Consequences of multiple infection with Plasmodium falciparum in an area of high endemicity

Most Plasmodium falciparum infections occur in partially immune hosts in highly endemic areas. In such situations, many hosts are simultaneously infected with multiple parasite genotypes, which must lead to intense competition between different parasite populations. We here summarise a series of studies of multiple infection, mostly using polymerase chain reaction-restriction fragment polymorphism (PCR-RFLP) genotyping of the highly polymorphic msp-2 gene. These indicate that chronic infections, characteristic of the partially immune host, appear to protect against super-infecting parasites. This protection is not seen in infants. A consequence is that selection for fast-growing (virulent) parasites, occurs mainly in the youngest, immunologically naïve, hosts. The normal situation for P. falciparum is one in which the host is partially immune, and competition between parasite genotypes in this situation is not expected to result in selection for virulence.