Phylum Apicomplexa

• Class Sporozoea
• Subclass Coccidia
• Order Eucoccidia
• Suborder Haemosporina
• Genus Plasmodium
• Suborder Eimeriina
• Genera Toxoplasma, Cryptosporidium, Isospora
• Subclass Piroplasmia
• Genus Babesia
 General Characteristics of Apicomplexa
• Morphology
• Subpellicular microtubules
• Apical complex with
distinctive organelles
- Rhoptries,
- Micronemes
- Dense granules.
Phylum Apicomplexa
• Class Sporozoea
• Subclass Coccidia
• Order Eucoccidia
• Suborder Haemosporina
• Genus Plasmodium
• Suborder Eimeriina
• Genera Toxoplasma, Cryptosporidium, Isospora
• Subclass Piroplasmia
• Genus Babesia
Genus Plasmodium
• Four species infect humans.
• All are transmitted by female Anopheles
mosquitoes
• Infect red blood cells
• Plasmodium falciparum (all RBC) – malignant
tertian
• Plasmodium vivax (Retic) – benign tertian
• Plasmodium ovale (Retic) – benign tertian
• Plasmodium malariae (older RBC) – quartan
malaria
• Plasmodium knowlesi? – (24 hour blood stage
cycle)
 Plasmodium falciparum - Epidemiology
• Vector: Anopheles spp. –
Anopheles gambiae
complex, A. funestus,
• Distribution. P. falciparum
mostly in tropics
• 300 to 500 million cases
yearly with at least 2-3
million deaths.
• Children and newly
exposed
• Selection for resistance
genes
 Anopheles spp.
• human malaria vectors
• An. gambiae complex (Africa)
• An. albimanus (C America, Carib.)
• An. darlingi (S America)
• An. maculipennis complex (Russia)
• An. stephensi (India)
• An. maculatus complex (SE Asia)
• An. punctulatus complex (New
Guinea)
• An. quadrimaculatus complex
(Eastern US, historical malaria vector)
Parasite stages

• Sporozoite -
• Merozoite – free parasites released from infected cells
• Ring stage – early trophozoite
• Trophozoite
• Schizont – Asexual division occurs here
• gametocytes
Plasmodium Life Cycle
Parasite stages

• Sporozoite -
• Merozoite – free parasites released from infected cells
• Ring stage – early trophozoite
• Trophozoite
• Schizont – Asexual division occurs here
• gametocytes
 Clinical Presentation
• Initial fever episode 10 to 14 days after bite – Pre-
patent period
• Fevers occur every 36 to 72 hours thereafter
• Characteristic presentation – chills (shaking), hot stage
(104oF body temperature, altered consciousness,
abdominal pain, diarrhea); sweat stage (fatigue)
• Massive red cell lysis results in anemia.
• Multiple organ diseases: Parasites in brain cause
Cerebral Malaria; In kidney it causes renal failure: In
gastrointestinal tract causes gastroenteritis.
• Most individuals become hypoglycemic.
• Individuals who carry sickle cell trait experience less
severe disease.
Species differences in clinical
presentation
 Why does Plasmodium falciparum cause
more severe disease
• They infect all blood cells
• Trophozoite and schizont stages are
sequestered
• Infected parasites express ‘knobs’
• Plasmodium falciparum erythrocyte
membrane protein (PfEMP) is
expressed in knobs
• PfEMP undergo antigenic variation
to elude antibody mediated host
defenses
• Infected parasites adhere to
thrombospondin, CD36, ICAM-1 on
endothelial cells
Front Microbiol. 2017; 8: 889
• Genome size – ~23.3Mb
Abbreviations: T. brucei, Trypanosoma brucei; P. falciparum,
Plasmodium falciparum; P. carinii, Pneumocystis carinii; G.
lamblia, Giardia lamblia; VSG, variant surface glycoprotein;
PfEMP1, Plasmodium falciparum erythrocyte membrane protein
1; MSG, major surface glycoprotein; VSP, variant specific surface
protein; B-ES, bloodstream form expression site; M-ES,
metacyclic expression site.
Mol Biochem Parasitol 2001 Apr 25;114(1):17-27
 Why does Plasmodium falciparum cause
more severe disease
• They infect all blood cells
• Trophozoite and schizont stages are
sequestered
• Infected parasites express ‘knobs’
• Plasmodium falciparum erythrocyte
membrane protein (PfEMP) is
expressed in knobs
• PfEMP undergo antigenic variation
to elude antibody mediated host
defenses
• Infected parasites adhere to
thrombospondin, CD36, ICAM-1 on
endothelial cells
• Genome size – ~23.3Mb
Knobs on infected cells mediates parasite
sequestration and cell lysis
Illustration of some of the pathogenic
mechanisms in cerebral malaria.

Front Immunol 2022 Feb 10;13:791488. doi: 10.3389/fimmu.2022.791488

 Natural host resistance to Plasmodium
infections
• Selection of Sickle cell trait- single amino acid
substitution (glu6val) in beta globin molecule.
sickle cell gene arose at least twice, once in
Africa and once in India or the Middle East
• HbAA normals
• HbAS – mild malaria (protected)
• HbSS (not protected)
• Upto 25% of population may contain
mutated gene (trait).
• HbF (fetal hemoglobin is regulator of sickle
cell disease)
• Other hemoglobinopathies
• -alpha(+)-Thalassemia, a condition
characterized by reduced production of the
normal alpha-globin component of hemoglobin
• Glucose-6-phosphate dehydrogenase (G6PD)
deficiency. This disorder can cause haemolytic
anaemia but it is very prevalent in SE Asia.
Plasmodium has impaired growth in G6PD
erythrocytes Blood. 2011 Jul 7; 118(1): 19–27.
Distribution
of sickle
cell gene
and
endemicity
of malaria
Distribution of thalassemias
Plasmodium falciparum
 Genus Plasmodium
• Infect Red blood cells
• Four species infect humans.
• Plasmodium falciparum (all RBC) – malignant
tertian
• Plasmodium vivax (Retic) – benign
tertian
• Plasmodium ovale (Retic) – benign
tertian
• Plasmodium malariae (older RBC) – quartan
malaria
Plasmodium vivax, Plasmodium Ovale -
Epidemiology
• Wider distribution than P. falciparum.
• Found in temperate climates as well (Siberia)
• Selection for resistance: Absence of Duffy antigen in West Africa-
Duffy is the receptor on red blood cells for P.vivax
Plasmodium falciparum

Plasmodium vivax
 Plasmodium Life Cycle

hypnozoites
P. vivax and P. ovale Pathogenesis

• Benign tertian malaria. Parasite development in

RBC’s takes 48hrs (fevers peak every third day).
• Infect reticulocytes so parasitemia is limited
(average of 1% of blood cells affected).
• Develop hypnozoites in liver (Blood transfusion?).
Can have longterm relapse (reappearance of
parasites).
• Infected blood cells do not adhere to endothelial
cells so are not sequestered. Trophozoites and
schizonts found in blood smear.
Species differences in clinical
presentation
P. vivax

Schuffner
granules
Plasmodium vivax
P. malariae pathogenesis cont’d
• P. malariae. Least pathogenic of Plasmodia.
• Infects older RBC’s preferentially. Rarely causes acute
illness.
• Incubation period of parasite in liver can last for months
and years. Longterm recrudescence expected.
Diagnosis
• Clinical presentation.
• Blood smear – identification of parasite (Geimsa stained).
• Thin blood smear – for studying detail
• Thick blood smear – larger blood sample/detection of low parasitemia
• DNA based techniques (PCR)
Plasmodium Parasites

Red cell tropism

Schuffner granules

Maurer’s cleft

Hypnozoite in
liver
 Sites of Parasite intervention
Targets of drug and immune therapy
• Insecticides, larvicides
repellants that limit vector or
exposure to vector (DDT).
• Drugs that target liver stage –
Primaquine
• Drugs that target blood
stages – chloroquine (drug
resistance) mefloquine,
Doxyclycline ...
• Artemisinin – new drug
• Immunological intervention
to limit effect of disease.
• Immunity to disease
symptoms
• Premunition
• Transmission blocking vaccine
WHO recommends malaria vaccine for at risk children
In a significant breakthrough, researchers have developed a vaccine against
malaria. Brian Ongoro/AFP via Getty Images
•In 2019, 409,000 people died from malaria.
•Cases of malaria have been falling but have recently stalled.
•The RTS,S/AS01 vaccine is the first and only vaccine that targets the parasite
P. falciparum, which is particularly deadly and prevalent.
•The vaccine represents decades of work and is a major breakthrough.
In an announcement, the World Health Organization (WHO)Trusted Source has
recommended a malaria vaccine for children in areas with moderate-to-high
transmission of P. falciparum malaria.
The RTS,S/AS01 (RTS,S) vaccine is safe. Since 2019, healthcare professionals
have trialed it in 800,000 children in Ghana, Kenya, and Malawi.

Approval of the RTS,S/AS01 vaccine, which goes by the name Mosquirix, provides a
“glimmer of hope” for Africa, according to Dr. Matshidiso Moeti, WHO regional director for
Africa. It will now be rolled out to protect children against one of the world’s oldest and most
deadly diseases.
Plasmodium Life Cycle
RTS.S (Mosquirix) – A subunit vaccine
•.

RTS.S (Mosquirix) – A subunit vaccine

• the RTS,S vaccine, in which “R” represents the
central repeat region, a single polypeptide chain
corresponding to a highly-conserved tandem
repeat tetrapeptide NANP amino acid sequence,
and “T” represents T-lymphocyte epitopes
separated by immunodominant CD4+ and CD8+
epitopes (Th2R and Th3R).
• This combined RT peptide is genetically fused to
the N-terminal of Hepatitis B surface antigen
(HBsAg), the “S” (Surface) portion when co-
expressed in yeast cells, yielding virus-like particles
that display both CSP and S at their surfaces. A
second “S” portion is an unfused HBsAg that
spontaneously fuses to the RTS component, hence
the name RTS,S
• The particulate and highly repetitive nature of the RTS,S antigen
provides enhanced presentation to the immune system, and likely
facilitates the strong anti-CSP antibody and T-cell responses
measured in vaccinated individuals.

Hum Vac Immuno 2020 Mar 3;16(3):480-489.

Vaccine efficacy
• The RTS,S/AS01 vaccine advanced to Phase 3 testing from 2009–2014 in 7 sub-
Saharan African countries, and enrolled 15,459 participants, including 8922
children 5–17 months of age and 6537 infants 6–12 weeks of age
• With regard to the primary aim, efficacy measured by negative binomial
regression against first or only episode of clinical malaria in the 12 months after
dose 3 was 31.3% (97.5%CI 23.6–38.3%, p < .0001) for infants and 55.8% (97.5%CI
50.6–60.4%, p < .0001) in the 5–17 month age group.27
• For the additional efficacy endpoint assessed at the end of study extension of
follow-up, the vaccine demonstrated four-dose efficacy measured by negative
binomial regression against clinical malaria of 25.9% in infants 6–12 weeks of age,
and 36.3% efficacy over median 48 months in children 5–17 months of age.27
Over the same follow-up period, the 3 dose regimen showed reduced efficacy
against clinical malaria in both age groups.
• Side effects:
Table 1.
RTS,S/AS01 Phase 3 efficacy results.

Age Group 6-12 weeks of age (n = 6537) 5-17 months of age (n = 8922)
Vaccine Efficacy against clinical
18.3% (11.7 to 24.4) 28.3% (23.3 to 32.9)
malaria, 3-dose group (95% CI)
Vaccine efficacy against clinical
25.9% (19.9 to 31.5) 36.3% (31.8 to 40.5)
malaria, 4-dose group (95% CI)
Vaccine Efficacy against severe
10.3% (–17.9 to 31.8) 1.1% (–23.0 to 20.5)
malaria, 3-dose group (95% CI)
Vaccine efficacy against severe
17.3% (–9.4 to 37.5) 32.2% (13.7 to 46.9)
malaria, 4-dose group (95% CI)
Cheaper, more effective malaria vaccine wins WHO
approval
• R21/Matrix-M vaccine, developed
by the University of Oxford, is the
first malaria vaccine to reach 75%
efficacy target
• A highly effective malaria vaccine
has been recommended for
widespread use by the World
Health Organization.
• The R21/Matrix-M vaccine,
developed by the University of
Oxford, is only the second malaria
vaccine to be recommended by the
WHO. It is the first to meet the
WHO’s target of 75% efficacy.

https://www.theguardian.com/profile/sarah-johnson