Use of a highly-sensitive rapid diagnostic test to screen for malaria in pregnancy in Indonesia

Vera T Unwin, Rukhsana Ahmed, Rintis Noviyanti, Agatha M Puspitasari, Retno A S Utami, Leily Trianty, Theda Lukito, Din Syafruddin, Jeanne R Poespoprodjo, Maria A Santana-Morales, Feiko O Ter Kuile, Emily R Adams, Vera T Unwin, Rukhsana Ahmed, Rintis Noviyanti, Agatha M Puspitasari, Retno A S Utami, Leily Trianty, Theda Lukito, Din Syafruddin, Jeanne R Poespoprodjo, Maria A Santana-Morales, Feiko O Ter Kuile, Emily R Adams

Abstract

Background: The sensitivity of rapid diagnostic tests (RDTs) for malaria is inadequate for detecting low-density, often asymptomatic infections, such as those that can occur when screening pregnant women for malaria. The performance of the Alere™ Ultra-sensitive Malaria Ag Plasmodium falciparum RDT (uRDT) was assessed retrospectively in pregnant women in Indonesia.

Methods: The diagnostic performance of the uRDT and the CareStart™ Malaria HRP2/pLDH VOM (Plasmodium vivax, Plasmodium ovale and Plasmodium malariae) Combo RDT (csRDT) were assessed using 270 stored red blood cell pellets and plasma samples from asymptomatic pregnant women. These included 112 P. falciparum negative and 158 P. falciparum positive samples detected by a composite test (qPCR, LAMP, nPCR) as reference standard. Diagnostic indicators: sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), diagnostic odds ratio (DOR) and the level of agreement (kappa) were calculated for comparison.

Results: Compared with the reference test, the uRDT had a sensitivity of 19.6% (95% CI 13.9-26.8) and specificity of 98.2% (93.1-99.7%). The csRDT was 22.8% (16.7-30.3) sensitive and 95.5% (89.4-98.3) specific for P. falciparum infections. Performance of the uRDT was non-significantly different to the csRDT (p = 0.169). RDT outcome was stratified by qPCR cycling threshold (Ct), and performance of the RDTs was found to be comparable across parasite loads.

Conclusion: The uRDT performed similarly to the currently used csRDTs in detecting P. falciparum infections in asymptomatic pregnant women. In these settings, molecular diagnostics are currently the most sensitive for malaria.

Keywords: Diagnostic performance; Diagnostics; Malaria; Molecular techniques; Pregnancy; Rapid diagnostic test.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Venn diagram showing the number of P. falciparum positive samples detected by each test. Positivity by uRDT, csRDT and the composite molecular reference test (Ref.Std) in 270 samples from asymptomatic pregnant women. Numbers within the circles (n) indicate the number of true positives detected by that test
Fig. 2
Fig. 2
Diagnostic performance stratified by qPCR Ct values. The bar chart shows the sensitivity of each test: uRDT (grey) and csRDT (white bar and black trendline) stratified by qPCR cycle-threshold (Ct) values. The number of qPCR- positive samples in each Ct category is given in brackets (n). Trendlines (dashed) are derived from the rolling mean sensitivity calculated for every 10 observations. R squared coefficient values are displayed (uRDT; grey text, csRDT; black text) and difference between R2 values is non-significant (n.s, p = 0.3 one-tailed t-test). (28) Error bars represent upper and lower 95% CI

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