Malaria rapid diagnostic tests in travel medicine

Malaria is a serious condition in the non-immune traveller, and prognosis depends on timely diagnosis. Although microscopy remains the cornerstone of diagnosis, malaria rapid diagnostic tests (RDTs) are increasingly used in non-endemic settings. They are easy to use, provide results rapidly and require no specific training and equipment. Reported sensitivities vary between different RDT products but are generally good for Plasmodium falciparum, with RDTs detecting the P. falciparum antigen histidine-rich protein-2 (PfHRP2) scoring slightly better than P. falciparum-lactate dehydrogenase (Pf-pLDH)-detecting RDTs. Sensitivity is lower for Plasmodium vivax (66.0 - 88.0%) and poor for Plasmodium ovale (5.5 - 86.7%) and Plasmodium malariae (21.4 - 45.2%). Rapid diagnostic tests have several other limitations, including persistence of the PfHRP2 antigen, cross-reactions of P. falciparum with the non-falciparum test line and vice versa and (rare) false-positive reactions due to other infectious agents or immunological factors. False-negative results occur in the case of low parasite densities, prozone effect or pfhrp2 gene deletions. In addition, errors in interpretation occur, partly due to inadequacies in the instructions for use. Finally, RDTs do not give information about parasite density. In the diagnostic laboratory, RDTs are a valuable adjunct to (but not a replacement for) microscopy for the diagnosis of malaria in the returned traveller.In malaria endemic settings, special groups of travellers (those travelling for long periods, expatriates and short-stay frequent travellers) who are remote from qualified medical services may benefit from self-diagnosis by RDTs, provided they use correctly stored RDT products of proven accuracy, with comprehensive instructions for use and appropriate hands-on training.