title: Low prevalence of laboratory-confirmed malaria in clinically diagnosed adult women from the Wakiso district of Uganda.
abstract: BACKGROUND
  The malaria burden in sub-Saharan Africa (SSA) has fallen substantially. Nevertheless, malaria remains a serious health concern, and Uganda ranks third in SSA in total malaria burden. Epidemiological studies of adult malaria in Uganda are scarce and little is known about rates of malaria in non-pregnant adult women. This pilot study assessed malaria prevalence among adult women from Wakiso district, historically a highly malaria endemic region.
  
  
  METHODS
  Adult women using public health services were screened for malaria, HIV and pregnancy. A physician-selected subset of women presenting to the Outpatient Department of Entebbe General Hospital (EGH) with current fever (axillary temperature ≥37.5 °C) or self-reporting fever during the previous 24 h, and a positive thick smear for malaria in the EGH laboratory were enrolled (n = 86). Women who self-identified as pregnant or HIV-positive were excluded from screening. Malaria infection was then assessed using HRP2/pLDH rapid diagnostic tests (RDTs) in all participants. Repeat microscopy and PCR were performed at a research laboratory for a subset of participants. In addition, 104 women without a history of fever were assessed for asymptomatic parasitaemia using RDT, and a subset of these women screened for parasitaemia using microscopy (40 women) and PCR (40 women).
  
  
  RESULTS
  Of 86 women diagnosed with malaria by EGH, only two (2.3%) had malaria confirmed using RDT, subsequently identified as a Plasmodium falciparum infection by research microscopy and PCR. Subset analysis of hospital diagnosed RDT-negative participants detected one sub-microscopic infection with Plasmodium ovale. Compared to RDT, sensitivity, specificity and PPV of hospital microscopy were 100% (CI 19.8-100), 0% (CI 0-5.32) and 2.33% (CI 0.403-8.94) respectively. Compared to PCR, sensitivity, specificity and PPV of hospital microscopy were 100% (CI 31.0-100), 0% (CI 0-34.5) and 23.1% (CI 6.16-54.0), respectively. No malaria was detected among asymptomatic women using RDT, research microscopy or PCR.
  
  
  CONCLUSIONS
  Malaria prevalence among adult women appears to be low in Wakiso, but is masked by high rates of malaria overdiagnosis. More accurate malaria testing is urgently needed in public hospitals in this region to identify true causes of febrile illness and reduce unnecessary provision of anti-malarial therapy.
authors.affiliation: Departments of Medicine and Immunology, University of Toronto, 1 King's College Circle, 6356, Toronto, ON, M5S1A8, Canada. sergey.yegorov@mail.utoronto.ca.
authors.forename: Sergey
authors.identifier: http://orcid.org/0000-0002-7136-7921
authors.initials: S
authors.lastname: Yegorov
authors.affiliation: Departments of Medicine and Immunology, University of Toronto, 1 King's College Circle, 6356, Toronto, ON, M5S1A8, Canada.
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Galiwango
authors.affiliation: UVRI-IAVI HIV Vaccine Program, Plot 50-55 Nakiwogo Road, Entebbe, Uganda.|Institute for Glycomics, Griffith University, Gold Coast, Parklands Drive, Southport, QLD, 4215, Australia.
authors.forename: Aloysious
authors.initials: A
authors.lastname: Ssemaganda
authors.affiliation: Entebbe General Hospital, P.O. Box 29, Entebbe, Uganda.
authors.forename: Moses
authors.initials: M
authors.lastname: Muwanga
authors.affiliation: Entebbe General Hospital, P.O. Box 29, Entebbe, Uganda.
authors.forename: Irene
authors.initials: I
authors.lastname: Wesonga
authors.affiliation: Uganda Virus Research Institute, Plot 51-59 Nakiwogo Road, Entebbe, Uganda.
authors.forename: George
authors.initials: G
authors.lastname: Miiro
authors.affiliation: Uganda Virus Research Institute, Plot 51-59 Nakiwogo Road, Entebbe, Uganda.
authors.forename: David A
authors.initials: DA
authors.lastname: Drajole
authors.affiliation: Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, MaRS Centre, University Health Network, 101 College St. TMDT 10-360A, Toronto, ON, M5G1L7, Canada.|Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Kain
authors.affiliation: UVRI-IAVI HIV Vaccine Program, Plot 50-55 Nakiwogo Road, Entebbe, Uganda.|Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
authors.forename: Noah
authors.initials: N
authors.lastname: Kiwanuka
authors.affiliation: UVRI-IAVI HIV Vaccine Program, Plot 50-55 Nakiwogo Road, Entebbe, Uganda.|Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
authors.forename: Bernard S
authors.initials: BS
authors.lastname: Bagaya
authors.affiliation: Departments of Medicine and Immunology, University of Toronto, 1 King's College Circle, 6356, Toronto, ON, M5S1A8, Canada.
authors.forename: Rupert
authors.initials: R
authors.lastname: Kaul
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D008288:Malaria / Q000453:epidemiology*; D008875:Middle Aged; D011247:Pregnancy; D015995:Prevalence; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
keywords: Adult malaria management; Malaria overdiagnosis; Malaria overtreatment; Microscopy; PCR; RDT