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Health facility-based malaria surveillance: The effects of age, area of residence and diagnostics on test positivity rates

Damon Francis1, Anne Gasasira2, Ruth Kigozi2, Simon Kigozi2, Sussann Nasr3, Moses R Kamya4 and Grant Dorsey1*

Author Affiliations

1 Department of Medicine, University of California, San Francisco General Hospital, 1001 Potrero Ave. Bldg. 30, Rm. 408, San Francisco, CA, 94110, USA

2 Uganda Malaria Surveillance Project, PO Box 7475, Mulago Hospital Complex, Kampala, Uganda

3 Malaria Branch, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30333, USA

4 Department of Medicine, Makerere University School of Medicine, PO Box 7475, Mulago Hospital Complex, Kampala, Uganda

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Malaria Journal 2012, 11:229  doi:10.1186/1475-2875-11-229

Published: 7 July 2012



The malaria test positivity rate (TPR) is increasingly used as an indicator of malaria morbidity because TPR is based on laboratory-confirmed cases and is simple to incorporate into existing surveillance systems. However, temporal trends in TPR may reflect changes in factors associated with malaria rather than true changes in malaria morbidity. This study examines the effects of age, area of residence and diagnostic test on TPR at two health facilities in regions of Uganda with differing malaria endemicity.


The analysis included data from diagnostic blood smears performed at health facilities in Walukuba and Aduku between January 2009 and December 2010. The associations between age and time and between age and TPR were evaluated independently to determine the potential for age to confound temporal trends in TPR. Subsequently, differences between observed TPR and TPR adjusted for age were compared to determine if confounding was present. A similar analysis was performed for area of residence. Temporal trends in observed TPR were compared to trends in TPR expected using rapid diagnostic tests, which were modelled based upon sensitivity and specificity in prior studies.


Age was independently associated with both TPR and time at both sites. At Aduku, age-adjusted TPR increased relative to observed TPR due to the association between younger age and TPR and the gradual increase in age distribution. At Walukuba, there were no clear differences between observed and age-adjusted TPR. Area of residence was independently associated with both TPR and time at both sites, though there were no clear differences in temporal trends in area of residence-adjusted TPR and observed TPR at either site. Expected TPR with pLDH- and HRP-2-based rapid diagnostic tests (RDTs) was higher than observed TPR at all time points at both sites.


Adjusting for potential confounders such as age and area of residence can ensure that temporal trends in TPR due to confounding are not mistakenly ascribed to true changes in malaria morbidity. The potentially large effect of diagnostic test on TPR can be accounted for by calculating and adjusting for the sensitivity and specificity of the test used.