Abstract
Background: With increasing spatial heterogeneity of malaria transmission and a shift of the disease burden towards older children and adults, pregnant women attending antenatal care (ANC) have been proposed as a pragmatic sentinel population for malaria surveillance. However, the representativeness of routine ANC malaria test-positivity and its relationship with prevalence in other population subgroups are yet to be investigated. Methods: Monthly ANC malaria test-positivity data from all Tanzanian health facilities for January 2014 to May 2016 was compared to prevalence data from the School Malaria Parasitemia Survey 2015, the Malaria Indicator Survey (MIS) 2015/16, the Malaria Atlas Project 2015, and a Bayesian model fitted to MIS data. Linear regression was used to describe the difference between the malaria test-positivity in pregnant women and the respective comparison group as a function of ANC test-positivity and potential covariates. Findings: The relationship between test-positivity in pregnant women and survey prevalence in children follows spatially and biologically meaningful patterns. However, the uncertainty of the relationship was substantial, particularly in areas with high or perennial transmission. In comparison, modeled data overestimated the prevalence in children at low transmission intensities and underestimated it at higher transmission intensities. Interpretation: Pregnant women attending ANC are a pragmatic sentinel population to assess sub-national heterogeneity and trends in malaria prevalence in Tanzania. Yet, since ANC malaria test-positivity cannot be used to directly predict the prevalence in other population subgroups, complementary community-level measurements remain highly relevant. Funding: This analysis was funded by the Swiss Tropical and Public Health Institute. Declaration of Interest: We declare no competing interests. Ethical Approval: This paper includes secondary analyses of published or publicly accessible anonymous data which does not require ethical approval.
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