Comparison of PCR and microscopy for the detection of asymptomatic malaria in a Plasmodium falciparum/vivax endemic area in Thailand.

OBJECTIVE: The main objective of this study was to compare the performance of nested PCR with expert microscopy as a means of detecting Plasmodium parasites during active malaria surveillance in western Thailand. METHODS: The study was performed from May 2000 to April 2002 in the village of Kong Mong Tha, located in western Thailand. Plasmodium vivax (PV) and Plasmodium falciparum (PF) are the predominant parasite species in this village, followed by Plasmodium malariae (PM) and Plasmodium ovale (PO). Each month, fingerprick blood samples were taken from each participating individual and used to prepare thick and thin blood films and for PCR analysis. RESULTS: PCR was sensitive (96%) and specific (98%) for malaria at parasite densities > or = 500/microl; however, only 18% (47/269) of P. falciparum- and 5% (20/390) of P. vivax-positive films had parasite densities this high. Performance of PCR decreased markedly at parasite densities <500/microl, with sensitivity of only 20% for P. falciparum and 24% for P. vivax at densities <100 parasites/microl. CONCLUSION: Although PCR performance appeared poor when compared to microscopy, data indicated that the discrepancy between the two methods resulted from poor performance of microscopy at low parasite densities rather than poor performance of PCR. These data are not unusual when the diagnostic method being evaluated is more sensitive than the reference method. PCR appears to be a useful method for detecting Plasmodium parasites during active malaria surveillance in Thailand.

Short report: Failure of the OptiMAL rapid malaria test as a tool for the detection of asymptomatic malaria in an area of Thailand endemic for Plasmodium falciparum and P. vivax.

We evaluated the efficacy of the OptiMAL assay in a cross-sectional malaria survey in western Thailand from April to August 2001. Expert microscopy of Giemsa-stained thick and thin blood films was used as the gold standard. Positive control lines were evident in 99% (1,128 of 1,137) of the assays tested. However, 34% (384 of 1,128) of assays produced an aberrant result (a positive P. falciparum-specific line and a negative panmalarial line). False-positive panmalarial and Plasmodium falciparum-specific lines occurred in 25.9% (270 of 1,042) and 60.3% (628 of 1,042) of microscopy-negative samples, respectively. Due to the preponderance of false-positive test results, it was necessary to develop subjective criteria for test positivity based on line intensity. For determination of assay performance during this study, we therefore considered all test lines that were scored as intermediate or strong as positive and lines that were faint as negative. Using these criteria, we determined that the sensitivity of the OptiMAL assay for P. falciparum was 25% with > 500 parasites/microl and 10.5% with > 100 parasites/microl, while for P. vivax, the sensitivity at the same parasite rates was 100% and 41.7%, respectively. Further studies are required to determine whether the problems we identified are limited to this particular lot of OptiMAL assays.

Field evaluation of the ICT Malaria Pf/Pv immunochromatographic test for the detection of asymptomatic malaria in a Plasmodium falciparum/vivax endemic area in Thailand.

Rapid antigen assays provide an effective tool for the detection of malaria in symptomatic patients. However, the efficacy of these devices for detecting asymptomatic malaria, where parasite levels are normally significantly lower than in symptomatic patients, is less well established. We evaluated the efficacy of a new combined Plasmodium falciparum-Plasmodim vivax immunochromatographic test (ICT Malaria Pf/Pv) in a cross-sectional malaria survey of the village of Ban Kong Mong Tha, Kanchanaburi Provice, Thailand, from August to December 2000. A total of 1,976 bleeds were made from 559 individuals over the course of the study. Blinded microscopy of thick and thin blood films was used as the gold standard; all discordant and 10% of concordant results were cross-checked. Of 1,976 ICT Malaria Pf/Pv dipsticks tested, 98.3% (n = 1,943) performed as expected, as evidenced by the appearance of the control line. The ICT Malaria Pf/Pv test was both sensitive (100.0%) and specific (99.7 %) for the diagnosis of falciparum malaria with parasitemias of > or = 500 trophozoites/microL; however, only 15.9% (13/82) of infected individuals had parasitemia rates this high. When P. falciparum parasitemia rates were < 500/microL, the sensitivity of the diagnosis was only 23.3%, with a positive predictive value (PPV) and a negative predictive value (NPV) of 76.2 and 97.2%, respectively. The ICT Malaria Pf/Pv test was specific, but not sensitive, for the diagnosis of vivax malaria with parasite rates of > or = 500 trophozoites/microl, with sensitivity, specificity, PPV, and NPV of 66.7%, 99.9%, 66.7%, and 99.9%, respectively. At parasite rates of < 500/microL, corresponding values were 0.0%, 99.9%, 0%, and 95.1%. Because of the relatively high cost of these assays, low parasite rates found in the majority of asymptomatic individuals, and low sensitivity of this assay with rates of < 500/microl, use of this assay as a tool for active case detection is of limited value in western Thailand.

Infectivity of asymptomatic Plasmodium-infected human populations to Anopheles dirus mosquitoes in western Thailand.

The infectivity of Plasmodium-infected humans in western Thailand was estimated by feeding laboratory-reared Anopheles dirus Peyton and Harrison mosquitoes on venous blood placed in a membrane-feeding apparatus. Between May 2000 and November 2001, a total of 6,494 blood films collected during an active malaria surveillance program were checked by microscopy for the presence of Plasmodium parasites: 3.3, 4.5, and 0.1% of slides were P. falciparum- (Pf), P. vivax- (Pv), and P. malariae (Pm)-positive. Venous blood was collected from 70, 52, 6, and 4 individuals infected with Pf, Pv, Pm, and mixed Pf/Pv, respectively, with 167 uninfected individuals serving as negative controls. Only 10% (7/70), 13% (7/52), and 0% (0/6) of membrane feeds conducted on Pf-, Pv-, and Pm-infected blood yielded infected mosquitoes. One percent (2/167) of microscope-negative samples infected mosquitoes; however, both samples were subsequently determined to be Pf-positive by polymerase chain reaction. Gametocytes were observed in only 29% (4/14) of the infectious samples. All infections resulted in low oocyst loads (average of 1.2 oocysts per positive mosquito). Only 4.5% (10/222) of mosquitoes fed on the seven infectious Pf samples developed oocysts, whereas 2.9% (9/311) of mosquitoes fed on the seven infectious Pv samples developed oocysts. The probability of a mosquito becoming infected with Pf or Pv after a blood meal on a member of the human population in Kong Mong Tha was estimated to be 1 in 6,700 and 1 in 5,700, respectively. The implications toward malaria transmission in western Thailand are discussed.