Activation of the hypnozoite: a part of Plasmodium vivax life cycle and survival

BACKGROUND: Plasmodium vivax is the most widespread malaria parasite. It has a dormant stage in the human liver, which makes it difficult to eradicate. It is proposed that a relapse of vivax malaria, besides being genetically determined by the specific strain, is induced by the bites of uninfected vectors. PRESENTATION OF THE HYPOTHESIS: The dormant stage maximizes the possibility for the parasite to reach the vector for sexual reproduction. The advantage would increase if the parasite was able to detect the presence of a new generation of vectors. The sporozoites function both in the vector and in the human hosts. They invade the cells of the salivary gland in the vector and the hepatocytes in the human. Some of the sporozoites develop into hypnozoites in the human liver. It is suggested that the hypnozoite activates when it recognizes the same Anopheles specific protein, which it had previously recognized as a sporozoite to invade the salivary gland in the vector. Another possibility is that the hypnozoite activates upon the bodily reaction by the human on a bite by an Anopheles female. TESTING THE HYPOTHESIS: The connection between the relapse and a new generation of vectors can be documented by simultaneous monitoring of both parasitaemia in humans and the presence of uninfective/infective vectors in the same area with seasonal malaria transmission. Experimental studies are needed to find the saliva components, which trigger the relapse. Although P. cynomolgi in monkeys also has hypnozoites and relapses, testing with monkeys might be problematical. These live in a reasonably stable tropical environment where relapses cannot easily be linked to vectors. The importance of the trigger increases in unpredictable variations in the vector season. IMPLICATIONS OF THE HYPOTHESIS: Artificial triggering of hypnozoites would make the medication more effective and resistance against a protein that the parasite itself uses during its life cycle would not develop. In areas with seasonal vivax malaria it could be used locally for eradication.