Diagnosis of loiasis and analysis of the specific immune response are limited by a paucity of parasite material. To circumvent this problem, a Loa loa antigen has been expressed in a prokaryote vector (pTrcHis). Immunization of Balb/c mice with this soluble recombinant protein produced a strong antibody response, with antibodies recognizing 2 major bands of 38 and 20 kDa in a native crude extract of Loa loa adult worms and microfilariae on Western blots. The target molecule was located mainly in the hypodermis and cuticle of the adult worm. Analysis of human IgG subclasses against this antigen by enzyme-linked immunosorbent assay (ELISA) showed IgG1, IgG2 and IgG3 but not IgG4 reactivity. IgG2 against this recombinant antigen was 100% specific for loiasis when tested against samples from European donor individuals. The same IgG2 antibodies showed 91% specificity for loiasis by comparison with Wuchereria bancrofti, Onchocerca volvulus, Mansonnella perstans and other helminth infections. Furthermore, the IgG2 antibody level correlated with the density of Loa loa microfilariae (r=0·400; P=0·02). This recombinant 15r3 molecule and specific IgG2 assay may be useful for monitoring control programmes.

Multiple parasitic infections have become increasingly recognized as a result of improvements in laboratory diagnosis and a growing population of immunocompromised individuals. This review examines the principles of chemotherapy in groupings of multiple infections which are of particular clinical significance.

Severe adverse events (SAEs) following ivermectin treatment may occur in people harbouring high Loa loa microfilarial (mf) densities. In the context of mass ivermectin distribution for onchocerciasis control in Africa, it is crucial to define precisely the geographical distribution of L. loa in relation to that of Onchocerca volvulus and predict the prevalence of heavy infections. To this end, we analysed the distribution of mf loads in 4183 individuals living in 36 villages of central Cameroon. Mf loads were assessed quantitatively by calibrated blood smears, collected prior to ivermectin distribution. We explored the pattern of L. loa mf aggregation by fitting the (zero-truncated) negative binomial distribution and estimating its overdispersion parameter k by maximum likelihood. The value of k varied around 0·3 independently of mf intensity, host age, village and endemicity level. Based on these results, we developed a semi-empirical model to predict the prevalence of heavy L. loa mf loads in a community given its overall mf prevalence. If validated at the continental scale and linked to predictive spatial models of loiasis distribution, this approach would be particularly useful for optimizing the identification of areas at risk of SAEs and providing estimates of populations at risk in localities where L. loa and O. volvulus are co-endemic.

Ivermectin treatment may induce severe adverse reactions in some individuals heavily infected with Loa loa. This hampers the implementation of mass ivermectin treatment against onchocerciasis in areas where Onchocerca volvulus and L. loa are co-endemic. In order to identify factors, including co-infections, which may explain the presence of high L. loa microfilaraemia in some individuals, we analysed data collected in 19 villages of central Cameroon. Two standardized skin snips and 30 μl of blood were obtained from each of 3190 participants and the microfilarial (mf) loads of both O. volvulus and L. loa were quantified. The data were analysed using multivariate hierarchical models. Individual-level variables were: age, sex, mf presence, and mf load; village-related variables included the endemicity levels for each infection. The two species show a certain degree of ecological separation in the study area. However, for a given individual host, the presence of microfilariae of one species was positively associated with the presence of microfilariae of the other (OR=1·79, 95% CI [1·43–2·24]). Among individuals harbouring Loa microfilariae, there was a slight positive relationship between the L. loa and O. volvulus mf loads which corresponded to an 11% increase in L. loa mf load per 100 O. volvulus microfilariae. Co-infection with O. volvulus is not sufficient to explain the very high L. loa mf loads harboured by some individuals.

This paper describes the structure of the microfilarial reservoir of Loa loa in an endemic population of central Cameroon. The possible effects of age and sex on the prevalence and intensity of microfilaraemia have been explored. Logistic analysis showed that the prevalence of microfilaraemia increased significantly with age, reaching 60% in the oldest males. This result suggests that the figure commonly reported, according to which only one third of the infected individuals were microfilaraemic, should be reconsidered; in addition, as part of surveys of loiasis, crude microfilaraemia prevalence values should be replaced by adjusted ones. The intensity of infection did not show any age-specific change. As a result, even if the oldest members of the male population are clearly the most at risk of developing post-ivermectin serious adverse reactions, especially Loa-encephalopathy, the other members of the population are not risk-free. Therefore, in those areas where the African Programme for Onchocerciasis Control is undertaking regular mass distributions of ivermectin for onchocerciasis control, and where loiasis is co-endemic, no subpopulation should be excluded from surveillance and monitoring during community directed treatments with ivermectin.

In order to identify antigens associated with protection and those associated with active infection, the humoral immune response of 6 Mandrillus sphinx immunized with 150 irradiated L3 and challenged with 100 normal L3 of Loa loa or 6 animals infected with 100 L3 were compared. The plasma of these animals was analysed by Western blot using adult, Mf and L3 antigens. Several antigens with molecular weights varying from 120 kDa to 13 kDa were recognized by the plasma of all animals. It was shown that early recognition of microfilarial antigens with molecular weights of 97, 68, 45 and 33 kDa correlated with the amicrofilaraemic state. A total of 83% of animals with circulating microfilariae had antibodies against the microfilariae 21 kDa antigen. Furthermore, the antibodies against the 21 kDa appeared 1 month before detection of microfilariae in the peripheral blood of 80% of these animals, and declined when animals became amicrofilaraemic. In contrast, when L3 antigen was used, a molecule with a relative molecular weight of 20 kDa was recognized by antibodies of the only animal which remained amicrofilaraemic for 1 year after immunization with irradiated L3. These results suggest that the microfilarial molecule of 21 kDa may be useful as a marker of Loa loa patent infection, whereas the 97, 68, 45 and 33 kDa molecules of microfilariae and the L3 molecule of 20 kDa may be associated with resistance against Loa loa.