bSevere malaria syndromes are precipitated by Plasmodium falciparum parasites binding to endothelial receptors on the vascular lining. This binding is mediated by members of the highly variant P. falciparum erythrocyte membrane protein 1 (PfEMP1) family. We have previously identified a subset of PfEMP1 proteins associated with severe malaria and found that the receptor for these PfEMP1 variants is endothelial protein C receptor (EPCR). The binding is mediated through the amino-terminal cysteinerich interdomain region (CIDR) of the subtypes ␣1.1 and ␣1.4 to ␣1.8. In this study, we investigated the acquisition of anti-CIDR antibodies using plasma samples collected in four study villages with different malaria transmission intensities in northeastern Tanzania during a period with a decline in malaria transmission. We show that individuals exposed to high levels of malaria transmission acquire antibodies to EPCR-binding CIDR domains early in life and that these antibodies are acquired more rapidly than antibodies to other CIDR domains. The rate by which antibodies to EPCR-binding CIDR domains are acquired in populations in areas where malaria is endemic is determined by the malaria transmission intensity, and on a population level, the antibodies are rapidly lost if transmission is interrupted. This indicates that sustained exposure is required to maintain the production of the antibodies.
Individuals in countries where malaria is endemic acquire immunity to febrile malaria episodes after years of exposure and repeated disease episodes (1, 2). The age at which protection is established depends on the malaria transmission intensity in the area of residence (3-6). Immunoglobulin G (IgG) targeting the asexual blood stages of the parasites is an important immunological effector mechanism mediating malaria immunity (7,8), and several lines of evidence indicate that members of the Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) protein family are important targets for immunity (6, 9-13). PfEMP1s are large multidomain proteins consisting of two to nine Duffy binding-like (DBL) and cysteine-rich interdomain region (CIDR) domains, which based on sequence similarity can be divided into different subgroups (14, 15). The proteins are expressed on the surface of infected erythrocytes and mediate binding of these cells to receptors on the vascular lining (16)(17)(18)(19). In this way, the infected erythrocytes are effectively sequestered, and they avoid splenic clearance. IgG recognizing PfEMP1 inhibits the binding between the infected erythrocytes and the endothelial cells, and parasites expressing a PfEMP1 targeted by binding inhibitory IgG will be killed in the spleen. However, in an evolutionary arms race each parasite genome has acquired about 60 var genes, encoding different PfEMP1s binding different endothelial receptors (20), and isogenic parasites can, depending on which PfEMP1 they express, bind different endothelial receptors. To multiply effectively, parasites are limited to expressing PfEMP1 types not t...