The reliability of diagnostic techniques in the diagnosis and management of malaria in the absence of a gold standard

SummaryThe accuracy of techniques for the diagnosis of malaria are usually compared with optical microscopy, which is considered to be a gold standard. However, microscopy is prone to error and therefore makes it difficult to assess the reliability of other diagnostic techniques. We did a systematic review to assess the specificity and sensitivity of diagnostic techniques in different settings, using a statistical method that avoided defining a gold standard. Performance varied depending on species of the malaria parasite, level of parasitaemia, and immunity. Overall, histidine-rich protein 2 (HRP2)-based dipsticks showed a high sensitivity (92·7%) and specificity (99·2%) for Plasmodium falciparum in endemic areas. The acridine orange test was more sensitive (97·1%) in detecting P falciparum in epidemiological studies, with a specificity of 97·9%. In the absence of a gold standard, HRP2 dipsticks and acridine orange could provide an alternative for detecting falciparum infections in endemic areas and epidemiological studies, respectively. Microscopy still remains more reliable in detecting non-falciparum infections.