Clinically silent Plasmodium vivax infections in native Amazonians of northwestern Brazil: acquired immunity or low parasite virulence?

Abstract

BACKGROUND Malaria remains common among native Amazonians, challenging Brazil′s elimination efforts. OBJECTIVES We examined the epidemiology of malaria in riverine populations of the country′s main hotspot – the upper Juruá Valley in Acre state, close to the Brazil-Peru border, where Plasmodium vivax accounts for > 80% of cases. METHODS Participants (n = 262) from 10 villages along the Azul River were screened for malaria parasites by microscopy and genus-specific, cytochrome b (cytb) gene-based polymerase chain reaction. Positive samples were further tested with quantitative TaqMan assays targeting P. vivax-and P. falciparum-specific cytb domains. We used multiple logistic regression analysis to identify independent correlates of P. vivax infection. FINDINGS Microscopy detected only one P. vivax and two P. falciparum infections. TaqMan assays detected 33 P. vivax infections (prevalence, 11.1%), 78.1% of which asymptomatic, with a median parasitaemia of 34/mL. Increasing age, male sex and use of insecticide-treated bed nets were significant predictors of elevated P. vivax malaria risk. Children and adults were similarly likely to remain asymptomatic once infected. MAIN CONCLUSIONS Our findings are at odds with the hypothesis of age-related clinical immunity in native Amazonians. The low virulence of local parasites is suggested as an alternative explanation for subclinical infections in isolated populations.