Abstract
BackgroundAccurate identification of Plasmodium infections in community surveys is essential to successful malaria control. Microscopy and rapid diagnostic tests (RDTs) are the main techniques used to diagnose malaria in field-based surveys. While microscopy is still considered the gold standard, RDTs are growing in popularity as they allow for rapid and inexpensive diagnosis. Using data from a prevalence survey conducted in north-western Angola in 2010, the authors aimed to compare the performance of microscopy and RDTs in identifying Plasmodium falciparum infections, using polymerase chain reaction (PCR) as the gold standard.MethodsResults from 3,307 subjects (1,225 preschool-aged children (zero to five year olds), 1,134 school-aged children (six to 15 year olds) and 948 mothers/caregivers (>15 years of age)), tested for P. falciparum infections, were utilized. The sensitivity, specificity, positive, and negative predictive values (PPV and NPV) of microscopy and Paracheck-Pf® were compared using the McNemar’s test and the weighted generalized score Chi-squared test for paired data.ResultsThe prevalence of P. falciparum infections determined by PCR and microscopy was 15.9% and by Paracheck- Pf® was 16.3%. Compared to microscopy, Paracheck-Pf® had significantly higher sensitivity (72.8% versus 60%), specificity (94.3% versus 92.5%), PPV (70.7% versus 60%) and NPV (94.8% versus 92.5%). Both tests had significantly lower sensitivity in mothers (36.8% for microscopy and 43.7% for Paracheck-Pf®) than in their children (68.4% in zero to five years-old and 60.6% in six to 15 years-old for microscopy and 80.4% in zero to five year-olds and 76.5% in six to 15 year-olds for Paracheck-Pf®).ConclusionBoth microscopy and RDTs performed suboptimally when compared to PCR. False negativity could be associated with the low parasite density profile of the samples. False positivity may be related to the well-described limitations of those techniques such as level of expertise of microscopists or persistent antigenicity from previous infections in the case of RDTs. Nevertheless, RDTs had enhanced performance comparatively to microscopy in detecting malaria infections, favouring their use in community cross-sectional malaria surveys, where expert performance of microscopy is hard to accomplish.
Highlights
Accurate identification of Plasmodium infections in community surveys is essential to successful malaria control
Active surveillance through field-based surveys is considered a powerful tool for estimating the burden of malaria, as it identifies sustained foci of transmission perpetuated by asymptomatic carriers and low parasitaemia infections [1,2,3]
The performance of HRP2immunochromatography-based rapid diagnostic tests (RDTs) is affected by the detection of persistent antigenicity from previous infections, which leads to false positives and overestimate prevalence [10,18,19,20]
Summary
Accurate identification of Plasmodium infections in community surveys is essential to successful malaria control. Sensitivity of RDTs can vary due to their vulnerability to extreme temperature and high humidity occurring in field-based surveys [26] Considering these limitations, the use of RDTs in malaria surveys is only advisable when used in comparison with microscopy, as recommended by WHO and performed in the majority of studies [9,10,18,27,28,29]. PCR is highly sensitive, detecting low parasitaemia cases missed by other techniques and reproducible [33,34,35,36,37] It is highly expensive, time and labour consuming and used in only a few studies for confirmation of prevalence data and to measure the accuracy of microscopy and RDTs [31,38,39,40]
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