Evaluation of Malaria Rapid Diagnostic Test Performance and pfhrp2 Deletion in Tanzania School Surveys, 2017

Billy Ngasala Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania;

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Frank Chacky National Malaria Control Programme, Dodoma, Tanzania;

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Ally Mohamed National Malaria Control Programme, Dodoma, Tanzania;

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Fabrizio Molteni Swiss Tropical and Public Health Institute, Basel, Switzerland;

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Ssanyu Nyinondi RTI International, Dar es Salaam, Tanzania;

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Bilali Kabula RTI International, Dar es Salaam, Tanzania;

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Humphrey Mkali RTI International, Dar es Salaam, Tanzania;

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Kyaw Thwai Institute for Global health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina;

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Zachary R. Popkin-Hall Institute for Global health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina;

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Cedar Mitchell Institute for Global health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina;

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Jonathan B. Parr Institute for Global health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina;
Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, North Carolina;
Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina;

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Jonathan J. Juliano Institute for Global health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina;
Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, North Carolina;
Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina;
Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina;

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Jessica T. Lin Institute for Global health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina;
Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, North Carolina;
Department of Microbiology and Immunology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina

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ABSTRACT.

As part of malaria nationwide monitoring and evaluation initiatives, there is an increasing trend of incorporating malaria rapid diagnostic tests (mRDTs) in surveys conducted within primary schools to detect malaria parasites. However, mRDTs based on the detection of histidine-rich protein 2 (HRP2) are known to yield false-positive results due to persistent antigenemia, and false-negative results may result from low parasitemia or Plasmodium falciparum hrp2/3 gene deletion. We evaluated diagnostic performance of an HRP2 and pan-parasite lactate dehydrogenase (HRP2/pLDH) mRDT against polymerase chain reaction (PCR) for detection of P. falciparum among 17,051 primary school–age children from eight regions of Tanzania in 2017. According to PCR, the prevalence of P. falciparum was 19.2% (95% CI: 18.6–19.8). Using PCR as reference, the sensitivity and specificity of mRDT was 76.2% (95% CI: 74.7–77.7) and 93.9% (95% CI: 93.5–94.3), respectively. Test agreement was lowest in low transmission areas, where true-positive mRDTs were outnumbered by false-negatives due to low parasitemia. Discordant samples (mRDT-negative but PCR-positive) were screened for pfhrp2/3 deletion by real-time PCR. Among those with a parasite density sufficient for analysis, pfhrp2 deletion was confirmed in 60 samples, whereas pfhrp3 deletion was confirmed in two samples; one sample had both pfhrp2 and pfhrp3 deletions. The majority of samples with gene deletions were detected in the high-transmission Kagera region. Compared with mRDTs, PCR and other molecular methods offer increased sensitivity and are not affected by pfhrp2/3 deletions, making them a useful supplement to mRDTs in schools and other epidemiological surveys.

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Author Notes

Financial support: The School Malaria Parasite Survey was supported by Global Fund to Fight AIDS, Tuberculosis and Malaria, grant no. TNZ-M-MOFEA. Molecular analysis and data analysis supported by U.S. President’s Malaria Initiative via the U.S. Agency for International Development Okoa Maisha Dhibiti Malaria (cooperative agreement no. 72062118CA-00002) implemented by RTI International, K24AI134990 to J. J. Juliano and R01AI137395 to J. T. Lin.

Conflicts of interest: J. B. Parr reports research support from Gilead Sciences, nonfinancial support from Abbott Laboratories, and consulting for Zymeron Corporation, all outside the scope of the submitted work.

Authors’ addresses: Billy Ngasala, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, E-mail: bngasala70@gmail.com. Frank Chacky and Ally Mohamed, National Malaria Control Programme, Dodoma, Tanzania, E-mails: chackyfa@gmail.com and allykayaga@gmail.com. Fabrizio Molteni, Swiss Tropical and Public Health Institute, Basel, Switzerland, E-mail: fabrizio.molteni@netcell.org. Ssanyu Nyinondi, Bilali Kabula, and Humphrey Mkali, RTI International, Dar es Salaam, E-mails: ssanyu@gmail.com, bika72@gmail.com, and hrmkali@omdm.rti.org. Kyaw Thwai, Zachary R. Popkin-Hall, Cedar Mitchell, and Jonathan B. Parr, Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, E-mails: thwai@email.unc.edu, zach_popkin-hall@med.unc.edu, and cdr.mit@gmail.com. Jonathan B. Parr, Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, and Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, E-mail: jonathan_parr@med.unc.edu. Jonathan J. Juliano, Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, E-mail: jonathan_juliano@med.unc.edu. Jessica T. Lin, Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, and Department of Microbiology and Immunology, School of Medicine, University of North Carolina, Chapel Hill, NC, E-mail: jessica_lin@med.unc.edu.

Address correspondence to Billy Ngasala, Muhimbili University of Health and Allied Sciences, Department of Parasitology & Medical Entomology, United Nations Road Upanga West, Multipurpose Building, Dar es Salaam, Tanzania. E-mail: bngasala70@gmail.com
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