Abstract.Sensitive field-deployable diagnostic tests can assist malaria programs in achieving elimination. The performance of a new Alere™ Malaria Ag P.f Ultra Sensitive rapid diagnostic test (uRDT) was compared with the currently available SD Bioline Malaria Ag P.f RDT in blood specimens from asymptomatic individuals in Nagongera, Uganda, and in a Karen Village, Myanmar, representative of high- and low-transmission areas, respectively, as well as in pretreatment specimens from study participants from four Plasmodium falciparum-induced blood-stage malaria (IBSM) studies. A quantitative reverse transcription PCR (qRT-PCR) and a highly sensitive enzyme-linked immunosorbent assay (ELISA) test for histidine-rich protein II (HRP2) were used as reference assays. The uRDT showed a greater than 10-fold lower limit of detection for HRP2 compared with the RDT. The sensitivity of the uRDT was 84% and 44% against qRT-PCR in Uganda and Myanmar, respectively, and that of the RDT was 62% and 0% for the same two sites. The specificities of the uRDT were 92% and 99.8% against qRT-PCR for Uganda and Myanmar, respectively, and 99% and 99.8% against the HRP2 reference ELISA. The RDT had specificities of 95% and 100% against qRT-PCR for Uganda and Myanmar, respectively, and 96% and 100% against the HRP2 reference ELISA. The uRDT detected new infections in IBSM study participants 1.5 days sooner than the RDT. The uRDT has the same workflow as currently available RDTs, but improved performance characteristics to identify asymptomatic malaria infections. The uRDT may be a useful tool for malaria elimination strategies.

BackgroundThe burden of malaria in Uganda remains unacceptably high, especially among children and pregnant women. To prevent malaria related complications, household possession and use of Insecticide Treated mosquito Nets (ITNs) has become a common practice in the country. Despite the availability of ITNs, malaria remains a foremost public health concern in Uganda. We sought to explore knowledge, attitude, and behaviour towards the use of ITNs as a nightly malaria prevention strategy among pregnant women and children under five years of age in Isingiro district, Southwestern Uganda.Materials and MethodsThis was a community based, descriptive cross-sectional study, in which households with children under 5 years, and/or pregnant women were enrolled. We used a structured questionnaire to collect data on participants’ understanding of the causes, signs and symptoms of malaria; use of ITNs to prevent malaria; attitudes and behaviours towards the use of ITNs. We also conducted key informant interviews (KIIs) to get in-depth understanding of responses from the participants. We analysed quantitative data using STATA version 12.Qualitative findings from the KIIs were transcribed and translated, and manually analysed using thematic content analysis.ResultsOf the 369 households enrolled, 98.4% (N = 363) households had children under five. Most participants (41.2%, N = 152) were in the 21–30 age category (mean age; 32.2 years). 98.1% (N = 362) of the respondents considered ITNs a key malaria prevention strategy. The ITN possession rate was 84.0% (N = 310), of these, 66.1% (N = 205) consistently used them. 39% of the respondents did not have a positive attitude towards ITNs.ConclusionsAlthough 84.0% of the respondents possessed ITNs, many were not consistently using them. To this, there is need to engage all stakeholders (including cultural leaders, community health workers, religious leaders and the government) in the malaria prevention campaigns using ITNs through: a) government’s concerted effort to ensure universal access of right fit ITNs, b) end-user directed health education to emphasize positive attributes of ITN use, c) telling the ITN success stories to improve on the usage.

Malaria rapid diagnostic tests (RDTs) primarily detect Plasmodium falciparum antigen histidine-rich protein 2 (HRP2) and the malaria-conserved antigen lactate dehydrogenase (LDH) for P. vivax and other malaria species. The performance of RDTs and their utility is dependent on circulating antigen concentration distributions in infected individuals in a population in which malaria is endemic and on the limit of detection of the RDT for the antigens.

Malaria antigen detection through rapid diagnostic tests (RDTs) is widely used to diagnose malaria and estimate prevalence. To support more sensitive next-generation RDT development and screen asymptomatic malaria, we developed and evaluated the Q-Plex ™ Human Malaria Array (Quansys Biosciences, Logan, UT), which quantifies the antigens commonly used in RDTs-Plasmodium falciparum-specific histidine-rich protein 2 (HRP2), P. falciparumspecific lactate dehydrogenase (Pf LDH), Plasmodium vivax-specific LDH (Pv LDH), and Pan malaria lactate dehydrogenase (Pan LDH), and human C-reactive protein (CRP), a biomarker of severity in malaria. At threshold levels yielding 99.5% or more diagnostic specificity, diagnostic sensitivities against polymerase chain reaction-confirmed malaria for HRP2, Pf LDH, Pv LDH, and Pan LDH were 92.7%, 71.5%, 46.1%, and 83.8%, respectively. P. falciparum culture strains and samples from Peru indicated that HRP2 and Pf LDH combined improves detection of P. falciparum parasites with hrp2 and hrp3 deletions. This array can be used for antigen-based malaria screening and detecting hrp2/3 deletion mutants of P. falciparum.

Malaria is a leading cause of pediatric mortality, and Uganda has among the highest incidences in the world. Increased morbidity and mortality are associated with delays to care. This qualitative study sought to characterize barriers to prompt allopathic care for children hospitalized with severe malaria in the endemic region of southwestern Uganda. Minimally structured, qualitative interviews were conducted with guardians of children admitted to a regional hospital with severe malaria. Using an inductive and content analytic approach, transcripts were analyzed to identify and define categories that explain delayed care. These categories represented two broad themes: sociocultural and structural factors. Sociocultural factors were 1) interviewee's distinctions of “traditional” versus “hospital” illnesses, which were mutually exclusive and 2) generational conflict, where deference to one's elders, who recommended traditional medicine, was expected. Structural factors were 1) inadequate distribution of health-care resources, 2) impoverishment limiting escalation of care, and 3) financial impact of illness on household economies. These factors perpetuate a cycle of illness, debt, and poverty consistent with a model of structural violence. Our findings inform a number of potential interventions that could alleviate the burden of this preventable, but often fatal, illness. Such interventions could be beneficial in similarly endemic, low-resource settings.