Estimating the Prevalence of Asymptomatic Malaria Parasite Carriage in Southern Ghana: Utility of Molecular and Serological Diagnostic Tools

Abstract Background. Asymptomatic malaria infections can serve as potential reservoirs for malaria transmission. These infections range from microscopic to submicroscopic densities, making an accurate estimation of asymptomatic parasite carriage highly dependent on the sensitivity of the tool used for the diagnosis. This study sought to evaluate the sensitivities of a variety of molecular and serological diagnostic tool at determining the prevalence of asymptomatic Plasmodium falciparum parasite infections in two communities of varying malaria parasite prevalence.Methods. Whole blood from 194 afebrile participants aged between 6- and 70-years old living in a high (Obom) and a low (Asutsuare) malaria transmission setting of Ghana was used in this study. Thick and thin blood smears, an HRP2-based malaria rapid diagnostic test (RDT) and filter paper dried blood spots (DBS) were prepared from each blood sample. Genomic DNA was extracted from the remaining blood and used in Plasmodium specific photo-induced electron transfer polymerase chain reaction (PET-PCR) and Nested PCR, whilst the HRP2 antigen content of the DBS was estimated using a bead immunoassay. Comparison of prevalence as determined by each method was performed.Results. Parasite prevalence in the high transmission site of Obom was estimated at 71.4%, 61.9%, 60%, 37.8% and 19.1% by Nested PCR, the HRP2 bead assay, PET-PCR, HRP2-RDT and microscopy respectively. Parasite prevalence in the low transmission site of Asutsuare was estimated at 50.1%, 11.2%, 5.6%, 0% and 2.2% by Nested PCR, the HRP2 bead assay, PET-PCR, RDT and microscopy respectively.Conclusions: Nested PCR exhibited the highest sensitivity by identifying the highest prevalence of asymptomatic P. falciparum in both the high and low parasite prevalence setting. However, parasite prevalence estimated by the HRP2 bead assay and PET-PCR had the highest level of inter-rater agreement relative to all the other tools tested and have the advantage of requiring fewer processing steps and producing quantitative results relative Nested PCR. These advantages make PET-PCR and the HRP2 bead assay very useful tools for estimating malaria parasite prevalence in community surveys in these settings.