A reason to celebrate in a time of uncertainty. Response to: Linblade et al. “Assessing the accuracy of the recording and reporting of malaria rapid diagnostic test results in four African countries—methods and key results”
Comment
Published: 21 November 2025
volume 24, Article number: 416 (2025)
Abstract
Linblade and colleagues should be commended for their recent publication “Assessing the accuracy of the recording and reporting of malaria rapid diagnostic test results in four African countries: methods and key results.” The authors missed an opportunity to assess those findings in the context of the past and recent history of malaria diagnosis and treatment. If viewed from such an historical perspective, there is reason to celebrate these findings and what they demonstrate about the success of country and global efforts to scale up diagnostic testing for malaria over the last 15 years.
Linblade and colleagues should be commended for their recent publication, “Assessing the accuracy of the recording and reporting of malaria rapid diagnostic test results in four African countries: methods and key results” published in July in this journal [1]. Hopefully, the robust results from a large assessment in four countries (Benin Côte d’Ivoire, Nigeria, and Uganda) put to rest concerns voiced by some well-placed members of the malaria community who believed that clinicians and laboratory staff were frequently misreading and/or misreporting malaria rapid diagnostic test (RDT) results leading to widespread overprescription of malaria treatments. Notably, the concordance between reported results and expert reading of photographs of the RDTs ranged from a kappa of 0.8 to 0.88, which approaches a perfect score for agreement of 1.0 [2].
As the authors point out, there is some room for improvement with from 5 to 7% of tests deemed to be negative being recorded as positive, which likely resulted in some of those patients receiving unnecessary treatment for malaria. Fortunately, very small percentages (0.7%–3.7%) of those with malaria antigenaemia were recorded as negative, indicating that the overwhelming majority of those with malaria were properly diagnosed. Nonetheless, countries should strive to maximize the correct use and interpretation of RDTs.
Although the author’s conclusions are consistent with the study findings, they miss the opportunity to place these results in their appropriate historical context. For much of the history of malaria control and elimination efforts, particularly in sub-Saharan Africa, treatment of malaria in high burden areas was recommended for anyone presenting with fever or a history of fever. At the time, this was a logical approach as chloroquine, the first-line treatment for malaria during the latter part of the twentieth century and the early 2000s, was well-tolerated and cheap, a high percentage (often more than 60%) of those presenting to a health facility with fever had malaria parasitaemia, and health facilities often lacked capacity for diagnostic testing or laboratory services were very limited.
It was not until 2009 and 2010 that the World Health Organization (WHO) updated their guidance on malaria diagnosis and treatment, respectively, to recommend testing of all patients with suspected malaria and that decisions around treatment should be based on the diagnostic test result [3, 4]. This change in guidance was made possible by the development of low-cost, reliable RDTs and dramatically increased availability of these tests made possible with support from affected countries, the Global Fund for AIDS, TB, and Malaria, the US President’s Malaria Initiative, and others.
Over the next decade, purchases by countries of RDTs rose from approximately 80 million tests in 2010 to almost 450 million in 2023 [5]. Training of facility and community health workers in the use and interpretation of RDTs was scaled up in every malaria-affected country in sub-Saharan Africa and other regions. Clinical and laboratory quality improvement programmes, such as Outreach Training and Supportive Supervision (OTSS) were scaled up in some, but not all, of these countries [5, 6].
The findings of Linblade et al. [1] are first and foremost a testament to the effectiveness of those investments in strengthening malaria diagnostic capacity and quality over little more than a decade. That fewer than 10% of all tests were incorrectly recorded should be viewed as a resounding public health success.
Furthermore, it is notable that Benin, which had the highest agreement between reported results and expert interpretation (kappa 0.88) is the only of the five countries to fully scale up a clinical quality improvement programme for malaria diagnosis and treatment, having introduced OTSS in 2009. In contrast, Côte d’Ivoire, with a kappa of 0.82, introduced OTSS in 2020. One can, therefore, hope that as OTSS or similar quality improvement programmes are scaled up in Côte d’Ivoire and other countries that the accuracy of diagnosis will further improve.
This study also should assuage the concerns raised by the author’s that Ministries of Health may have created, as they state in their introduction, “incentives for HCWs to intentionally mis-record RDT results in health facility registers to account for the treatments provided.” Concerns about the overdiagnosis of malaria leading to overuse of malaria treatments long predate the introduction of RDTs and efforts to promote strict adherence to diagnostic test results. My colleagues and I documented similar practices in Zambia in 1997, with 35% of those whose blood slides were confirmed to be negative having been prescribed malaria treatment [7]. These results were replicated by Hamer et al. 10 years later in Zambia with 58% of those testing negative by microscopy and 36% of those testing negative by RDT still being provided treatment for malaria [8].
In the 1997 assessment, interviews were conducted with laboratory staff and clinicians which provided insights into some of the incentives and pressures laboratory staff were encountering. Clinicians assessed, who were faced with very limited availability of malaria microscopy, indicated that they selectively requested microscopy on patients where they had strong suspicions that the fever was being caused by malaria. Laboratory staff indicated they sometimes felt pressure from clinicians to record negative blood slides as positive, which is not surprising given the clinicians were only referring patients for testing if they were convinced they had malaria. A similar unpublished assessment in Kenya in 1998 identified a laboratory where almost every blood slide was recorded as positive, despite most of the blood slides sampled being deemed negative on expert review. When the technician was interviewed, he indicated that he recorded all slides positive because the clinician would scold him if he sent back a negative result.
When viewed in that historical context, the results presented by Lindblade et al. should reassure us that pressure from higher level health authorities do not appear to be affecting the reporting of RDT results. It also is not unreasonable to posit that implementation of quality improvement programmes that improved the accuracy of RDT interpretation and recording were a contributing factor in high accuracy documented by this assessment.
One thing that Lindblade et al. cover in this report that is not historical is the use of test positivity rate (TPR) as a tool for monitoring the quality and accuracy of diagnostic testing. This relatively recent development has been problematic, particularly when these data are viewed without the needed context. For example, much has been made in some settings when TPR at health facilities is significantly higher than community prevalence in the catchment area. This fails to recognize first that TPR is measuring incident cases, rather than the prevalence measured in community surveys, and that those presenting at health facilities who undergo malaria testing are a highly selected subset of community members, namely those whose symptoms were significant enough to prompt patients or their caretakers to seek care, of which only a subset of those undergo diagnostic testing.
TPR has been proposed as a simple tool for identifying facilities where diagnostic testing performance may be weak, i.e., an unexpectedly high TPR may indicate a higher frequency of false positive RDTs. Some also have argued that TPR could be a tool to monitor testing performance over time. Of course, this ignores that the greatest drivers of TPR are malaria incidence and access to testing services. TPR will decrease or increase as transmission intensity drops or increases. TPR also will be heavily affected by the ease of which patients and clinicians can access testing. A facility with a very limited number of RDTs will logically reserve them for cases meeting more rigorous criteria, whereas a facility with an uninterrupted supply of RDTs may test anyone who seeks care with a current or past fever. One would expect a much higher TPR in the former setting compared to the latter. TPR may also reflect overall access to health services. If the nearest healthcare facility is miles away or there are user fees for accessing services, only those that live more closely, those with more serious illness, and/or those with greater financial means, may access these services. These factors may greatly affect the TPR measured at a facility.
That is not to say that TPR, when assessed alongside the appropriate contextual information, cannot be of some use when included in a robust set of indicators to monitor diagnostic quality. Certainly, the finding reported from Côte d’Ivoire, where TPR decreased during the observation period, could suggest that expanded quality improvement efforts for diagnostic testing at health facilities could lead to improvements in the accuracy of RDT testing and reporting. TPR, though, should not be seen as a replacement for long-standing, validated, standardized indicators of diagnostic testing performance, such as those used in OTSS, which directly measure the performance of laboratory and clinic procedures. Nor should TPR results take precedence over data from other indicators of diagnostic performance in programmatic decision making. Of course, TPR has been used by many countries as a useful indicator of progress towards malaria elimination, both as a proxy for malaria incidence and an indirect measure of the sufficiency of malaria testing.
At a time when global resources for malaria control and elimination are at grave risk, the results of this study give us reason to celebrate and offer important evidence of the success of countries’ efforts to implement malaria programmes that have reduced sickness and death from malaria.
Data availability
No datasets were generated or analysed during the current study.
References
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Funding
No funding was provided to the author for the preparation of this manuscript. Information from previously unpublished work was collected with the support of the US Agency for International Development.
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LB conceived and drafted this commentary.
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Information on previous unpublished work contained in this commentary was collected in an assessment that was deemed programmatic evaluation by the US Centers for Disease Control and Prevention Institutional Review Board. Verbal informed consent was obtained from health workers participating in the study.
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The authors declare no competing interests.
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Barat, L.M. A reason to celebrate in a time of uncertainty. Response to: Linblade et al. “Assessing the accuracy of the recording and reporting of malaria rapid diagnostic test results in four African countries—methods and key results”.
Malar J 24, 416 (2025). https://doi.org/10.1186/s12936-025-05655-5
Received: 11 September 2025
Accepted: 29 October 2025
Published: 21 November 2025
Version of record: 21 November 2025
DOI: https://doi.org/10.1186/s12936-025-05655-5
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