A Novel Multiplex qPCR Assay for Detection ofPlasmodium falciparumwithHistidine-rich Protein 2 and 3 (pfhrp2 and pfhrp3)Deletions in Polyclonal Infections

Background Rapid diagnostic tests (RDTs) that detect the malaria antigen histidine-rich protein 2 (HRP2) are widely used in endemic areas globally to confirm Plasmodium falciparum infection in febrile patients. The emergence of parasites lacking the gene encoding HRP2 and escaping RDT detection threatens progress in malaria control and elimination. Many health facilities in malaria endemic countries are dependent on RDTs for diagnosis and some National Health Service hospitals without expert microscopists rely on them for diagnosis out of hours. It is vital to study the emergence and the extent of such parasites globally to guide diagnostic policy. Currently, verification of the presence of such parasites in a blood sample requires a series of PCR assays to confirm the presence of P. falciparum and in the absence of amplicons from pfhrp2 and/or pfhrp3 , which encodes a cross-reactive protein isoform. These tests have different limits of detection and many laboratories have reported difficulty in confirming the absence of pfhrp2 and pfhrp3 with certainty. Methods We developed and validated a novel and rapid multiplex real time quantitative (qPCR) assay to detect pfhrp2, pfhrp3, confirmatory parasite and human reference genes simultaneously. We also applied the assay to detect pfhrp2 and pfhrp3 deletion in 462 field samples from different endemic countries and UK travellers. Results The qPCR assay showed limit of detection and quantification of 0.76-1.5 parasites per μl. The amplification efficiency, coefficient of determination (R 2 ) and slope for the genes were 96-1.07%, 0.96-0.98 and −3.375 2 to −3.416 respectively. The assay demonstrated diagnostic sensitivity of 100% (n=19, 95% CI= (82.3%; 100%)) and diagnostic specificity of 100% (n=31; 95% CI= (88.8%; 100%)) in detecting pfhrp2 and pfhrp3 in. In addition, the qPCR assay estimates P. falciparum parasite density and can detect pfhrp2 and pfhrp3 deletions masked in polyclonal infections. We report pfhrp2 and pfhrp3 deletions in parasite isolates from Kenya, Tanzania and in UK travellers. Conclusion The new qPCR assay is simple to use and offers significant advantages in speed and ease of interpretation. It is easily scalable to routine surveillance studies in countries where P. falciparum parasites lacking pfhrp2 and pfhrp3 are a threat to malaria control.