Utility of the detection of Plasmodium parasites for the diagnosis of malaria in endemic areas

BACKGROUND: In populations where the prevalence of infection with Plasmodium parasites is high, blood tests that identify Plasmodium parasites in patients with fever may lead to false positive diagnosis of malaria-disease. We characterised the diminishing value of the parasite detection test as a function of the prevalence of infection. METHODS: We computed the ability of the parasite detection test to identify malaria at various levels of prevalence (0% to 90%), assuming plausible estimates of sensitivity (95% and 85%) and specificity (99% and 95%) for the detection of parasites. In each situation, we computed likelihood ratios of malaria (or absence of malaria) for positive and negative parasite detection tests. Likelihood ratios were classified as clinically useful (≥ 10), intermediate (5–10), or unhelpful (<5). RESULTS: Likelihood ratios of positive tests were strongly related to the prevalence of infection in the general population: a positive test was unhelpful when the prevalence was 20% or more, and useful only when prevalence was 5% or less. The sensitivity and specificity of the test had little influence on these results. Likelihood ratios of negative tests were clinically useful when prevalence was 70% or less, but only for high levels of sensitivity (95%). If sensitivity was low (85%), the negative test was at best of intermediate utility, and was unhelpful if the prevalence of asymptomatic infection exceeded 30%. CONCLUSION: Identification of Plasmodium parasites supports a diagnosis of malaria only in areas where the prevalence of Plasmodium infection is low. Wherever this prevalence exceeds about 20%, a positive test is clinically unhelpful.