Characteristics of Subpatent Malaria in a Pre-Elimination Setting in Southern Zambia

Tamaki Kobayashi Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Mufaro Kanyangarara Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Natasha M. Laban Macha Research Trust, Choma, Zambia;

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Masiliso Phiri Ministry of Fisheries and Livestock, Nchelenge, Zambia;

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Harry Hamapumbu Macha Research Trust, Choma, Zambia;

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Kelly M. Searle Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Jennifer C. Stevenson Macha Research Trust, Choma, Zambia;
W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

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Philip E. Thuma Macha Research Trust, Choma, Zambia;
W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

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William J. Moss Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

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for the Southern Africa International Centers of Excellence for Malaria Research Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
Macha Research Trust, Choma, Zambia;
Ministry of Fisheries and Livestock, Nchelenge, Zambia;
W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

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To achieve and sustain malaria elimination, identification and treatment of the asymptomatic infectious reservoir is critical. Malaria rapid diagnostic tests (RDTs) are frequently used to identify asymptomatic, Plasmodium-infected individuals through test-and-treat strategies, but their sensitivity is low when used in low transmission settings. Characteristics of individuals with subpatent (RDT-negative but polymerase chain reaction [PCR]–positive) Plasmodium parasitemia were evaluated in southern Zambia where malaria transmission has declined and efforts to achieve malaria elimination are underway. Simple random sampling based on satellite imagery was used to select households for participation in community-based, cross-sectional surveys between 2008 and 2013. Questionnaires were administered to collect information on age, gender, recent history of malaria symptoms, and recent antimalarial drug use. Blood samples were collected by finger prick for Plasmodium falciparum histidine-rich protein 2 RDT, blood smears for microscopy, and dried blood spots for molecular analysis to detect malaria parasites and their sexual stage. Of 3,863 participants with complete data, 102 (2.6%) were positive by microscopy, RDT, or PCR. Of these, 48 (47%) had subpatent parasitemia. Most individuals with subpatent parasitemia were asymptomatic (85%). Compared with individuals without parasitemia, individuals with subpatent parasitemia were significantly more likely to be aged 5–25 years. Approximately one quarter (27%) of those with subpatent parasitemia had detectable gametocytemia. These findings suggest that strategies based on active or reactive case detection can identify asymptomatic individuals positive by RDT, but more sensitive diagnostic tests or focal drug administration may be necessary to target individuals with subpatent parasitemia to achieve malaria elimination.

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Author Notes

Address correspondence to Tamaki Kobayashi, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. W4612, Baltimore, MD 21205. E-mails: tkobaya2@jhu.edu

Conflicts of interest: P. T. reports grants from NIH/NIAID during the conduct of the study.

Authors’ addresses: Tamaki Kobayashi, Kelly M. Searle, and William J. Moss, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mails: tkobaya2@jhu.edu, ksearle1@jhu.edu, and wmoss1@jhu.edu. Mufaro Kanyangarara, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: mkanyan1@jhu.edu. Natasha M. Laban, Harry Hamapumbu, Jennifer C. Stevenson, and Philip E. Thuma, Macha Research Trust, Choma, Zambia, E-mails: natasha.laban1@gmail.com, harry.hamapumbu@macharesearch.org, jennyc.stevenson@macharesearch.org, and phil.thuma@macharesearch.org. Masiliso Phiri, Ministry of Fisheries and Livestock, Nchelenge, Zambia, E-mail: masilisophiri@gmail.com.

The Southern Africa International Centers of Excellence for Malaria Research includes: Biomedical Research and Training Institute, Zimbabwe; Johns Hopkins Malaria Research Institute, Baltimore, MD; Macha Research Trust, Zambia; National Institute of Health Research, Zimbabwe; Tropical Diseases Research Centre, Zambia; University of the Witwatersrand, South Africa; and the University of Zambia, Zambia.

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