Expert Review of Anti-infective Therapy

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The silent threat: asymptomatic parasitemia and

malaria transmission

Kim A Lindblade, Laura Steinhardt, Aaron Samuels, S Patrick Kachur &

Laurence Slutsker

To cite this article: Kim A Lindblade, Laura Steinhardt, Aaron Samuels, S Patrick Kachur
& Laurence Slutsker (2013) The silent threat: asymptomatic parasitemia and malaria
transmission, Expert Review of Anti-infective Therapy, 11:6, 623-639, DOI: 10.1586/eri.13.45

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Kim A Lindblade*,
Laura Steinhardt,
Aaron Samuels,
S Patrick Kachur and
Laurence Slutsker
Malaria Branch, Division of Parasitic
Diseases and Malaria, Centers for
Disease Control and Prevention,
1600Clifton Rd. NE, MS A-06, Atlanta,
GA30333, USA
*Author for correspondence:
Tel.: +1 404 718 4750
Fax: +1 404 718 4815
kil2@cdc.gov
www.expert-reviews.com
Review
The silent threat:
asymptomatic parasitemia
and malaria transmission
Expert Rev. Anti Infect. Ther. 11(6), 623639 (2013)
Scale-up of malaria control interventions has resulted in a substantial decline in global malaria
morbidity and mortality. Despite this achievement, there is evidence that current interventions
alone will not lead to malaria elimination in most malaria-endemic areas and additional strategies
need to be considered. Use of antimalarial drugs to target the reservoir of malaria infection is an
option to reduce the transmission of malaria between humans and mosquito vectors. However,
a large proportion of human malaria infections are asymptomatic, requiring treatment that is not
triggered by care-seeking for clinical illness. This article reviews the evidence that asymptomatic
malaria infection plays an important role in malaria transmission and that interventions to
target this parasite reservoir may be needed to achieve malaria elimination in both low- and
hightransmission areas.
Keywords: antimalarial asymptomatic elimination infection interventions malaria parasite
There has been an extraordinary scale-up of despite more than 10years with high coverage of
malaria control interventions over the last decade ITNs, parasite prevalence in children <5years of
with significant increases in household owner age had declined from 83% in 1992 to only 41%
ship and individual use of insecticide-treated by slide microscopy in 2009[5,6] . Similar obser-
bednets (ITNs), unprecedented growth in the vations have been noted in areas formerly consid-
number of houses protected by indoor residual ered as high-transmission areas, such as Zambia
spraying (IRS) and important improvements in [7] and Uganda [8] . A mathematical simulation
access to effective treatment for clinical malaria. of Plasmodium falciparum transmission in Africa
As a result, there has been an estimated 17% suggested that only in areas with the lowest base-
decline in the number of malaria cases and a 26% line level of transmission (<three infective bites
decrease in the malaria-specific child mortality per person per year) could malaria be elimi-
rate globally between 2000 and 2011 [1] . In this nated through a combination of ITNs, IRS and
optimistic climate, the African Union, at its third case management with an a rtemisinin-based
session of the Conference of Ministers of Health combination therapy (ACT) [9] .
(Johannesburg, South Africa) in April 2007, The situation in the Americas and Asia is some-
advocated for eventual elimination of malaria what different from Africa due to the higher pro-
from the continent [2] ; this was followed by a portion of malaria cases caused by Plasmodium
call in October of the same year from Bill and vivax, whose dormant liver stage poses an extra
Melinda Gates [201] , with support from the WHO challenge to elimination. Additionally, many
[3] , for global malaria eradication. As of 2011, of the vectors in these areas are exophagic and,
36 of the 99countries remaining with malaria therefore, are less likely to be affected by the
transmission are pursuing elimination [4] . use of ITNs or IRS. It is recognized that the
Despite the recent progress on reducing same malaria interventions successfully used
malaria morbidity and mortality, there is empiri- in sub-Saharan Africa may not work as well in
cal and theoretical evidence that the current suite P.vivax-endemic areas, and the technical feasi-
of interventions will not be sufficient to elimi- bility of eliminating P. vivax from areas where it
nate malaria from many areas in sub-Saharan is currently endemic is not yet known [10] .
Africa with historically high levels of malaria As a result of the empirical and modeling data
transmission. For example, in western Kenya, suggesting that current interventions will need
10.1586/ERI.13.45 2013 Expert Reviews Ltd ISSN 1478-7210 623
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker
to be supplemented by additional strategies for malaria to be elim-
inated in most of sub-Saharan Africa, and the recognition that
there is not yet a feasible technical strategy to eliminate P. vivax
from Latin America and Asia, there is increased attention being
paid to the human parasite reservoir [9,11] . The human parasite
reservoir consists of all malaria infections in people in a given
area, including symptomatic and asymptomatic infections, and
both the sexual and asexual stages of the parasite (the special case
of dormant liver stages of P. vivax and Plasmodium ovale will not
be addressed in this review).
Improvements in case management through the use of more
effective antimalarials have helped in reducing malaria t ransmission
in some areas [12] , but low utilization of healthcare, suboptimal per-
formance of healthcare workers, problems with patient adherence
to treatment regimens and drug stock-outs limit the ability of case
management strategies to significantly decrease the fraction of the
parasite reservoir harbored in symptomatic individuals [13] . The
expansion of community case management may help to address
problems of access, but health system issues are likely to remain a
challenge in most areas. Additionally, case management, by defini-
tion, only addresses symptomatic individuals, and there has been
increasing recognition that a substantial proportion of the parasite
reservoir may be found in persons who do not show symptoms and
therefore do not seek care [11] . In part, the use of molecular assays
such as PCR to detect parasite DNA has improved the sensitivity
of diagnostics to find subpatent (i.e., below the detection limits for
microscopy) infections that are more likely to be asymptomatic,
and this has contributed to the understanding of the extent of the
asymptomatic parasite reservoir [14] .
As the magnitude of the asymptomatic parasite reservoir has
been revealed through increasing use of more sensitive molecu-
lar diagnostic methods, new strategies to target individuals with
silent infections are being developed and evaluated. The objective
of this review is to examine the data that support the hypothesis
that targeting the asymptomatic parasite reservoir will contribute
substantially to reductions in malaria transmission and eventual
malaria elimination.
How does Plasmodium infection cause acute clinical
symptoms?
Malaria sporozoites of the genus Plasmodium (comprising four
species that are transmitted between humans by Anopheles mos-
quitoes: P. falciparum, P. vivax, P. ovale and Plasmodium malariae)
are injected into humans through the bite of an infective female
Anopheles mosquito. The malaria sporozoites pass rapidly to the
liver, within 30min of infection, where they mature into schizonts
within hepatocytes over 516days, depending on the parasite
species. The mature schizonts then rupture the cell and enter the
bloodstream as merozoites. Merozoites infect red blood cells and
over 23days develop into eryrthrocytic schizonts, eventually
destroying the erythrocyte, and releasing more merozoites and
cellular debris into the bloodstream. The immediate impact of this
rupture is a significant decline in red cell mass, and cellular debris
and cytokines released by the host lead to the development of
acute clinical symptoms, including fever, rigors and myalgias [15] .
624
How are malaria infections transmitted?
Gametocytes, the transmissible stage of the Plasmodium parasite,
are produced by a small fraction of merozoites that differentiate
into gametocytes upon entering the red blood cell, although
gametocytes of P. vivax, P. ovale and P. malariae can also arise
from emerging liver stage merozoites [16] . Whereas these three spe-
cies produce gametocytes within the same time frame as asexual
parasitemia, P. falciparum gametocyte production is delayed in
comparison [17] . As a consequence, a higher proportion of P.vivax
malaria patients are found with gametocytes shortly after devel-
oping symptoms than in patients with P. falciparum [18] , and
P.vivax infections can be transmitted before becoming sympto-
matic. Gametocytes are ingested by female Anopheles mosquitoes
in a blood meal and they undergo sexual reproduction in the
mosquito midgut, eventually forming an ookinete that crosses
the midgut wall and develops into an oocyst. The oocyst pro-
duces sporozoites that migrate into the mosquito salivary gland,
waiting to be injected into a susceptible host at the time of the
anophelines next blood meal. The extrinsic incubation period
of the Plasmodium parasite within the mosquito is temperature
dependent and ranges from 10 to 14days for P. falciparum [19]
and 11 to 22days for P. vivax [20] .
Why are some malaria infections asymptomatic?
Partial immunity to malaria infections can lead to a reduction
in the acute clinical symptoms of disease. Antidisease immu-
nity is acquired from exposure to malaria infection and develops
more quickly with frequent exposure; most children in areas with
moderate-to-high levels of malaria transmission gain protection
from severe disease by a very young age, usually by 25years
of age, followed by a decrease in the rate of symptomatic ill-
ness in early adolescence [21] . By contrast, antiparasite immunity
increases with maturation of the immune system and appears
to be somewhat independent of exposure frequency in areas of
moderate-to-high transmission. By adulthood, parasite densities
following infection often remain at very low levels, frequently
undetectable by microscopy, and most infected adults do not
exhibit clinical symptoms. However, asymptomatic parasitemia
can occur at any age.
Development of partial immunity to clinical malaria is antigen-
specific, mediated by exposure to different genetically distinct
parasite subpopulations, termed clones. Cross-protection can be
conferred by antigenically similar clones [22] ; in areas of high
transmission, residents are frequently exposed to a diversity of
clones, resulting in rapid development of antidisease immunity
and asymptomatic infections [23] . In areas of low transmission,
however, there is a lower rate of multiclonal infections and
antidisease immunity develops more slowly [24] .
Immunity to P. vivax is acquired more rapidly than to
P.falciparum. In Papua, New Guinea, children aged 513years
were 21-times more likely to experience fever after infection with
P. falciparum than P. vivax [25] . These findings were mirrored
in children aged 14years of age who showed an increasing
ability with age to keep parasite densities of P. vivax, but not
P.falciparum, below the pyrogenic threshold [26] .
Expert Rev. Anti Infect. Ther. 11(6), (2013)
 Asymptomatic parasitemia & malaria transmission
How is asymptomatic parasitemia defined?
There is no standard definition of asymptomatic parasitemia, and
previous studies have used a range of definitions and diagnostic
criteria. Most definitions involve the detection of asexual or sexual
parasites and an absence of any acute clinical symptoms of malaria
(usually fever) during a specified time frame. Whereas it is not
always explicit, asymptomatic parasitemia refers to bloodstream
infections and does not include dormant liver stages.
A number of studies have used parasite density thresholds to
define cases of clinical malaria, that is, only cases of fever with
parasite densities above a predetermined cutoff were considered
to be symptomatic malaria cases [27] . This results in a defacto
classification of febrile infections with low density parasitemia
as asymptomatic, since their fever was not statistically attributed
to malaria. While the use of parasite density threshold cutoffs
provides a more specific end point for studies of vaccines or
clinical treatments [28] , its converse should not be used to define
asymptomatic parasitemia for burden or impact assessments.
Laishram etal. provide a list of diagnostic criteria that have
been used in various studies to define asymptomatic malaria cases
(Table 1) [29] . The duration of time used to define an infection
as asymptomatic, both prior to and after the diagnosis, varies
between studies; many have defined asymptomatic infection
as no measured fever at the time of the survey, whereas others
have required as many as 60days of follow-up without clinical
symptoms [30] . In some cases, fever is the only clinical symptom
considered whereas other studies include a variety of additional
nonspecific disease symptoms. When follow-up periods are not
monitored for the development of symptoms, there may be a
concern that parasitemia detected during the malaria incubation
period may be misclassified as an asymptomatic infection, but
given the short duration of the time between the completion of the
prepatent period and the end of the incubation period (~1day for
P. falciparum and 4days for P. vivax), this is likely an infrequent
occurrence. In some studies, cases have been excluded if they
reported prior use of antimalarial medication to avoid infections
in the process of being cleared.
Gametocytes do not cause disease symptoms, and asympto-
matic individuals may or may not have detectable gametocytes.
The relationship between asexual parasite density and gametocyte
density is not straightforward; studies have found both positive
and negative associations [31] . Gametocytes may linger in peri
pheral blood up to several weeks after an asexual parasite infection
has been cleared (whether by natural immunity or by drugs); one
trial demonstrated that gametocytes persist an average of 55days
after treatment with a non-ACT and 13.4days after treatment
with an ACT [32] .
What factors are associated with asymptomatic
malaria infection?
Immunity is the factor that most strongly determines whether
a malaria infection produces symptoms. An individuals level
of immunity to infection is determined by past exposure his-
tory and age. Increased immunity leads to improved control
over parasite multiplication and decreased parasite density,
www.expert-reviews.com
Review
which in turn lessens the severity of symptoms. In a national
survey in Mozambique, children <10years of age with low-
density P. falciparum infections (1499 parasites [p]/l) had a
prevalence of fever of 7.2%, compared with 42.1% among chil-
dren whose asexual parasite densities were 50,000 p/l [33] . In
Brazil, parasite density was compared between symptomatic (age
1278years) and asymptomatic (age 456years, with no fever or
malaria symptoms for 7days prior to blood collection) individu-
als infected with P. vivax and P. falciparum; lower asexual parasite
densities were found among the asymptomatic individuals for
both parasite species, although the difference was much greater
for P. vivax [34] .
Some asymptomatic infections may be residual or recrudescent
parasitemia remaining after treatment for a clinical episode. In a
low-transmission setting in Sudan, a higher proportion of people
who experienced a clinical episode of malaria during the trans
mission season from September to December had an asympto-
matic infection detected by PCR in the following January than
did those without a prior clinical episode (35 vs 8%, respectively),
despite having been clinically cured of their symptomatic infec-
tion by treatment with chloroquine [35] . It is possible that drug-
resistant parasites could persist at a low level after treatment, with
densities controlled by immunity developed during the initial
infection [36] . However, the parasites in these infections were
not genotyped to determine whether they were the same clones
present during the clinical episode or new infections.
Coinfections may affect the development of symptoms by alter-
ing immune system function. HIV-1 infection has been shown
to increase rates of malarial fevers in a doseresponse fashion,
with declining CD4 T-cell counts [37] . The association between
soil-transmitted helminths and development of clinical symptoms
among children with malaria parasitemia is less clear: hookworm
infection appears to increase malaria symptoms, whereas infec-
tion with Ascaris lumbricoides appears to decrease symptoms [38] .
Coinfection of malaria and schistosomiasis is a frequent occur-
rence, but the effects on malaria immunity and transmission are
complex. Some studies suggest that s chistosomiasis coinfection
favors development of antimalarial immunity [39,40] , whereas
others have found lower levels of protective malaria antibodies
in Schistosoma haematobium carriers [41] . A recent prospective
study demonstrated that children coinfected with malaria and
schistosomiasis were more likely to have detectable gameto-
cytes and higher gametocyte densities than children infected
only with malaria, potentially facilitating more intense malaria
transmission [42] .
The method used to diagnose infection will determine the num-
ber of low density, asymptomatic infections that are identified. The
detection limits of microscopy are typically estimated at 420p/l
in a reference laboratory, but are more realistically 50100p/l
under field conditions [43] . A few rapid diagnostic tests (RDTs)
have been shown to have greater than 90% sensitivity and specific-
ity for P. falciparum at parasite densities 200p/l [4345] but may
often fail to detect lower density infections. PCR is considered to
be the gold standard for detection of parasitemia with a limit of
detection of 0.02p/l for the most sensitive procedures [46] .
625
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker

Table 1. Examples of diagnostic criteria used for defining malaria patients as asymptomatic.
Study (year), Criteria used for identifying asymptomatic malaria Study subjects, Follow-up protocol Ref.
region cases sample size (n) and duration
Africa
Abdel-Latif et al. No clinical symptoms of malaria with a Plasmodium falciparum Children 6 months to Examined once daily [92]
(2003), Gabon positive blood smear, asymptomatic for at least 5 days during 10 years of age (60) for 7 days; thereafter,
follow-up once every 2 days
Rottmann et al. Presence of P. falciparum on blood smear, axillary temperature Children 459 No follow-up [93]
(2006), Tanzania of <37.5C and no other symptoms or signs of malaria months of age (127)
South America
Alves et al. (2002), Individuals tested positive with microscopy and/or with PCR, All age groups (172) Follow-up on days 10 [94]
Brazilian Amazon and individuals tested negative with microscopy, which and 60
subsequently became positive using PCR
Cucunub et al. Presence of patent asexual parasite stages of P. falciparum, Individuals 278 years Follow-up on days 14 [95]
(2008), Colombia Plasmodium vivax or Plasmodium malariae or of mixed of age (21) and 28
infections in blood, which persisted for at least 2 weeks
without causing any symptoms, or as the detection of parasite
DNA by PCR on day 0 in people who remained asymptomatic
during the follow-up period
Asia
Boutlis et al. No fever history or treatment for malaria within the past Adults >16 years of Supervised overnight [96]
(2003), Papua week, no clinical evidence of malaria or other infection, no age (105) at local health center.
diarrhea and no current pregnancy but both A third axillary
P.falciparum-and P. vivax-positive individuals temperature was
recorded the
following morning
de Mast et al. Presence of asexual P. falciparum or P. vivax parasitemia in the Children 515 years No follow-up [97]
(2010), Indonesia absence of fever (temperature 37.9C) and clinical signs or of age (381)
symptoms that are suggestive for malaria or another
infectious disease
A more comprehensive list of studies is given in the supplementary material of [29].

A review of studies reporting both PCR and microscopy results
for P. falciparum detection found that, on average, microscopy
underestimates the prevalence of Plasmodium infection as
detected by PCR by 50.8%, and this difference is greatest in low-
transmission settings [14] . RDTs, with detection thresholds higher
than microscopy, would also be expected to underestimate the
proportion of the population that has an infection, most of which
will be asymptomatic. As a result, interpretation of estimates of
asymptomatic infections should consider the diagnostic method
used. Despite the increased sensitivity of PCR over microscopy
and RDTs, there is still concern that it may not detect all malaria
cases with very low parasite densities [47] .
Does the prevalence of asymptomatic parasitemia vary
by Plasmodium species?
All malaria species can infect without causing symptoms, but
because P. falciparum and P. vivax are more prevalent globally,
more asymptomatic infections of these two species occur than the
other two human malaria species. Asymptomatic infections with
P. ovale are rare but have been noted [48,49] , whereas P. malariae is
known to persist in the bloodstream for decades without causing
any, or only mild, symptoms [48] .
Individuals with P. vivax develop immunity more quickly
than with P. falciparum and consequently are able to control
parasite densities to a greater degree, but it is not clear whether
this translates into a different proportion of infections that are
asymptomatic by species. Few comparisons of the prevalence of
symptoms among individuals infected with P.falciparum and
P. vivax have been conducted in areas where the two species
are sympatric, and results are contradictory. Using microscopy
to diagnose infections, a larger proportion of P. falciparum
infections (37.5%) compared with P. vivax infections (18.5%)
in Brazil were asymptomatic (presenting with none of the
13malarial symptoms) [50] . In comparison, a greater propor-
tion of P. vivax infections (97.1%) in the Solomon Islands
compared with P. falciparum infections (82.2%) were asymp-
tomatic (axillary temperature: <38C) [51] . Few studies have
reported both the number of species-specific malaria cases and
species-specific symptom rates, and diagnosed all infections by
PCR; in Cambodia, 92% of the P. falciparum and 83% of the
P.vivax infections were asymptomatic [52] , whereas in Brazil,
these proportions were 78 and 93%, respectively [53] . While it
appears that the majority of prevalent infections of both species
are asymptomatic in cross-sectional surveys, there are no data

626 Expert Rev. Anti Infect. Ther. 11(6), (2013)

 Asymptomatic parasitemia & malaria transmission
to suggest that either species is associated with a larger reservoir
of a symptomatic infections.
Do asymptomatic blood-stage infections eventually
become symptomatic?
Studies have suggested that a proportion of people with asympto
matic blood-stage malaria infection may become symptomatic,
although reinfections or other causes of fever cannot always be
ruled out. In Brazil, 93 asymptomatic (presenting with none of
13 malarial symptoms) infections in 33 persons aged 5years
and older were followed for 2months after their infection was
identified and ten (10.7%) became symptomatic during that
period [50] . However, the background transmission rate would
suggest that eight of those cases could have been the result of
new infections. In a cohort study of asymptomatic (defined as
no self-reported fever for the previous 24h and axillary tempera-
ture <37.5C) parasitemic Tanzanian children aged 15years
who were followed over 31days, 55.9% (19 out of 34) of the
children eventually developed fever, which was associated with
spikes in parasite density [23] . Aprospective study of the risk
of developing clinical malaria in a high-transmission area of
Tanzania followed 265 parasitemic but asymptomatic (no fever
during previous 4weeks or during 1week after recruitment)
residents aged 184years of age over 40weeks, and observed
21 (7.9%) cases of fever in conjunction with a parasite density
>400 p/l [54] .
Subpatent asymptomatic infections may be less likely to
become symptomatic than infections detectable by microscopy.
In Uganda, 25 out of 63 (39%) children aged 6months to 5years
with subpatent infections who were asymptomatic (no malaria
treatment in previous 2weeks or fever in previous 48h) devel-
oped symptoms within 20weeks of observation compared with
43 outof 53 (82%) children with patent infections [55] . These
findings suggest that low-density malaria infections may persist
for long periods without causing symptoms if not treated.
It is not clear what triggers the appearance of symptoms in
individuals who have been parasitemic but remained asympto-
matic for a period of time. It has been suggested that reinfection
with new clones (to which the individual had not previously been
exposed) could trigger an increase in parasite density and the
development of symptoms [56] , but other studies have demon-
strated that symptoms can appear without any change in clonal
diversity [55] .
How long do asymptomatic infections last?
As described above, some portion of asymptomatic infections
may become symptomatic and receive appropriate antimalarial
treatment. However, many asymptomatic infections can per-
sist for significant periods of time. Reports in the literature of
soldiers returning home from malaria-endemic areas have dem-
onstrated asymptomatic infections lasting up to 13months for
P.falciparum [57] . A statistical modeling approach combined with
highly sensitive molecular techniques using an all-age cohort in
Ghanaan area of high P. falciparum transmissionestimated between a symptomatic infection and gametocyte density has
that untreated asymptomatic infections had a mean duration of
www.expert-reviews.com
Review
194days (95%CI: 191196) [58] . In areas of highly seasonal
transmission, low-density asymptomatic infections are believed to
persist over the course of the dry season and to reseed transmission
when mosquito populations increase along with wetter conditions
[59,60] . P. malariae has been found in at least one case to remain
asymptomatic for decades [61] .
Does the prevalence or density of gametocytes differ
between symptomatic & asymptomatic infections?
Several studies have shown that the presence of P. falciparum
gametocytes is positively associated with an absence of symp-
toms and low asexual parasite densities. While some anti
malarial treatments such as sulfadoxinepyrimethamine (SP)
may stimulate the production of gametocytes [62] , this associa-
tion has been detected even when non-gametocyte-stimulating
treatments or no treatments have been used, and may arise
from the natural concurrence between resolving infections and
the delay before gametocytes are produced in P. falciparum
infections. On the western border of Thailand, being afebrile
and having low P.falciparum asexual parasite densities were
independently associated with increased prevalence of game-
tocytemia [63] . Researchers in The Gambia evaluating children
with P.falciparum infections at enrollment for antimalarial trials
found that being afebrile at the time of examination increased
the risk of gametoc ytemia by 67%, and having lower asexual
parasite density (<100,000p/l) increased the risk fivefold [64] .
Similarly, in children with P.falciparum infections in Nigeria,
being afebrile (a xillary temperature 37.5C) was associated with
a 61% increase in gametocytemia, and having asexual parasite
densities <5000p/l more than doubled the odds of being game-
tocytemic [65] . None of these studies used PCR to detect game-
tocytes, suggesting that the prevalence of gametocytemia may
have been underestimated; however, it is unlikely that this would
have changed the association described between asymptomatic
infections and the presence of gametocytes.
Whereas a greater proportion of asymptomatic infections
may have gametocytes, it is not clear whether gametocyte den-
sity will be higher. As gametocytes in P. falciparum infections
arise from asexual parasites (i.e., merozoites), there could be a
positive correlation between the density of asexual and sexual
parasite infections, leading to an association between low den-
sity, asymptomatic infection and lower gametocyte densities.
However, it is also possible that inflammatory and nonspe-
cific immune factors related to symptomatic infections may
negatively affect gametocyte production, potentially leading to
higher gametocyte densities among asymptomatic infections.
In Brazil, asymptomatic P.vivax gametocyte carriers had lower
gametocyte densities as measured by PCR than symptomatic
individuals [66] . However, in Kenya, asymptomatic P. falciparum
gametocyte carriers had higher gametocyte densities, but lower
asexual parasite densities than symptomatic individuals [67] .
These inconsistencies could be attributed to differences in the
biology of P.falciparum and P.vivax. No clear relationship
been established.
627
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker
How much do asymptomatic infections contribute to
transmission?
Gametocyte density appears to be a critical factor in determining
whether a mosquito develops infection from an infective blood
meal. An analysis of 930 transmission experiments showed a
largely loglinear positive relationship between gametocyte den-
sity and the prevalence of infection in mosquitoes [68] . This sug-
gests that if asymptomatic infections are associated with lower
gametocyte densities, asymptomatic infections would be less likely
to result in mosquito infections. In a Brazilian study aimed at
demonstrating the viability and contribution of asymptomatic
infections to malaria transmission, 1.2% of the mosquitoes feed-
ing on asymptomatic persons (n=15) versus 22% of the mosqui-
toes feeding on symptomatic persons (n=17) developed oocysts
in their midguts [30] . Different feeding techniques in the two pop-
ulations may have affected the comparison but it is likely that the
lower gametocyte density among the asymptomatic individuals
contributed to the observed differences in mosquito infection.
Despite increasing probability of infection with increasing
gametocyte density, numerous studies have demonstrated that
mosquitoes can become infected by blood from individuals with
gametocyte densities as low as five gametocytes (g)/l, and theo-
retically as low as 1g/l [69] . To look at the relative transmissibility
of infections when gametocytes were detectable by microscopy,
by PCR or were not detectable, researchers in western Kenya
used venous blood from children with and without gametocytes
detected by microscopy to feed mosquitoes through membrane
feeders [70] . Blood from children with subpatent gametocytes
infected half as many mosquitoes as those with patent gameto-
cytemia, but due to the frequency of subpatent gametocytemia
in the sample of children, the end result was that both groups
contributed equally to the total number of infected mosquitoes.
In this study, children with gametocytemia that was undetect-
able even by PCR were still found to contribute to almost 10%
of the overall number of infected mosquitoes, demonstrating
that gametocytes below detection thresholds can still result in
malaria transmission. P. vivax and other Plasmodium species are
more efficient at transmitting earlier in the infection and at lower
densities than P. falciparum, and therefore a greater proportion
of individuals infected with these species can transmit without
detectable gametocytemia [69] .
There may be factors associated with the presence of symptoms
that alters infectivity to mosquitoes. In western Kenya, a signifi-
cantly smaller proportion of mosquitoes that fed on blood from
symptomatic individuals (0.6%) developed oocysts than those
that fed on asymptomatic persons (12%) [67] . Although symp-
tomatic individuals were found to have higher asexual but lower
gametocyte densities than asymptomatic individuals, the authors
concluded that the increased oocyst development in mosquitoes
that fed on asymptomatic individuals was not due solely to the
higher gametocyte densities, but also to an increased infectivity
of these gametocytes. This increased quality of gametocytes has
been postulated by others [29] and could be due to a variety of
factors, including the stage of development of the gametocytes
(for P. falciparum, symptoms tend to occur earlier in infection
628
when gametocytes may not have reached a level of maturity to be
optimally infective), an inherent property of the parasite strain,
a direct effect of symptomatology (i.e., the febrile response may
affect the infectivity of gametocytes), or to a more specific host
immune response, such as transmission-reducing antibodies [17] .
Are individuals with asymptomatic infections more
likely to get bitten by malaria vectors?
There is no direct evidence that individuals with asymptomatic
infections are more likely to be bitten than symptomatic individu-
als, but gametocyte carriers have been shown in one study to be
more attractive to mosquitoes than both uninfected individu-
als and individuals with only asexual parasites. Comparing the
same children before and after they were cleared of P.falciparum
gametoc ytes to control for inherent differences in individual
attractiveness, researchers in Kenya were able to show that
Anopheles gambiae were more attracted to children when they
were gametocytemic than when they were uninfected or when
they harbored only asexual parasites [71] . As asymptomatic indi-
viduals infected with P.falciparum may be more likely to be
gametocytemic than symptomatic individuals, it is possible that
asymptomatic persons have an increased likelihood of being bit-
ten, but there is no clear evidence yet to support this hypothesis,
nor is there any information on P.vivax infections.
How does transmission intensity affect the prevalence
of asymptomatic parasitemia?
It has long been held as conventional wisdom that in lower
transmission settings, the proportion of infected individuals who
are asymptomatic will be less than in high-transmission settings
because the population level of immunity is decreased [72] . Figure1
(updated from data presented by Macauley [73] to include more
recent surveys that use PCR) shows the proportion of malaria
infections (all species) that are asymptomatic across a wide range
of transmission, prepared from 16 different sites in 14 countries.
Only studies that measured the point prevalence of all malaria
infections using a population-based cross-sectional survey design
and included the number of infections that were asymptomatic
were included, although the symptoms and the reference time
period used in the definition of asymptomatic differed between
studies. The data suggest that, while there is an increase in the
proportion of the parasite reservoir that is asymptomatic as trans-
mission increases, the majority (>60%) of prevalent infections
are asymptomatic even at low transmission. Studies using PCR
had the highest rates of asymptomatic parasitemia, but even
some studies based on microscopy found greater than 80% of
the cases of parasitemia to be asymptomatic. Many of the stud-
ies did not report information allowing calculation of the pro-
portion of asymptomatic infections by species, but seven studies
that reported on P. falciparum found 7398% of infections to be
asymptomatic, and the five studies reporting on P. vivax found
64100% of infections to be asymptomatic.
The data presented by this graph challenge conventional
wisdom and understanding of how immunity develops, but the
malaria cases reported in these studies were identified through
Expert Rev. Anti Infect. Ther. 11(6), (2013)
 Asymptomatic parasitemia & malaria transmission Review

active surveillance and are estimates of

point prevalence. Prevalence is a product 100
of incidence and duration of infection; as
90
symptomatic infections are more likely
to receive treatment, and the duration of 80
treated infections is significantly shorter

Proportion of malaria infections

that are asymptomatic (%)
than untreated infections, it follows that 70
symptomatic infections are less likely than
60
asymptomatic infections to be present at
any one point in time. Similarly, once 50
appropriate treatment is provided, symp-
toms may resolve more quickly than infec- 40
tion. The few studies that have attempted
to capture all new infections over a period 30
of time, both symptomatic and asymp-
20
tomatic, have found a lower proportion
of asymptomatic infections using cumu- 10
lative incidence than point prevalence.
Employing a combination of passive and 0
0 10 20 30 40 50 60 70 80 90 100
active case detection over a 14-month
Prevalence of malaria (%)
period to identify all new malaria infec-
tions in an area of Brazil, 326episodes
Figure 1. The proportion of malaria infections that are asymptomatic compared
of malaria were identified, of which 96 with population prevalence of malaria across 16 sites in 14 countries. Error bars
(29.4%) were asymptomatic at the time of correspond to the 95% CI. Hollow and filled shapes indicate diagnosis by microscopy and
diagnosis [50]a proportion much lower PCR, respectively. Diamonds, triangles and squares indicate surveys conducted in Asia,
than has been found in any cross-sectional Latin America and Africa, respectively.
survey. Data taken from [35,36,51,52,94,114,120,124,126132] .
Without a strong association between
transmission intensity and the proportion of infections that trend in the proportions of infections that are asymptomatic with
are asymptomatic, the population prevalence of asymptomatic age across the five sites, but confidence intervals are wide. The lack
malaria infection mirrors the overall transmission level. Figure 2 of more significant differences by age could be a result of using
demonstrates the relationship between the prevalence of infec- prevalent rather than incident infections, or the age groupings may
tion, as detected by PCR, among asymptomatic individuals and be too wide to detect differences between age categories.
transmission intensity (as measured by the overall prevalence of
infection) in 34 different studies in 38 sites in Latin America What public health interventions target asymptomatic
(n=9), Asia (n=10) and sub-Saharan Africa (n=19). In this parasitemia?
analysis, studies using a population-based cross-sectional survey There are a number of drug-mediated strategies that implicitly
design, in which the asymptomatic population could be identi- or explicitly target the asymptomatic parasite reservoir. By defi-
fied and malaria was confirmed using PCR, were included. Age nition, these strategies do not rely on any symptomatic trigger,
groups varied, but there is a positive correlation between trans- and thus do not include health facility treatment, community
mission intensity and the prevalence of malaria infection among case management, or fever surveys. Essentially, there are three
asymptomatic individuals (Table 2) . approaches that will target drugs to the asymptomatic parasite res-
ervoir: providing the population in a given geographic area with
How does age affect the proportion of malaria antimalarials irrespective of their infection or symptom status
infections that are asymptomatic? (mass drug administration [MDA]); universal screening of the
In areas of high malaria transmission, the proportion of the popu- population with a malaria diagnostic test, followed by treatment
lation that is parasitemic tends to decrease with age [31,74] , although of those infected (mass screen and treat [MSaT], also referred to
this relationship may be somewhat muted when molecular assays as aggressive-active case detection) [73] ; and repeated treatment of
are utilized [75] . Conversely, the proportion of malaria infections high-risk groups with an antimalarial not guided by diagnostic
that are asymptomatic generally increases with age, presumably testing (intermittent preventive therapy). Whereas the primary
due to acquired immunity and maturation of the immune system. objective of the first two approaches is a reduction of malaria
After manipulating age categories to develop consistent groupings transmission, intermittent preventive therapy strategies were con-
between studies, Figure 3 presents the proportion of malaria infec- ceived to reduce the burden of malaria and associated adverse con-
tions by age (04, 514 and 15+years) across three studies in five sequences in high-risk groups, although theoretically, there may
sites that used PCR for diagnosis. There is a consistent positive be an impact on transmission if the high-risk group comprises a

www.expert-reviews.com 629
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker
100
90
Proportion of asymptomatic population
80
with malaria parasitemia (%)
70
60
50
40
30
20
10
0
Low Medium
Transmission intensity
Figure 2. Studies reporting on the proportion of the asymptomatic population
with malaria parasitemia as diagnosed by PCR, by estimated malaria
transmission intensity (n=39). The top and bottom of the error bars indicate the
maximum and minimum malaria prevalence, respectively; the dark line in the box
indicates the median prevalence; and the top and bottom of the box indicate the 75th
and 25th percentile, respectively.
Data taken from [5153,77,91,95,98126] .
significant proportion of the infective reservoir. These approaches
can be modified by targeting smaller geographic areas (such as
hotspots of transmission) or combined with other interventions,
such as follow-up of passively detected cases, to fit different trans-
mission settings and objectives [76] . Additionally, the frequency
of MDA and MSaT can be adjusted in light of the underlying
transmission intensity, seasonality and type of antimalarial used.
What theoretical data suggest that these approaches
can reduce malaria transmission?
Several modeling attempts have demonstrated that targeting the
asymptomatic parasite reservoir with MSaT or MDA could result
in reductions in malaria transmission, even though some of the
effects were modest [9,77,78] . Griffin etal. found that absolute
reductions of 512% in parasite prevalence could be achieved in
low-to-moderate transmission settings (entomologic inoculation
rates of 794infective bites per person per year) with 80% cover-
age of annual single rounds of MSaT using RDTs, in conjunction
with 80% ITN coverage over 15years of sustained program; the
addition of IRS would significantly improve the final outcome
[9] . In areas with high malaria transmission (entomologic inocula-
tion rates of 630and 703 infective bites per person per year), the
modeled impact of MSaT alone was marginal, with the ultimate
outcomes depending greatly on the initial transmission level as
well as the frequency and duration of the intervention and the
level of vector control established in conjunction.
630
Using the same basic underlying model,
Okell etal. examined the impact of MDA
and MSaT under different assumptions of
coverage, drug choice, timing and screen-
ing sensitivity, and found that MDA could
significantly improve chances for malaria
elimination in small, concentrated pockets
of transmission [78] . In areas of moderate
transmission (baseline parasitemia preva-
lence: 1030%), single rounds of MDA
would not have a lasting effect, but repeated
rounds could reduce malaria transmission
substantially. The authors found that in
these higher transmission settings, MSaT
using microscopy to identify infections
had less of an impact than MDA, but they
noted that information on the infectivity
of subpatent infections is limited.
High
What empirical data suggest that
these approaches can reduce
malaria transmission?
Italy was the first country to implement
MDA on a large scale beginning in 1900,
through both quinine prophylaxis and cura-
tive treatment [79] . This approach led to large
reductions in malaria morbidity and mor-
tality, but the country eliminated malaria
only after an IRS program using DDT
was added to the MDA with quinine after World War II. Since
the 1930s, at least two dozen additional MDA interventions have
been conducted [80] . Whereas many MDA interventions achieved
temporary reductions in malaria morbidity and transmission, few
had rigorous study designs and MDA was often combined with
other interventions. Only one project on the small, isolated island
of Aneityum in Vanuatu succeeded in permanently interrupting
transmission through a combination of weekly chloroquine, SP
and primaquine, as well as high coverage of ITNs [81] . In 1981,
70% of the Nicaragua population participated in a 3-day MDA
with chloroquine and primaquine. The immediate impact of the
MDA was substantial but the effect lasted only a few months [82] .
The first large-scale community-randomized, placebo-con-
trolled trial of MDA in Africa, which took place in The Gambia
in 1999, found that one round of MDA with SP and single-
dose artesunate in the dry season resulted in a brief reduction
in malaria incidence that was not sustained over the 20-week
observation period [83] . The only other recent trial of MDA in
Africa attempted to interrupt malaria transmission in Tanzania
using a treatment course of artesunate and SP plus primaquine
to clear gametocytes [84] . However, despite achievement of high
coverage, transmission intensity was too low overall to demon-
strate any impact. A recent trial of MDA with one round of a
full course of dihydroartemisininpiperaquine and a low dose of
primaquine every 10days for 6months in 17villages of Cambodia
found that parasite prevalence among both children and adults
Expert Rev. Anti Infect. Ther. 11(6), (2013)
 Asymptomatic parasitemia & malaria transmission Review

Table 2. Studies reporting on malaria prevalence in asymptomatic individuals diagnosed using PCR.
Study (year), Study design Age group Patients Patients Patients Patients Ref.
country (years) tested (n) positive for positive for positive for
malaria (%) Plasmodium Plasmodium
falciparum (%) vivax (%)
Low transmission
Fernando etal. (2009), Cross-sectional All age 1854 0 [98]
SriLanka groups
Turki etal. (2012), Iran Cross-sectional 460 500 0 [99]

Zoghi etal. (2012), Iran Cohort of 500patients 260+ 1000 0 [100]

in each of two study
areas (threecross-
sectional surveys)
Atkinson etal. (2012), Cross-sectional All age 541 0.6 0 0.6 [101]
Solomon Islands groups
Kumudunayana etal. Cross-sectional All age 140 1.4 0 1.4 [102]
(2011), SriLanka groups
Hoyer etal. (2012), Focused screening and All age 6310 1.8 0.9 1.0 [52]
Cambodia treatment groups
Congpuong etal. Cross-sectional All age 475 1.9 [103]
(2012), Thailand groups
Diallo etal. (2012), Stratified urban sample 210 2231 2.2 [104]
Senegal
Eisele etal. (2011), Cross-sectional All age 647 2.2 2.2 0 [105]
Haiti groups
Barracks etal. (2010), Cross-sectional 212 4230 2.5 [106]
Vanuatu
Hsiang etal. (2010), Cohort 110 472 3.2 3.2 0 [107]
Uganda
Harris etal. (2010), Cross-sectional All age 8107 3.6 [51]
Solomon Islands groups
da Silva etal. (2010), Cross-sectional 5+ 334 4.8 2.4 2.4 [108]
Brazil
Kritsiriwuthinan and Cross-sectional Adults 241 6.2 3.3 2.5 [109]
Ngrenngarmlert
(2011), Thailand
Stresman etal. (2010), Cohort All age 176 7.4 7.4 0 [91]
Zambia groups
Harris (2010), Solomon Cross-sectional All age 9,491 8.2 4.5 2.8 [51]
Islands groups
Roper et al. (1998), Serial cross-sectional All age 77 10.4 10.4 0 [110]
Sudan studies groups
Rodulfo et al. (2007), Cross-sectional All age 133 10.5 3.8 6.0 [111]
Venezuela groups
Gahutu et al. (2011), Cross-sectional 05 529 13.2 13.2 0 [112]
Rwanda
Katsuragawa etal. Cross-sectional 5+ 324 13.9 1.2 12.7 [113]
(2010), Brazil
Cucunub et al. Cross-sectional with All age 212 14.6 4.2 9.4 [95]
(2008), Colombia follow-up on days 14 groups
and 28

www.expert-reviews.com 631
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker

Table 2. Studies reporting on malaria prevalence in asymptomatic individuals diagnosed using PCR (cont.).
Study (year), Study design Age group Patients Patients Patients Patients Ref.
country (years) tested (n) positive for positive for positive for
malaria (%) Plasmodium Plasmodium
falciparum (%) vivax (%)
Low transmission (cont.)
Camargo et al. (1999), Longitudinal All age 169 14.8 0 14.8 [114]
Brazil groups
Alves et al. (2002), Cross-sectional All age 147 15.0 4.8 9.5 [53]
Brazil groups
Frnert et al. (2009), Cross-sectional survey 011 273 16.8 16.8 0 [115]
Kenya with follow-up
Moderate transmission
Ladeia-Andrade et al. Five cross-sectional All age 644 9.6 3.4 6.2 [116]
(2009), Brazil surveys (different groups
villages)
Vafa et al. (2008), Cross-sectional survey 210 372 13.7 13.7 0 [117]
Senegal as part of cohort study
Suarez-Mutis and Cross-sectional All age 98 20.4 0 20.4 [118]
Coura (2007), Brazil groups
Baliraine et al. (2009), Pooled data from 12 514 81 22.6 22.6 0 [119]
Kenya monthly cross-
sectional surveys of a
cohort
Baliraine et al. (2009), Pooled data from 12 514 81 25.8 25.8 0 [119]
Kenya monthly cross-
sectional surveys of a
cohort
Baliraine et al. (2009), Pooled data from 12 514 2611 33.3 33.3 0 [119]
Kenya monthly cross-
sectional surveys of a
cohort
Pinto et al. (2000), So Cross-sectional All age 81 35.7 28.6 2.4 [120]
Tome and Principe groups
Kern et al. (2011), Cross-sectional survey 011 264 36.7 36.7 0 [77]
Kenya with follow-up
Crookston et al. Cross-sectional 05 84 51.9 51.9 0 [121]
(2010), Ghana
Liljander et al. (2011), Cross-sectional 16 360 58.9 58.9 0 [122]
Kenya
High transmission
Koukouikila- Cross-sectional survey 19 313 16.3 16.3 0 [123]
Koussounda etal. of cohort of children
(2012), Congo
Bereczky et al. (2007), Cross-sectional part of 184 756 38.0 38.0 0 [124]
Tanzania cohort study
Dal-Bianco etal. Cross-sectional 1851 470 51.9 51.9 0 [125]
(2007), Gabon
Pinto et al. (2000), So Cross-sectional All age 563 53.3 51.6 2.9 [120]
Tome and Principe groups
Owusu-Agyei et al. Cross-sectional All age 297 82.5 82.5 0 [126]
(2002), Ghana groups

632 Expert Rev. Anti Infect. Ther. 11(6), (2013)

 Asymptomatic parasitemia & malaria transmission
was dramatically reduced after 3years from 52.3 to 2.6%, as
measured by microscopy [85] .
The Malaria Eradication Program of the 1950s and 1960s used
screening of symptomatic individuals through mass fever surveys
as an intervention, and in 1960, this approach was proposed to be
extended to asymptomatic carriers [86] . MSaT of asymptomatic
carriers was carried out on a large scale in Taiwan, India, Oman,
Brazil, China and on one island of the Philippines, and led to large
reductions in malaria and, in one case (Taiwan), elimination [73] .
In the USSR, significant declines in malaria cases to near-elim-
ination levels resulted after the implementation of mass surveys
in the late 1950s focused on asymptomatic parasite carriers [87] .
China was also able to achieve malaria elimination in a signifi-
cant proportion of the country in the second half of the 20th
century through rigorous active case detection focused on both
symptomatic and asymptomatic individuals [88,89] . Despite their
apparent success, these early experiences with MSaTfrom the
1950s to the 1990stypically did not have a control group and
were often implemented in combination with other interventions.
One variation on MSaT is screening and treating only within
known malaria hotspots, also termed focal or focused screen and
treat (FSaT). Given the focalized nature of malaria, particularly
in low-transmission settings, FSaT has the potential to more
efficiently target screening and treatment resources to areas that
could have a disproportionate impact on transmission reduction.
The malaria control program of Zanzibar, conducted prior to the
transmission season, has experimented with FSaT in hotspots and
documented significant decreases in malaria cases in the inter
vention areas over time and compared with control areas [90] .
FSaT using PCR was used in 20 villages of Cambodia in 2010,
reaching 6931 (72.7%) residents over a 5-month period [52] . A
total of 133 infections were detected and successfully treated, but
the impact on transmission is not yet known.
Using passively detected, symptomatic cases to identify high-
risk households or geographic areas has been referred to as reac-
tive or targeted case detection. In response to a household with
a positive case, other household members along with the popu-
lation within some distance of the index household would be
screened and treated [13] . Depending on how clustered or focalized
malaria transmission is in the area, reactive case detection could
more efficiently identify asymptomatic infections than MSaT.
Using this approach in Zambia, members of RDT-positive house-
holds, passively detected clinical malaria cases had a prevalence
of malaria parasitemia by nested PCR of 8.0% compared with
0.7% in households in which no member had sought treatment
for clinical illness [91] . The study was not designed to evaluate the
impact of the approach on malaria transmission. Both Zanzibar
and selected areas of Zambia have implemented reactive case
detection in a programmatic fashion, although results are not
yet available on the impact of this approach on malaria prevalence
and transmission.
Conclusion
Individuals who receive repeated malaria infections over time
eventually achieve increased immune control with a resultant
www.expert-reviews.com
Review
decrease in acute symptoms. Without clinical illness, these infec-
tions are silent and remain untreated, resulting in chronic carriage
that can last for 6months or longer. Asymptomatic infections may
be associated with a greater probability of gametocyte carriage,
although there is also likely to be a lower density of gametocytes
in these individuals, and these effects may cancel themselves out
with respect to altering the infectivity of asymptomatic infections.
However, the proportion of mosquito infections that arise from
asymptomatic infections is likely to be high due to a combination
of the proportion of asymptomatic infected individuals in the
population at any given point in time and the duration of their
infections. Evidence summarized in this report suggests that even
in areas of low transmission, the contribution of asymptomatic
infections to transmission is likely to be substantial, and in areas
with seasonal transmission, asymptomatic infections may serve
as the source of infections for a new generation of mosquitoes
emerging after the start of the rains.
Lack of a standardized definition of asymptomatic infection
may be limiting the ability to compare burden across space and
time, and to measure the impact of control or elimination pro-
grams that target the asymptomatic parasite reservoir. Given
that both P. falciparum and P. vivax have an approximately 48-h
febrile cycle, it seems reasonable to define asymptomatic infec-
tions operationally as cases of malaria parasitemia of any density,
preferably diagnosed using PCR, without current, measured fever
or history of fever in the past 48h that have not received appro-
priate antimalarial treatment in the past 3days. Increasing the
time without symptoms prior to diagnosis or adding an obser-
vation period afterwards (often not feasible) would potentially
decrease the specificity of the definition by increasing the prob-
ability of encountering fever caused by another infection. It could
be argued that including other symptoms besides fever might
improve the specificity of the case definition, but there are no
other symptoms commonly used to define clinical malaria, and
use of fever alone greatly simplifies the definition of asymptomatic
infections.
Strategies targeting asymptomatic infections are available, but
rigorous research efforts to compare the relative effectiveness of
different approaches at varying levels of malaria transmission are
needed. The approaches that most efficiently and quickly find
and eliminate asymptomatic parasite reservoirs may provide the
endgame for malaria elimination in many areas.
Expert commentary
With the advent of molecular diagnostic techniques, there has
been increasing recognition that a significant proportion of the
infective reservoir across the spectrum of malaria transmission is
comprised of asymptomatic infections. Ultimately, it is the game-
tocytes that are taken up in the blood meal of female Anopheles
mosquitoes that go on to form sporozoites responsible for infect-
ing other humans, but programmatic interventions to interrupt
this transaction must focus on individuals with malaria infection
at any stage, as asexual parasitemia left untreated will eventually
produce gametocytes, and diagnostics for the sexual stage are
limited.
633
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker
100
04 years
90
54 years
80 15+ years
Proportion of malaria infections
70
that are asymptomatic (%)
60
50
40
30
20
10
0 occur as a result of eliminating asympto-
Sudan (24) Burkina
Faso (31)
Location, malaria prevalence (%)
Figure 3. Proportion of malaria infections detected by PCR that are
asymptomatic by age across three studies in five sites. The error bars correspond to
the 95% CI for the proportion.
Data taken from [90,110,131] .
Whereas our understanding of how partial immunity to
malaria develops would suggest that malaria infections are
more likely to be symptomatic in low-transmission settings,
data summarized in this report suggest that at any one point
in time, the majority of the parasite reservoir is likely to be
asymptomatic. This finding is consistent across transmission
settings and may be a result of symptomatic individuals receiv-
ing treatment that reduces both the length of time they are
symptomatic as well as the time they are parasitemic, thereby
removing symptomatic infections from the parasite reservoir
more rapidly than asymptomatic infections. Regardless of why
prevalent infections are more likely to be asymptomatic, inter-
ventions that are not linked to the presence of symptoms will
be needed, even in low-transmission settings, to significantly
reduce malaria transmission.
These data suggest several research questions that remain to
be answered. At least one study has found that prevalent, asymp-
tomatic infections are associated with earlier episodes that were
clinically cured, albeit with an antimalarial medication (chlo-
roquine) no longer recommended for sub-Saharan Africa [35] .
The extent to which asymptomatic parasitemia is associated with
partial treatment, treatment failures and residual populations of
resistant parasites should be investigated further. The relative
contributions of symptomatic and asymptomatic infections to
transmission have been measured in very few studies; in particu-
lar, the role played by subpatent asymptomatic infections should
be investigated further in both low- and high-transmission areas,
634
as this proportion of the asymptomatic res-
ervoir is reached by MDA but not by MSaT
and could help determine which of these
two strategies will be most efficacious in a
given setting. It is essential to rigorously
evaluate the costeffectiveness of different
approaches to target the parasite reservoir.
Community-randomized controlled trials
of different strategies in areas with varying
levels of P. falciparum and P. vivax trans-
mission should be initiated to inform pro-
gram managers and elimination strategies
of the best way forward. Care should be
taken to monitor populations participating
in MSaT, FSaT and MDA interventions
for safety issues and development of drug
resistance, as well as to identify any poten-
tial rebound in clinical malaria that could
Brazil (45) Brazil (51) Burkina matic infections. Finally, integrated drug-
Faso (69) and insecticide-mediated interventions
should be evaluated in the field to identify
optimal mixes that will result in malaria
elimination.
Five-year view
Strategies targeting the asymptomatic par-
asite reservoir were used in the past, but
results did not always match expectations. In particular, MDA
has fallen out of favor because results were short lived and there
was the potential for selection of drug-resistant strains. As a result,
there is significant interest in evaluating MSaT approaches. MSaT
has the additional advantage in that the location of malaria infec-
tions can be mapped easily without additional effort, allowing
for more focused interventions to be layered on top. As we learn
more about the potential for infections missed by MSaT to sustain
transmission, MDA may prove to be a better option. Currently,
there are a number of efforts underway to evaluate MSaT, MDA
and FSaT in a variety of transmission intensities and with slightly
different strategies for identification of cases and responses. Some
evaluations will compare these approaches directly to case man-
agement, and much information on the role of asymptomatic
parasitemia in malaria transmission will be gleaned from com-
parisons of strategies that target different segments of the parasite
reservoir. Over the next 5years, this research agenda is likely to
expand significantly and contribute to new strategies to find and
eliminate malaria infections.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Expert Rev. Anti Infect. Ther. 11(6), (2013)
 Asymptomatic parasitemia & malaria transmission Review

Key issues
Advances in molecular diagnostic techniques have revealed a larger reservoir of asymptomatic human malaria infections than previously
recognized.
Even in low-transmission settings, the majority of prevalent malaria infections are asymptomatic and may persist for weeks or months.
With renewed focus on global malaria eradication, strategies targeting the human parasite reservoir are needed to continue to drive
down transmission and achieve elimination in malaria-endemic areas.
Strategies to target asymptomatic parasitemia include mass drug administration (MDA), mass screen and treat (MSaT), and focused
screen and treat (FSaT) in defined hotspots of malaria.
New research trials of MDA, MSaT and FSaT are underway in a number of countries. Findings from these studies will help inform
elimination efforts in a variety of transmission settings.
Additional unanswered research questions on asymptomatic parasitemia include the extent to which asymptomatic parasitemia is
associated with partial treatment, treatment failures and resistant parasites; the relative contribution of asymptomatic infections to
malaria transmission; and the costeffectiveness and safety of MSaT, FSaT and MDA interventions in different transmission settings.

References
1 WHO. World Malaria Report 2011. WHO,
Geneva, Switzerland (2011).
2 African Union. Fight Malaria: Africa Goes
from Control to Elimination by 2010.
African Union, Johannesburg, South Africa
(2007).
3 Feachem R, Sabot O. A new global malaria
eradication strategy. Lancet 371(9624),
16331635 (2008).
4 UCSF Global Health Group; Malaria Atlas
Project.Atlas of Malaria-Eliminating
Countries, 2011. The Global Health Group,
CA, USA (2011).
5 Hamel MJ, Adazu K, Obor D etal.
Areversal in reductions of child mortality
in western Kenya, 20032009. Am. J. Trop.
Med. Hyg. 85(4), 597605 (2011).
6 Bloland PB, Ruebush TK, McCormick JB
etal. Longitudinal cohort study of the
epidemiology of malaria infections in an
area of intense malaria transmission I.
Description of study site, general method-
ology, and study population. Am. J. Trop.
Med. Hyg. 60(4), 635640 (1999).
7 Eisele TP, Miller JM, Moonga HB,
Hamainza B, Hutchinson P, Keating J.
Malaria infection and anemia prevalence in
Zambias Luangwa district an area of
near-universal insecticide-treated mosquito
net coverage. Am. J. Tropical Med. Hyg.
84(1), 152157 (2011).
8 Yeka A, Gasasira A, Mpimbaza A etal.
Malaria in Uganda: challenges to control
on the long road to elimination: I.
Epidemiology and current control efforts.
Acta Trop. 121(3), 184195 (2012).
9 Griffin JT, Hollingsworth TD, Okell LC
etal. Reducing Plasmodium falciparum
malaria transmission in Africa: a model-
based evaluation of intervention strategies.
PLoS Med. 7(8), pii: e1000324 (2010).
10 Tatem AJ, Smith DL, Gething PW,
Kabaria CW, Snow RW, Hay SI. Ranking
of elimination feasibility between
malaria-endemic countries. Lancet
376(9752), 15791591 (2010).
11 Ogutu BR, Baiden R, Diallo D, Smith PG,
Binka FN. Sustainable development of a
GCP-compliant clinical trials platform in
Africa: the malaria clinical trials alliance
perspective. Malar. J. 9, 103 (2010).
12 Khatib RA, Skarbinski J, Njau JD etal.
Routine delivery of artemisinin-based
combination treatment at fixed health
facilities reduces malaria prevalence in
Tanzania: an observational study.
Malar.J. 11, 140 (2012).
13 Moonen B, Cohen JM, Snow RW etal.
Operational strategies to achieve and
maintain malaria elimination. Lancet
376(9752), 15921603 (2010).
14 Okell LC, Ghani AC, Lyons E, Drakeley
CJ. Submicroscopic infection in
Plasmodium falciparum-endemic popula-
tions: a systematic review and meta-analysis.
J.Infect. Dis. 200(10), 15091517 (2009).
15 Warrell DA, Gilles HM. Essential
Malariology. Hodder Arnold, London, UK
(2002).
16 Liu Z, Miao J, Cui L. Gametocytogenesis
in malaria parasite: commitment,
development and regulation. Future
Microbiol. 6(11), 13511369 (2011).
17 Bousema T, Drakeley C. Epidemiology and
infectivity of Plasmodium falciparum and
Plasmodium vivax gametocytes in relation
to malaria control and elimination. Clin.
Microbiol. Rev. 24(2), 377410 (2011).
18 Ratcliff A, Siswantoro H, Kenangalem E
etal. Two fixed-dose artemisinin combina-
tions for drug-resistant falciparum and
vivax malaria in Papua, Indonesia: anopen-
label randomised comparison. Lancet
369(9563), 757765 (2007).
19 Paaijmans KP, Read AF, Thomas MB.
Understanding the link between malaria
risk and climate. Proc. Natl Acad. Sci. USA
106(33), 1384413849 (2009).
20 Boyd MF. Studies on Plasmodium vivax. 2.
The influence of temperature on the
duration of the extrinsic incubation period.
Am. J. Epidemiol. 16, 851853 (1932).
21 Filipe JA, Riley EM, Drakeley CJ,
Sutherland CJ, Ghani AC. Determination
of the processes driving the acquisition of
immunity to malaria using a mathematical
transmission model. PLoS Comput. Biol.
3(12), e255 (2007).
22 Smith T, Felger I, Tanner M, Beck HP.
Premunition in Plasmodium falciparum
infection: insights from the epidemiology
of multiple infections. Trans. R. Soc. Trop.
Med. Hyg. 93(Suppl. 1), 5964 (1999).
23 Magesa SM, Mdira KY, Babiker HA etal.
Diversity of Plasmodium falciparum clones
infecting children living in a holoendemic
area in north-eastern Tanzania. Acta Trop.
84(2), 8392 (2002).
24 Hamad AA, El Hassan IM, El Khalifa AA
etal. Chronic Plasmodium falciparum infec-
tions in an area of low intensity malaria
transmission in the Sudan. Parasitology
120(Pt 5), 447456 (2000).
Michon P, Cole-Tobian JL, Dabod E etal.
25
The risk of malarial infections and disease
in Papua New Guinean children. Am. J.
Trop. Med. Hyg. 76(6), 9971008 (2007).
Lin E, Kiniboro B, Gray L etal. Differen-
26
tial patterns of infection and disease with
P. falciparum and P. vivax in young Papua
New Guinean children. PLoS ONE 5(2),
e9047 (2010).
Smith T, Schellenberg JA, Hayes R.
27
Attributable fraction estimates and case
definitions for malaria in endemic areas.
Stat. Med. 13(22), 23452358 (1994).

www.expert-reviews.com 635
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker
28 Lievens M, Aponte JJ, Williamson J etal.
Statistical methodology for the evaluation
of vaccine efficacy in a Phase III multi-
centre trial of the RTS, S/AS01 malaria
vaccine in African children. Malar. J. 10,
222 (2011).
29 Laishram DD, Sutton PL, Nanda N etal.
The complexities of malaria disease
manifestations with a focus on
asymptomatic malaria. Malar. J. 11, 29
(2012).
30 Alves FP, Gil LH, Marrelli MT,
R ibollaPE, Camargo EP, Da Silva LH.
Asymptomatic carriers of Plasmodium spp.
as infection source for malaria vector
mosquitoes in the Brazilian Amazon.
J.Med. Entomol. 42(5), 777779 (2005).
31 Oudraogo AL, Bousema T, de Vlas SJ
etal. The plasticity of Plasmodium
falciparum gametocytaemia in relation to
age in Burkina Faso. Malar. J. 9, 281
(2010).
32 Bousema T, Okell L, Shekalaghe S etal.
Revisiting the circulation time of
Plasmodium falciparum gametocytes:
molecular detection methods to estimate
the duration of gametocyte carriage and
the effect of gametocytocidal drugs.
Malar.J. 9, 136 (2010).
33 Mabunda S, Aponte JJ, Tiago A, Alonso P.
A country-wide malaria survey in
Mozambique. II. Malaria attributable
proportion of fever and establishment of
malaria case definition in children across
different epidemiological settings. Malar.J.
8, 74 (2009).
34 Gonalves RM, Scopel KK, Bastos MS,
Ferreira MU. Cytokine balance in human
malaria: does Plasmodium vivax elicit more
inflammatory responses than Plasmodium
falciparum? PLoS ONE 7(9), e44394
(2012).
35 Roper C, Elhassan IM, Hviid L etal.
Detection of very low level Plasmodium
falciparum infections using the nested
polymerase chain reaction and a reassess-
ment of the epidemiology of unstable
malaria in Sudan. Am. J. Trop. Med. Hyg.
54(4), 325331 (1996).
36 Snounou G, Pinheiro L, Gonalves A etal.
The importance of sensitive detection of
malaria parasites in the human and insect
hosts in epidemiological studies, as shown
by the analysis of field samples from
Guinea Bissau. Trans. R. Soc. Trop. Med.
Hyg. 87(6), 649653 (1993).
37 French N, Nakiyingi J, Lugada E, WateraC,
Whitworth JA, Gilks CF. Increasing rates of
malarial fever with deteriorating immune
636
status in HIV-1-infected Ugandan adults.
AIDS 15(7), 899906 (2001).
38 Nacher M. Helminth-infected patients
with malaria: a low profile transmission
hub? Malar. J. 11, 376 (2012).
39 Diallo TO, Remoue F, Gaayeb L etal.
Schistosomiasis coinfection in children
influences acquired immune response
against Plasmodium falciparum malaria
antigens. PLoS ONE 5(9), e12764 (2010).
40 Lyke KE, Wang A, Dabo A etal. Antigen-
specific B memory cell responses to
Plasmodium falciparum malaria antigens
and Schistosoma haematobium antigens in
co-infected Malian children. PLoS ONE
7(6), e37868 (2012).
41 Courtin D, Djilali-Saah A, Milet J etal.
Schistosoma haematobium infection affects
Plasmodium falciparum-specific IgG
responses associated with protection
against malaria. Parasite Immunol. 33(2),
124131 (2011).
42 Sangweme DT, Midzi N,
Zinyowera-Mutapuri S, Mduluza T,
Diener-West M, KumarN. Impact of
schistosome infection on Plasmodium
falciparum malariometric indices and
immune correlates in school age children in
Burma Valley, Zimbabwe. PLoS Negl. Trop.
Dis. 4(11), e882 (2010).
43 Wongsrichanalai C, Barcus MJ, Muth S,
Sutamihardja A, Wernsdorfer WH.
A review of malaria diagnostic tools:
microscopy and rapid diagnostic test
(RDT). Am. J. Trop. Med. Hyg.
77(Suppl.6), 119127 (2007).
44 Hopkins H, Kambale W, Kamya MR,
Staedke SG, Dorsey G, Rosenthal PJ.
Comparison of HRP2- and pLDH-based
rapid diagnostic tests for malaria with
longitudinal follow-up in Kampala,
Uganda. Am. J. Trop. Med. Hyg. 76(6),
10921097 (2007).
45 Moody A. Rapid diagnostic tests for
malaria parasites. Clin. Microbiol. Rev.
15(1), 6678 (2002).
46 Mahajan B, Zheng H, Pham PT etal.
Polymerase chain reaction-based tests for
pan-species and species-specific detection
of human Plasmodium parasites.
Transfusion 52(9), 19491956 (2012).
47 Stresman G, Kobayashi T, Kamanga A
etal. Malaria research challenges in low
prevalence settings. Malar. J. 11, 353
(2012).
48 Scuracchio P, Vieira SD, Dourado DA etal.
Transfusion-transmitted malaria: case
report of asymptomatic donor harboring
Plasmodium malariae. Rev. Inst. Med. Trop.
So Paulo 53(1), 5559 (2011).
49 Rojo-Marcos G, Cuadros-Gonzalez J,
Gete-Garcia L etal. [Plasmodium ovale
infection: description of 16 cases and a
review]. Enfermedades Infecciosas Y
Microbiologia Clinica 29(3), 204208
(2011).
50 da Silva-Nunes M, Ferreira MU. Clinical
spectrum of uncomplicated malaria in
semi-immune Amazonians: beyond the
symptomatic vs asymptomatic
dichotomy. Memorias Do Instituto Oswaldo
Cruz 102(3), 341347 (2007).
51 Harris I, Sharrock WW, Bain LM etal.
A large proportion of asymptomatic
Plasmodium infections with low and
sub-microscopic parasite densities in the
low transmission setting of Temotu
Province, Solomon Islands: challenges for
malaria diagnostics in an elimination
setting. Malar. J. 9, 254 (2010).
52 Hoyer S, Nguon S, Kim S etal. Focused
Screening and Treatment (FSAT):
aPCR-based strategy to detect malaria
parasite carriers and contain drug resistant
P. falciparum, Pailin, Cambodia. PLoS
ONE 7(10), e45797 (2012).
53 Alves FP, Durlacher RR, Menezes MJ,
Krieger H, Silva LH, Camargo EP. High
prevalence of asymptomatic Plasmodium
vivax and Plasmodium falciparum infections
in native Amazonian populations. Am. J.
Trop. Med. Hyg. 66(6), 641648 (2002).
54 Bereczky S, Montgomery SM,
Troye-Blomberg M, Rooth I, Shaw MA,
FrnertA. Elevated anti-malarial IgE in
asymptomatic individuals is associated with
reduced risk for subsequent clinical
malaria. Int. J. Parasitol. 34(8), 935942
(2004).
55 Nsobya SL, Parikh S, Kironde F etal.
Molecular evaluation of the natural history
of asymptomatic parasitemia in Ugandan
children. J. Infect. Dis. 189(12),
22202226 (2004).
56 Kun JF, Missinou MA, Lell B etal. New
emerging Plasmodium falciparum genotypes
in children during the transition phase
from asymptomatic parasitemia to malaria.
Am. J. Trop. Med. Hyg. 66(6), 653658
(2002).
57 Rieckmann KH. Asymptomatic malaria.
Lancet 1(7637), 8283 (1970).
58 Felger I, Maire M, Bretscher MT etal. The
dynamics of natural Plasmodium falciparum
infections. PLoS ONE 7(9), e45542 (2012).
59 McCarra MB, Ayodo G, Sumba PO etal.
Antibodies to Plasmodium falciparum
Expert Rev. Anti Infect. Ther. 11(6), (2013)

erythrocyte-binding antigen-175 are
associated with protection from clinical
malaria. Pediatr. Infect. Dis. J. 30(12),
10371042 (2011).
60 Babiker HA, Abdel-Muhsin AM,
Ranford-Cartwright LC, Satti G,
WallikerD. Characteristics of Plasmodium
falciparum parasites that survive the
lengthy dry season in eastern Sudan where
malaria transmission is markedly seasonal.
Am. J. Trop. Med. Hyg. 59(4), 582590
(1998).
61 Vinetz JM, Li J, McCutchan TF,
K aslow DC. Plasmodium malariae
infection in an asymptomatic 74-year-old
Greek woman with splenomegaly. N. Engl.
J. Med. 338(6), 367371 (1998).
62 Bousema JT, Gouagna LC, Meutstege AM
etal. Treatment failure of pyrimethamine
sulphadoxine and induction of Plasmodium
falciparum gametocytaemia in children in
western Kenya. Trop. Med. Int. Health 8(5),
427430 (2003).
63 Price R, Nosten F, Simpson JA etal. Risk
factors for gametocyte carriage in
uncomplicated falciparum malaria. Am. J.
Trop. Med. Hyg. 60(6), 10191023 (1999).
64 von Seidlein L, Drakeley C, Greenwood B,
Walraven G, Targett G. Risk factors for
gametocyte carriage in Gambian children.
Am. J. Trop. Med. Hyg. 65(5), 523527
(2001).
65 Sowunmi A, Fateye BA, Adedeji AA,
Fehintola FA, Happi TC. Risk factors for
gametocyte carriage in uncomplicated
falciparum malaria in children. Parasitology
129(Pt 3), 255262 (2004).
66 Lima NF, Bastos MS, Ferreira MU.
Plasmodium vivax: reverse transcriptase
real-time PCR for gametocyte detection
and quantitation in clinical samples. Exp.
Parasitol. 132(3), 348354 (2012).
67 Gouagna LC, Ferguson HM, Okech BA
etal. Plasmodium falciparum malaria
disease manifestations in humans and
transmission to Anopheles gambiae: a field
study in western Kenya. Parasitology
128(Pt3), 235243 (2004).
68 Bousema T, Dinglasan RR, Morlais I etal.
Mosquito feeding assays to determine the
infectiousness of naturally infected
Plasmodium falciparum gametocyte
carriers. PLoS ONE 7(8), e42821 (2012).
69 White NJ. The role of anti-malarial drugs
in eliminating malaria. Malar. J.
7(Suppl.1), S8 (2008).
70 Schneider P, Bousema JT, Gouagna LC
etal. Submicroscopic Plasmodium
falciparum gametocyte densities frequently
www.expert-reviews.com
Asymptomatic parasitemia & malaria transmission
result in mosquito infection. Am. J. Trop.
Med. Hyg. 76(3), 470474 (2007).
71 Lacroix R, Mukabana WR, Gouagna LC,
Koella JC. Malaria infection increases
attractiveness of humans to mosquitoes.
PLoS Biol. 3(9), e298 (2005).
72 Ghani AC, Sutherland CJ, Riley EM etal.
Loss of population levels of immunity to
malaria as a result of exposure-reducing
interventions: consequences for interpreta-
tion of disease trends. PLoS ONE 4(2),
e4383 (2009).
73 Macauley C. Aggressive active case
detection: a malaria control strategy based
on the Brazilian model. Soc. Sci. Med.
60(3), 563573 (2005).
74 Bousema JT, Gouagna LC, Drakeley CJ
etal. Plasmodium falciparum gametocyte
carriage in asymptomatic children in
western Kenya. Malar. J. 3, 18 (2004).
75 Manjurano A, Okell L, Lukindo T etal.
Association of sub-microscopic malaria
parasite carriage with transmission
intensity in north-eastern Tanzania.
Malar.J. 10, 370 (2011).
76 Gosling RD, Okell L, Mosha J,
Chandramohan D. The role of antimalarial
treatment in the elimination of malaria.
Clin. Microbiol. Infect. 17(11), 16171623
(2011).
77 Kern SE, Tiono AB, Makanga M etal.
Community screening and treatment of
asymptomatic carriers of Plasmodium
falciparum with artemetherlumefantrine
to reduce malaria disease burden:
amodelling and simulation analysis.
Malar. J. 10, 210 (2011).
78 Okell LC, Griffin JT, Kleinschmidt I etal.
The potential contribution of mass
treatment to the control of Plasmodium
falciparum malaria. PLoS ONE 6(5),
e20179 (2011).
79 Snowden F. The Conquest of Malaria: Italy,
19001962. Yale University Press, CT,
USA (2006).
80 von Seidlein L, Greenwood BM. Mass
administrations of antimalarial drugs.
Trends Parasitol. 19(10), 452460 (2003).
81 Kaneko A, Taleo G, Kalkoa M, Yamar S,
Kobayakawa T, Bjrkman A. Malaria
eradication on islands. Lancet 356(9241),
15601564 (2000).
82 Garfield RM, Vermund SH. Changes in
malaria incidence after mass drug
administration in Nicaragua. Lancet
2(8348), 500503 (1983).
83 von Seidlein L, Walraven G, Milligan PJ
etal. The effect of mass administration of
Review
sulfadoxinepyrimethamine combined
with artesunate on malaria incidence:
adouble-blind, community-randomized,
placebo-controlled trial in The Gambia.
Trans. R. Soc. Trop. Med. Hyg. 97(2),
217225 (2003).
84 Shekalaghe SA, Drakeley C, vandenBosch
S etal. A cluster-randomized trial of mass
drug administration with a gameto
cytocidal drug combination to interrupt
malaria transmission in a low endemic area
in Tanzania. Malar. J. 10, 247 (2011).
85 Song J, Socheat D, Tan B etal. Rapid and
effective malaria control in Cambodia
through mass administration of arte-
misininpiperaquine. Malar. J. 9, 57
(2010).
86 Yekutiel P. Problems of epidemiology in
malaria eradication. Bull. World Health
Organ. 22, 669683 (1960).
87 Bruce-Chwatt LJ. Malaria research and
eradication in the USSR. A review of Soviet
achievements in the field of malariology.
Bull. World Health Organ. 21, 737772
(1959).
88 Njera JA, Gonzlez-Silva M, Alonso PL.
Some lessons for the future from the Global
Malaria Eradication Programme
(19551969). PLoS Med. 8(1), e1000412
(2011).
89 Kidson C, Indaratna K. Ecology,
economics and political will: the vicissi-
tudes of malaria strategies in Asia.
Parassitologia 40(12), 3946 (1998).
90 Molteni F, Anderegg C, Ali A etal. Is active
malaria case detection in the community
able to inhibit low-level focal malaria
transmission in Zanzibar? Presented at:
American Society of Tropical Medicine and
Hygiene 60th Annual Meeting. PA, USA,
48 December 2011 (Abstract676).
91 Stresman GH, Kamanga A, Moono P etal.
A method of active case detection to target
reservoirs of asymptomatic malaria and
gametocyte carriers in a rural area in
Southern Province, Zambia. Malar. J. 9,
265 (2010).
92 Abdel-Latif MS, Dietz K, Issifou S,
Kremsner PG, Klinkert MQ. Antibodies to
Plasmodium falciparum rifin proteins are
associated with rapid parasite clearance and
asymptomatic infections. Infect. Immun.
71(11), 62296233 (2003).
93 Rottmann M, Lavstsen T, Mugasa JP etal.
Differential expression of var gene groups is
associated with morbidity caused by
Plasmodium falciparum infection in
Tanzanian children. Infect. Immun. 74(7),
39043911 (2006).
637
 Review Lindblade, Steinhardt, Samuels, Kachur & Slutsker
94 Alves FP, Durlacher RR, Menezes MJ,
Krieger H, Silva LH, Camargo EP. High
prevalence of asymptomatic Plasmodium
vivax and Plasmodium falciparum infections
in native Amazonian populations. Am. J.
Trop. Med. Hyg. 66(6), 641648 (2002).
95 Cucunub ZM, Guerra AP, Rahirant SJ,
Rivera JA, Corts LJ, Nicholls RS.
Asymptomatic Plasmodium spp. infection
in Tierralta, Colombia. Mem. Inst. Oswaldo
Cruz 103(7), 668673 (2008).
96 Boutlis CS, Tjitra E, Maniboey H etal.
Nitric oxide production and mononuclear
cell nitric oxide synthase activity in
malaria-tolerant Papuan adults. Infect.
Immun. 71(7), 36823689 (2003).
97 de Mast Q, Syafruddin D, Keijmel S etal.
Increased serum hepcidin and alterations in
blood iron parameters associated with
asymptomatic P. falciparum and P. vivax
malaria. Haematologica 95(7), 10681074
(2010).
98 Fernando SD, Abeyasinghe RR,
Galappaththy GN, Rajapaksa LC. Absence
of asymptomatic malaria infections in
previously high endemic areas of Sri Lanka.
Am. J. Trop. Med. Hyg. 81(5), 763767
(2009).
99 Turki H, Zoghi S, Mehrizi AA etal.
Absence of asymptomatic malaria infection
in endemic area of Bashagard district,
Hormozgan province, Iran. Iran. J.
Parasitol. 7(1), 3644 (2012).
100 Zoghi S, Mehrizi AA, Raeisi A etal. Survey
for asymptomatic malaria cases in low
transmission settings of Iran under
elimination programme. Malar. J.
11, 126 (2012).
101 Atkinson JA, Johnson ML, Wijesinghe R
etal. Operational research to inform a
sub-national surveillance intervention for
malaria elimination in Solomon Islands.
Malar. J. 11, 101 (2012).
102 Kumudunayana WM, Gunasekera TDW,
Abeyasinghe RR, Premawansa S, Fernando
SD. Usefulness of polymerase chain
reaction to supplement field microscopy in
a pre-selected population with a high
probability of malaria infections. Am. J.
Trop. Med. Hyg. 85(1), 611 (2011).
103 Congpuong K, Saejeng A, Sug-Aram R
etal. Mass blood survey for malaria:
pooling and real-time PCR combined with
expert microscopy in north-west Thailand.
Malar. J. 11, 288 (2012).
104 Diallo A, Ndam NT, Moussiliou A etal.
Asymptomatic carriage of Plasmodium in
urban Dakar: the risk of malaria should not
be underestimated. PLoS ONE 7(2),
e31100 (2012).
638
105 Eisele TP, Miller JM, Moonga HB,
Hamainza B, Hutchinson P, Keating J.
Malaria infection and anemia prevalence in
Zambias Luangwa District: an area of
near-universal insecticide-treated mosquito
net coverage. Am. J. Trop. Med. Hyg. 84(1),
152157 (2011).
106 Barracks G, Atkins C, Auliff A etal.
Malaria on isolated Melanesian islands
prior to the initiation of malaria
elimination activities. Malaria Journal. 9,
(2010).
107 Hsiang MS, Lin M, Dokomajilar C etal.
PCR-based pooling of dried blood spots for
detection of malaria parasites: optimization
and application to a cohort of Ugandan
children. J. Clin. Microbiol. 48(10),
35393543 (2010).
108 da Silva NS, da Silva-Nunes M, Malafronte
RS etal. Epidemiology and control of
frontier malaria in Brazil: lessons from
community-based studies in rural
Amazonia. Trans. R. Soc. Trop. Med. Hyg.
104(5), 343350 (2010).
109 Kritsiriwuthinan K, Ngrenngarmlert W.
Molecular screening of Plasmodium
infections among migrant workers in
Thailand. J. Vector Borne Dis. 48(4),
214218 (2011).
110 Roper C, Richardson W, Elhassan IM etal.
Seasonal changes in the Plasmodium
falciparum population in individuals and
their relationship to clinical malaria:
alongitudinal study in a Sudanese village.
Parasitology 116 (Pt 6), 501510 (1998).
111 Rodulfo H, de Donato M, Quijada I,
PeaA. High prevalence of malaria
infection in Amazonas State, Venezuela.
Rev. Inst. Med. Trop. So Paulo 49(2),
7985 (2007).
112 Gahutu JB, Steininger C, Shyirambere C
etal. Prevalence and risk factors of malaria
among children in southern highland
Rwanda. Malar. J. 10, 134 (2011).
113 Katsuragawa TH, Gil LH, Tada MS etal.
The dynamics of transmission and spatial
distribution of malaria in riverside areas of
Porto Velho, Rondnia, in the Amazon
region of Brazil. PLoS ONE 5(2), e9245
(2010).
114 Camargo EP, Alves F, Pereira da Silva LH.
Symptomless Plasmodium vivax infections
in native Amazonians. Lancet 353(9162),
14151416 (1999).
115 Frnert A, Williams TN, Mwangi TW
etal. Transmission-dependent tolerance to
multiclonal Plasmodium falciparum
infection. J. Infect. Dis. 200(7), 11661175
(2009).
116 Ladeia-Andrade S, Ferreira MU, de
Carvalho ME, Curado I, Coura JR.
Age-dependent acquisition of protective
immunity to malaria in riverine popula-
tions of the Amazon Basin of Brazil. Am. J.
Trop. Med. Hyg. 80(3), 452459 (2009).
117 Vafa M, Troye-Blomberg M, Anchang J,
Garcia A, Migot-Nabias F. Multiplicity of
Plasmodium falciparum infection in
asymptomatic children in Senegal: relation
to transmission, age and erythrocyte
variants. Malar. J. 7, 17 (2008).
118 Suarez-Mutis MC, Coura JR. Changes in
the epidemiological pattern of malaria in a
rural area of the middle Rio Negro,
Brazilian Amazon: a retrospective analysis.
Cad. Saude Publica 23(4), 795804
(2007).
119 Baliraine FN, Afrane YA, Amenya DA
etal. High prevalence of asymptomatic
Plasmodium falciparum infections in a
highland area of western Kenya: a cohort
study. J. Infect. Dis. 200(1), 6674 (2009).
120 Pinto J, Sousa CA, Gil V etal. Malaria in
So Tom and Prncipe: parasite preva-
lences and vector densities. Acta Trop.
76(2), 185193 (2000).
121 Crookston BT, Alder SC, Boakye I etal.
Exploring the relationship between chronic
undernutrition and asymptomatic malaria
in Ghanaian children. Malar. J. 9, 39
(2010).
122 Liljander A, Bejon P, Mwacharo J etal.
Clearance of asymptomatic P. falciparum
infections interacts with the number of
clones to predict the risk of subsequent
malaria in Kenyan children. PLoS ONE
6(2), e16940 (2011).
123 Koukouikila-Koussounda F, Malonga V,
Mayengue PI, Ndounga M,
VouvounguiCJ, Ntoumi F. Genetic
polymorphism of merozoite surface
protein2 and prevalence of K76T Pfcrt
mutation in Plasmodium falciparum field
isolates from Congolese children with
asymptomatic infections. Malar. J. 11, 105
(2012).
124 Bereczky S, Liljander A, Rooth I etal.
Multiclonal asymptomatic Plasmodium
falciparum infections predict a reduced risk
of malaria disease in a Tanzanian
population. Microbes Infect. 9(1), 103110
(2007).
125 Dal-Bianco MP, Kster KB, Kombila UD
etal. High prevalence of asymptomatic
Plasmodium falciparum infection in
Gabonese adults. Am. J. Trop. Med. Hyg.
77(5), 939942 (2007).
126 Owusu-Agyei S, Smith T, Beck HP,
Amenga-Etego L, Felger I. Molecular
Expert Rev. Anti Infect. Ther. 11(6), (2013)

epidemiology of Plasmodium falciparum
infections among asymptomatic inhabit-
ants of a holoendemic malarious area in
northern Ghana. Trop. Med. Int. Health
7(5), 421428 (2002).
127 Rajagopalan PK, Das PK, Pani SP etal.
Parasitological aspects of malaria persis-
tence in Koraput district Orissa, India.
Indian J. Med. Res. 91, 4451 (1990).
128 Gonzlez JM, Olano V, Vergara J etal.
Unstable, low-level transmission of malaria
on the Colombian Pacific Coast. Ann.
Trop. Med. Parasitol. 91(4), 349358
(1997).
www.expert-reviews.com
Asymptomatic parasitemia & malaria transmission
129 Mato SP. Anemia and malaria in a
Yanomami Amerindian population from
the southern Venezuelan Amazon. Am. J.
Trop. Med. Hyg. 59(6), 9981001 (1998).
130 Anothay O, Pongvongsa T. Childhood
malaria in the Lao Peoples Democratic
Republic. Bull. World Health Organ.
76(Suppl. 1), 2934 (1998).
131 Geiger C, Agustar HK, Compaor G etal.
Declining malaria parasite prevalence and
trends of asymptomatic parasitaemia in a
seasonal transmission setting in north-
western Burkina Faso between 2000 and
20092012. Malar. J. 12(1), 27 (2013).
Review
132 Eisele TP, Keating J, Bennett A etal.
Prevalence of Plasmodium falciparum
infection in rainy season, Artibonite Valley,
Haiti, 2006. Emerging Infect. Dis. 13(10),
14941496 (2007).
Website
201 Bill and Melinda Gates Foundation press
room.
www.gatesfoundation.org/media-center/
speeches/2007/10/melinda-french-gates-
malaria-forum
(Accessed 4 January 2013)
639