1 Contrasting Epidemiology and Genetic Variation of Plasmodium vivax Infecting Duffy Negatives across Africa Eugenia Lo 1* , Gianluca Russo 2* , Kareen Pestana 1 , Daniel Kepple 1 , Beka Raya Abargero 3 , Ghyslaine Bruna Djeunang Dongho 2,4 , Karthigayan Gunalan 5 , Louis H Miller 5 , Muzamil Mahdi Abdel Hamid 6 , Delenasaw Yewhalaw 3 , Giacomo Maria Paganotti 7,8,9 1 Biological Sciences, University of North Carolina at Charlotte, USA 2 Department of Public Health and Infectious diseases, Sapienza University, Rome, Italy 3 Tropical Infectious Disease Research Center, Jimma University, Jimma, Ethiopia 4 Evangelical University of Cameroon, Bandjoun, Cameroon 5 Laboratory of Malaria and Vector Research, NIAID/NIH, Bethesda, USA 6 Department of Parasitology and Medical Entomology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan 7 Botswana-University of Pennsylvania Partnership, Gaborone, Botswana 8 Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA 9 Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana * Correspondence authors: Eugenia Lo; email: eugenia.lo@uncc.edu; Gianluca Russo; email: gianluca.russo@uniroma1.it Abstract Recent studies indicated that Plasmodium vivax can infect Duffy-negative individuals, but the varied diagnostic and methodological approaches have limited our ability to characterize P. vivax across Africa. Here, we utilized a standardized approach to compare epidemiological and genetic attributes of P. vivax from Botswana, Ethiopia, and Sudan, where Duffy-positive and Duffy-negative individuals coexist. Among 1,215 febrile patients, the proportions of Duffy negativity range from 20-36% in East Africa to 84% in Southern Africa. Considerable differences were observed in P. vivax prevalence among Duffy-negative populations ranging from averaged 9.2% in Sudan to 86% in Botswana. P. vivax parasite density in Duffy-negative infections is significantly lower than in Duffy-positive infections. Phylogenetic analyses of 229 PvDBP sequences indicated that Duffy-negative P. vivax were not monophyletic but occurred in multiple well-supported clades, suggesting independent origins. Duffy-negative Africans are clearly not resistant to P. vivax and the public health significance should no longer be neglected. Keywords: Plasmodium vivax; Duffy Negatives; Africa; Molecular epidemiology; Genetic relatedness Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 8 December 2020 doi:10.20944/preprints202012.0209.v1 © 2020 by the author(s). Distributed under a Creative Commons CC BY license.