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Peer-reviewedCC BY 4.0PLOS Global Public Health

Identifying subgroups with decreased performance on malaria rapid diagnostic tests in Malawi

  • Geoffrey Guenther1
  • Alick Sixpence2
  • Charles Mangani3
  • Alfred Matengeni4
  • Jaroslaw Harezlak5
  • Don P. Mathanga6
  • Terrie E. Taylor7
  • Miriam K. Laufer8
  • Karl B. Seydel9
  • Lauren M. Cohee10
  • Clarissa Valim11
11 affiliations
  1. 1Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, United States of America
  2. 2Margaret C. Ryan Global Health Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
  3. 3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
  4. 4Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
  5. 5MAC Communicable Diseases Alert Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
  6. 6Department of Community and Environmental Health, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
  7. 7Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana, United States of America
  8. 8Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan, United States of America
  9. 9Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
  10. 10Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
  11. 11Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Abstract

We sought to identify groups in which performance of point-of-care malaria rapid diagnostic tests (MRDTs) was decreased to improve the accuracy of MRDT-based diagnosis. We evaluated the performance of Plasmodium falciparum MRDTs compared to quantitative polymerase chain reaction (PCR) in population subgroups based on 1108 patient visits to rural health centers in Malawi from 2019 to 2021. Approximately 48% of malaria PCRs and 37% of MRDTs were positive. Overall, the fraction of positive MRDTs among participants with positive PCR (sensitivity) was 67% and the fraction of negative MRDTs among participants with negative PCR (specificity) was 91%. Sensitivity varied with age, lowest among subjects aged 25–40 years (38%) and < 1 year (33%) and highest among those 5–8 years (86%). Nearly all cases of MRDT-negative/PCR-positive discordance (false negative MRDTs) had < 200 parasites/µl of blood. In regression models, male sex, younger age, and presence of fever, headache, chills, and vomiting reduced the likelihood of a false negative result. Presence of fever, headache, chills, and vomiting were more likely to result in a false positive result. Using classification tree analysis, combinations of clinical and demographic characteristics predicted true positive and true negative MRDT results with 79% and 84% overall accuracy, respectively. Age and parasite density were negatively correlated; age was included in regression models and classification trees rather than parasite density because it would be information readily available to clinicians. Though there are several possible explanations for discordance between PCR and MRDT (including incidental malaria infections), MRDTs performed less well in certain subgroups, which may inform deployment and development of these important tools in clinical settings and for malaria surveillance.

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Cite

BibTeXRIS
BibTeX
@article{guenther2026identifying,
  title = {{Identifying subgroups with decreased performance on malaria rapid diagnostic tests in Malawi}},
  author = {Geoffrey Guenther and Alick Sixpence and Charles Mangani and Alfred Matengeni and Jaroslaw Harezlak and Don P. Mathanga and Terrie E. Taylor and Miriam K. Laufer and Karl B. Seydel and Lauren M. Cohee and Clarissa Valim},
  journal = {PLOS Global Public Health},
  year = {2026},
  month = nov,
  doi = {10.1371/journal.pgph.0007366},
  url = {https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0007366},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Identifying subgroups with decreased performance on malaria rapid diagnostic tests in Malawi
AU  - Geoffrey Guenther
AU  - Alick Sixpence
AU  - Charles Mangani
AU  - Alfred Matengeni
AU  - Jaroslaw Harezlak
AU  - Don P. Mathanga
AU  - Terrie E. Taylor
AU  - Miriam K. Laufer
AU  - Karl B. Seydel
AU  - Lauren M. Cohee
AU  - Clarissa Valim
PY  - 2026
DA  - 2026/11/03
JO  - PLOS Global Public Health
DO  - 10.1371/journal.pgph.0007366
UR  - https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0007366
AB  - We sought to identify groups in which performance of point-of-care malaria rapid diagnostic tests (MRDTs) was decreased to improve the accuracy of MRDT-based diagnosis. We evaluated the performance of Plasmodium falciparum MRDTs compared to quantitative polymerase chain reaction (PCR) in population subgroups based on 1108 patient visits to rural health centers in Malawi from 2019 to 2021. Approximately 48% of malaria PCRs and 37% of MRDTs were positive. Overall, the fraction of positive MRDTs among participants with positive PCR (sensitivity) was 67% and the fraction of negative MRDTs among participants with negative PCR (specificity) was 91%. Sensitivity varied with age, lowest among subjects aged 25–40 years (38%) and < 1 year (33%) and highest among those 5–8 years (86%). Nearly all cases of MRDT-negative/PCR-positive discordance (false negative MRDTs) had < 200 parasites/µl of blood. In regression models, male sex, younger age, and presence of fever, headache, chills, and vomiting reduced the likelihood of a false negative result. Presence of fever, headache, chills, and vomiting were more likely to result in a false positive result. Using classification tree analysis, combinations of clinical and demographic characteristics predicted true positive and true negative MRDT results with 79% and 84% overall accuracy, respectively. Age and parasite density were negatively correlated; age was included in regression models and classification trees rather than parasite density because it would be information readily available to clinicians. Though there are several possible explanations for discordance between PCR and MRDT (including incidental malaria infections), MRDTs performed less well in certain subgroups, which may inform deployment and development of these important tools in clinical settings and for malaria surveillance.
SN  - 2767-3375
ER  -