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As a result, a majority of RDTs procured globally target this antigen. However, previous reports from South America and recent reports from sub-Saharan Africa and Asia indicate that certain <jats:italic>P. falciparum<\/jats:italic> parasites have deletions of the gene coding for HRP2. The HRP2 antigen is paralogous to another <jats:italic>P. falciparum<\/jats:italic> antigen HRP3 and some antibodies to HRP2 cross-react with HRP3. Multiple parasites have been described with deletions of one or both <jats:italic>hrp2<\/jats:italic> and <jats:italic>hrp3<\/jats:italic> genes. It is unclear how the various combinations of <jats:italic>hrp2<\/jats:italic> and <jats:italic>hrp3<\/jats:italic> deletion genotypes affect clinical sensitivity of HRP2-based RDTs.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Cross-reactivity between HRP2 and HRP3 was tested on malaria RDTs using culture-adapted <jats:italic>P. falciparum<\/jats:italic> parasites with both <jats:italic>hrp2<\/jats:italic> and <jats:italic>hrp3<\/jats:italic> intact or with one or both genes deleted. Ten-fold serial dilutions of four culture-adapted <jats:italic>P. falciparum<\/jats:italic> parasites [3D7 (<jats:italic>hrp2<\/jats:italic>+\/<jats:italic>hrp3<\/jats:italic>+), Dd2 (<jats:italic>hrp2<\/jats:italic>\u2212\/<jats:italic>hrp3<\/jats:italic>+), HB3 (<jats:italic>hrp2<\/jats:italic>+\/<jats:italic>hrp3<\/jats:italic>\u2212) and 3BD5 (<jats:italic>hrp2<\/jats:italic>\u2212\/<jats:italic>hrp3<\/jats:italic>\u2212)] ranging from 100,000 to 0.01 parasites\/\u00b5L were prepared. HRP2, <jats:italic>Plasmodium<\/jats:italic> lactate dehydrogenase (pLDH) and aldolase concentrations were determined for the diluted samples using a multiplex bead assay. The samples were subsequently tested on three RDT products designed to detect <jats:italic>P. falciparum<\/jats:italic> by HRP2 alone or in combination with pLDH.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>At parasite densities of approximately 1000 parasites\/\u00b5L, parasites that expressed either <jats:italic>hrp2<\/jats:italic> or <jats:italic>hrp3<\/jats:italic> were detected by all three RDTs. Multiplex based antigen measurement using HRP2- conjugated beads demonstrated higher antigen concentration when both <jats:italic>hrp2<\/jats:italic> and <jats:italic>hrp3<\/jats:italic> genes were intact (3D7 parasites, 47.9\u00a0ng\/ml) compared to HB3 (3.02\u00a0ng\/mL) and Dd2 (0.20\u00a0ng\/mL) strains that had one gene deleted. 3D7 at 10 parasites\/\u00b5L (0.45\u00a0ng\/mL) was reactive on all three RDT products whereas none of the other parasites were reactive at that density.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>Above a certain antigen threshold, HRP3 cross-reactivity on HRP2-based RDTs is sufficient to mask the effects of deletions of <jats:italic>hrp2<\/jats:italic> only. Studies of <jats:italic>hrp2<\/jats:italic> deletion and its effects on HRP2-based RDTs must be studied alongside <jats:italic>hrp3<\/jats:italic> deletions and include clinical sample reactivity on HRP2-based tests.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12936-021-03739-6","type":"journal-article","created":{"date-parts":[[2021,4,29]],"date-time":"2021-04-29T20:02:28Z","timestamp":1619726548000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":53,"title":["HRP2 and HRP3 cross-reactivity and implications for HRP2-based RDT use in regions with Plasmodium falciparum hrp2 gene deletions"],"prefix":"10.1186","volume":"20","author":[{"given":"Amy","family":"Kong","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott A.","family":"Wilson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yong","family":"Ah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas","family":"Nace","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Rogier","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Aidoo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,4,29]]},"reference":[{"key":"3739_CR1","unstructured":"WHO. 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