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Background. Approximately 4 million US travelers to developing countries are ill enough to seek health care,
with 1500 malaria cases reported in the United States annually. The diagnosis of malaria is frequently delayed
because of the time required to prepare malaria blood films and lack of technical expertise. An easy, reliable rapid
diagnostic test (RDT) with high sensitivity and negative predictive value (NPV), particularly for Plasmodium
falciparum, would be clinically useful. The objective of this study was to determine the diagnostic performance of
a RDT approved by the US Food and Drug Administration compared with traditional thick and thin blood smears
for malaria diagnosis.
Methods. This prospective study tested 852 consecutive blood samples that underwent thick and thin smears
and blinded malaria RDTs at 3 hospital laboratories during 20032006. Polymerase chain reaction verified positive
test results and discordant results.
Results. Malaria was noted in 95 (11%) of the 852 samples. The RDT had superior performance than the
standard Giemsa thick blood smear (P p .003 ). The RDTs sensitivity for all malaria was 97% (92 of 95 samples),
compared with 85% (81 of 95) for the blood smear, and the RDT had a superior NPV of 99.6%, compared with
98.2% for the blood smear (P p .001 ). The P. falciparum performance was excellent, with 100% rapid test sensitivity,
compared with only 88% (65 of 74) by blood smear (P p .003).
Conclusions. This operational study demonstrates that the US Food and Drug Administrationapproved RDT
for malaria is superior to a single set of blood smears performed under routine US clinical laboratory conditions.
The most valuable clinical role of the RDT is in the rapid diagnosis or the exclusion of P. falciparum malaria,
which is particularly useful in outpatient settings when evaluating febrile travelers.
An estimated 4 million returning US travelers are ill
enough to seek health care annually, with 11500 cases
of malaria reported in the United States [13]. Of travelers who contract malaria, 90%95% will not become
ill until after they return home, with 85% developing
Departments of 1Medicine and 2Pediatrics, Division of Infectious Diseases and International Medicine, University of Minnesota, and 3Department
of Laboratory Medicine and Pathology, Hennepin County Medical Center, Minneapolis, 4Department of Pathology, HeathPartners/Regions Hospital,
and 5Public Health Laboratory Division, Minnesota Department of Health, St. Paul, 6Department of Pathology, Park Nicollet Methodist Hospital, St.
Louis Park, and 7Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota
METHODS
Setting and participants. This prospective, operational laboratory study was conducted at the 3 hospital-based laboratories with the highest incidence of malaria in Minnesota from
1 March 2003 through 28 February 2006. All consecutive samples sent to the laboratories for thick and thin blood smears
to test for malaria were included. Participants were returning
travelers, most of whom were visiting friends and relatives.
Methods of measurement. Thick and thin Giemsa-stain
blood smears were prepared from EDTA-anticoagulated venous blood. Smears were examined for the presence of malarial
parasites by trained technologists or hematopathologists per
individual laboratory protocol with a minimum of 500 highpowered fields examined. An expert pathologist or hematopathologist confirmed all positive smears. The rapid antigen
capture assay was performed per the manufacturers instruc-
Rapid Diagnosis of Malaria in the United States CID 2009:49 (15 September) 909
frequently encountered, delay is common because of the necessary time for formal Giemsa-stained thick blood smear preparation and reading (68 h).
Of individuals developing P. falciparum infection in the United
States, 1% will die [4, 5]. Yet an estimated 80% of deaths are
preventable, with a significant proportion due to diagnostic delay
or error [6]. An easily performed test that is sensitive and reliable
would be a desirable tool that could augment malaria diagnosis.
A rapid diagnostic test (RDT) with high sensitivity and a negative
predictive value (NPV) for P. falciparum would be of particular
use in the acute care setting, where the decision for hospitalization
is being made. Lastly, it also may benefit severely ill patients by
confirming or excluding a malaria diagnosis rapidly and facilitating prompt intervention.
The rapid antigen capture assay (NOW Malaria Test; Binax,
Inverness Medical Professional Diagnostics) received US Food
and Drug Administration (FDA) approval in June 2007 for
diagnosis of symptomatic malaria. Antigens detected by monoclonal antibodies in this rapid antigen capture assay include
the histidine-rich protein for specific identification of P. falciparum and Plasmodium aldolase for identification of all malaria
species. Reasonable sensitivity and specificity have been reported in clinical research trials outside the United States,
mainly in endemic areas where malaria dynamics and environmental conditions differ greatly from those in the United
States [7, 8]. Few studies have investigated RDTs in settings
where malaria is not endemic, and no study has evaluated the
operational use of the current FDA-approved version of the
test in the United States. This study investigated the diagnostic performance of a single blood smear versus the rapid antigen capture assay (NOW Malaria Test) in detecting symptomatic malaria to determine the strengths and limitations of this
test in real-world US clinical use.
DISCUSSION
Malaria is the leading infectious cause of mortality among travelers, yet most returning febrile travelers will not have malaria
[2]. Thus, the diagnosis is frequently delayed or missed in
regions where it is not endemic. It is likely that a sensitive and
reliable RDT would improve malaria diagnosis and treatment
in the United States. This study compared the rapid antigen
capture assay (NOW Malaria Test) with the current clinical
method of Giemsa-stained blood smears in returning travelers.
This was an operational study to compare the performance of
each test in a typical US setting to assess the utility of the RDT
in clinical practice. Thus, we believe the results are generalizable to other US acute care settings.
There are many rapid tests available on the global market,
and although they have shown variable results in the past, the
newer-generation assays have been refined, particularly for
Table 1. Test Performance Characteristics of the Rapid Diagnostic Test (RDT) versus Blood Smear for Malaria
Diagnosis
Species, test
Sensitivity, %
(95% CI)
Specificity,
%
PPV,
%
NPV,
%
Positive
LR
Negative
LR
97 (99.391.0)
99
92
98
24
0.03
85 (91.776.5)
100
99
93
160
0.15
100 (10095.1)
99
90
100
100b
100
95
Blood smear
Plasmodium falciparum (n p 74)
Malaria RDT
Blood smear
Pa
.003
.003
88 (94.378.2)
9.3
166
0
.12
.63
Malaria RDT
86 (97.063.7)
99
Blood smear
76 (91.852.8)
100
69
100
99
98.5
21
0.15
144
0.33
NOTE. Blood smear, Giemsa-stained thick and thin blood smear; LR, likelihood ratio; NPV, negative predictive value; PPV, positive
predictive value; RDT, rapid diagnostic test.
a
b
Figure 1. Distribution of positive malaria test results. The rapid diagnostic test (RDT) had false-positive results not confirmed by polymerase
chain reaction (PCR) in 8 patients, with 7 of these patients having received
documented, recent malaria treatment. Two Plasmodium ovale specimens
were missed by both smear and RDT and were detected in negative
control specimens.
Figure 2. Example of the rapid antigen capture assay (Binax NOW) results.
Rapid Diagnosis of Malaria in the United States CID 2009:49 (15 September) 911
acute P. falciparum infections [7, 8]. Because P. falciparum malaria is the most common life-threatening infection in travelers,
and because the health of infected persons may deteriorate
rapidly [2, 13], outpatient physicians must be able to reasonably
exclude P. falciparum before allowing outpatient treatment in
nonimmune patients. Therefore, a rapid test with a high NPV
would be of particular use in treating outpatients if a physician
must decide in a timely manner if a nontoxic-appearing, nonimmune patient with exposure to P. falciparum should be hospitalized. Such a test with a high NPV may fundamentally alter
the current approach to treating the febrile returning traveler
as an outpatient.
A pivotal clinical trial evaluating the performance of the rapid
antigen capture assay in areas of endemicity among 14000 patients was recently presented at the American Society of Tropical
Medicine and Hygiene annual conference [14]. For P. falciparum, the sensitivity was 95% and the specificity was 94%
overall. In those with higher parasitemia (parasite count, 15000/
mL), the sensitivity was 99.7%. Travelers presenting in regions
where malaria is not endemic to acute care centers have relatively high malaria parasite loads, typically with a parasite count
on the order of 110,000/mL (0.2% parasite percentage) [15].
Thus, the slightly better RDT performance in our study is most
likely due to 2 facts. First, the study population consisted of
nonimmune, returning US travelers who typically have higher
parasite loads than other studies populations in malaria-endemic areas. Second, we compared the RDT to single blood
smears performed under real-world conditions (rather than the
gold standard of 3 tests read by expert malariologists).
Few other studies evaluating this newer-generation RDT assay have been presented or published. Farcas et al [16], in a
laboratory research protocol, evaluated 256 ill Canadian travelers and found comparable results, with a sensitivity of 95.5%
for P. falciparum, 87% for P. vivax, and 83.5% for all nonfalciparum malaria. In another study of returning French travelers, the sensitivities were 98.8% for P. falciparum and 80%
for P. vivax [17]. In an Italian study of 145 persons with malaria
from among 171 immigrants and 136 returning travelers, 100%
P. falciparum sensitivity was reported [18]. All studies have
reported excellent specificity (198%) for all species [1418].
blood smears being diagnostic in 99% but not all [4]. In febrile
travelers recently returned from a malaria-endemic region with
unexplained febrile illness, physicians should arrange clinical
follow-up within 24 h and consider repeated malaria tests.
Conclusions. This operative study comparing traditional
blood smear to rapid antigen capture test demonstrates that
the RDT, as performed in a routine clinical setting, is superior to a single set of Giemsa-stained blood smears for quickly
evaluating a patient for malaria. Importantly, the rapid antigen
capture assay had a 100% NPV for P. falciparum malaria. Although further clinical experience with this test is necessary,
this FDA-approved test appears to be an ideal tool for timely
decision making when P. falciparum must be considered for
patient disposition. This is especially true when reliable, experienced microscopy is not immediately available, such as after
hours or in small or rural settings with physicians without
expertise in reading malaria blood smears. Although we believe
that blood smears and expert microscopy remain essential, the
overall RDT performance provides physicians with a valuable
adjunctive diagnostic tool in the timely evaluation of the ill
returning traveler.
Acknowledgments
We thank Aaron Devries for assistance with laboratory testing and
David Neitzel for provision of Minnesota malaria statistics.
Financial support. W.M.S. and D.R.B. received support from the
National Institute for Allergy and Infectious Disease (T32-AI055433,
L30AI066779, and K12RR023247). Binax (Now, Inverness Medical Professional Diagnostics) supplied the NOW Malaria tests but no financial
support. They were not involved in study design, data analysis, or manuscript preparation.
Potential conflicts of interest. All authors: no conflicts.
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