SummaryThe development of a malaria vaccine seems to be a definite possibility despite the fact that even individuals with a life time of endemic exposure do not develop sterile immunity. An effective malaria vaccine would be invaluable in preventing malaria-associated deaths in endemic areas, especially amongst children less than 5 years of age and pregnant women. This review discusses our current understanding of immunity against the asexual blood stage of malaria -the stage that is responsible for the symptoms of the disease -and approaches to the design of an asexual blood stage vaccine.Keywords: asexual blood stage, malaria, vaccine.
Malaria and Plasmodium life cycleMalaria, a parasitic infection, is an important cause of mortality and morbidity in many parts of the world. Each year, an estimated 300-500 million people are affected worldwide. In reality, the true figure could be greater than three times this number. 1 Malaria kills 1-2 million people each year, mostly children under the age of 5 years and a significant number of pregnant women in sub-Saharan Africa. 2 It is a devastating infectious disease that not only affects the health system, but also slows the rate of long-term economic growth and development. The emergence of drug-resistant strains of the parasite has exacerbated the situation, and global climate change, disintegration of health services, human migration and population displacement have also contributed. 2 In recent years, there have also been more cases of malaria in travellers to endemic countries.Malaria is caused by unicellular protozoan parasites of the Plasmodium genus. 3 There are four species of malaria parasites that infect humans: P. falciparum, P. vivax, P. ovale and P. malariae. The most severe form of malaria is caused by P. falciparum. The severity of the disease depends largely on the species and strain of the infecting parasite, and the immunological status of the person who is infected.Cyclical fevers are the hallmark of malaria and typically occur shortly before or at the time of red blood cell (RBC) lysis as schizonts rupture to release new infectious merozoites (see below). This occurs every 48 h in P. vivax, P. ovale and P. falciparum, and every 72 h in P. malariae infection. Intense fever is accompanied by nausea, headaches and muscular pain, amongst other symptoms. In patients infected with P. vivax and P. ovale, relapse may recur months to years after initial infection. This is caused by re-activation of the silent liver-stage form of the parasites (hypnozoites). Renal failure, hypoglycaemia, hepatic dysfunction, severe anaemia, pulmonary oedema, convulsions and shock are complications in severe malaria. Cerebral malaria is a frequent presentation of severe P. falciparum infection and has been attributed in part to the unique ability of the parasites to alter the surface of infected RBC so that they bind to endothelial surfaces causing obstruction of cerebral blood flow. 4 Recent observations suggest that pro-inflammatory cytokines and nitric oxide induced by p...