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Apinjoh TO, Tangi LN, Oriero EC, Drammeh S, Ntui-Njock VN, Etoketim B, Chi HF, Kwi PN, Njie B, Oboh MA, Achidi EA, Amambua-Ngwa A. Histidine-rich protein (hrp) 2-based RDT false-negatives and Plasmodium falciparum hrp 2 and 3 gene deletions in low, seasonal and intense perennial transmission zones in Cameroon: a cross - sectional study. BMC Infect Dis 2024; 24:1080. [PMID: 39350071 PMCID: PMC11443727 DOI: 10.1186/s12879-024-09935-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 09/16/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND False negative rapid diagnostic tests (RDTs) accruing to the non-detection of Plasmodium falciparum histidine-rich protein 2/3 (Pfhrp2/3) is threatening the diagnosis and management of malaria. Although regular monitoring is necessary to gauge the level of efficacy of the tool, studies in Cameroon remain limited. This study assessed Plasmodium spp. prevalence and Pfhrp2/3 gene deletions across ecological and transmission zones in Cameroon. METHODS This is a cross-sectional, multi-site, community- and hospital- based study, in 21 health facilities and 14 communities covering all five ecological settings in low seasonal (LS) and intense perennial (IPT) malaria transmission zones between 2019 and 2021. Participants were screened for malaria parasite using Pfhrp2 RDT and light microscopic examination of thick peripheral blood smears. DNA was extracted from dried blood spot using chelex®-100 and P. falciparum confirmed using varATS real-time quantitative Polymerase Chain Reaction (qPCR), P. malariae and P. ovale by real-time qPCR of Plasmepsin gene, and P. vivax using a commercial kit. Isolates with amplified Pfcsp and Pfama-1 genes were assayed for Pfhrp 2/3 gene deletions by conventional PCR. RESULTS A total of 3,373 participants enrolled, 1,786 Plasmodium spp. infected, with 77.4% P. falciparum. Discordant RDT and qPCR results (False negatives) were reported in 191 (15.7%) P. falciparum mono-infected samples from LS (29%, 42) and IPT (13.9%, 149). The Pfhrp2+/Pfhrp3 + genotype was most frequent, similar between LS (5.5%, 8/145) and IPT (6.0%, 65/1,076). Single Pfhrp2 and Pfhrp3 gene deletions occurred in LS (0.7%, 1/145 each) and IPT (3.6%, 39/1,076 vs. 2.9%, 31/1,076), respectively. Whilst a single sample harboured Pfhrp2-/Pfhrp3- genotype in LS, 2.4% (26/1,076) were double deleted at IPT. Pfhrp2+/Pfhrp3- (0.3%, 3/1,076) and Pfhrp2-/Pfhrp3+ (1.2%, 13/1,076) genotypes were only observed in IPT. Pfhrp2, Pfhrp3 deletions and Pfhrp2-/Pfhrp3- genotype accounted for 78.8% (26), 69.7% (23) and 63.6% (21) RDT false negatives, respectively. CONCLUSION Plasmodium falciparum remains the most dominant and widely distributed Plasmodium species across transmission and ecological zones in Cameroon. Although the low prevalence of Pfhrp2/3 gene deletions supports the continued use of HRP2-based RDTs for routine malaria diagnosis, the high proportion of false-negatives due to gene deleted parasites necessitates continued surveillance to inform control and elimination efforts.
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Affiliation(s)
- Tobias Obejum Apinjoh
- Department of Biochemistry and Molecular Biology, University of Buea, Buea, Cameroon.
- Department of Chemical and Biological Engineering, The University of Bamenda, Bambili, Cameroon.
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia.
| | - Livinus Ngu Tangi
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
| | - Eniyou Cheryll Oriero
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Sainabou Drammeh
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | | | - Blessed Etoketim
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Hanesh Fru Chi
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
| | - Pilate Nkineh Kwi
- Department of Biochemistry and Molecular Biology, University of Buea, Buea, Cameroon
| | - Bekai Njie
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Mary Aigbiremo Oboh
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Eric Akum Achidi
- Department of Biochemistry and Molecular Biology, University of Buea, Buea, Cameroon
| | - Alfred Amambua-Ngwa
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia.
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Bae CY, Shin YM, Kim M, Song Y, Lee HJ, Kim KH, Lee HW, Kim YJ, Kanyemba C, Lungu DK, Kang BI, Han S, Beck HP, Cho SH, Woo BM, Lim CY, Choi KH. Embedded-deep-learning-based sample-to-answer device for on-site malaria diagnosis. Front Bioeng Biotechnol 2024; 12:1392269. [PMID: 39100623 PMCID: PMC11294195 DOI: 10.3389/fbioe.2024.1392269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 06/21/2024] [Indexed: 08/06/2024] Open
Abstract
Improvements in digital microscopy are critical for the development of a malaria diagnosis method that is accurate at the cellular level and exhibits satisfactory clinical performance. Digital microscopy can be enhanced by improving deep learning algorithms and achieving consistent staining results. In this study, a novel miLab™ device incorporating the solid hydrogel staining method was proposed for consistent blood film preparation, eliminating the use of complex equipment and liquid reagent maintenance. The miLab™ ensures consistent, high-quality, and reproducible blood films across various hematocrits by leveraging deformable staining patches. Embedded-deep-learning-enabled miLab™ was utilized to detect and classify malarial parasites from autofocused images of stained blood cells using an internal optical system. The results of this method were consistent with manual microscopy images. This method not only minimizes human error but also facilitates remote assistance and review by experts through digital image transmission. This method can set a new paradigm for on-site malaria diagnosis. The miLab™ algorithm for malaria detection achieved a total accuracy of 98.86% for infected red blood cell (RBC) classification. Clinical validation performed in Malawi demonstrated an overall percent agreement of 92.21%. Based on these results, miLab™ can become a reliable and efficient tool for decentralized malaria diagnosis.
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Affiliation(s)
| | | | - Mijin Kim
- Noul Co., Ltd., Yongin-si, Republic of Korea
| | | | | | | | | | | | | | | | | | | | - Hans-Peter Beck
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Shin-Hyeong Cho
- Noul Co., Ltd., Yongin-si, Republic of Korea
- Korea Centers for Disease Control and Preventions (KCDC), Department of Malaria and Parasitic Diseases, Cheongju-si, Republic of Korea
| | - Bo Mee Woo
- Noul Co., Ltd., Yongin-si, Republic of Korea
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3
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Ewnetu Y, Badu K, Carlier L, Vera-Arias CA, Troth EV, Mutala AH, Afriyie SO, Addison TK, Berhane N, Lemma W, Koepfli C. A digital microscope for the diagnosis of Plasmodium falciparum and Plasmodium vivax, including P. falciparum with hrp2/hrp3 deletion. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003091. [PMID: 38768243 PMCID: PMC11104649 DOI: 10.1371/journal.pgph.0003091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/18/2024] [Indexed: 05/22/2024]
Abstract
Sensitive and accurate malaria diagnosis is required for case management to accelerate control efforts. Diagnosis is particularly challenging where multiple Plasmodium species are endemic, and where P. falciparum hrp2/3 deletions are frequent. The Noul miLab is a fully automated portable digital microscope that prepares a blood film from a droplet of blood, followed by staining and detection of parasites by an algorithm. Infected red blood cells are displayed on the screen of the instrument. Time-to-result is approximately 20 minutes, with less than two minutes hands-on time. We evaluated the miLab among 659 suspected malaria patients in Gondar, Ethiopia, where P. falciparum and P. vivax are endemic, and the frequency of hrp2/3 deletions is high, and 991 patients in Ghana, where P. falciparum transmission is intense. Across both countries combined, the sensitivity of the miLab for P. falciparum was 94.3% at densities >200 parasites/μL by qPCR, and 83% at densities >20 parasites/μL. The miLab was more sensitive than local microscopy, and comparable to RDT. In Ethiopia, the miLab diagnosed 51/52 (98.1%) of P. falciparum infections with hrp2 deletion at densities >20 parasites/μL. Specificity of the miLab was 94.0%. For P. vivax diagnosis in Ethiopia, the sensitivity of the miLab was 97.0% at densities >200 parasites/μL (RDT: 76.8%, microscopy: 67.0%), 93.9% at densities >20 parasites/μL, and specificity was 97.6%. In Ethiopia, where P. falciparum and P. vivax were frequent, the miLab assigned the wrong species to 15/195 mono-infections at densities >20 parasites/μL by qPCR, and identified only 5/18 mixed-species infections correctly. In conclusion, the miLab was more sensitive than microscopy and thus is a valuable addition to the toolkit for malaria diagnosis, particularly for areas with high frequencies of hrp2/3 deletions.
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Affiliation(s)
- Yalemwork Ewnetu
- Department of Medical Biotechnology, Institute of Biotechnology, University of Gondar, Gondar, Ethiopia
- University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia
| | - Kingsley Badu
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Claudia A. Vera-Arias
- Department of Biological Sciences & Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Emma V Troth
- Department of Biological Sciences & Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Abdul-Hakim Mutala
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Stephen Opoku Afriyie
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Thomas Kwame Addison
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Nega Berhane
- Department of Medical Biotechnology, Institute of Biotechnology, University of Gondar, Gondar, Ethiopia
| | - Wossenseged Lemma
- Department of Medical Parasitology, School of Biomedical and Laboratory Sciences, Collage of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Cristian Koepfli
- Department of Biological Sciences & Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
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Bechtold P, Wagner P, Hosch S, Gregorini M, Stark WJ, Gody JC, Kodia-Lenguetama ER, Pagonendji MS, Donfack OT, Phiri WP, García GA, Nsanzanbana C, Daubenberger CA, Schindler T, Vickos U. Development and evaluation of PlasmoPod: A cartridge-based nucleic acid amplification test for rapid malaria diagnosis and surveillance. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001516. [PMID: 37756280 PMCID: PMC10529553 DOI: 10.1371/journal.pgph.0001516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
Malaria surveillance is hampered by the widespread use of diagnostic tests with low sensitivity. Adequate molecular malaria diagnostics are often only available in centralized laboratories. PlasmoPod is a novel cartridge-based nucleic acid amplification test for rapid, sensitive, and quantitative detection of malaria parasites. PlasmoPod is based on reverse-transcription quantitative polymerase chain reaction (RT-qPCR) of the highly abundant Plasmodium spp. 18S ribosomal RNA/DNA biomarker and is run on a portable qPCR instrument which allows diagnosis in less than 30 minutes. Our analytical performance evaluation indicates that a limit-of-detection as low as 0.02 parasites/μL can be achieved and no cross-reactivity with other pathogens common in malaria endemic regions was observed. In a cohort of 102 asymptomatic individuals from Bioko Island with low malaria parasite densities, PlasmoPod accurately detected 83 cases, resulting in an overall detection rate of 81.4%. Notably, there was a strong correlation between the Cq values obtained from the reference RT-qPCR assay and those obtained from PlasmoPod. In an independent cohort, using dried blood spots from malaria symptomatic children living in the Central African Republic, we demonstrated that PlasmoPod outperforms malaria rapid diagnostic tests based on the PfHRP2 and panLDH antigens as well as thick blood smear microscopy. Our data suggest that this 30-minute sample-to-result RT-qPCR procedure is likely to achieve a diagnostic performance comparable to a standard laboratory-based RT-qPCR setup. We believe that the PlasmoPod rapid NAAT could enable widespread accessibility of high-quality and cost-effective molecular malaria surveillance data through decentralization of testing and surveillance activities, especially in elimination settings.
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Affiliation(s)
- Philippe Bechtold
- Institute for Chemical and Bioengineering, ETH Zurich, Zuerich, Switzerland
- Diaxxo AG, Zuerich, Switzerland
| | - Philipp Wagner
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Salome Hosch
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Michele Gregorini
- Institute for Chemical and Bioengineering, ETH Zurich, Zuerich, Switzerland
- Diaxxo AG, Zuerich, Switzerland
| | - Wendelin J. Stark
- Institute for Chemical and Bioengineering, ETH Zurich, Zuerich, Switzerland
- Diaxxo AG, Zuerich, Switzerland
| | - Jean Chrysostome Gody
- Paediatric Hospital and University Complex of Bangui, Bangui, Central African Republic
| | | | | | | | | | | | - Christian Nsanzanbana
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Claudia A. Daubenberger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Tobias Schindler
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ulrich Vickos
- Infectious and Tropical Diseases Unit, Department of Medicine, Amitié Hospital, Bangui, Central African Republic
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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Djoufounna J, Mayi MPA, Bamou R, Foyet JV, Tabue R, Lontsi-Demano M, Achu-Fosah D, Antonio-Nkondjio C, Tchuinkam T. High prevalence of asymptomatic Plasmodium falciparum malaria in Makenene, a locality in the forest-savannah transition zone, Centre Region of Cameroon. CURRENT RESEARCH IN PARASITOLOGY & VECTOR-BORNE DISEASES 2022; 2:100104. [PMID: 36504597 PMCID: PMC9731883 DOI: 10.1016/j.crpvbd.2022.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/13/2022] [Accepted: 11/17/2022] [Indexed: 11/29/2022]
Abstract
Malaria transmission and prevalence is still not well documented across Cameroon particularly in medium-sized cities or localities representing high transit zone. Different risk factors could be associated with persistence malaria transmission such as population movement from high to low transmission settings. A cross-sectional community-based study was carried out to determine malaria prevalence and risk factors in Makenene, a small city in a forest-savannah which is a crossroads between different parts of the country where travellers usually stop-over day and night to rest. Using malaria diagnostic test (mRDTs from SD-BIOLINE) and microscopy (thin and thick blood smears), 406 participants from 237 households were tested for malaria infection. The prevalence of malaria was high irrespective of the detection method: mRDT (41.87%) or microscopy (38.42%). At household level, 46.41% of households had at least one case of malaria with an average of 1.41 infected individuals per household. Parasite density was also high with the majority of infected individuals (64.74%) bearing more than 500 parasites/μl. Only Plasmodium falciparum was found. The chances of being infected with malaria parasites was almost the same for all participants irrespective of the sleeping behavior, bednet usage, house type and environmental factors. The study supports high malaria transmission in the locality and the need for additional studies on vectors bionomics and transmission patterns.
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Affiliation(s)
- Joel Djoufounna
- Vector Borne Diseases Laboratory of the Research Unit for Biology and Applied Ecology (VBID-RUBAE), Department of Animal Biology, Faculty of Science of the University of Dschang, Cameroon
| | - Marie Paul Audrey Mayi
- Vector Borne Diseases Laboratory of the Research Unit for Biology and Applied Ecology (VBID-RUBAE), Department of Animal Biology, Faculty of Science of the University of Dschang, Cameroon
| | - Roland Bamou
- Vector Borne Diseases Laboratory of the Research Unit for Biology and Applied Ecology (VBID-RUBAE), Department of Animal Biology, Faculty of Science of the University of Dschang, Cameroon,Corresponding author.
| | - Juluis Visnel Foyet
- Vector Borne Diseases Laboratory of the Research Unit for Biology and Applied Ecology (VBID-RUBAE), Department of Animal Biology, Faculty of Science of the University of Dschang, Cameroon
| | - Raymond Tabue
- National Malaria Control Programme, Ministry of Public Health, Yaounde, Cameroon
| | - Michel Lontsi-Demano
- Vector Borne Diseases Laboratory of the Research Unit for Biology and Applied Ecology (VBID-RUBAE), Department of Animal Biology, Faculty of Science of the University of Dschang, Cameroon
| | - Dorothy Achu-Fosah
- National Malaria Control Programme, Ministry of Public Health, Yaounde, Cameroon
| | - Christophe Antonio-Nkondjio
- Organisation de Coordination pour la lutte contre les Endémies en Afrique Centrale (OCEAC), Yaounde, Cameroon
| | - Timoléon Tchuinkam
- Vector Borne Diseases Laboratory of the Research Unit for Biology and Applied Ecology (VBID-RUBAE), Department of Animal Biology, Faculty of Science of the University of Dschang, Cameroon,Corresponding author.
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Martiáñez-Vendrell X, Skjefte M, Sikka R, Gupta H. Factors Affecting the Performance of HRP2-Based Malaria Rapid Diagnostic Tests. Trop Med Infect Dis 2022; 7:265. [PMID: 36288006 PMCID: PMC9611031 DOI: 10.3390/tropicalmed7100265] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
The recent COVID-19 pandemic has profoundly impacted global malaria elimination programs, resulting in a sharp increase in malaria morbidity and mortality. To reduce this impact, unmet needs in malaria diagnostics must be addressed while resuming malaria elimination activities. Rapid diagnostic tests (RDTs), the unsung hero in malaria diagnosis, work to eliminate the prevalence of Plasmodium falciparum malaria through their efficient, cost-effective, and user-friendly qualities in detecting the antigen HRP2 (histidine-rich protein 2), among other proteins. However, the testing mechanism and management of malaria with RDTs presents a variety of limitations. This paper discusses the numerous factors (including parasitic, host, and environmental) that limit the performance of RDTs. Additionally, the paper explores outside factors that can hinder RDT performance. By understanding these factors that affect the performance of HRP2-based RDTs in the field, researchers can work toward creating and implementing more effective and accurate HRP2-based diagnostic tools. Further research is required to understand the extent of these factors, as the rapidly changing interplay between parasite and host directly hinders the effectiveness of the tool.
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Affiliation(s)
- Xavier Martiáñez-Vendrell
- Molecular Virology Laboratory, Department of Medical Microbiology, LUMC Center for Infectious Diseases (LU-CID), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands or
| | - Malia Skjefte
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
| | - Ruhi Sikka
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, Mathura 281406, UP, India
| | - Himanshu Gupta
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, Mathura 281406, UP, India
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Niyukuri D, Sinzinkayo D, Troth EV, Oduma CO, Barengayabo M, Ndereyimana M, Holzschuh A, Vera-Arias CA, Gebre Y, Badu K, Nyandwi J, Baza D, Juma E, Koepfli C. Performance of highly sensitive and conventional rapid diagnostic tests for clinical and subclinical Plasmodium falciparum infections, and hrp2/3 deletion status in Burundi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000828. [PMID: 36962426 PMCID: PMC10022336 DOI: 10.1371/journal.pgph.0000828] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022]
Abstract
Rapid diagnostic tests (RDTs) are a key tool for the diagnosis of malaria infections among clinical and subclinical individuals. Low-density infections, and deletions of the P. falciparum hrp2/3 genes (encoding the HRP2 and HRP3 proteins detected by many RDTs) present challenges for RDT-based diagnosis. The novel Rapigen Biocredit three-band Plasmodium falciparum HRP2/LDH RDT was evaluated among 444 clinical and 468 subclinical individuals in a high transmission setting in Burundi. Results were compared to the AccessBio CareStart HRP2 RDT, and qPCR with a sensitivity of <0.3 parasites/μL blood. Sensitivity compared to qPCR among clinical patients for the Biocredit RDT was 79.9% (250/313, either of HRP2/LDH positive), compared to 73.2% (229/313) for CareStart (P = 0.048). Specificity of the Biocredit was 82.4% compared to 96.2% for CareStart. Among subclinical infections, sensitivity was 72.3% (162/224) compared to 58.5% (131/224) for CareStart (P = 0.003), and reached 88.3% (53/60) in children <15 years. Specificity was 84.4% for the Biocredit and 93.4% for the CareStart RDT. No (0/362) hrp2 and 2/366 hrp3 deletions were observed. In conclusion, the novel RDT showed improved sensitivity for the diagnosis of P. falciparum.
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Affiliation(s)
- David Niyukuri
- Doctoral School, University of Burundi, Bujumbura, Burundi
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Denis Sinzinkayo
- Doctoral School, University of Burundi, Bujumbura, Burundi
- National Malaria Control Program, Bujumbura, Burundi
| | - Emma V Troth
- Eck Institute for Global Health and Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana, United States of America
| | | | | | | | - Aurel Holzschuh
- Eck Institute for Global Health and Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Claudia A Vera-Arias
- Eck Institute for Global Health and Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Yilekal Gebre
- Eck Institute for Global Health and Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Kingsley Badu
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Joseph Nyandwi
- Doctoral School, University of Burundi, Bujumbura, Burundi
- National Institute of Public Health, Bujumbura, Burundi
| | | | | | - Cristian Koepfli
- Eck Institute for Global Health and Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana, United States of America
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