article · Malaria Journal
Subpatent malaria infections fall below the detection limits of standard diagnostic tests, allowing parasites to persist silently in communities. This investigation evaluated the presence of hidden Plasmodium falciparum infections across 14 regions of Mainland Tanzania with varying transmission levels. Using quantitative polymerase chain reaction on dried blood spot samples that had tested negative with rapid diagnostic tests, nearly a fifth of the analysed samples were confirmed to carry the parasite. Children under five years presenting at health facilities showed higher odds of carrying these infections compared to other age cohorts. Even in areas classified as having very low transmission, subpatent malaria was detected in over a tenth of samples, whilst low transmission zones showed an even higher proportion. These persistent, undetectable parasite reservoirs present a direct challenge to standard case management and national malaria elimination efforts.
Routine malaria rapid tests miss low-density infections, leaving a hidden reservoir of parasites that can sustain disease transmission. Demonstrating that substantial numbers of people carry undetected malaria, even in areas nearing elimination, highlights why standard health facility testing alone is insufficient. Addressing these hidden cases is critical for public health initiatives aiming to eliminate malaria entirely.
The findings point to an operational need for developers of diagnostics and surveillance tools to supply highly sensitive, field-deployable detection methods, such as point-of-care molecular tests, to national malaria elimination programmes. The research reflects applied epidemiological testing using existing laboratory assays rather than a commercial product launch, indicating that any resulting market translation would involve integrating advanced diagnostic kits into public health supply chains and surveillance workflows.
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BACKGROUND: Subpatent Plasmodium falciparum infections, defined as infections with parasite density below the detection limit of routine malaria diagnostic tests, contribute to infectious reservoirs, sustain transmission, and cause the failure of elimination strategies in target areas. This study assessed the prevalence of subpatent P. falciparum infections and associated risk factors in 14 regions of Mainland Tanzania. METHODS: The study used samples randomly selected from RDT-negative dried blood spots (DBS) (n = 2685/10,101) collected in 2021 at 100 health facilities across 10 regions of Mainland Tanzania, and four communities in four additional regions. The regions were selected from four transmission strata; high (five regions), moderate (three regions), low (three regions), and very low (three regions). DNA was extracted by Tween-Chelex method, and the Pf18S rRNA gene was amplified by quantitative polymerase chain reaction (qPCR). Logistic regression analysis was used to assess the associations between age groups, sex, fever status, and transmission strata with subpatent infection status, while linear regression analysis was used to assess the association between these factors and subpatent parasite density. RESULTS: Of the selected samples, 525/2685 (19.6%) were positive by qPCR for P. falciparum, and the positivity rates varied across different regions. Under-fives (aOR: 1.4, 95% CI 1.04-1.88; p < 0.05) from health facilities had higher odds of subpatent infections compared to other groups, while those from community surveys (aOR: 0.33, 95% CI 0.15-0.72; p = 0.005) had lower odds. Participants from very low transmission stratum had significantly lower odds of subpatent infection compared to those from high transmission stratum (aOR = 0.53, 95% CI = 0.37-0.78; p < 0.01). The log-transformed median parasite density (interquartile range) was 6.9 (5.8-8.5) parasites/µL, with significantly higher parasitaemia in the low transmission stratum compared to a very low one (11.4 vs 7.0 parasites/µL, p < 0.001). CONCLUSION: Even in very low transmission settings, the prevalence of subpatent infections was 13%, and in low transmission settings it was even higher at 29.4%, suggesting a substantial reservoir that is likely to perpetuate transmission but can be missed by routine malaria case management strategies. Thus, control and elimination programmes may benefit from adoption of more sensitive detection methods to ensure that a higher proportion of subpatent infections are detected.
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DOI: 10.1186/s12936-025-05341-6
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