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Lieberman M, Badea A, Desnoyers C, Hayes K, Park JN. An urgent need for community lot testing of lateral flow fentanyl test strips marketed for harm reduction in Northern America. Harm Reduct J 2024; 21:115. [PMID: 38877522 PMCID: PMC11179324 DOI: 10.1186/s12954-024-01025-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/15/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Fentanyl test strips (FTS) are lateral flow immunoassay strips designed for detection of ng/mL levels of fentanyl in urine. In 2021, the US Centers for Disease Control and the Substance Abuse and Mental Health Administration stated that federal funds could be used for procurement of FTS for harm reduction strategies approved by the government such as drug checking. The market for FTS has expanded rapidly in the US and Canada. However, there is no regulatory oversight by either government to ensure proper function of FTS that are being marketed for drug checking. MAIN BODY Many brands of FTS have rapidly entered the harm reduction market, creating concerns about the reproducibility and accuracy of their performance from brand to brand and lot to lot. Some examples are provided in this Comment. Similar problems with product quality were observed in the mid 2000's when lateral flow immunoassays for malaria were funded in many countries and again in 2020, when COVID-19 tests were in huge demand. The combination of high demand and low levels of regulation and enforcement led some manufacturers to join the goldrush without adequate field testing or quality assurance. We argue that the harm reduction community urgently needs to set a lot checking program in place. A set of simple protocols for conducting the tests and communicating the results have been developed, and are described in the following Perspectives paper in this issue. CONCLUSION In the absence of governmental regulation and enforcement, the harm reduction community should implement a FTS lot checking program. Based on previous experience with the malaria diagnostic lot checking program, this inexpensive effort could identify products that are not suitable for harm reduction applications and provide valuable feedback to manufacturers. Dissemination of the results will help harm reduction organizations to ensure that FTS they use for drug checking are fit for the purpose.
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Affiliation(s)
| | - Adina Badea
- Lifespan Academic Medical Center, Providence, RI, USA
- Warren Alpert Medical School, Brown University, Providence, RI, USA
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Srivastava B, Sharma S, Swarnkar D, Ahmed N, Valecha N, Anvikar AR. Benefits of Lot Testing to Improve the Quality of Malaria Rapid Diagnostic Tests in India. Am J Trop Med Hyg 2024; 110:431-435. [PMID: 38350136 PMCID: PMC10919188 DOI: 10.4269/ajtmh.23-0339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/02/2023] [Indexed: 02/15/2024] Open
Abstract
Since 2010, malaria rapid diagnostic tests (RDTs) are widely used to detect malaria. The Indian Council of Medical Research-National Institute of Malaria Research performed lot testing (LT) according to WHO procedures since 2016. Lot testing is performed to evaluate the lot-to-lot variation in performance of malaria RDTs. Four sets of positive quality control (QC) panels for P. falciparum (Pf) and P. vivax (Pv) and 10 negative panels tested RDTs. RDTs were reported as pass, failed, or deferred on the basis of WHO criteria. In the past 5 years, 275 lots containing 15,488 RDT kits for malaria diagnosis were subjected to LT. The monovalent RDTs (n = 1,216), based on either Pf histidine rich protein 2 (HRP2) or Pan-Plasmodium lactate dehydrogenase (Pan-pLDH) antigens, showed 90.4% sensitivity and 100% specificity, whereas RDTs based on HRP2 + Pan-pLDH or HRP2 + pLDH (n = 13,924) had sensitivity 95.6% and specificity 99.5%, respectively. RDTs based on PfHRP2 + Pv-pLDH + Pan-pLDH (n = 348) had 100% sensitivity and specificity. In a comparison between HRP2 + pLDH or HRP2 + Pan-pLDH to HRP2 + pLDH + Pan-pLDH RDTs, it was found that the sensitivity of PfHRP2 with Pan-pLDH RDTs (n = 2,382) was only 83%. Of the 275 lots analyzed, 15 lots of PfHRP2 with Pan-pLDH were deferred. The QC panel for Pf revealed a faint Pan band in the tested lots, which is a cause for concern. The results of deferred lots were reported to concerned government agencies. Quality-compromised RDTs may lead to an incorrect diagnosis. It is critical to have a QC system in place for effective malaria management.
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Affiliation(s)
- Bina Srivastava
- Indian Council of Medical Research, National Institute of Malaria Research, Dwarka, New Delhi, India
| | - Supriya Sharma
- Indian Council of Medical Research, National Institute of Malaria Research, Dwarka, New Delhi, India
| | - Deendayal Swarnkar
- Indian Council of Medical Research, National Institute of Malaria Research, Dwarka, New Delhi, India
| | - Naseem Ahmed
- Indian Council of Medical Research, National Institute of Malaria Research, Dwarka, New Delhi, India
| | - Neena Valecha
- Independent Malaria Technical Expert, New Delhi, India
| | - Anupkumar R. Anvikar
- Indian Council of Medical Research, National Institute of Malaria Research, Dwarka, New Delhi, India
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Molina-de la Fuente I, Yimar M, García L, González V, Amor A, Anegagrie M, Benito A, Martínez J, Moreno M, Berzosa P. Deletion patterns, genetic variability and protein structure of pfhrp2 and pfhrp3: implications for malaria rapid diagnostic test in Amhara region, Ethiopia. Malar J 2022; 21:287. [PMID: 36209103 PMCID: PMC9548178 DOI: 10.1186/s12936-022-04306-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 09/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although rapid diagnostic tests (RDTs) play a key role in malaria-control strategies, their efficacy has been threatened by deletion and genetic variability of the genes pfhrp2/3. This study aims to characterize the deletion, genetic patterns and diversity of these genes and their implication for malaria RDT effectiveness, as well as their genetic evolution in the Amhara region of Ethiopia. Methods The study included 354 isolates from symptomatic patients from the Amhara region of Ethiopia who tested positive by microscopy. Exon 1–2 and exon 2 of genes pfhrp2 and -3 were amplified, and exon 2 was sequenced to analyse the genetic diversity, phylogenetic relationship and epitope availability. Results The deletion frequency in exon 1–2 and exon 2 was 22 and 4.6% for pfhrp2, and 68 and 18% for pfhrp3, respectively. Double deletion frequency for pfhrp2 and pfhrp3 was 1.4%. High genetic diversity, lack of clustering by phylogenetic analysis and evidence of positive selection suggested a diversifying selection for both genes. The amino-acid sequences, classified into different haplotypes, varied widely in terms of frequency of repeats, with novel amino-acid changes. Aminoacidic repetition type 2 and type 7 were the most frequent in all the sequences. The most frequent epitopes among protein sequences were those recognized by MAbs 3A4 and C1-13. Conclusion Deletions and high amino acidic variation in pfhrp2 and pfhrp3 suggest their possible impact on RDT use in the Amhara region, and the high genetic diversity of these genes could be associated with a diversifying selection in Ethiopia. Surveillance of these genes is, therefore, essential to ensure the effectiveness of public health interventions in this region. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04306-3.
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Affiliation(s)
- Irene Molina-de la Fuente
- Department of Biomedicine and Biotechnology, School of Pharmacy, University of Alcalá, Alcalá de Henares, Madrid, Spain. .,Malaria and Neglected Diseases Laboratory, National Centre of Tropical Medicine, Institute of Health Carlos III, Madrid, Spain. .,Public Health and Epidemiology Research Group, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain.
| | - Mulat Yimar
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Luz García
- Malaria and Neglected Diseases Laboratory, National Centre of Tropical Medicine, Institute of Health Carlos III, Madrid, Spain.,CIBERINFECT - CIBER Infectious Diseases (ISCIII), Madrid, Spain
| | - Vicenta González
- Malaria and Neglected Diseases Laboratory, National Centre of Tropical Medicine, Institute of Health Carlos III, Madrid, Spain.,CIBERINFECT - CIBER Infectious Diseases (ISCIII), Madrid, Spain
| | - Arancha Amor
- Mundo Sano Foundations, Institute of Health Carlos III, Madrid, Spain
| | - Melaku Anegagrie
- Mundo Sano Foundations, Institute of Health Carlos III, Madrid, Spain
| | - Agustín Benito
- Malaria and Neglected Diseases Laboratory, National Centre of Tropical Medicine, Institute of Health Carlos III, Madrid, Spain.,CIBERINFECT - CIBER Infectious Diseases (ISCIII), Madrid, Spain
| | - Javier Martínez
- Department of Biomedicine and Biotechnology, School of Pharmacy, University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - Marta Moreno
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Pedro Berzosa
- Malaria and Neglected Diseases Laboratory, National Centre of Tropical Medicine, Institute of Health Carlos III, Madrid, Spain.,CIBERINFECT - CIBER Infectious Diseases (ISCIII), Madrid, Spain
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Wittenauer R, Nowak S, Luter N. Price, quality, and market dynamics of malaria rapid diagnostic tests: analysis of Global Fund 2009-2018 data. Malar J 2022; 21:12. [PMID: 35016684 PMCID: PMC8752184 DOI: 10.1186/s12936-021-04008-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/04/2021] [Indexed: 12/02/2022] Open
Abstract
Background Rapid diagnostic tests (RDTs) for malaria are a vital part of global malaria control. Over the past decade, RDT prices have declined, and quality has improved. However, the relationship between price and product quality and their larger implications on the market have yet to be characterized. This analysis used purchase data from the Global Fund together with product quality data from the World Health Organization (WHO) and Foundation for Innovative New Diagnostics (FIND) Malaria RDT Product Testing Programme to understand three unanswered questions: (1) Has the market share by quality of RDTs in the Global Fund’s procurement orders changed over time? (2) What is the relationship between unit price and RDT quality? (3) Has the market for RDTs financed by the Global Fund become more concentrated over time? Methods Data from 10,075 procurement transactions in the Global Fund’s database, which includes year, product, volume, and price, was merged with product quality data from all eight rounds of the WHO-FIND programme, which evaluated 227 unique RDT products. To describe trends in market share by quality level of RDT, descriptive statistics were used to analyse trends in market share from 2009 to 2018. A generalized linear regression model was then applied to characterize the relationship between price and panel detection score (PDS), adjusting for order volume, year purchased, product type, and manufacturer. Third, a Herfindahl–Hirschman Index (HHI) score was calculated to characterize the degree of market concentration. Results Lower-quality RDTs have lost market share between 2009 and 2018, as have the highest-quality RDTs. No statistically significant relationship between price per test and PDS was found when adjusting for order volume, product type, and year of purchase. The HHI was 3,570, indicating a highly concentrated market. Conclusions Advancements in RDT affordability, quality, and access over the past decade risk stagnation if health of the RDT market as a whole is neglected. These results suggest that from 2009 to 2018, this market was highly concentrated and that quality was not a distinguishing feature between RDTs. This information adds to previous reports noting concerns about the long-term sustainability of this market. Further research is needed to understand the causes and implications of these trends. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-04008-2.
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Affiliation(s)
- Rachel Wittenauer
- University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Spike Nowak
- PATH, 2201 Westlake Ave, Seattle, WA, 98121, USA
| | - Nick Luter
- PATH, 2201 Westlake Ave, Seattle, WA, 98121, USA
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Minakawa N, Kongere JO, Sonye GO, Lutiali PA, Awuor B, Kawada H, Isozumi R, Futami K. Long-Lasting Insecticidal Nets Incorporating Piperonyl Butoxide Reduce the Risk of Malaria in Children in Western Kenya: A Cluster Randomized Controlled Trial. Am J Trop Med Hyg 2021; 105:461-471. [PMID: 34125699 PMCID: PMC8437186 DOI: 10.4269/ajtmh.20-1069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
Malaria vectors have acquired an enzyme that metabolizes pyrethroids. To tackle this problem, we evaluated long-lasting insecticidal nets incorporating piperonyl butoxide (PBO-LLINs) with a community-based cluster randomized control trial in western Kenya. The primary endpoints were anopheline density and Plasmodium falciparum polymerase chain reaction (PCR)-positive prevalence (PCRpfPR) of children aged 7 months to 10 years. Four clusters were randomly selected for each of the treatment and control arms (eight clusters in total) from 12 clusters, and PBO-LLINs and standard LLINs were distributed in February 2011 to 982 and 1,028 houses for treatment and control arms, respectively. Entomological surveys targeted 20 houses in each cluster, and epidemiological surveys targeted 150 children. Cluster-level permutation tests evaluated the effectiveness using the fitted values from individual level regression models adjusted for baseline. Bootstrapping estimated 95% confidence intervals (CIs). The medians of anophelines per house were 1.4 (interquartile range [IQR]: 2.3) and 3.4 (IQR: 3.7) in the intervention and control arms after 3 months, and 0.4 (IQR: 0.2) and 1.6 (IQR: 0.5) after 10 months, respectively. The differences were -2.5 (95% CI: -6.4 to -0.6) and -1.3 (95% CI: -2.0 to -0.7), respectively. The datasets of 861 and 775 children were analyzed in two epidemiological surveys. The median PCRpfPRs were 25% (IQR: 11%) in the intervention arm and 52% (IQR: 11%) in the control arm after 5 months and 33% (IQR: 11%) and 45% (IQR: 5%) after 12 months. The PCRpfPR ratios were 0.67 (95% CI: 0.38, 0.91) and 0.74 (95% CI: 0.53, 0.90), respectively. We confirmed the superiority of PBO-LLINs.
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Affiliation(s)
- Noboru Minakawa
- Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - James O. Kongere
- Kenya Medical Research Institute, Nairobi, Kenya
- Center for Research in Tropical Medicine and Community Development (CRTMCD), Nairobi, Kenya
| | | | - Peter A. Lutiali
- Kenya Medical Research Institute, Nairobi, Kenya
- Center for Research in Tropical Medicine and Community Development (CRTMCD), Nairobi, Kenya
| | | | - Hitoshi Kawada
- Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Rie Isozumi
- Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Kyoko Futami
- Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
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