Low prevalence of Plasmodium falciparum parasites lacking pfhrp2/3 genes among asymptomatic and symptomatic school-age children in Kinshasa, Democratic Republic of Congo

Background: Loss of efcacy of diagnostic tests may lead to untreated or mistreated malaria cases, compromising case management and control. There is an increasing reliance on rapid diagnostic tests (RDTs) for malaria diagnosis, with the most widely used of these targeting the Plasmodium falciparum histidine-rich protein 2 (PfHRP2). There are numerous reports of the deletion of this gene in P. falciparum parasites in some populations, rendering them unde‑ tectable by PfHRP2 RDTs. The aim of this study was to identify P. falciparum parasites lacking the P. falciparum histidine rich protein 2 and 3 genes (pfhrp2/3) isolated from asymptomatic and symptomatic school-age children in Kinshasa, Democratic Republic of Congo.Methods: The performance of PfHRP2-based RDTs in comparison to microscopy and PCR was assessed using blood samples collected and spotted on Whatman 903™ flter papers between October and November 2019 from schoolage children aged 6–14 years. PCR was then used to identify parasite isolates lacking pfhrp2/3 genes.Results: Among asymptomatic malaria carriers (N=266), 49%, 65%, and 70% were microscopy, PfHRP2_RDT, and pfdh-qPCR positive, respectively. The sensitivity and specifcity of RDTs compared to PCR were 80% and 70% while the sensitivity and specifcity of RDTs compared to microscopy were 92% and 60%, respectively. Among sympto‑ matic malaria carriers (N=196), 62%, 67%, and 87% were microscopy, PfHRP2-based RDT, pfdh-qPCR and positive, respectively. The sensitivity and specifcity of RDTs compared to PCR were 75% and 88%, whereas the sensitivity and specifcity of RDTs compared to microscopy were 93% and 77%, respectively. Of 173 samples with sufcient DNA for PCR amplifcation of pfhrp2/3, deletions of pfhrp2 and pfhrp3 were identifed in 2% and 1%, respectively. Three (4%)of samples harboured deletions of the pfhrp2 gene in asymptomatic parasite carriers and one (1%) isolate lacked the pfhrp3 gene among symptomatic parasite carriers in the RDT positive subgroup. No parasites lacking the pfhrp2/3 genes were found in the RDT negative subgroup.Conclusion: Plasmodium falciparum histidine-rich protein 2/3 gene deletions are uncommon in the surveyed popu‑ lation, and do not result in diagnostic failure. The use of rigorous PCR methods to identify pfhrp2/3 gene deletions is encouraged in order to minimize the overestimation of their prevalence