Am. J. Trop. Med. Hyg., 86(2), 2012, pp. 192–193 doi:10.4269/ajtmh.2012.11-0619 Copyright # 2012 by The American Society of Tropical Medicine and Hygiene Editorial How Do We Best Diagnose Malaria in Africa? Philip J. Rosenthal* Department of Medicine, University of California, San Francisco, California For many decades, the cornerstone of malaria management in Africa was to treat all febrile children with chloroquine. With high-level resistance to chloroquine and improved means of malaria diagnosis, recommendations for the management of malaria in Africa have changed in two important ways in the last few years. First, recommended therapy for uncomplicated falciparum malaria has moved to highly effective artemisinin- based combination therapies.1 Second, it is now recommended that the treatment of malaria be confined to parasitologically confirmed cases. This recommendation requires the availabil- ity of reliable diagnostic tests. The gold standard test for the diagnosis of malaria is microscopy. Evaluation of Giemsa- stained thick smears, when performed by expert microsco- pists, provides accurate diagnosis of malaria, although assuring expert slide preparation and reading can be difficult.2 Indeed, microscopy is often unavailable, especially in rural settings. In this regard, the advent of rapid diagnostic tests (RDTs) for malaria is an important advance. Multiple immunochro- matographic tests, incorporating a number of different para- site antigens and produced by many different manufacturers, are now available.3 At best, these tests offer a simple, fairly inexpensive, and reliable means of diagnosis that can be per- formed by healthcare workers with limited training. However, concerns with RDTs include potential unreliability because of inconsistent manufacture or poor storage, uncertain sup- ply, and potential misreading of results by unskilled health workers. An additional, generally unappreciated concern when considering RDTs is differences between available tests. RDTs for malaria are based principally on the detection of one of three antigens, histidine-rich protein-2 (HRP2), lactate dehydrogenase (LDH), and aldolase. These tests have impor- tant differences. HRP2 is only expressed by Plasmodium falci- parum, and therefore, HRP2-based tests necessarily diagnose only falciparum malaria. This limitation has generally not been considered important in Africa, where in most areas, over 95% of episodes of malaria are caused by P. falciparum. In addition, HRP2 can circulate for an extended period of time after an infection has been cleared4 and is also expressed by gameto- cytes.5 Thus, false-positive tests may be caused by recent but not current infection. LDH-based RDTs can be designed to recognize only the P. falciparum antigen or those antigens produced by all human malaria parasites. LDH tests are gen- erally less sensitive than those tests directed against HRP2. However, they may be more specific, because the antigen cir- culates only briefly after eradication of infection.4 In a study from multiple sites in Uganda using microscopy as a gold stan- dard, an HRP2-based assay offered improved sensitivity over an LDH-based assay, and the negative predictive value of the *Address correspondence to Philip J. Rosenthal, Box 0811, Department or Medicine, University of California, San Francisco, CA 94143. E-mail: prosenthal@medsfgh.ucsf.edu 192 LDH-based test dropped significantly as transmission inten- sity increased; thus, the HRP2-based test was recommended for areas with medium to high levels of malaria transmis- sion.6 Genus-specific aldolase-based RDTs are also available; these RDTs are offered with HRP2 detection to provide pan- species diagnosis of malaria and diagnosis of falciparum malaria in a single test. Surprisingly, the malaria control community seems to pay quite little attention to the type of RDT that is used for malaria diagnosis. World Health Organization (WHO) guide- lines state that the tests “have different characteristics, which may affect suitability for use in different situations,” but they do not offer specific guidance as to the choice of test.1 In prac- tice, HRP2-based tests have been most widely used, with the improved sensitivity of these tests considered more important than their potential for loss of specificity because of identi- fication of antigen after prior infections have been cleared. Indeed, there is particular interest in avoiding false negatives, because failure to treat a child with acute falciparum malaria can have disastrous consequences. However, might the HRP2- based RDT also engender concerns regarding sensitivity? In this issue of the journal, Koita and others7 identify another limitation of HRP2-based RDTs in Africa. Koita and others7 evaluated 480 blood samples from Mali that were positive by standard malaria microscopy and found that 26 were negative by HRP2-based RDT. All of these samples were posi- tive for malaria based on repeat microscopy and polymerase chain reaction (PCR) using primers that amplify conserved P. falciparum sequences. However, for the 22 evaluable samples, amplification of the HRP2 gene was successful for only 12; 10 samples, thus, seemed to include P. falciparum lacking an intact HRP2 gene. All of these samples contained monoclonal infections, whereas most of the HRP2-positive samples were polyclonal, supporting the existence in Mali of a minority of P. falciparum parasites that do not express the HRP2 gene. The results do not rule out the possibility that these parasites expressed an altered HRP2 that was not recog- nized by the RDT and whose gene was not amplified by stan- dard primers. Regardless, these infections were not identified by the RDT, pointing to definitive false negatives for this test. Similarly, failure to amplify the HRP2 gene was recognized previously in multiple P. falciparum samples from Peru.8 The new work had some limitations.7 First, it studied sam- ples that were collected in 1996 and then stored for an undis- closed number of years before PCR analysis, potentially increasing the likelihood of false-negative assays for HRP2. It is not clear if parasites from Mali and elsewhere in Africa are more or less likely to be undetectable by HRP2-based RDT at the present time. Second, only one set of primers was used to detect the HRP2 gene in these samples. It is possible that the gene was present in some or all of these samples but that the primers could not detect the gene because of some varia- tion in sequence. Third, all HRP2-negative infections in Mali