Malaria in Burkina Faso from 2000 to 2019: Assessment of Diagnostic

Tools

Silvere Dieudonne Zaongo

1,4,

*, Wilfried Noel Sam

, Blaise Raogo Ouedraogo

Jean-Bosco Ouedraogo

, Dar-Der Ji

Tianjin Medical University, Tianjin, China

Kunming Institute of zoology, University of Chinese Academy of Sciences, China

Institut de Recherche en Sciences de la Santé, Burkina Faso

Nankai University Second People’s Hospital, School of Medicine, Nankai University, Tianjin, China

International Health Program, National Yang Ming University, Taiwan

Keywords: Burkina Faso, Sub-microscopic malaria, PCR, Microscopy, Rapid Diagnostic tests

Abstract: Malaria elimination depends on the potency of surveillance tools. We assessed the efficacy of rapid

diagnostic tests (RDTs) and polymerase chain reaction (PCR) in sub-microscopic malaria detection. Cross

sectional or screening studies realized in Burkina Faso from 2000 to 2019 were found in PubMed using

keywords “malaria”, “PCR” and “Burkina Faso” and specific inclusion criteria. Malaria prevalence and sub-

microscopic (SM) were calculated from PCR, LM, and RDTs results. Overall, 6 studies (4 in Nanoro, 1 in

Bourasso, and 1 in Bobo-Dioulasso) fit the inclusion criteria. The prevalence by PCR in Bourasso (before

2009) was the highest compared to Nanoro (92% vs 27.3%, p<0.001) and Bobo-Dioulasso (92% vs 34.5%,

p<0.001). From PCR results it seems that SM prevalence is relatively stable over the last 20 years

independently from the location (11.4% in Bourasso, 10.3% in Nanoro, 19.9% in Bobo-Dioulasso). Except

in Nanoro where SM

HRP2

was higher than SM

PCR

(12.8% vs 10.3%, p=0.04), RDT HRP2 and RDT pLDH

failed to compete with PCR in SM detection. Although implementation of RDTs have triggered the

reduction of malaria cases, they are not suitable for sub-microscopic malaria detection. Therefore, novel

diagnostic tools as sensitive as PCR and as easy to perform as RTDs are needed.

1 INTRODUCTION

From 2010 to 2015, the number of infected and

death cases of malaria have reduced by 21% and

29% among all age groups. Despite that, malaria is

still a public health issue especially in Sub-Saharan

Africa. This region is the most affected where

Children under 5 years and pregnant women are the

most vulnerable population in terms of mortality and

morbidity (UNICEF and WHO, 2000). An early

diagnostic of malaria is essential to prevent the fatal

outcomes such as anemia, low bird weight, and

mother and/or child death (Steketee et al., 1996;

Luxemburger et al., 1997). In 2015, 90% of cases

and 92% of malaria deaths were reported in the same

African region although the death rate felt by 35%

among children under 5 years. Recent estimations

suggest that 91 countries and areas had ongoing

malaria transmission (WHO, 2016).

In Burkina Faso, malaria represents 63.2% of

hospitalizations and 49.6% of deaths among children

under 5 year-old. Noticing the reduction of malaria

cases worldwide, the National Malaria Control

Program of Burkina Faso aims to end the disease by

2030. Thus, political commitment, implementation

of Artemisinin Combination Therapy (ACT), better

access of population to diagnostic and vector control

strategies (insecticide treated bed nets) are already

implemented ((PNLP), 2014). However, the success

of malaria surveillance depends on the performance

of existing surveillance tools (Breman and

Holloway, 2007) especially on asymptomatic

individuals who can exhibit low-density malaria

infection or submicroscopic malaria (Cheng et al.,

2015). The major tools so far used are light

microscopy (LM), rapid diagnostic tests (RDTs) and

polymerase chain reaction (PCR). Microscopy has

been the main tool for more than two decades as it is

cheap (Siala et al., 2010); RDTs recently introduced

Zaongo, S., Sam, W., Ouedraogo, B., Ouedraogo, J. and Ji, D.

Malaria in Burkina Faso from 2000 to 2019: Assessment of Diagnostic Tools.

DOI: 10.5220/0008788001490155

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 149-155

ISBN: 978-989-758-438-1

149

as an alternative to microscopy weakness (Makler et

al., 1998) are implemented in Burkina Faso since

2009 (Natama et al., 2017); and PCR, introduced in

malaria regions in the 1990s, showed increased

prevalence of malaria in communities screened.

Herein, we proposed to assess these malaria

diagnostic tools efficacy in sub-microscopic malaria

detection over the last 20 years in Burkina Faso.

2 MATERIALS AND METHODS

2.1 Literature Search and Inclusion

Criteria

Were considered as relevant, all articles identified in

PubMed using search terms “malaria”, “PCR” and

“Burkina Faso”. The literature research was done on

April 10

, 2019. The studies were eligible only if

they had the inclusion criteria that are: (a) the

articles were written in English and published within

2000 to the 4

of March 2019, (b) the study

participants consisted of a population sample of

individuals in, an endemic area who were not chosen

on the basis of malaria symptoms or test results, (c)

cross sectional studies or screening studies, (d) Data

of light microscopy (LM), RDTs [Histidine Rich

Protein 2 (HRP2) and/or Plasmodium Lactate

Dehydrogenase (pLDH)] and/or PCR/ quantitative

PCR (qPCR) / Retro-Transcription PCR (RT-PCR) /

direct blood PCR (db-PCR) should be presented, (e)

at least Plasmodium falciparum infection was

detected. For the screening of cohorts, only the data

at the inclusion (before any intervention) were

considered.

2.2 Malaria Prevalence by PCR, LM,

and RDTs

Based on the results of each diagnostic tool, malaria

prevalence (P) was estimated by dividing the total

number of positive individual by the total number of

screened population. Therefore, the prevalence by

PCR (P

PCR

), Microscopy (P

), HPR2 (P

HRP2

), and

pLDH (P

pLDH

) were used to estimate the sub-

microscopic malaria ongoing for 20 years in Burkina

Faso.

2.3 Burkina Faso Map and Study Sites

Location

The map was drawn in RStudio software (Version

1.0.153, RStudio, Inc) using the packages “map and

mapdata”. To represent the study sites location, their

geographic coordinates were integrated before the

map generating.

2.4 Sub-microscopic Malaria

Evaluation

The sub-microscopic (SM) infection was calculated

either based on PCR or RDTs results. When the

PCR results were considered:

PCR

= P

PCR

– P

Considering the RDTs as reference:

HRP2

= P

HRP2

– P

; or SM

pLDH

= P

pLDH

– P

2.5 Data Analysis

Data were entered on Microsoft Excel 2013 then

subsequently transferred and analyzed on SPSS

(Version 20, IBM Corporation). The Fisher exact

test was used to compare the proportions as

previously described (Campbell, 2007; Richardson,

2011). Therefore, the prevalence based on diagnostic

tools or location were compared using α=0.05 as

significance level.

3 RESULTS

3.1 Descriptive Statistics

From PubMed using the specific keywords, 92

articles were found and 6 studies fit the inclusion

criteria (Figure 1).

Figure 1.

Paper mining flowchart

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

150

They were predominantly conducted in Nanoro (4/6,

66.7%). Among the 2 remaining studies one was

performed in Bourasso (1/6, 16.7%) and the other in

Bobo-Dioulasso (1/6, 16.7%). The geographical

location of Nanoro (in Center-West, located at 85

km of Ouagadougou the capital city) and Bobo-

Dioulasso (in West, the second largest town of the

country) are represented in Fig 2. Bourasso is a rural

village located between Bobo-Dioulasso and

Ouagadougou; its location is closer to the Malian

border of the country (see Figure 2).

Figure 2. Burkina Faso map with study sites location

The most targeted populations were pregnant

women and infants (4/6, 66.7%) as shown in Table 1

Location Target population Positive test Total

sam

Ref

PCR Microscopy RDT

HRP2

RDT

pLDH

Nanoro Infants 16 0 3 - 400 (Natama et

al., 2017)

Bobo-

Dioulasso

Pregnant women 224 95 134 102 650 (Kyabayinze

et al., 2016)

Nanoro All inhabitants 139 122 136 - 283 (Mens et al.,

2012)

Nanoro Pregnant women 201 112 178 380 (Kattenberg

et al., 2012)

Nanoro Infants 120 62 - - 678 (Natama et

al., 2018)

Bourasso All inhabitants 185 162 - - 201 (Stich et al.,

2006)

Table 1. Details of the selected studies

3.2 Sub-microscopic Malaria

Prevalence

From the selected articles, a total of 2592 people

were screened by PCR and LM. The number was

reduced when we split the screened populations into

before 2009 (201 screened people) and after 2009

(2391 screened people). However, considering RDT

HRP2 and RDT pLDH, which were not used in

every study, the screened populations were 1713 and

650 respectively.

Overall, in 20 years the prevalence of malaria by

PCR, and microscopy was 33.1 % (885/2592), and

21.3% (553/2592). Considering that RDTs were

implemented after 2009, the Prevalence of malaria

by PCR, LM, HRP2, and pLDH from 2009 until

now is at 29.3 % (700/2391), 16.4% (391/2391),

23.3% (451/1713), and 16% (102/650). Thus, the

sub-microscopic SM

PCR,

HRP2,

and

pLDH

are

estimated at 12.9%, 6.9% and -0.4% (considered as

0) respectively.

In Nanoro, the malaria prevalence with PCR

PCR

) was 27.3% (476/1741). It was the highest

estimated prevalence in comparison to microscopy

= 17%, 296/1741), and HRP2 (P

HRP2

=29.8%,

317/1063). Thus, SM

PCR

= 10.3%, and SM

HRP2

12.8%. In Bobo-Dioulasso, P

PCR

was at 34.5%

(224/650) whereas P

(14.6% (95/650), HRP2

HRP2

=20.6%, 134/650), and pLDH (P

pLDH

= 15.7%,

102/650) were showing lower prevalence. The

estimated SM

PCR

= 19.9%, SM

HRP2

6%, and

Malaria in Burkina Faso from 2000 to 2019: Assessment of Diagnostic Tools

151

pLDH

1.3%. In Bourasso, malaria prevalence

using PCR (P

PCR

) was estimated at 92% (185/201).

Therefore, SM

PCR

was at 11.4% as the prevalence by

microscopy (P

) was 80.6% (162/201).

Interestingly, we noted from Fig. 3 that malaria

prevalence by PCR in Bourasso was the highest in

comparison to Nanoro (92% vs 27.3%, p<0.001) and

Bobo-Dioulasso (92% vs 34.5%, p<0.001). The

same observation was noted when we compared the

prevalence in Bourasso to the overall prevalence

after 2009 (92% vs 29.3%, p<0.001). Except in

Bourasso, the investigations conducted in Nanoro

and Bobo-Dioulasso were performed after 2009.

After 2009, the overall prevalence vs Nanoro (29.3

vs 27.3%, p= 0.16) was relatively similar while

overall prevalence vs Bobo-Dioulasso (29.3% vs

34.5%, p=0.01) was statistically different. Moreover,

compared to Nanoro the prevalence in Bobo-

Dioulasso was higher (34.5% vs 27.3%, p<0.001).

Figure 3. Prevalence by PCR before and after the

implementation of RDTs in Burkina Faso

In comparing the SM calculated from PCR and

RDTs, we noted that PCR had the highest detection

rate. Moreover, considering PCR results it seems

that SM is relatively stable over the last 20 years

independently from the location (11.4% in Bourasso,

10.3% in Nanoro, 19.9% in Bobo-Dioulasso, and

12.9% overall). Except in Nanoro where SM

HRP2

was higher than SM

PCR

(12.8% vs 10.3%, p=0.04)

the general trend is showing that RDT HRP2 failed

to compete with PCR in terms of SM diagnostic.

However, RDT HRP2 showed a relatively higher

sensitivity for SM diagnostic compared to RDT

pLDH (6.9% vs 0% Overall, p= and 12.8 vs 1.3 in

Bobo-Dioulasso). The details of the aforementioned

results are presented in Figure 4.

Figure 4. Submicroscopic malaria prevalence based on

PCR, RDTs, locations and period.

4 DISCUSSION

From PubMed, few articles fitting the selection

criteria were found. 3 regions were of interest:

Bourasso (before 2009), Nanoro and Bobo-

Dioulasso (after 2009) (Figure 1 and 2). Bourasso is

a village belonging to the rural area located near the

Malian border. Like Bobo-Dioulasso, malaria

transmission in Bourasso is holoendemic with a peak

during the rainy season May to October (Soma et al.,

2018). Thus, the prevalence in Bourasso before 2009

could be assimilated to the one observed in Bobo-

dioulasso during the same period. Nanoro and Bobo-

Dioulasso are well-known for their health research

centers of reference. That is probably why most of

the studies were conducted in Nanoro (Figure 1)

which in contrary is a hyperendemic transmission

area from July to November (Natama et al., 2018).

We found that prevalence by PCR in Bourasso

(before 2009) was the highest (92%). After 2009,

the prevalence was estimated at 27.3% in Nanoro

and 34.5% in Bobo-Dioulasso. From 92% the

prevalence was reduced to 29.3% (Overall) after

2009 (Figure 3). This suggest that after the usage of

RDTs, malaria cases were somehow divided by 3.

This is parallel with earlier studies addressing the

positive impact of RDT as they enhanced the

surveillance for malaria elimination (Linn et al.,

2015; Donald et al., 2016). However, malaria

elimination program also depends on the ability of

diagnostic tools to detect SM.

We evaluated the SM rates by PCR, and RDT.

Considering PCR results it seems that SM is

relatively stable over the last 20 years independently

from the study site (between 10.3% and 19.9%, see

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

152

figure 4). In contrary, RDTs HRP2 and pLDH failed

to detect SM. This could be explained by the high

sensitivity of PCR which is able to detect very low

levels of parasitemia (de Monbrison et al., 2003);

while (a) Antigen-based detection RDTs are not

efficient for the infection detection during the early

stages (Siala et al., 2010), (b) their problems of

storage are well-known (Gamboa et al., 2010; WHO

et al., 2011) and (c) they are not quantitative enough

to distinguish between levels of infections (Murray

and Bennett, 2009). Golassa and coll. after

comparing PCR, and RDT had concluded that only

PCR was able to detect low-density malaria

infection also called asymptomatic malaria (Golassa

et al., 2013). In areas where PCR cannot be

performed daily, this finding represents a threat to

elimination programs. Actually, SM infections only

rarely provoke acute diseases (Rogier et al., 1996),

but they are capable of infecting mosquitoes and

continuing the transmission (Muirhead-Thomson,

1957; Coleman et al., 2004). Moreover, it is known

that SM can persist for several months without any

symptoms that would prompt treatment seeking

(Roper et al., 1996); which is not appropriate for

pregnant women in high transmission areas as they

are exposed to anemia, placental malaria, and low-

birth weight (Steketee et al., 1996). Considering our

findings suggesting there are lot of SM ongoing in

Burkina Faso, and knowing the risks of this form of

malaria, we could therefore assume that it is an urge

to promote more sensitive diagnostic tests.

Plasmodium feeds on hemoglobin and excrete

iron under toxic form for the parasite that converts it

into hemozoin. Hemozoin behaves like little

magnets that are detectable and measurable. In the

past few years, Magnets detection technique is

becoming prominent (Kim et al., 2010; Mens et al.,

2010; Castilho Mde et al., 2011; Yuen and Liu,

2012). From research published, RDTs limit of

detection was estimated at 100 parasites/ul while the

threshold of the device detecting hemozoin was

equivalent to ≤ 30 parasites/ul (Butykai et al., 2013).

The technic is faster than RDT and more than 3

times as accurate as current kits. To our knowledge,

despite Sub-Saharan African countries like Burkina

Faso are majorly exposed to malaria, the magnet

detection technique has not been used yet.

CONFLICT OF INTERESTS

The authors declare that they have no competing

interests

ACKNOWLEDGEMENTS

Thanks to N. Aida N. Ouedraogo for her help with

the proofreading of this paper.

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