The use of Fionet technology for external quality control of malaria rapid diagnostic tests and monitoring health workers' performance in rural military health facilities in Tanzania

PLoS One. 2018 Dec 27;13(12):e0208583. doi: 10.1371/journal.pone.0208583. eCollection 2018.

Abstract

Introduction: Internal and external quality control (QC) of rapid diagnostic tests (RDTs) is important to increase reliability of RDTs currently used to diagnose malaria. However, cross-checking of used RDTs as part of quality assurance can rarely be done by off-site personnel because there is no guarantee of retaining visible test lines after manufacturers' recommended reading time. Therefore, this study examined the potential of using Fionet™ technology for remote RDT quality monitoring at seven clinics, identifying reasons for making RDT processing and interpretation errors, and taking corrective actions for improvement of diagnosis and consequently improved management of febrile patients.

Methods: The study was conducted at seven military health facilities in Mainland Tanzania and utilized RDTs capable of detecting Plasmodium falciparum specific Histidine-rich protein 2 (Pf-HRP2) and the genus specific Plasmodium lactate dehydrogenase (pLDH) for other species of plasmodium (P. vivax, P. malariae or P. ovale; pan-pLDH). Patients' data and images of processed RDTs from seven clinics were uploaded on a Fionet web portal and reviewed regularly to monitor preparation procedures and visual interpretation of test results compared to automated analysis using the Deki reader of RDT. Problems detected were rapidly communicated to remote laboratory personnel at the clinic for corrective action and follow-up of patients who were falsely diagnosed as negative and missed treatment. Factors contributing to making errors in visual interpretation of RDT results were analyzed during visits to the health facilities.

Results: A total of 1,367 (1.6%) out of 83,294 RDT test images uploaded to the Fionet portal had discordant test results of which 822 (60.1%) and 545 (39.9%) were falsely reported as negative and positive, respectively. False negative and false positive test results were common for a single test line in 515 (62.7%) and 741 (54.2%) tests, respectively. Out of 1,367 RDT images assessed, 98 (7.2%) had quality problems related to preparation procedures of which 95(96.9%) errors were due to putting too much blood on the sample well or insufficient buffer in the respective wells. The reasons for discrepant results included, false reporting of none existent lines in 526 (38.5%) tests, missing a faint positive line in 493 (36.1%), missing a strong positive line in 248(18.1%) and errors caused by poorly processed RDTs in 96 (7.2%) tests. Among the false negative tests (n = 822), 669 (48.9%) patients were eligible for follow-up and only 339 (48.5%) were reached and 291 (85.8%) received appropriate anti-malaria therapy.

Conclusion: Fionet technology enabled remote monitoring of RDT quality issues, identifying reasons contributing to laboratory personnel making errors and provided a rapid method to implement corrective actions at remote sites to improve malaria diagnosis and consequently improved health care management of febrile patients infected with malaria.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Antigens, Protozoan / analysis
  • Child
  • Child, Preschool
  • Diagnostic Errors
  • Diagnostic Tests, Routine* / standards
  • Female
  • Health Facilities
  • Health Personnel*
  • Humans
  • Infant
  • Infant, Newborn
  • L-Lactate Dehydrogenase / analysis
  • L-Lactate Dehydrogenase / standards
  • Malaria / diagnosis*
  • Male
  • Plasmodium falciparum / metabolism
  • Protozoan Proteins / analysis
  • Protozoan Proteins / standards
  • Quality Control
  • Tanzania
  • Task Performance and Analysis*
  • Young Adult

Substances

  • Antigens, Protozoan
  • HRP-2 antigen, Plasmodium falciparum
  • Protozoan Proteins
  • L-Lactate Dehydrogenase

Grants and funding

This study was supported through funding received from Walter Reed Army Institute of Research (WRAIR) for malaria surveillance and diagnostic quality improvement program in Tanzania. The material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the US Department of the Army or the Department of Defense. The investigators have adhered to the policies for protection of human subjects as prescribed in AR 70– 25. The corresponding Author [AK] who is a PhD student, received financial support from the government of Tanzania through Tanzania Commission for Science and Technology (COSTECH) and Fio Corporation for school fees and stipend at the college. One author [GA] was employed by a commercial company called FORGYN Health Systems Consultants LLc at the time of submission of this article. The company did not fund the project; it just provided support in the form.