{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T12:02:36Z","timestamp":1791460956373,"version":"4.3.4"},"reference-count":69,"publisher":"Public Library of Science (PLoS)","issue":"11","license":[{"start":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T00:00:00Z","timestamp":1763596800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100013885","name":"Ministry of Health Malaysia","doi-asserted-by":"crossref","award":["MRG JPP-NIH 19-009 (Project ID: NMRR-19-470-47341"],"award-info":[{"award-number":["MRG JPP-NIH 19-009 (Project ID: NMRR-19-470-47341"]}],"id":[{"id":"10.13039\/501100013885","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>\n                    Malaysia successfully achieved zero indigenous human malaria cases since 2018. However, challenges persist from\n                    <jats:italic>Plasmodium knowlesi<\/jats:italic>\n                    (zoonotic malaria) and low-density infections, posing reintroduction risks in previously malaria-free areas. Addressing these hidden infections is critical for sustaining Malaysia\u2019s elimination gains. This study investigated the persistence of low-density malaria transmission in high-risk localities declared malaria-free for at least three consecutive years. A community-based cross-sectional survey was conducted from June to October 2020 in 23 high-receptivity localities across Sabah, Perak, Kelantan, and Johor. Blood samples from asymptomatic residents were screened via conventional microscopy and nested PCR (nPCR) targeting the\n                    <jats:italic>Plasmodium<\/jats:italic>\n                    18S rRNA gene, with positive nPCR products species-determined. Sociodemographic and geospatial data were analyzed for associations with infection status. Of 3,322 asymptomatic individuals, no infections were detected by microscopy, whereas nPCR revealed a low-density malaria prevalence of 1.86% (62\/3,322). Infections comprised\n                    <jats:italic>P. malariae<\/jats:italic>\n                    (40.3%),\n                    <jats:italic>P. vivax<\/jats:italic>\n                    (29.0%),\n                    <jats:italic>P. knowlesi<\/jats:italic>\n                    (24.2%),\n                    <jats:italic>P. falciparum<\/jats:italic>\n                    (1.6%),\n                    <jats:italic>P. cynomolgi<\/jats:italic>\n                    (1.6%), and mixed\n                    <jats:italic>P. vivax\/P. knowlesi<\/jats:italic>\n                    (3.2%). All PCR-positive cases originated from Sabah and an Orang Asli settlement in Perak. Adults (\u226517 years) constituted the majority (~68%), with no significant difference in prevalence by gender or previous malaria history (p\u2009&gt;\u20090.05). Asymptomatic low-density malaria infections persist in purportedly malaria-free communities, remaining undetectable by routine microscopy. These hidden parasite reservoirs pose a risk for malaria reintroduction, especially in receptive areas. Malaria surveillance programs must thus incorporate highly sensitive diagnostic tools to detect low-density infections and safeguard elimination gains. Intensified, targeted interventions in identified \u201cmalaria hotspots\u201d, including community engagement and vector control, are crucial to eliminate residual foci and prevent disease resurgence.\n                  <\/jats:p>","DOI":"10.1371\/journal.pone.0329219","type":"journal-article","created":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T18:24:36Z","timestamp":1763663076000},"page":"e0329219","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":3,"title":["Persistent low-density infection in areas at risk of malaria reintroduction in Malaysia"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9669-6927","authenticated-orcid":true,"given":"Adela Ida","family":"Jiram","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shamilah","family":"Hisam","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohd Hafizi","family":"Abdul Hamid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenarun","family":"Jelip","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7583-0752","authenticated-orcid":true,"given":"Rahmah","family":"Noordin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kamarul Imran","family":"Musa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6568-5651","authenticated-orcid":true,"given":"Nurhainis","family":"Ogu Salim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Noor Azian","family":"Md Yusuf","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4797-0683","authenticated-orcid":true,"given":"Nur Fariha","family":"Amir","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aliaa","family":"Rasyidina","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nor Parina","family":"Ismail","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dg Izyan","family":"Hazwani Aziz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nur Hafizah","family":"Abdullah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aqidah","family":"Kep","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zaini","family":"Hussin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aziah","family":"Ismail","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,11,20]]},"reference":[{"key":"pone.0329219.ref001","volume-title":"The E-2020 initiative of 21 malaria-eliminating countries [Internet]","author":"WHO","year":"2021"},{"key":"pone.0329219.ref002","volume-title":"Management Guidelines of Malaria in Malaysia 2013","author":"Vector Borne Disease Sector, Disease Control Division, Ministry of Health 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