Transactions of the Royal Society of Tropical Medicine and Hygiene (2008) 102, 699—704

avai lab le at www.sc iencedi rec t .com

journa l homepage: www.e lsev ierhea l th .com/ journa ls / t rs t

Point-of-care testing for malaria outbreakmanagement

Ratnawati a, Mochammad Hattab, Henk L. Smitsc,∗

a Department of Parasitology, Hasanuddin University, Makassar, Indonesiab Department of Medical Microbiology, Molecular Biology and Immunology Laboratory, Faculty of Medicine, HasanuddinUniversity, Makassar, Indonesiac KIT Biomedical Research, Royal Tropical Institute/Koninklijk Instituut voor de Tropen (KIT), Meibergdreef 39, 1105 AZAmsterdam, The Netherlands

Received 24 October 2007; received in revised form 10 April 2008; accepted 10 April 2008Available online 2 June 2008

KEYWORDSMalaria;Plasmodiumfalciparum;Plasmodium vivax;Point of care;Outbreakmanagement;

Summary A rapid antigen assay for malaria was performed on blood samples collected duringa simultaneous outbreak of falciparum malaria and vivax malaria on a remote island in theIndonesian archipelago. During the outbreak, a total of 89 patients (4.3% of the population)were diagnosed with malaria within a week. Microscopic examination revealed 78 malaria slide-positive cases, of whom 49 (62.8%) were identified as P. falciparum, 7 (9.0%) as P. vivax and22 (28.2%) as mixed P. falciparum and P. vivax infections. The rapid malaria assay showedexcellent correlation with expert-confirmed routine microscopy for P. falciparum and P. vivaxmonoinfections and mixed infections with a parasite density >50 parasites/�l. Several slide-

Indonesia negative blood samples collected from febrile patients with clinical malaria tested positive inthe rapid test. The estimated sensitivity calculated for the rapid test (91.0%) was slightly higherthan that of microscopy (87.6%). The result indicates that rapid antigen detection for malariacould be a useful alternative to microscopy to reduce the workload during emergency outbreaksituations.

r Ltd

i

© 2008 Published by Elsevie

1. Introduction

Although simple and cheap, microscopic examination ofGiemsa-stained thick and thin films for confirmation ofmalaria parasites in the blood of a patient is time consum-

∗ Corresponding author. Tel.: +31 20 566 5470;fax: +31 20 697 1841.

E-mail address: h.smits@kit.nl (H.L. Smits)

wgfmu(mcif

0035-9203/$ — see front matter © 2008 Published by Elsevier Ltd on behadoi:10.1016/j.trstmh.2008.04.018

on behalf of Royal Society of Tropical Medicine and Hygiene.

ng and requires an experienced microscopist as well as aell maintained and good quality microscope to achieveood sensitivity. Several different antigen detection devicesor malaria have been developed as an alternative toicroscopy and these rapid tests have been promoted for

se in healthcare centres where microscopy is not available

Moody, 2002). Several studies have examined the perfor-ance of these rapid assays under different epidemiological

onditions and in different countries, with some variationn results (Murray et al., 2003). The consensus is that theunctioning of these rapid assays is acceptable, with a

lf of Royal Society of Tropical Medicine and Hygiene.

7

smoroostocetts

2

STS2anahootaPSsfi

rrphpwhnbacnbww(aaaatp

etab

wwbccrha(1ftmr

fgpdmftorltrpmrinPlfnrtaaac

tpt

3

Mmpoada

00

ensitivity similar to or slightly lower than routineicroscopy. Microscopy is held to have a detection limit

f approximately 20 parasites/�l (Jonkman et al., 1995). Aapid test could also be very useful in the control of malariautbreaks when preparation and microscopic examinationf the increased number of blood films becomes cumber-ome. An outbreak of malaria occurred in March 2006 onhe remote Indonesian island of Sapuka Besar. We carriedut the rapid One-Step Malaria test to analyse blood samplesollected during the outbreak and compared the results withxpert-confirmed routine microscopy to see whether rapidesting for malaria can provide a rapid and simple alterna-ive to microscopy and thus be beneficial during outbreakituations.

. Materials and methods

apuka Besar is 1 of 29 inhabited small islands of the Liukangangaya archipelago belonging to the Pangkep district ofouth Sulawesi Province and is located in the Flores Sea59 km south of Makassar, the capital of South Sulawesi. Therchipelago is spread across two coral reefs and occupiesearly 700 km2. The island measures approximately 1 km2

nd has a population of 2068 inhabitants living in 474 house-olds. The Pangkep district includes part of the mainlandf South Sulawesi and the health service for the islands isrganised from there. Only two primary healthcare cen-res (Puskesmas) are located on the islands, one of themt Sapuka Besar. At the time of the study, each of theuskesmas was staffed by a single nurse. The Puskesmas atapuka Besar has very limited resources, including a micro-cope and tools for the preparation of Giemsa-stained bloodlms.

A malaria epidemic arose during a visit of a leprosyesearch team to the island in March 2006. Assisted by theesearch team, blood samples were collected from 89 febrileatients presenting at the Puskesmas or identified duringome visits, all of whom were diagnosed with malaria. Allatients with ≥2 days of fever and/or flu-like symptomsere entered into the study. The 89 patients came from 81ouseholds and were diagnosed over a period of 7 days. Theumber of patients diagnosed with malaria during the out-reak amounted to 4.3% of the population of Sapuka Besarnd is approximately one-quarter of the total number ofases recorded in 2006 and approximately one-half of theumber of cases recorded in the year preceding the out-reak. The average duration of fever at the time of diagnosisas 3.6 days (range 2—6 days), the male to female ratioas 0.9 and the average age of the patients was 25.7 years

range 7—53 years). Giemsa slide-positive patients as wells slide-negative patients diagnosed with malaria receivedstandard daily dosage of chloroquine for 3 days. The nurset the Puskesmas is the only person on the island who hasstock of antimalarials and none of the patients entered in

he study had been treated for malaria during the 2 monthsreceding the outbreak.

Giemsa-stained thick and thin films were prepared andxamined for the presence of parasites by an experiencedechnician of the research team. The films were labellednd transported to Makassar were they were re-examinedy an experienced parasitologist. Parasite densities

wbi(c

Ratnawati et al.

ere calculated after counting parasites in at least 100indows as follows: total number of parasites/mm3

lood = 8000/(a × b), where a = total number of leukocytesounted by microscopy and b = total number of parasitesounted, with the assumption that 1 mm3 of blood cor-esponds to 8000 leukocytes. Blood samples treated witheparin as anticoagulant were frozen immediately, storedt −20 ◦C and tested with the rapid One-Step Malaria testArista Biologicals Inc., Allentown, PA, USA) approximatelyyear later. Frozen blood samples collected in March 2007

rom 152 healthy individuals living on the island were alsoested. However, the latter samples were not examined byicroscopy as these samples had been collected for other

esearch purposes and slides had not been prepared.The rapid One-Step Malaria test employs Plasmodium

alciparum-specific histidine-rich protein-2 (PfHRP-2) anti-en for the identification of P. falciparum in the blood ofatients and a pan-malaria antigen, the plasmodium lactateehydrogenase (pLDH) antigen, for the detection of otheralaria species. The rapid One-Step Malaria test was per-

ormed by spotting 5 �l of blood onto the sample pad ofhe sample well of the plastic cassette. Next, two dropsf assay buffer were added into the developer well. Testesults were read after 10 min and 20 min and reported fol-owing the package insert guidelines as follows: staining ofhe control line and the PfHRP-2 line indicates a positiveesult for P. falciparum; staining of the control line and theLDH line indicates a positive result for P. vivax or other Plas-odium spp.; staining of all three lines indicates a positive

esult for P. falciparum and for P. vivax or other Plasmod-um spp.; and staining of the control line only indicates aegative result. However, as P. falciparum expresses thefHRP-2 as well as the pLDH antigen, staining of all threeines also could be interpreted as a positive result for a P.alciparum monoinfection. The rapid test does not discrimi-ate between any of the malaria species in the case of a testesult indicating a mixed infection and also does not iden-ify malaria species in the case of a test result indicatingnon-falciparum malaria infection (Moody, 2002; Murray et

l., 2003). The package label indicated a residual shelf-lifet 2—30 ◦C of 1 year and hence storage under hot tropicalonditions may require special care.

Permission for the study was obtained from the leader ofhe island, and oral informed consent was obtained from allatients, their parents or family to take blood for examina-ion for infectious diseases.

. Results

icroscopy revealed 78 Giemsa film-positive cases ofalaria, of which 49 (62.8%) were identified as P. falci-arum, 7 (9.0%) as P. vivax and 22 (28.2%) as mixed infectionsf P. falciparum and P. vivax (Table 1). Plasmodium malariaend P. ovale were not observed. In addition, 11 patients wereiagnosed with malaria based on clinical signs and symptomsnd response to treatment. The sensitivity of microscopy

as estimated to be 87.6% (95% CI 79—89%). Re-examinationy an expert parasitologist confirmed the original find-ngs. The median parasite density was 346 parasites/�lrange 16—8765 parasites/�l) and was similar for fal-iparum monoinfections (median 503 parasites/�l; range

Point-of-care testing for malaria outbreak management

Tabl

e1

Det

ecti

onan

dsp

ecie

sid

enti

ficat

ion

ofm

alar

iapa

rasi

tes

bya

rapi

dbl

ood

test

and

com

pari

son

wit

hm

icro

scop

ydu

ring

anou

tbre

akan

din

heal

thy

indi

vidu

als

Mal

aria

spec

ies

acco

rdin

gto

Gie

msa

-sta

ined

film

(no.

ofsa

mpl

es;

med

ian

para

site

coun

t,ra

nge)

No.

ofsa

mpl

esw

ith

the

follo

win

gte

stre

sult

inth

eO

ne-S

tep

Mal

aria

cass

ette

Neg

ativ

eFa

lcip

arum

Non

-fal

cipa

rum

Mix

edor

falc

ipar

umon

ly

Mal

aria

pati

ents

Neg

ativ

e(1

1)2

81

0Pl

asm

odiu

mfa

lcip

arum

(49;

503,

16—

8765

)6

391

3Pl

asm

odiu

mvi

vax

(7;

427,

56—

598)

00

70

Mix

edP.

falc

ipar

um/P

.vi

vax

(22;

398,

76—

6780

)0

00

22

Hea

lthy

Not

perf

orm

ed(1

52)

142

91

0

1pt�a

pm2tct9att<pt

imtftmwdan

prr

tmsit1

4

Tf>dmshaapl<p(rsp

701

6—8765 parasites/�l), vivax monoinfections (median 427arasites/�l; range 56—598 parasites/�l) and mixed infec-ions (median 398 parasites/�l; range 76—6780 parasites/l). Notably, very high parasite densities were not observedmong the vivax malaria monoinfections.

The rapid test gave a positive result for blood sam-les from 43 (87.8%) of the patients with a P. falciparumonoinfection, 7 (100%) with a P. vivax monoinfection and

2 (100%) with a mixed infection. Furthermore, the rapidest showed a positive result for 9 (81.8%) microscopi-ally negative patients diagnosed with malaria. Combined,he rapid test presented a positive result for 81 (91.0%;5% CI 83—96%) of the total group of Giemsa slide-positivend -negative malaria patients. All samples collected fromhe patients with a monoinfection of P. falciparum thatested negative in the rapid test had a parasite density50 parasites/�l. However, several other samples with aarasite count just above the threshold value tested posi-ive.

The rapid test correctly identified the infecting speciesn 39 (90.7%) of the film-positive samples with a falciparumonoinfection. In three other falciparum monoinfections

he result of the rapid test indicated a mixed or P.alciparum-only infection and in a single case the rapidest result revealed a monoinfection with a non-falciparumalaria species. The result of the rapid test was consistentith a mixed infection in all patients with a microscopicallyetermined mixed infection of P. falciparum and P. vivax,nd the result of the rapid test confirmed infection withon-falciparum malaria in all cases of P. vivax malaria.

Ten samples (6.6%) from the healthy individuals testedositive in the rapid test, nine of them with a rapid testesult indicating a falciparum monoinfection and one with aapid test result denoting a non-falciparum monoinfection.

Compared with microscopy the rapid test was very easyo perform without any significant amount of training; whilsticroscopy required at least 90 min to collect the blood

ample and to prepare, stain and read the films with approx-mately 45 min hands-on time in total, the result of the rapidest could be reported within 25 min with no more than0 min hands-on time.

. Discussion

he One-Step Malaria test closely matched microscopyor film-positive samples with a parasite density50 parasites/�l for P. falciparum and P. vivax and correctlyiscriminated between almost all P. falciparum and P. vivaxonoinfections and mixed infections. We estimated the

ensitivity of the rapid test to be 91.0%, which is slightlyigher than the 87.6% sensitivity calculated for microscopynd is consistent with earlier studies generally indicatingsensitivity of >90% for rapid antigen detection tests at

arasite densities >100—500 parasites/�l. The observedack of reactivity for the samples with a parasite density50 parasites/�l is consistent with the notion that at low

arasite densities the rapid tests are more likely to failMurray et al., 2003). However, the ability to obtain testesults rapidly and to screen many patients in a relativelymall timespan recommends the rapid test for screeningatients during outbreaks.

7

aTiltIMfbfitdesiadftta2ffseSevcme

hmteipSthao

maeaM1PRiniaIrie

atca

hiweoAfsuPrTFsbapi

aHtbfatItwp

bwbesbpnpbtefch

AppiA

02

Two published studies have field-investigated a rapidntigen test for malaria in Indonesia (Fryauff et al., 2000;jitra et al., 1999). In the study by Tjitra et al. (1999) the

mmunochromatographic ICT Malaria Pf/Pv test was ana-ysed in a field study performed in a primary healthcare cen-re in West Sumba, East Nusa Tenggara Province in Easternndonesia, and in the study by Fryauff et al. (2000) the Opti-AL assay was applied for screening asymptomatic residents

rom Armopa on the northeast coast of Irian Jaya. The studyy Tjitra et al. (1999) showed a sensitivity of 96% and a speci-city of 90% for the diagnosis of falciparum malaria in the ICTest and a sensitivity of 75% and a specificity of 95% for theiagnosis of vivax malaria. The sensitivity of the ICT test wasspecially low for vivax malaria parasitaemia with a para-ite density <500 parasites/�l. A similar result was obtainedn the study by Fryauff et al. (2000). We did not observe

difference in detection level for the two malaria speciesespite the fact that all but one of the P. vivax monoin-ections had a parasite density <500 parasites/�l. The ICTest utilises the same antigen as the One-Step Malaria testo target P. falciparum but employs the aldolase protein aspan-specific antigen (Coleman et al., 2002; Singh et al.,

000). The OptiMAL assay is based on the detection of a P.alciparum-specific pLDH antigen for the identification of P.alciparum and, like the One-Step Malaria test, uses a pan-pecific pLDH antigen for the other malaria species (Forneyt al., 2003; Palmer et al., 1998; Pattanasin et al., 2003).uch differences in assay design may contribute to a differ-nce in detection level. Despite the lack of sensitivity forivax malaria, the authors of these two studies have indi-ated that these rapid tests are useful tools for diagnosingalaria in Indonesia but commented that they are relatively

xpensive.Several individuals who participated in our study and

ad negative films tested positive in the rapid test. Whilsticroscopy provides direct evidence for the presence of

he parasite in the blood, the rapid tests provide indirectvidence and could be detecting residual antigen persist-ng after treatment of a previous infection or reflecting theresence of gametocytes (Bell et al., 2005; Moody, 2002;ingh et al., 2005; Tjitra et al., 2001). However, examina-ion of the medical records indicated that these individualsad not been treated for malaria recently and hence wessume that they had a current infection at the time of theutbreak.

Plasmodium falciparum and P. vivax are the most com-on species in Indonesia but P. malariae and P. ovale have

lso been reported occasionally (Anthony et al., 1992; Bairdt al., 1990, 1997; Bangs et al., 1992, 1996; Bragonier etl., 2002; Gundelfinger, 1975; Joesoef and Dennis, 1980;aguire et al., 2002; Pribadi et al., 1998; Purnomo et al.,999; Syafruddin et al., 2006). However, P. malariae and. ovale infections were not observed during the outbreak.apid testing allows correct identification of the parasite

n the case of falciparum malaria but does not discrimi-ate between the infecting species in the case of mixednfection or non-falciparum malaria (Moody, 2002; Murray et

l., 2003). However, as drug resistance is not a problem inndonesia and as in general all uncomplicated malaria caseseceive the same standard treatment, knowledge of thenfecting species is not an absolute requirement (Syafruddint al., 2005; Tjaniadi et al., 2003). Microscopy also has the

H

Ao

Ratnawati et al.

dvantage of providing accurate estimates of parasite densi-ies, which could be important in identifying and monitoringases at risk of severe malaria (Bejon et al., 2007; Idro etl., 2004, 2006).

The outbreak at Sapuka Besar was characterised by aigh percentage of mixed infections. During other outbreaknvestigations in different parts of Indonesia, P. falciparumas the dominant infection (Maguire et al., 2005; Muellert al., 2005). To explain the difference in the epidemiologyf P. falciparum and P. vivax in a native population from themazon, it was postulated that an epidemic pattern of P.alciparum infection could reflect the introduction of a newtrain either by a visitor or by a resident who had pickedp the infection elsewhere, whilst an endemic pattern of. vivax may well reflect the capability of this species toelapse (Laserson et al., 1999). Fishermen from the Liukangangaya archipelago occasionally visit other islands in thelores Sea or travel to the mainland of Sulawesi to gatherupplies and on such an occasion one of them may well haveecome infected. The high percentage of mixed infectionsppears unusual and raises the question whether they wereerhaps introduced by a person who had picked up a mixednfection elsewhere.

The use of a rapid test may help to reduce the work loadnd facilitated the management of the malaria outbreak.owever, it should be taken into account that to make effec-ive use of a rapid test the healthcare centre would need toe well stocked with the test devices. This may be crucial as,or instance, Sapuka Besar can only be reached by boat andone-way trip takes approximately 40 h to reach Makassar,

he nearest place where medical supplies can be obtained.t may be admitted, however, that the logistic situation inhe Liukang Tangaya archipelago is exceptional and that itill be easier to keep stock or to call in assistance in otherarts of Indonesia.

We conclude that in Indonesia the One-Step Malaria test,ecause of its favourable assay characteristics combinedith its user friendliness, could be highly beneficial in out-reak situations. None the less, application of rapid tests formergency examination involves complex logistics to keepufficient supplies in stock. Other issues that may need toe addressed before introduction of rapid testing are testerformance in routine clinical practice and cost effective-ess. In most studies evaluating rapid tests, testing waserformed by experienced research staff and results maye less favourable if performed during routine clinical prac-ice (Jelinek et al., 1999; Wiese et al., 2006). The costffectiveness of rapid testing was addressed in a study per-ormed in sub-Saharan Africa (Rolland et al., 2006) but theost—benefit balance is likely to be different for the malaria,ealthcare and economic situation in Indonesia.

uthors’ contributions: MH and HLS designed the studyrotocol; MH carried out the clinical assessment; R and MHerformed the parasite determinations, and analysis andnterpretation of these data; HLS drafted the manuscript.ll authors read and approved the final manuscript. MH and

LS are guarantors of the paper.

cknowledgements: The authors appreciate the donationf the One-Step Malaria test by Arista Biologicals Inc., PA,

F

G

I

I

J

J

J

L

M

M

M

M

M

P

P

P

P

Point-of-care testing for malaria outbreak management

USA. They also thank Coosje Tuijn for critical reading of themanuscript, and Dr H.M. Noor, Head of the Pangkep HealthDistrict Pangkep, for permission and active support. Thededicated technical support of Mr Saeni and Mr Arif of theP2M laboratory of Pangkep, and of Mr Romi Usman, Mr Mar-wani, Mr Syafri, Mrs Asni, Mrs Christina and Mr Mus Jebaruof the Hasanuddin University, Makassar, Indonesia, is greatlyappreciated. Furthermore, the authors are grateful to Hj.Rabiah, Head of the Primary Health Centre (Puskesmas)Liukang Tangaya Pangkep, for hospitality and support dur-ing their stay at Sapuka Besar. They also wish to thank allthe inhabitants of the island for their kind co-operation.

Funding: None.

Conflicts of interest: None declared.

Ethical approval: Medical Ethical Committee of theHasanuddin University, Makassar, Indonesia (ref. no. 21/Pen-Ethic-Clear/2005).

References

Anthony, R.L., Bangs, M.J., Hamzah, N., Basri, H., Purnomo,Subianto, B., 1992. Heightened transmission of stable malaria inan isolated population in the highlands of Irian Jaya, Indonesia.Am. J. Trop. Med. Hyg. 47, 346—356.

Baird, J.K., Purnomo, Masbar, S., 1990. Plasmodium ovale in Indone-sia. Southeast Asian J. Trop. Med. Public Health 21, 541—544.

Baird, J.K., Wiady, I., Fryauff, D.J., Sutanihardja, M.A., Leksana, B.,Widjaya, H., Kysdarmanto, Subianto, B., 1997. In vivo resistanceto chloroquine by Plasmodium vivax and Plasmodium falciparumat Nabire, Irian Jaya, Indonesia. Am. J. Trop. Med. Hyg. 56,627—631.

Bangs, M.J., Purnomo, Anthony, R.L., 1992. Plasmodium ovale in thehighlands of Irian Jaya, Indonesia. Ann. Trop. Med. Parasitol. 86,307—308.

Bangs, M.J., Rusmiarto, S., Anthony, R.L., Wirtz, R.A., Subianto,D.B., 1996. Malaria transmission by Anopheles punctulatus in thehighlands of Irian Jaya, Indonesia. Ann. Trop. Med. Parasitol. 90,29—38.

Bejon, P., Berkley, J.A., Mwangi, T., Ogada, E., Mwangi, I., Mait-land, K., Williams, T., Scott, J.A., English, M., Lowe, B.S., Peshu,N., Newton, C.R., Marsh, K., 2007. Defining childhood severefalciparum malaria for intervention studies. PLoS Med. 4, e251.

Bell, D.R., Wilson, D.W., Martin, L.B., 2005. False-positive resultsof a Plasmodium falciparum histidine-rich protein 2-detectingmalaria rapid diagnostic test due to high sensitivity in a com-munity with fluctuating low parasite density. Am. J. Trop. Med.Hyg. 73, 199—203.

Bragonier, R., Nasveld, P., Auliffe, A., 2002. Plasmodium malariaein East Timor. Southeast Asian J. Trop. Med. Public Health 33,689—690.

Coleman, R.E., Maneechai, N., Rachapaew, N., Kumpitak, C., Soy-seng, V., Miller, R.S., Thimasarn, K., Sattabongkot, J., 2002.Field evaluation of the ICT Malaria Pf/Pv immunochromato-graphic test for the detection of asymptomatic malaria in aPlasmodium falciparum/vivax endemic area in Thailand. Am.J. Trop. Med. Hyg. 66, 379—383.

Forney, J.R., Wongsrichanalai, C., Magill, A.J., Craig, L.G.,

Sirichaisinthop, J., Bautista, C.T., Miller, R.S., Ockenhouse, C.F.,Kester, K.E., Aronson, N.E., Andersen, E.M., Quino-Ascurra,H.A., Vidal, C., Moran, K.A., Murray, C.K., DeWitt, C.C., Hep-pner, D.G., Kain, K.C., Ballou, W.R., Gasser Jr, R.A., 2003.Devices for rapid diagnosis of malaria: evaluation of prototype

R

703

assays that detect Plasmodium falciparum histidine-rich protein2 and a Plasmodium vivax-specific antigen. J. Clin. Microbiol. 41,2358—2366.

ryauff, D.J., Purnomo, Sutamihardja, M.A., Elyazar, I.R., Susanti,I., Krisin, Subianto, B., Marwoto, H., 2000. Performance of theOptiMAL assay for detection and identification of malaria infec-tions in asymptomatic residents of Irian Jaya, Indonesia. Am. J.Trop. Med. Hyg. 63, 139—145.

undelfinger, B.F., 1975. Observations on malaria in IndonesianTimor. Am. J. Trop. Med. Hyg. 24, 393—396.

dro, R., Karamagi, C., Tumwine, J., 2004. Immediate outcome andprognostic factors for cerebral malaria among children admittedto Mulago Hospital, Uganda. Ann. Trop. Paediatr. 24, 17—24.

dro, R., Aloyo, J., Mayende, L., Bitarakwate, E., John, C.C.,Kivumbi, G.W., 2006. Severe malaria in children in areas withlow, moderate and high transmission intensity in Uganda. Trop.Med. Int. Health 11, 115—124.

elinek, T., Amsler, L., Grobusch, M.P., Nothdurft, H.D., 1999. Self-use of rapid tests for malaria diagnosis by tourists. Lancet 354,1609.

oesoef, A., Dennis, D.T., 1980. Intestinal and blood parasites ofman on Alor Island Southeast Indonesia. Southeast Asian J. Trop.Med. Public Health 11, 43—47.

onkman, A., Chibwe, R.A., Khoromana, C.O., Liabunya, U.L.,Chaponda, M.E., Kandiero, G.E., Molyneux, M.E., Taylor, T.E.,1995. Cost-saving through microscopy-based versus presumptivediagnosis of malaria in adult outpatients in Malawi. Bull. WorldHealth Organ. 73, 223—227.

aserson, K.F., Wypij, D., Petralanda, I., Spielman, A., Maguire,J.H., 1999. Differential perpetuation of malaria species amongAmazonian Yanomami Amerindians. Am. J. Trop. Med. Hyg. 60,767—773.

aguire, J.D., Sumawinata, I.W., Masbar, S., Laksana, B., Prod-jodipuro, P., Susanti, I., Sismadi, P., Mahmud, N., Bangs, M.J.,Baird, J.K., 2002. Chloroquine-resistant Plasmodium malariae insouth Sumatra, Indonesia. Lancet 360, 58—60.

aguire, J.D., Tuti, S., Sismadi, P., Wiady, I., Basri, H., Krisin, Mas-bar, S., Projodipuro, P., Elyazar, I.R., Corwin, A.L., Bangs, M.J.,2005. Endemic coastal malaria in the Thousand Islands District,near Jakarta, Indonesia. Trop. Med. Int. Health 10, 489—496.

oody, A., 2002. Rapid diagnostic tests for malaria parasites. Clin.Microbiol. Rev. 15, 66—78.

ueller, I., Namuigi, P., Kundi, J., Ivivi, R., Tandrapah, T., Bjorge, S.,Reeder, J.C., 2005. Epidemic malaria in the highlands of PapuaNew Guinea. Am. J. Trop. Med. Hyg. 72, 554—560.

urray, C.K., Bell, D., Gasser, R.A., Wongsrichanalai, C., 2003.Rapid diagnostic testing for malaria. Trop. Med. Int. Health 8,876—883.

almer, C.J., Lindo, J.F., Klaskala, W.I., Quesada, J.A., Kaminsky,R., Baum, M.K., Ager, A.L., 1998. Evaluation of the OptiMALtest for rapid diagnosis of Plasmodium vivax and Plasmodiumfalciparum malaria. J. Clin. Microbiol. 36, 203—206.

attanasin, S., Proux, S., Chompasuk, D., Luwiradaj, K., Jacquier,P., Looareesuwan, S., Nosten, F., 2003. Evaluation of a newPlasmodium lactate dehydrogenase assay (OptiMAL-IT) for thedetection of malaria. Trans. R. Soc. Trop. Med. Hyg. 97,672—674.

ribadi, W., Sutanto, I., Atmosoedjono, S., Rasidi, R., Surya, L.K.,Susanto, L., 1998. Malaria situation in several villages aroundTimika, south central Irian Jaya, Indonesia. Southeast Asian J.Trop. Med. Public Health 29, 228—235.

urnomo, Solihin, A., Gomez-Saladin, E., Bangs, M.J., 1999. Rarequadruple malaria infection in Irian Jaya Indonesia. J. Parasitol.

85, 574—579.

olland, E., Checchi, F., Pinoges, L., Balkan, S., Guthmann, J.P.,Guerin, P.J., 2006. Operational response to malaria epidemics:are rapid diagnostic tests cost-effective? Trop. Med. Int. Health11, 398—408.

7

S

S

S

S

T

T

T

Wiese, L., Bruun, B., Baek, L., Friis-Møller, A., Gahrn-Hansen, B.,

04

ingh, N., Saxena, A., Valecha, N., 2000. Field evaluation of theICT malaria P.f/P.v immunochromatographic test for diagnosis ofPlasmodium falciparum and P. vivax infection in forest villagesof Chhindwara, central India. Trop. Med. Int. Health 5, 765—770.

ingh, N., Mishra, A.K., Shukla, M.M., Chand, S.K., Bharti, P.K.,2005. Diagnostic and prognostic utility of an inexpensive rapidon site malaria diagnostic test (ParaHIT f) among ethnic tribalpopulation in areas of high, low and no transmission in centralIndia. BMC Infect. Dis. 5, 50—55.

yafruddin, D., Asih, P.B., Casey, G.J., Maguire, J., Baird, J.K.,Nagesha, H.S., Cowman, A.F., Reeder, J.C., 2005. Molecular epi-demiology of Plasmodium falciparum resistance to antimalarialdrugs in Indonesia. Am. J. Trop. Med. Hyg. 72, 174—181.

yafruddin, D., Asih, P.B., Coutrier, F.N., Trianty, L., Noviyanti, R.,Luase, Y., Sumarto, W., Caley, M., van der Ven, A.J., Sauer-wein, R.W., 2006. Malaria in Wanokaka and Loli sub-districts,

West Sumba District, East Nusa Tenggara Province, Indonesia.Am. J. Trop. Med. Hyg. 74, 733—737.

janiadi, P., Lesmana, M., Subekti, D., Machpud, N., Komalarini,S., Santoso, W., Simanjuntak, C.H., Punjabi, N., Campbell, J.R.,Alexander, W.K., Beecham 3rd, H.J., Corwin, A.L., Oyofo, B.A.,

Ratnawati et al.

2003. Antimicrobial resistance of bacterial pathogens associatedwith diarrheal patients in Indonesia. Am. J. Trop. Med. Hyg. 68,666—670.

jitra, E., Suprianto, S., Dyer, M., Currie, B.J., Anstey, N.M.,1999. Field evaluation of the ICT malaria P.f/P.v immunochro-matographic test for detection of Plasmodium falciparum andPlasmodium vivax in patients with a presumptive clinical diag-nosis of malaria in eastern Indonesia. J. Clin. Microbiol. 37,2412—2417.

jitra, E., Suprianto, S., McBroom, J., Currie, B.J., Anstey, N.M.,2001. Persistent ICT malaria P.f/P.v panmalarial and HRP2antigen reactivity after treatment of Plasmodium falciparummalaria is associated with gametocytemia and results in false-positive diagnoses of Plasmodium vivax in convalescence. J.Clin. Microbiol. 39, 1025—1031.

Hansen, J., Heltberg, O., Højbjerg, T., Hornstrup, M.K., Kvines-dal, B., Gomme, G., Kurtzhals, J.A., 2006. Bedside diagnosis ofimported malaria using the Binax Now malaria antigen detectiontest. Scand. J. Infect. Dis. 38, 1063—1068.