I never found the order I searched for But always a sinister And well-planned disorder

That increases in the hands

Of those who hold power While the others who clamor for

A more kindly world

A world with less hunger and more hopefulness Die of torture in the prisons Claribel Alegria, Nicaraguan poet

How can we defeat this disease?

Leading causes of death in Sub-Saharan Africa, South Asia, and Southeast Asia for persons age 0-44 (World Health Organization)

First, how does your body strike back?

Can you say antibodies and T cells?

Antibodies work at all stages

but T cells are only effective

when the parasite is in the liver

Why?

Red blood cells do NOT express MHC proteins

and thus infected cells cannot

generate a T cell response!

In adults the immune system does

a pretty good job,

but in kids its a different story

Young kids are hit much harder by malaria

Because of differences in their immune response

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

How does the malaria parasite respond to

the natural selection produced by immune attack?

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

One clue comes fromdo theNOT fact that malaria makes Red blood cells express MHC

Red blood cells sticky so they lodge in capillaries

proteins

and thus infected cells cannot

generate a T cell response

This allows them to prevent theirexpress host cells MHC from Red blood cells do NOT Going through the spleen where they can be killed

proteins

and thus infected cells cannot

generate a T cell response

Infected red blood cells can be recognized by a change

In shape--the cells get knobs

Red blood cells do NOT express MHC proteins

and thus infected cells cannot

generate a T cell response

parasite

www3.niaid.nih.gov/.../ malariaGeneticsSection/

The knobs and the stickiness from Red blood cells do NOTresult express

MHC proteins

Plasmodium proteins that are put on the plasma membrane

and thus infected cells cannot of the red blood cell including the PfEMP proteins
generate a T cell response

www3.niaid.nih.gov/.../ malariaGeneticsSection/

Red blood cells NOTby express MHC proteins PfEMP-1 proteins aredo encoded the var (for variable) genes.
individual parasite genomes contain 50-150 var genes and thus infected cells cannot but only one is expressed at any one time.

generate a T cell response

PfEMP-1 proteins are very antigenic and thus we mount a strong and effective response

Parasites fight back: they switchexpress on different var genes Red blood cells do NOT MHC proteins during asexual reproduction allowing them

and thus infected cells cannot to evade the initial immune response!
generate a T cell response

Nature 415: 673 (2002)

Variation also allows the parasite to re-infect previously exposed hosts

Nature 415: 673 (2002)

Despite this, as we have seen, most adults

fight off the infection over time

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

How can we speed up this process, protect children

and the elderly, and reduce the death rate?

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

How can we speed up this process, protect children

and the elderly, and reduce the death rate?

We need drugs

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

Well focus on the deadliest parasite

But there is a problem that takes us back to the family tree

mushrooms

You and me

Plasmodium
plants

http://drnelson.utmem.edu/Woods.Hole/slide5.png

We seem like distant relatives

but this is only part of the tree of life

mushrooms

You and me

Plasmodium
plants

http://drnelson.utmem.edu/Woods.Hole/slide5.png

Heres the bigger picture--we are actually relatively closely related to Plasmodium
Staph. aureus

TB bug

E. coli

Plasmodium and me!

Genome Research 12, 1080-1090 (2002)

We share much more of our cellular machinery Than we do with bacteria.

Staph. aureus

TB bug

E. coli

Plasmodium and me!

Genome Research 12, 1080-1090 (2002)

We need to find drug targets that Plasmodium have And people do not share

The first insight goes back >400 years

Following their arrival in the New World, Spanish Jesuit missionaries in Peru learned of a medicinal bark That the native Quechua used to treat fever.

web1.caryacademy.org/.../ Quinine/history.htm

Legend suggests that the Countess of Chinchn, wife of the Viceroy of Peru, was cured of her fever with the bark. The tree was named Cinchona after the countess. The Quechua called it Quinquina = bark of barks

In 1820 J.B. Caventou and P.J. Pelletier isolated the active chemical and named it quinine

A synthesis approach was discovered in the 1940s But most is still purified From Cinchona bark

Quinine remains an effective drug and was dominant through 1950. But chemists sought more effective derivatives that had less side effects Hans Andersag at Bayer discovered chloroquine in 1934 and by the 1950s it became the drug of choice

How do quinine And its derivatives kill Plasmodium?

Most current drugs target the red blood cell stage

Plasmodium eats blood!

(actually really hemoglobin)

Plasmodium eats blood!

When living in red blood cells It survives by digesting Hemoglobin in its food vacuole (the parasite lysosome).

However, the leftover heme, the metal complex that actually carries oxygen, Is quite toxic.

Wikipedia.com

Plasmodium eats blood!

The parasites
heme polymerase converts the toxic heme into non-toxic hemazoin Which then crystalizes

Chloroquine accumulates in the food vacoule Where it inhibits conversion of heme to hemazoin Either by directly binding heme and/or By inhibiting heme polymerase

http://www.tulane.edu/~wiser/protozoology/notes/drugs.html

Chloroquine accumulates in the food vacoule Where it inhibits conversion of heme to hemazoin Either by directly binding heme and/or By inhibiting heme polymerase No, not chloroquine! Ahhhhhhhhh..

http://www.tulane.edu/~wiser/protozoology/notes/drugs.html

Chloroquine allowed major progress against malaria-What do you think happened next?

No, not chloroquine! Ahhhhhhhhh..

http://www.tulane.edu/~wiser/protozoology/notes/drugs.html

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

What cellular changes underline resistance?

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

Chloroquine is linked to a mutation in a Red blood resistance cells do NOT express MHC proteins membrane-located food vacuolar drug-metabolite transporter protein and thus infected cells cannot

ato T move cell response Mutant PfCRTgenerate is thought Chloroquine out of the food vacuole

www3.niaid.nih.gov/.../ malariaGeneticsSection/

Choroquine resistance set back the fight against malaria

www.uhhg.org/mcrh/resources/video/malariappt.pdf

www.uhhg.org/mcrh/resources/video/malariappt.pdf

Option 1: make more derivatives of quinine or use quinine again

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

Option 2: new drug targets

http://www.tulane.edu/~wiser/protozoology/notes/drugs.html

Pyrimethamine (DHFR) + sulfadoxine or dapsone (DHPS) attack enzymes involved in making nucleotides (we can take in folate from our diet- they cannot)

www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf

One of the newest medicines has one of the longest histories

Artemisia has been used by Chinese herbalists for >1000years to treat many illnesses including malaria

Med Trop (Mars). 1998;58(3 Suppl):13-7.

Int J Parasitol. 2002 Dec 4;32(13):1655-60.

The active compound was found to be Artemisinin

Med Trop (Mars). 1998;58(3 Suppl):13-7.

Int J Parasitol. 2002 Dec 4;32(13):1655-60.

Artemisinin is not toxic until it is cleaved inside the parasite by exposure to heme-iron A resulting free radical intermediate may kill the parasite by poisoning one or more essential malarial protein(s).

Med Trop (Mars). 1998;58(3 Suppl):13-7.

Int J Parasitol. 2002 Dec 4;32(13):1655-60.

Whats another rule to prevent resistance we learned from treating TB?

When you use new drugs, use them in combination!

Current CDC guidelines are:

If malaria was acquired in areas without chloroquine resistance Then Treat with chloroquine

Current CDC guidelines are:

If from area with resistance :

1. quinine plus doxycycline or tetracycline or

2. Atovaquone + proguanil (Malarone)

Current CDC guidelines are:

If P. vivax or P. Ovale Chloroquine plus PRIMAQUINE to hit liver stage

Plasmodium is also evolving resistance to other drugs

http://www.tulane.edu/~wiser/protozoology/notes/drugs.html

Research continues to identify new drugs

Nature 415: 686 (2002)

Scientists also sequenced the genome of P. falciparum In 2002 looking for new drug targets
23 million base pairs 5,300 proteins encoded

60% are not similar

to known proteins!

Nature 415: 686 (2002)

The genome of P. vivax was completed this past month (October 2008)
More similar to P. falciparum than expected

Only 150 unique proteins

Hey wait a minute, arent you forgetting something?

pathmicro.med.sc.edu/ppt-vir/vaccine.ppt

What about a vaccine against malaria?

pathmicro.med.sc.edu/ppt-vir/vaccine.ppt

(Program for Appropriate Technology in Health)

Genetically attenuated P. falciparum sporozoites.

Developmentally arrested at an early stage following liver cell invasion, or

Radiation attenuated sporozoite

Of all malaria vaccines, GlaxoSmithKlines

RTS,S/AS02A is the furthest along

in clinical testing, "at least by four to five years,"

Zarifah Reed at the WHO Initiative for Vaccine Research

RTS,S/AS02A is generated against CSP, the most abundant cell surface protein during the malaria parasite's infectious sporozoite stage

The RTS,S/AS02A antigen is a fusion of CSP with a surface protein from hepatitis B, to stimulate a more effective immune response

CS is attached to the plasma membrane and contains a large immunodominant domain

that consists of repeats of a short, species-specific peptide.

It is important for invasion of liver cells

Membrane anchor

Since RTS,S incorporates a hepatitis B antigen,

it "will also be a hepatitis B vaccine," she adds.

An estimated one million people die annually worldwide from hepatitis B and ensuing liver complications.

After Phase I trials demonstrated safety,

the vaccine entered Phase II trials in children in Africa

Heres the data--did it work?

It continues to look good after a longer follow up

The Lancet 366 10 December 2005, pp. 2012-2018

Other vaccines are following this

though trials are less far along

Thats high techhow about low tech

Reduce Contact Between Humans And Mosquitoes

Personal protective measures

DEET PERMETHRIN Bed nets

Insecticide treated bednets can reduce infection by 63%

For example, 20 million Bednets have been distributed in Ethiopia

Legend: PSI - Population Services International; WB -World Bank. GFATM 2, 5 - Global Fund for AIDS, TB and Malaria Cum nets: Cumulative number of nets distributed.
UNICEF Ethiopia

WHO, UNICEF, the World Bank and the UN Development Program formed a new partnership in 1998

Its goal: eliminate malaria as a major disease by 2015

Accessible drugs
Nets and Insecticide Rapid diagnostic tests

More Artemesia

A U.S. government initiative designed to cut malaria deaths in half in sub-Saharan Africa.

Announced by President Bush on June 30, 2005.

Pledges to increase U.S. funding of malaria prevention and treatment in sub-Saharan Africa by > $1.2 billion over 5 years.

Before we end, lets consider one other cool aspect of malaria

This brings us back to blood and how it carries oxygen

J. Mol. Biol., 235, 657

Hemoglobin is a finely tuned machine crafted by natural selection to deliver oxygen and remove CO2

J. Mol. Biol., 235, 657

A single amino acid change alters hemoglobin structure And allows the protein to form long rods

A single amino acid change alters hemoglobin structure And allows the protein to form long rods

These protein rods change the shape of the Red blood cell
and this change occurs when hemoglobin is not bound to oxygen

Sickled cell block capillaries and trigger

lower oxygen and more sickling

The disease is treatable in the developed world

But still shortens life expectancy

Untreated, as in much of the developing world,

the disease is fatal in childhood

The mutation responsible for sickle cell anemia is surprisingly common in parts of the world

anthro.palomar.edu/synthetic/synth_4.htm

Why hasnt natural selection eliminated this allele?

anthro.palomar.edu/synthetic/synth_4.htm

Does this map look familiar?

anthro.palomar.edu/synthetic/synth_4.htm

Does this map look familiar?

Malaria distribution

Heterozygotes have an advantage!

While red blood cells from heterozygotes are usually normal,

they are prone to sickle and be destroyed if infected by Plasmodium, eliminating the blood stage of the parasite before it can reproduce

And this is not the only such example!

Glucose-6-phosphate dehydrogenase plays a key role

in glucose metabolism but also generates glutathione

Protects red blood cells Against oxidative stress

200 million people are deficient in this process

Protects red blood cells Against oxidative stress

Complete loss of function can

lead to episodes of anemia

Protects red blood cells Against oxidative stress

Milder reductions can provide partial resistance

to malaria as malaria-infected red cells

are susceptible to more rapid death

Protects red blood cells Against oxidative stress

However, these individuals are also

hypersensitive to certain antimalarials

like primaquine that affect oxidative stress

Protects red blood cells Against oxidative stress