Performance of Loop-Mediated Isothermal Amplification for the Identification of Submicroscopic Plasmodium falciparum Infection in Uganda

Shereen Katrak Department of Medicine, University of California San Francisco, San Francisco, California;

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Maxwell Murphy Department of Medicine, University of California San Francisco, San Francisco, California;

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Patience Nayebare Infectious Diseases Research Collaboration, Kampala, Uganda;

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John Rek Infectious Diseases Research Collaboration, Kampala, Uganda;

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Mary Smith Chicago Medical School, Rosalind Franklin University, North Chicago, Illinois;

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Emmanuel Arinaitwe Infectious Diseases Research Collaboration, Kampala, Uganda;
London School of Hygiene and Tropical Medicine, London, United Kingdom;

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Joaniter I. Nankabirwa Infectious Diseases Research Collaboration, Kampala, Uganda;
School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

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Moses Kamya Infectious Diseases Research Collaboration, Kampala, Uganda;
School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

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Grant Dorsey Department of Medicine, University of California San Francisco, San Francisco, California;

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Philip J. Rosenthal Department of Medicine, University of California San Francisco, San Francisco, California;

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Bryan Greenhouse Department of Medicine, University of California San Francisco, San Francisco, California;

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Accurately identifying and targeting the human reservoir of malaria parasitemia is critical for malaria control, and requires a reliable and sensitive diagnostic method. Loop-mediated isothermal amplification (LAMP) is increasingly used to diagnose submicroscopic parasitemia. Although most published studies report the sensitivity of LAMP compared with nested polymerase chain reaction (PCR) as ≥ 80%, they have failed to use a consistent, sensitive diagnostic as a comparator. We used cross-sectional samples from children and adults in Tororo, Uganda, a region with high but declining transmission due to indoor residual spraying, to characterize the sensitivity and specificity of pan-Plasmodium LAMP for detecting submicroscopic infections. We compared LAMP results targeting a mitochondrial DNA sequence conserved in all Plasmodium species, performed on DNA extracted from dried blood spots, to those of a gold standard quantitative PCR assay targeting the var gene acidic terminal sequence of Plasmodium falciparum (varATS qPCR), performed on DNA extracted from 200 µL of whole blood. Using LAMP and varATS qPCR increased the detection of parasitemia 2- to 5-fold, compared with microscopy. Among microscopy-negative samples, the sensitivity of LAMP was 81.5% for detecting infection ≥ 1 parasites/µL. However, low density infections were common, and LAMP failed to identify more than half of all infections diagnosed by varATS qPCR, performing with an overall sensitivity of 44.7% for detecting submicroscopic infections ≥ 0.01 parasites/µL. Thus, although the LAMP assay is more sensitive than microscopy, it missed a significant portion of the submicroscopic reservoir. These findings have important implications for malaria control, particularly in settings where low-density infections predominate.

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Author Notes

Address correspondence to Shereen Katrak, Department of Medicine, University of California San Francisco, 513 Parnassus Avenue, Room S380, Box 0654, San Francisco, CA 94143. E-mail: shereen.katrak@ucsf.edu

Authors’ addresses: Shereen Katrak, Maxwell Murphy, Grant Dorsey, Philip J. Rosenthal, and Bryan Greenhouse, Department of Medicine, University of California, San Francisco, CA, E-mails: shereen.katrak@ucsf.edu, maxwell.murphy@ucsf.edu, grant.dorsey@ucsf.edu, philip.rosenthal@ucsf.edu, and bryan.greenhouse@ucsf.edu. Patience Nayebare, John Rek, and Emmanuel Arinaitwe, Infectious Diseases Research Collaboration, Kampala, Uganda, E-mails: pnayebare@ymail.com, jrek@idrc-uganda.org, and earinaitwe@idrc-uganda.org. Mary Smith, Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, E-mail: marydsmith37@yahoo.com. Joaniter I. Nankabirwa and Moses Kamya, Makerere University College of Health Sciences, Kampala, Uganda, and Infectious Disease Research Collaboration, Kampala, Uganda, E-mails: jnankabirwa@yahoo.co.uk and mkamya@idrc-uganda.org.

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