043), sICAM-1 (r  = 0.255, p<0.0001) and sTM (r = 0.175, p = 0.0001) levels. After adjusting for parasite density, UA levels predict sTM levels.
Elevated UA levels may contribute to malaria pathogenesis by damaging endothelium and promoting a procoagulant state. The correlation between UA levels and parasite densities suggests that parasitized erythrocytes are one possible source of excess UA. UA-induced shedding of endothelial TM may represent a novel mechanism of malaria pathogenesis, in which activated thrombin induces fibrin deposition and platelet aggregation in microvessels. This protocol is registered at (NCT00669084).
PMCID: PMC3551755  PMID: 23349902
22.  Delayed-Type Hypersensitivity to Sand Fly Saliva in Humans from a Leishmaniasis-Endemic Area of Mali is TH1-Mediated and Persists to Midlife 
Immunity to sand fly saliva in rodents induces a TH1 delayed-type hypersensitivity (DTH) response conferring protection against leishmaniasis. The relevance of DTH to sand fly bites in humans living in a leishmaniasis-endemic area remains unknown. Here, we describe the duration and nature of DTH to sand fly saliva in humans from an endemic area of Mali. DTH was assessed at 24, 48, 72 and 96h post-bite in volunteers exposed to colony-bred sand flies. Dermal biopsies were obtained 48h post-bite; cytokines were quantified from PBMCs stimulated with sand fly saliva in vitro. A DTH response to bites was observed in 75% of individuals aged 1–15 years, decreasing gradually to 48% by age 45, and dropping to 21% thereafter. Dermal biopsies were dominated by T lymphocytes and macrophages. Abundant expression of IFN-γ and absence of TGF-β establishes the TH1 nature of this DTH response. PBMCs from 98% of individuals responded to sand fly saliva. Of these, 23% were polarized to a TH1 and 25% to a TH2 response.
We demonstrate the durability and TH1 nature of DTH to sand fly bites in humans living in a CL-endemic area. A systemic TH2 response may explain why some individuals remain susceptible to disease.
PMCID: PMC3529997  PMID: 22992802
23.  Endemic Foci of the Tick-Borne Relapsing Fever Spirochete Borrelia crocidurae in Mali, West Africa, and the Potential for Human Infection 
Tick-borne relapsing fever spirochetes are maintained in endemic foci that involve a diversity of small mammals and argasid ticks in the genus Ornithodoros. Most epidemiological studies of tick-borne relapsing fever in West Africa caused by Borrelia crocidurae have been conducted in Senegal. The risk for humans to acquire relapsing fever in Mali is uncertain, as only a few human cases have been identified. Given the high incidence of malaria in Mali, and the potential to confuse the clinical diagnosis of these two diseases, we initiated studies to determine if there were endemic foci of relapsing fever spirochetes that could pose a risk for human infection.
Methodology/Principal Findings
We investigated 20 villages across southern Mali for the presence of relapsing fever spirochetes. Small mammals were captured, thin blood smears were examined microscopically for spirochetes, and serum samples were tested for antibodies to relapsing fever spirochetes. Ornithodoros sonrai ticks were collected and examined for spirochetal infection. In total, 11.0% of the 663 rodents and 14.3% of the 63 shrews tested were seropositive and 2.2% of the animals had active spirochete infections when captured. In the Bandiagara region, the prevalence of infection was higher with 35% of the animals seropositive and 10% infected. Here also Ornithodoros sonrai were abundant and 17.3% of 278 individual ticks tested were infected with Borrelia crocidurae. Fifteen isolates of B. crocidurae were established and characterized by multi-locus sequence typing.
The potential for human tick-borne relapsing fever exists in many areas of southern Mali.
Author Summary
Tick-borne relapsing fever is a spirochete-caused, recurrent illness acquired by the bite of fast-feeding ticks. In Mali, the potential for people to acquire relapsing fever is unknown although a few human cases have been reported there. Human malaria is also abundant in Mali, and could be complicating the diagnosis of relapsing fever. The relapsing fever spirochete, Borrelia crocidurae, is maintained in natural cycles involving small mammals and its tick vector Ornithodoros sonrai. Therefore, we investigated 20 villages across southern Mali to determine if relapsing fever spirochetes were circulating in small mammals and ticks that lived with people. We found that 11.3% of the 726 mammals tested showed evidence of prior infection, while 2.2% of the animals were actively infected. The tick vector was abundant in two villages we sampled, and overall 17.3% of the individual ticks tested were infected with spirochetes. We also isolated the spirochetes, Borrelia crocidurae, from rodents and ticks and compared their genetic makeup to other species of African spirochetes. We conclude that in some areas of Mali, people are at risk of acquiring tick-borne relapsing fever. Therefore, we recommend that blood smears from acutely ill patients be examined microscopically for spirochetes.
PMCID: PMC3510061  PMID: 23209863
24.  An insight into the sialotranscriptome and proteome of the coarse bontlegged tick, Hyalomma marginatum rufipes 
Journal of proteomics  2011;74(12):2892-2908.
Ticks are mites specialized in acquiring blood from vertebrates as their sole source of food and are important disease vectors to humans and animals. Among the specializations required for this peculiar diet, ticks evolved a sophisticated salivary potion that can disarm their host’s hemostasis, inflammation, and immune reactions. Previous transcriptome analysis of tick salivary proteins has revealed many new protein families indicative of fast evolution, possibly due to host immune pressure. The hard ticks (family Ixodidae) are further divided into two basal groups, of which the Metastriata have 11 genera. While salivary transcriptomes and proteomes have been described for some of these genera, no tick of the genus Hyalomma has been studied so far. The analysis of 2,084 expressed sequence tags (EST) from a salivary gland cDNA library allowed an exploration of the proteome of this tick species by matching peptide ions derived from MS/MS experiments to this data set. We additionally compared these MS/MS derived peptide sequences against the proteins from the bovine host, finding many host proteins in the salivary glands of this tick. This annotated data set can assist the discovery of new targets for anti-tick vaccines as well as help to identify pharmacologically active proteins.
PMCID: PMC3215792  PMID: 21851864
Tick; hematophagy; salivary glands; sialome
25.  Plasma Uric Acid Levels Correlate with Inflammation and Disease Severity in Malian Children with Plasmodium falciparum Malaria 
PLoS ONE  2012;7(10):e46424.
Plasmodium falciparum elicits host inflammatory responses that cause the symptoms and severe manifestations of malaria. One proposed mechanism involves formation of immunostimulatory uric acid (UA) precipitates, which are released from sequestered schizonts into microvessels. Another involves hypoxanthine and xanthine, which accumulate in parasitized red blood cells (RBCs) and may be converted by plasma xanthine oxidase to UA at schizont rupture. These two forms of ‘parasite-derived’ UA stimulate immune cells to produce inflammatory cytokines in vitro.
Methods and Findings
We measured plasma levels of soluble UA and inflammatory cytokines and chemokines (IL-6, IL-10, sTNFRII, MCP-1, IL-8, TNFα, IP-10, IFNγ, GM-CSF, IL-1β) in 470 Malian children presenting with uncomplicated malaria (UM), non-cerebral severe malaria (NCSM) or cerebral malaria (CM). UA levels were elevated in children with NCSM (median 5.74 mg/dl, 1.21-fold increase, 95% CI 1.09–1.35, n = 23, p = 0.0007) and CM (median 5.69 mg/dl, 1.19-fold increase, 95% CI 0.97–1.41, n = 9, p = 0.0890) compared to those with UM (median 4.60 mg/dl, n = 438). In children with UM, parasite density and plasma creatinine levels correlated with UA levels. These UA levels correlated with the levels of seven cytokines [IL-6 (r = 0.259, p<0.00001), IL-10 (r = 0.242, p<0.00001), sTNFRII (r = 0.221, p<0.00001), MCP-1 (r = 0.220, p<0.00001), IL-8 (r = 0.147, p = 0.002), TNFα (r = 0.132, p = 0.006) and IP-10 (r = 0.120, p = 0.012)]. In 39 children, UA levels were 1.49-fold (95% CI 1.34–1.65; p<0.0001) higher during their malaria episode [geometric mean titer (GMT) 4.67 mg/dl] than when they were previously healthy and aparasitemic (GMT 3.14 mg/dl).
Elevated UA levels may contribute to the pathogenesis of P. falciparum malaria by activating immune cells to produce inflammatory cytokines. While this study cannot identify the cause of elevated UA levels, their association with parasite density and creatinine levels suggest that parasite-derived UA and renal function may be involved. Defining pathogenic roles for parasite-derived UA precipitates, which we have not directly studied here, requires further investigation.
Trial Registration NCT00669084
PMCID: PMC3465329  PMID: 23071567

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