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Data from surveys totaling 3031 participants at three sites revealed a high proportion of asymptomatic infections, complicating diagnosis. The aim of this study was to identify differences in complaints and symptoms between sites, and factors associated with asymptomatic <jats:italic>Plasmodium<\/jats:italic> infections.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Methods<\/jats:title>\n<jats:p>Published data from community-based cross-sectional studies conducted between 2012 and 2015 in Nadiad (Gujarat), Chennai (Tamil Nadu), and Rourkela (Odisha) as part of the Center for the Study of Complex Malaria in India were analysed. Complaints and symptoms were systematically recorded, and <jats:italic>Plasmodium<\/jats:italic> infections confirmed using microscopy, rapid diagnostic tests (RDTs), and polymerase chain reaction (PCR). Multivariate analyses were conducted to determine the association between general symptoms and age, season, or gender, and factors associated with asymptomatic <jats:italic>Plasmodium<\/jats:italic> infections were assessed.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Results<\/jats:title>\n<jats:p>Complaints of any illness were lowest in Chennai (17.7%), 30.6% in Rourkela and 42.7% in Nadiad. Complaints were more often reported for children; gender differences were noted in Rourkela only. In Nadiad, 7.0% of 796 participants were positive for malaria by PCR (32% <jats:italic>Plasmodium falciparum<\/jats:italic>); 78.6% had a history of fever or documented fever, 14.3% had other symptoms, and 7.1% were \u201ctruly asymptomatic\u201d. For Chennai this was 29.2%, 4.2% and 66.7% respectively, with a malaria prevalence of 2.6% by PCR of 928 participants (29% <jats:italic>P. falciparum<\/jats:italic>). In Rourkela, with 7.7% of 1307 participants positive for malaria by PCR (82% <jats:italic>P. falciparum<\/jats:italic>), the percentages were 35.6%, 24.8% and 39.6%, respectively. In Rourkela, asymptomatic infections were associated with young age and male gender (microscopy or RDT), and with rainy season (PCR). In the same site, participants with <jats:italic>Plasmodium vivax<\/jats:italic> were more likely to be asymptomatic (11\/18 or 61.1%) than persons with <jats:italic>P. falciparum<\/jats:italic> mono-infections (27\/78 or 34.6%); gametocytes for <jats:italic>P. falciparum<\/jats:italic> were evenly distributed between symptomatic and asymptomatic infections (2\/53 vs. 2\/49, respectively). The addition of the symptoms \u201cheadache\u201d, \u201caches\u201d and \u201cchills\u201d to fever improved the case-definition of symptomatic malaria.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Conclusion<\/jats:title>\n<jats:p>There were considerable differences in complaints at the three sites in India. Malaria and asymptomatic infections differ by region, indicating that malaria elimination will require localized approaches.<\/jats:p>\n<\/jats:sec>","DOI":"10.1186\/s12936-020-03310-9","type":"journal-article","created":{"date-parts":[[2020,7,6]],"date-time":"2020-07-06T12:03:44Z","timestamp":1594037024000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Defining symptoms of malaria in India in an era of asymptomatic infections"],"prefix":"10.1186","volume":"19","author":[{"given":"Anna Maria","family":"van Eijk","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asad S.","family":"Mannan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven A.","family":"Sullivan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jane M.","family":"Carlton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2020,7,6]]},"reference":[{"key":"3310_CR1","unstructured":"National Vector Borne Disease Control Programme, Directorate general of Health Services, Ministry of Health and Family Welfare. 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Informed consent was obtained from all research participants.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"237"}}