Diagnostic Performance of Blood Film Microscopy and PfHRP2-based RDT in a Routine Clinical Setting of a Secondary Health Facility in Ghana

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Francis O. Agyapong
Daniel Ansong
Alex Owusu-Ofori
Ruby Martin-Peprah


Background: Malaria remains a major public health threat claiming many lives particularly in Sub-Saharan Africa. Light microscopy and RDT are the mainstay tests in the clinical settings for malaria diagnosis. Many studies report varying levels of validity of these tests compared to molecular methods like PCR. Documentation on such comparative study involving the use of molecular techniques as reference test is scanty in Ghana. This study therefore assesses the diagnostic performance of these tests compared to PCR.

Methods: Blood film microscopy (thin and thick), RDT and nested PCR were run on blood samples from a total of 188 malaria suspected patients. The accuracy indices of the microscopy and RDT were calculated using the results of the PCR as the reference test.

Results: A total of 188 patients were recruited with females constituting the majority 128 (68%). The paediatric age group 1-10 years carried the largest burden of malaria by means of all the 3 tests. A sensitivity of 47.37% (95% ci, 37.03 – 57.88%) was shown by both the microscopy and RDT with specificity of 93.55% (95% ci, 86.48 – 97.60) and 100% (95% ci, 96.11 – 100.00%) and kappa co – efficient of 0.41 and 0.47 respectively.

Conclusion: Both microscopy and RDT exhibited high level of specificity but low sensitivity. Significant number of malaria parasitaemic patients as revealed by the PCR was missed by both the RDT and blood film microscopy and thus went undiagnosed.

RDT, microscopy, PCR, malaria, plasmodium.

Article Details

How to Cite
Agyapong, F. O., Ansong, D., Owusu-Ofori, A., & Martin-Peprah, R. (2019). Diagnostic Performance of Blood Film Microscopy and PfHRP2-based RDT in a Routine Clinical Setting of a Secondary Health Facility in Ghana. Journal of Advances in Medicine and Medical Research, 31(4), 1-9. https://doi.org/10.9734/jammr/2019/v31i430294
Short Research Article


WHO, World Malaria Report. Geneva: World Health Organization; 2017.

Parsel SM, Gustafson SA, Friedlander E, Shnyra AA, Adegbulu AA, Liu Y, Parrish NM, Jamal SA, Lofthus E, Ayuk L, Awason C, Henry CJ, McArthur CP. Malaria over-diagnosis in Cameroon: Diagnostic accuracy of Fluorescence and Staining Technologies (FAST) Malaria Stain and LED microscopy versus Giemsa and bright field microscopy validated by polymerase chain reaction. Infect Dis Poverty. 2017; 6(1):32.

Malm KBPC, Armah G, Gyapong J, Owusu-Adjei S, Koram K, Binka F. Malaria as a cause of acute febrile illness in an urban paediatric population in Ghana. Proceedings of the Annual Meeting of the American Society of Tropical Medicine and Hygiene, Atlanta, GA; 2012.

Shillcutt S, Morel C, Goodman C, Coleman P, Bell D, Whitty CJM, Mills A. Cost-effectiveness of malaria diagnostic methods in sub-Saharan Africa in an era of combination therapy. Bull World Health Organ. 2008;86:101–110.

Thiam S, Thior M, Faye B, Ndiop M, Diouf ML, Diouf MB, Diallo I, Fall FB, Ndiaye JL, Albertini A, Lee E, Jorgensen P, Gaye O, Bell D. Major Reduction in Anti-Malarial Drug Consumption in Senegal after Nation-Wide Introduction of Malaria Rapid Diagnostic Tests. PLoS One. 2011;6(4).

Golassa L, Enweji N, Erko B, Assefa A, Swedberg G. Detection of a substantial number of sub-microscopic Plasmodium falciparum infections by Polymerase chain reaction: A potential threat to malaria control and diagnosis in Ethiopia. Malar. J. 2013;12:352.

Laban MN, Kobayashi T, Hamapumbu H, Sullivan D, Mharajurwa S, Thuma PE, Shiff CJ, Moss WJ. Comparison of a PfHRP2-based rapid diagnostic test and PCR for malaria in a low prevalence setting in rural southern Zambia: Implications for elimination. Malar. J. 2015; 14:25.

Batwala V, Magnussen P, Nuwaha F. Are rapid diagnostic tests more accurate in diagnosis of Plasmodium falciparum malaria compared to microscopy at rural health centres? Malar. J. 2010;9:349.

Miguel-Oteo M, Jiram AI, Ta-Tang TH, Lanza M, Hisam S, Rubio JM. Nested Multiplex PCR for identification and detection of human Plasmodium species including Plasmodium knowlesi. Asian Pac J Trop Med. 2017;10(3):299-304.

Haanshuus CG, Chandy S, Manoharan A, Vivek R, Mathai D. Correction: A High Malaria Prevalence Identified by PCR among Patients with Acute Undifferentiated Fever in India. PLoS One. 2018;13(2):23.

Macedo de Oliveira A, Skarbinski J, Ouma PO, Kariuki S, Barnwell JW, Otieno K, Onyona P, Causer LM, Laserson KF, Akhwale WS, Slutsker L, Hamel M. Performance of Malaria Rapid Diagnostic Tests as Part of Routine Malaria Case Management in Kenya. Am J Trop Med Hyg. 2009;80(3):470–474.

Parr JB, Belson C, Patel JC, Hoffman IF, Kamthunzi P, Martinson F, Tegha G, Thengolese I, Drakeley C, Meshnick RS, Escamillia V, Emch M, Juliano JJ. Estimation of Plasmodium falciparum Transmission Intensity in Lilongwe, Malawi, by Microscopy, Rapid Diagnostic Testing, and Nucleic Acid Detection Am J Trop Med Hyg. 2016;95(2):373– 377.

Kyabayinze DJ, Zongo I, Cunningham J, Gatton M, Angutoko P, Ategeka J. HRP2 and pLDH- Based Rapid Diagnostic Tests, Expert Microscopy, and PCR for Detection of Malaria Infection during Pregnancy and at Delivery in Areas of Varied Transmission: A Prospective Cohort Study in Burkina Faso and Uganda. PLoS One. 2016;11(7): E0156954-E0156954.

Ochola LB, Vounatsou P, Smith T, Mabaso ML, Newton CR. The reliability of diagnostic techniques in the diagnosis and management of malaria in the absence of a gold standard. Lancet Infect Dis. 2006; 6(9):582–588.

Pakalapati D, Garg S, Middha S, Kochar A, Subudhi AK, Arunachalam BP, Kochar DK, Das A. Comparative evaluation of microscopy, OptiMALand 18S rRNA gene based multiplex PCR for detection of Plasmodium falciparum &Plasmodium vivax from field isolates of Bikaner, India. Asian Pac J Trop Med. 2013;6(5):346-351.

Francisca L, Kusnanto JH, Sabatoto TBT, Sebayang B, Supriyanto, Andriyan E, Bangs MJ. Comparison of rapid diagnostic test Plasmotec Malaria-3, microscopy and quantitative real-time PCR for diagnoses of Plasmodium falciparum and Plasmodium vivax infections in Mimika Regency, Papua, Indonesia. Malar. J. 2015;14:103.

Ameyaw B, Mutocheluh M, Owusu M, Khalifah AA, Duneeh VR, Narkwa W. Performance of First Response® and CareStart™ Malaria Rapid Diagnostic Tests for the Detection of Plasmodium falciparum in a Tertiary Hospital in Ghana. BJMMR. 2017;19(8):1-7.

Baiden F, Webster J, Tivura M, Delimini R, Berko Y, Amenga-Etego S, Agyeman-Budu A, Karikari AB, Bruce J, Owusu-Agyei S, Chandramohan D. Accuracy of Rapid Tests for Malaria and Treatment Outcomes for Malaria and Non-Malaria Cases among Under-Five Children in Rural Ghana. PLoS One. 2012;7(4):e34073.

Osman MMM, Nour YMB, Sedig MF, De Bes L, Babkir AM, Mohamedani AA, Mens PF. Informed decision making before changing to RDT: A comparison of microscopy, Rapid Diagnostic Test and molecular techniques for the diagnosis and identification of Malaria parasites in Kassala Eastern Sudan. Malar. J. 2010; 9(Suppl 2):32.

Amoah LE, Abankwa J, Oppong A. Plasmodium falciparum histidine rich protein 2 diversity and the implications for PfHRP 2-based malaria diagnostic tests in Ghana. Malar. J. 2016;15:101.

WHO. False-negative RDT results and implications of new reports of P. falciparum histidine-rich protein 2/3 gene deletions. World Health Organization, Geneva, Switzerland; 2016.

Mathison BA, Pritt BS. Update on malaria diagnostics and test utilization. J Clin Microbiol. 2017;55(7):2009-2017.