Evaluation of the Clinical Proficiency of RDTs, Microscopy and Nested PCR in the Diagnosis of Symptomatic Malaria in Ilorin, North-Central, Nigeria.

Background: Accurate laboratory diagnosis of suspected malaria is the hallmark to the control of the disease.

Aim: The clinical proficiency of commercial Rapid Diagnostic test kits (RDTs) using nested PCR as quality control was evaluated among patients attending two public healthcare providing institutions in Ilorin, Kwara state, North-Central, Nigeria.

Method: A cross-sectional evaluation of finger prick blood samples of volunteer patients were accessed for malaria parasites with pLDH, HRP2, Pf, Pf/PAN and nested PCR molecular assays. The data derived were analysed using standard formulae for diagnostic accuracy, and the obtained predictive values were subjected to a comparison with one-way analysis of variance (ANOVA).

Result: Three hundred and sixty-eight (368) patients comprising 203 (55%) females and 165 (45%) males participated in this study. Routine microscopy revealed that 54 (32.7%) males and 80 (39.4%) was infected with Plasmodium falciparum. SD Bioline (pLDH) 47.4%; Carestart Malaria (HRP2) 49.8% recorded low sensitivities. Micropoint (pfPAN) 82.8% and Micropoint (Mal. Pf) 64.4% recorded a high sensitivity. SD Bioline (pLDH) 67.4%; Carestart Malaria (HRP2) 85.9%; Micropoint (PfPAN) 62.2% and Micropoint (Mal. Pf) 86.7% had high specificities. The positive predictive value (PPV) ranged from 67.7% to 85.94%, while the negative predictive values (NPV) of 64.4% for SD Bioline (pLDH); 86.7% for Carestart Malaria (HRP2); 89.3% for Micropoint (pfPAN) and 58.5% for Micropoint (Mal. Pf). Agarose gel analysis of gene (206 bp) for 28 specimens containing 10% concordant and discordant samples showed that all 12 negative specimens for RDTs and routine microscopy were truly negative for nPCR. However, the remaining 16 specimens were positive for nPCR and showed discrepancies with routine microscopy and RDTs. Cohen's interrater diagnostic measure analysis revealed that the weighted kappa for the RDTs was moderate 0.417 (p=0.027), 95%CI (0.756, 0.078) and good for nPCR 0.720 (p < 0.001), 95%CI (0.963, 0.477). The area under the curve (AUC) specify that nPCR has been more effective than the RDTs (nPCRAUC = 0.875; p < 0.001 and RDTsAUC = 0.708; p = 0.063).

Conclusion: A thorough large-scale quality control is advocated on all commercial RDTs being used in most sub-Saharan African countries. This is to avoid double jeopardy consequent upon misdiagnosis on unidentified positive cases serving as pool reservoir for the insect vector and cyclical infection and re-infection of the populace.