IAI Accepted Manuscript Posted Online 19 January 2016 Infect. Immun. doi:10.1128/IAI.01120-15 Copyright © 2016 Murungi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International license.
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Severe Plasmodium falciparum malaria: targets and mechanisms associated with protection
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in Kenyan children
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Linda M. Murungi, a# Klara Sondén,
b
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Andrew R. Williams, c ‡ Edna Ogada, a Amos Thairu, a Anna Färnert, b Kevin Marsh, a, d Simon J.
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Draper c and Faith H.A. Osiera
David Llewellyn,
c
Josea Rono,
a*
Fatuma Guleid,
a
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KEMRI Wellcome Trust Research Programme, Centre for Geographical Medicine Research-
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Coast, Kilifi, Kenyaa; Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska
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Institutet, Stockholm, Swedenb; The Jenner Institute, University of Oxford, Old Road Campus
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Research Building, Oxford, UKc; Nuffield Department of Medicine, Centre for Clinical
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Vaccinology and Tropical Medicine, University of Oxford, Churchill Hospital, Oxford, UKd
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Running Head: Mechanisms of antibody function and severe malaria
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#Address correspondence to Linda M. Murungi,
[email protected]
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*Present address: E&K Health Consulting, 7th Floor Kimathi House, Kimathi Street, Nairobi,
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Kenya.
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‡Present address: Department of Veterinary Disease Biology, University of Copenhagen,
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Denmark.
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ABSTRACT
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Severe malaria (SM) is a life-threatening complication of infection with Plasmodium falciparum.
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Epidemiological observations have long indicated that immunity against SM is acquired
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relatively rapidly but prospective studies to investigate its immunological basis are logistically
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challenging and have rarely been undertaken. We investigated the merozoite targets and
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antibody-mediated mechanisms associated with protection against SM in Kenyan children aged
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0-2 years. We designed a unique prospective matched case-control study of well-characterized
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SM clinical phenotypes, nested within a longitudinal birth cohort of children (n=5,949)
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monitored over the first two years of life. We quantified immunological parameters in serum
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collected before the SM event in cases and their individually matched controls to evaluate the
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prospective odds of developing SM in the first two years of life.
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Anti-AMA1 antibodies were associated with a significant reduction in the odds of developing
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SM (OR 0.37, 95% CI 0.15 - 0.90, P=0.029) after adjustment for responses to all other merozoite
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antigens tested, whilst those against MSP-2, MSP-3, PfRh2, MSP-119 and the infected red blood
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cell surface were not. The combined ability of total IgG to inhibit parasite growth and mediate
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the release of reactive oxygen species from neutrophils was associated with a marked reduction
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in the odds of developing SM (OR 0.07 95% CI 0.006 - 0.82, P=0.03). Assays of these two
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functional mechanisms were poorly correlated (rs=0.12, P=0.07). Our data provides
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epidemiological evidence that multiple antibody-dependent mechanisms contribute to protective
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immunity via distinct targets whose identification could accelerate the development of vaccines
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to protect against SM.
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Key words:
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Severe malaria, Plasmodium falciparum, Merozoite, Antibodies, Odds ratio
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Background
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Severe malaria (SM) afflicts young children commonly under the age of 5 years in areas with
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stable and high malaria transmission intensity (1-3). Children present to hospital with three main
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and often overlapping syndromes of coma (cerebral malaria), severe anemia (Hb
