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Plasmodium ovale  is a benign tertian malaria parasite that morphologically resembles  Plasmodium vivax .  P. ovale  also shares similar tertian periodicity and can cause relapse in patients without a radical cure, making it easily misidentified as  P. vivax  in routine diagnosis. Therefore, its prevalence might be underreported worldwide. The present study aimed to quantify the prevalence of  P. ovale  misidentified as  P. vivax  malaria using data from studies reporting confirmed  P. ovale  cases by molecular methods. Studies reporting the misidentification of  P. ovale  as  P. vivax  malaria were identified from three databases, MEDLINE, Web of Science, and Scopus, without language restrictions, but the publication date was restricted to 1993 and 2020. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS). The random-effects model was used to estimate the pooled prevalence of the misidentification of  P. ovale  as  P. vivax  malaria by the microscopic method when compared to those with the reference polymerase chain reaction method. Subgroup analysis of participants was also performed to demonstrate the difference between imported and indigenous  P. ovale  cases. The heterogeneity of the included studies was assessed using Cochran's Q and I 2  statistics. Publication bias across the included studies was assessed using the funnel plot and Egger’s test, and if required, contour-enhanced funnel plots were used to identify the source(s) of funnel plot asymmetry. Of 641 articles retrieved from databases, 22 articles met the eligibility criteria and were included in the present study. Of the 8,297 malaria-positive cases identified by the PCR method, 453  P. ovale  cases were confirmed. The pooled prevalence of misidentification of  P. ovale  as  P. vivax  malaria by the microscopic method was 11% (95% CI: 7–14%, I 2 : 25.46%). Subgroup analysis of the participants demonstrated a higher prevalence of misidentification in indigenous cases (13%, 95% CI: 6–21%, I 2 : 27.8%) than in imported cases (10%, 95% CI: 6–14%, I 2 : 24.1%). The pooled prevalence of misidentification of  P. vivax  as  P. ovale  malaria by the microscopic method was 1%, without heterogeneity (95% CI: 0–3%, I 2 : 16.8%). PCR was more sensitive in identifying  P. ovale  cases than the microscopic method (p < 0.00001, OR: 2.76, 95% CI: 1.83–4.15, I 2 : 65%). Subgroup analysis of participants demonstrated the better performance of PCR in detecting  P. ovale  malaria in indigenous cases (p: 0.0009, OR: 6.92, 95% CI: 2.21–21.7%, I 2 : 68%) than in imported cases (p: 0.0004, OR: 2.15, 95% CI: 1.41–3.29%, I 2 : 63%).  P. ovale  infections misidentified as  P. vivax  malaria by the microscopic method were frequent and led to underreported  P. ovale  cases. The molecular identification of  P. ovale  malaria in endemic areas is needed because a higher rate of  P. ovale  misidentification was found in endemic or indigenous cases than in imported cases. In addition, updated courses, enhanced training, and refreshers for microscopic examinations, particularly for  P. ovale  identification, are necessary to improve the microscopic identification of  Plasmodium  species in rural health centres where PCR is unavailable.

Misidentification of Plasmodium ovale as Plasmodium vivax malaria by a microscopic method: a meta-analysis of confirmed P. ovale cases