In areas of endemic parasite transmission, protective immunity to Plasmodium falciparum malaria is acquired over several years with numerous disease episodes. Acquisition of Abs to parasite-encoded variant surface Ags (VSA) on the infected erythrocyte membrane is important in the development of immunity, as disease-causing parasites appear to be those not controlled by preexisting VSA-specific Abs. In this work we report that VSA expressed by parasites from young Ghanaian children with P. falciparum malaria were commonly and strongly recognized by plasma Abs from healthy children in the same area, whereas recognition of VSA expressed by parasites from older children was weaker and less frequent. Independent of this, parasites isolated from children with severe malaria (cerebral malaria and severe anemia) were better recognized by VSA-specific plasma Abs than parasites obtained from children with nonsevere disease. This was not due to a higher infection multiplicity in younger patients or in patients with severe disease. Our data suggest that acquisition of VSA-specific Ab responses gradually restricts the VSA repertoire that is compatible with parasite survival in the semi-immune host. This appears to limit the risk of severe disease by discriminating against the expression of VSA likely to cause life-threatening complications, such as cerebral malaria and severe anemia. Such VSA seem to be preferred by parasites infecting a nonimmune host, suggesting that VSA expression and switching are not random, and that the VSA expression pattern is modulated by immunity. This opens the possibility of developing morbidity-reducing vaccines targeting a limited subset of common and particularly virulent VSA.

The relationship between malaria-related outcomes and cytokine production in whole blood cultures associated with cellular immune responses and immunity to Plasmodium falciparum malaria was examined in a study in southern Ghana. Production of malaria-specific interferon (IFN)-gamma was associated with reduced risk of fever and clinical malaria. Protective IFN-gamma responses were induced by live schizonts but not by dead parasites. Production of malaria-specific tumor necrosis factor (TNF)-alpha was associated with reduced risk of fever during follow-up. Baseline levels of TNF-alpha and phytohemagglutinin (PHA)-induced interleukin (IL)-10 were positively associated with hemoglobin concentration. IL-12 production was associated with reduced risk of parasitemia. PHA-induced transforming growth factor-beta production was associated with reduced risk of fever during follow-up. High ratios of proinflammatory to anti-inflammatory cytokines were associated with increased risk of fever and higher hemoglobin concentrations. Thus, absolute levels and ratios of proinflammatory and anti-inflammatory cytokines influence susceptibility to infection, clinical disease, and anemia. These data contradict data from cross-sectional clinical studies and indicate a need for detailed analysis of the relationship between cellular immunity to malaria and resistance to disease.

There is longstanding evidence that immunoglobulin G (IgG) has a role in protection against clinical malaria, and human antibodies of the cytophilic subclasses are thought to be particularly critical in this respect. In this cohort study, 286 Burkinabè children 6 months to 15 years old were kept under malaria surveillance in order to assess the protective role of antibody responses against four antigens which are currently being evaluated as vaccine candidates: apical membrane antigen 1 (AMA1), merozoite surface protein 1-19 (MSP1-19), MSP3, and glutamate-rich protein (GLURP). Total IgG, IgM, and IgG subclass responses were measured just before the malaria transmission season. The incidence of malaria was 2.4 episodes per child year of risk. After adjusting for the confounding effects of age, the level of total IgG to GLURP was strongly associated with reduced malaria incidence (incidence rate ratio associated with a doubling of total IgG, 0.79; 95% confidence interval, 0.66 to 0.94; P ‫؍‬ 0.009.); there was a borderline statistically significant association between the level of total IgG to MSP3 and malaria incidence and no evidence of an association for total IgG to AMA1 and to MSP1-19. Of the IgG subclass responses studied, only IgG3 and IgG4 against GLURP and IgG1 against AMA1 were associated with reduced risk of clinical malaria. There was no evidence of an interaction between responses to AMA1 and baseline parasitemia in their effects on malaria incidence. Currently included in malaria vaccine formulations for clinical trials in humans, these blood-stage antigens, AMA1 and GLURP, offer good prospects for malaria vaccine development.In sub-Saharan Africa, the clinical manifestations of malaria are caused by asexual blood stages of Plasmodium falciparum, and antigens on asexual parasite stages in the bloodstream are critical in the development of protective immunity to the disease. After repeated exposure, nonsterile immunity to malaria can be acquired by people living in areas of endemicity. Strong evidence exists, from the passive transfer of antibodies between immune and nonimmune individuals, that this immunity can be antibody mediated (18,29,40). The most efficient in vivo model for this antibody-mediated parasite control in areas where the disease is endemic requires the participation of monocytes and has been called antibody-dependent cellular inhibition (ADCI) (24,26). This assay is assumed to mimic the in vivo cooperation between monocytes and cytophilic parasite-specific antibodies and is considered a surrogate marker of immunity against P. falciparum blood stages (21). BouharounTayoun and Druilhe observed profound differences in the distribution of immunoglobulin (Ig) subclasses between clinically protected and susceptible individuals, with cytophilic subclasses (immunoglobulin G1 [IgG1] and IgG3) being dominant in protected individuals (10). In different epidemiological settings, similar findings have been made, underscoring the importance of cytophilic antibodies against blood-stage antigens in ...

In areas of intense Plasmodium falciparum transmission, protective immunity is acquired during childhood in parallel with acquisition of agglutinating antibodies to parasite-encoded variant surface antigens (VSA) expressed on parasitized red blood cells. In a semi-immune child in such an area, clinical disease is caused mainly by parasites expressing VSA not recognized by preexisting VSA-specific antibodies in that child. Such malaria episodes are known to cause an increase in agglutinating antibodies specifically recognizing VSA expressed by the parasite isolate causing the illness, whereas antibody responses to other parasite isolates are relatively unaffected. However, the detailed kinetics of this VSA antibody acquisition are unknown and hence were the aim of this study. We show that P. falciparum malaria in Ghanaian children generally caused a rapid and sustained increase in variant-specific VSA antibody levels, while more transient and limited increases in levels of antibodies to VSA expressed by other parasite isolates were also seen. Plasma VSA antibody levels were positively correlated with the age of the healthy plasma donors but negatively correlated with the age of the parasite donors (the malaria patient). The data from this first detailed longitudinal study of acquisition of VSA antibodies support the hypothesis that naturally acquired protective immunity to P. falciparum malaria is mediated, at least in part, by VSA-specific antibodies.Plasmodium falciparum malaria remains one of the leading health problems of the world. In areas where malaria is endemic, substantial clinical protection is acquired during the first decade of life and the majority of malaria-related morbidity and mortality are concentrated in young children (reviewed in reference 27). This acquisition of protective immunity is paralleled by increases in levels of antibodies capable of agglutinating red blood cells (RBC) infected by late developmental stages of malaria parasites (20,21). The agglutination is mediated by antibodies recognizing variant surface antigens (VSA) inserted by the parasites into the RBC membrane (22,31). The best characterized of these VSA is P. falciparum erythrocyte membrane protein 1, which mediates adhesion of parasitized RBC to a number of specific receptors in the host vasculature (3,4,7,(23)(24)(25)(28)(29)(30). This in vivo adhesion, termed sequestration, is thought to be an important parasite survival strategy and a key element in the pathogenesis of P. falciparum malaria (18). Previous studies have shown that P. falciparum parasites causing clinical disease in semi-immune children express VSA not recognized by preexisting variantspecific antibodies and that malaria episodes cause an increase in antibodies specifically recognizing VSA expressed by the parasite isolate causing illness (10,15,20). However, the detailed kinetics of changes in VSA antibody levels in relation to clinical episodes are not known, particularly during the period shortly after the clinical episode, and the aim of the present ...