Philip Bejon and colleagues document the clustering of malaria episodes and malarial parasite infection. These patterns may enable future prediction of hotspots of malaria infection and targeting of treatment or preventive interventions.

Background-The candidate malaria vaccine RTS,S/AS01 is being evaluated in order to inform a decision regarding its inclusion in routine vaccination schedules.

The efficacy of RTS,S/AS01E vaccine over the 4-year period was 16.8%. Efficacy declined over time and with increasing malaria exposure. (Funded by the PATH Malaria Vaccine Initiative and Wellcome Trust; ClinicalTrials.gov number, NCT00872963.).

are named inventors on patent applications relating to RH5 and/or other malaria vaccines and immunization regimens. L. Siani and S. Di Marco are employees of ReiThera (formerly Okairos), which is currently developing vectored vaccines for a number of diseases. J. Vekemans was an employee of GSK, which has acquired the ChAd63 vector from Okairos. R. Ashfield is a director of Ducentis and holds shares in the company, which is developing a therapy for autoimmune disease. A.M. Minassian has an immediate family member who is an inventor on patents relating to RH5 and/or other malaria vaccines and immunization regimens and who is a cofounder of, shareholder in, and consultant for SpyBiotech. S. Biswas is a cofounder and CEO of, and shareholder in, SpyBiotech and is a contributor in a patent application relating to multimerisation technology. J. Jin is a cofounder of and shareholder in SpyBiotech.

Plasmodium falciparum antigens expressed on the surface of infected erythrocytes are important targets of naturally acquired immunity against malaria, but their high number and variability provide the pathogen with a powerful means of escape from host antibodies1–4. Although broadly reactive antibodies against these antigens could be useful as therapeutics and in vaccine design, their identification has proven elusive. Here, we report the isolation of human monoclonal antibodies that recognize erythrocytes infected by different P. falciparum isolates and opsonize these cells by binding to members of the RIFIN family. These antibodies acquired broad reactivity through a novel mechanism of insertion of a large DNA fragment between the V and DJ segments. The insert, which is both necessary and sufficient for binding to RIFINs, encodes the entire 100 amino acid collagen-binding domain of LAIR-1, an Ig superfamily inhibitory receptor encoded on chromosome 19. In each of the two donors studied, the antibodies are produced by a single expanded B cell clone and carry distinct somatic mutations in the LAIR-1 domain that abolish binding to collagen and increase binding to infected erythrocytes. These findings illustrate, with a biologically relevant example, a novel mechanism of antibody diversification by interchromosomal DNA transposition and demonstrate the existence of conserved epitopes that may be suitable candidates for the development of a malaria vaccine.