Malaria rapid diagnostic test performance: results of WHO product testing of malaira RDTs: round 7 (2016-2017)

Malaria Rapid Diagnostic Test Performance Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Malaria Rapid Diagnostic Test Performance Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

WHO Library Cataloguing-in-Publication Data: Malaria rapid diagnostic test performance: results of WHO product testing of malaira RDTs: round 7 (2016-2017) ISBN 978-92-4-151268-8y © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Malaria rapid diagnostic test performance: results of WHO product testing of malaira RDTs: round 7 (2016-2017). Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in [add country – for customs purposes] Layout: Bruno Duret Editor: Elisabeth Heseltine

WHO does not warrant that: (1) the lists and figures are complete and/or error free and/or that (2) any products mentioned in the figures and tables are of acceptable quality, have obtained regulatory approval in any country or that their use is otherwise in accordance with the national laws and regulations of any country, including patent laws. Mention of any product in this report, particularly in any of the figures and tables on pp. 8 and 9, does not imply their approval by WHO (as this is the sole prerogative of national authorities). The WHO Programme of Prequalification of Diagnostics and Medical Devices uses the results of the WHO Malaria RDT Product Testing Programme as the laboratory evaluation component of the prequalification process for malaria RDTs. Although WHO prequalification is not currently a requirement for WHO procurement, manufacturers are encouraged to apply for it. A regularly updated list of WHO-prequalified diagnostics, including malaria RDTs, is available at http://www.who.int/diagnostics_laboratory/evaluations/PQ_list/en/. WHO recommendations for procurement of malaria RDTs are currently based on the attainment of a set of minimum performance criteria in the WHO Malaria RDT Product Testing Programme. The recommendations were established by the WHO Malaria Policy Advisory Committee in 2012, are outlined in this report and are presented in full in a WHO information note (available at http://www.who.int/ malaria/publications/atoz/rdt-selection-criteria.pdf ). Products that do not meet the full set of minimum performance criteria are not eligible for procurement by WHO. As of 1 January 2018, WHO prequalification will become a requirement for procurement recommendation (http://www.who.int/malaria/news/2016/rdt-procurement-criteria/en/ ). The lists of RDTs included in this report are not exhaustive but reflect those products that were submitted for evaluation in rounds 4–7 of the WHO Malaria RDT Product Testing Programme. Their mention indicates the extent to which these products, as manufactured by the listed companies, were – at the time of their evaluation – found to meet the above-mentioned set of minimum performance criteria. The evaluations indicated in the figures and tables apply only to the specific product listed with its unique product code or catalogue number and as manufactured by the listed company. Improper storage, transport or handling of malaria RDTs may affect their performance. The fact that certain products are not included in any of the lists and figures in this report indicates that they have not or not yet been submitted for evaluation to the WHO Malaria RDT Product Testing Programme or that their evaluation has not yet been completed and published or that they have been removed from summary reports due to noncompliance with compulsory resubmission requirements. It does not indicate anything in respect of such products’ performance. The lists and figures are updated regularly, and malaria RDTs are added to the lists and figures as and when (following voluntary participation in the WHO Malaria RDT Product Testing Programme) their evaluation against the above-mentioned set of minimum performance criteria has been completed. Although the malaria RDTs listed in the tables and figures are regularly re-evaluated, and updated evaluations are published by WHO, WHO cannot ensure that products on the lists and in figures will continue to meet the performance criteria in the same manner as indicated. WHO recommends therefore that, before procuring a malaria RDT, each lot of that product be tested at one of the two following lot-testing laboratories: the Institut Pasteur du Cambodge, Cambodia, or the Research Institute for Tropical Medicine, Philippines. WHO disclaims any and all liability and responsibility whatsoever for any injury, death, loss, damage or other prejudice of any kind that may arise as a result of or in connection with the procurement, distribution and use of any product included in this report and the figures and tables listed on pages V-VIII. This report may not be used by manufacturers and suppliers for commercial or promotional purposes.

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Contents

Acknowledgements IX Abbreviations X 1. Summary of performance of rapid diagnostic tests for malaria: WHO product 1 testing rounds 1–7 1.1. Introduction 1.2. The WHO product testing programme 1.3. Panel detection score and other results of the evaluation 1.4. Summary of outcomes 1.5. De-listing of products in summary report 1.6.  How product testing results can inform RDT procurement and use 1.7. Product testing and WHO programme for prequalification of diagnostics and medical devices 1 1 2 4 5 5 6

2. Executive summary 2.1. Introduction 2.2. The WHO product testing programme 2.3. Results of the evaluation 2.4. Use of the results

21 21 21 22 23

3. Background 4. Objective 5. Materials and methods 5.1. Test selection 5.2. The product testing protocol 5.3. Evaluation panels 5.4. Product registration 5.5. Specimen panel registration 5.6. Test phases 5.7. Performing rapid tests 5.8.  Interpreting the results 5.9. Recording anomalies

24 24 26 26 28 28 30 30 30 32 32 32

6. Data management 7.  Quality assurance 7.1.  Quality of malaria RDTs and their use 7.2.  Quality and objectivity of RDT readings 7.3.  Quality of WHO specimen bank samples 7.4.  Quality of the product testing site

32 33 33 33 33 33

8. Ethical considerations 9. Data analysis 9.1. Measures of parasite detection: panel detection score and positivity rates 9.2. False-positive results

33 34 34 34 34 34

9.2.1  Incorrect species identification 9.2.2 False-positive results for Plasmodium-negative samples

9.3. Band intensity 9.4. Lot agreement 9.5. Invalid tests 9.6.  Heat (thermal) stability 9.7. Anomalies 9.8. Labelling and instructions for use

34 35 35 35 35 35

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10.  ASSOCIATION BETWEEN PARASITE DENSITY AND ANTIGEN CONCENTRATION 11.  evaluation of malaria rapid diagnostic tests in the Laboratory and in the field 12. Results 12.1. Summary 12.2. Phase 1: P. falciparum culture panel 12.3. Phase 2: wild -type P. falciparum and P. vivax- and Plasmodium spp.-negative samples.

36 36 37 37 43 43 43 44 45 45 45 47

12.3.1  P. falciparum detection 12.3.2  P. vivax detection 12.3.3 Combined detection of P. falciparum and P. vivax 12.3.4  P. falciparum and P. vivax positivity rate 12.3.5 Band intensity 12.3.6 False-positive rates

12.4. Performance of resubmitted products

50

13.  Heat stability 13.1. Summary 13.2. Plasmodium falciparum 13.3. Plasmodium vivax

52 52 52 52

14. Ease of use, anomalies, Labelling and instructions for use 14.1. Ease of use 14.2. Anomalies 14.3. Labelling and instructions for use

60 60 60 60

15. Discussion of key findings 15.1. Panel detection score and its relation to sensitivity 15.2. False-positive rate and specificity 15.3. Reactivity of combination HRP2 and pan-pLDH test lines against P. falciparum samples 15.4.  Heat (thermal) stability 15.5. Ease-of-use description 15.6. Labelling and instructions for use 15.7.  Anomalies in RDT production lots 15.8.  Inter-lot variation 15.9. Selecting RDTs: target antigens, species and sensitivity

73 73 74 74 75 75 75 76 76 76

16. USING RESULTS TO ENSURE HIGH-QUALITY DIAGNOSIS IN THE FIELD 16.1. WHO prequalification 16.2. Beyond procurement 16.3. Post-market surveillance: lot verification

78 78 78 79

17. Conclusions 79 18. References 80 Annexes 83 Annex S1: Characteristics of evaluation panels used in rounds 1–7 of WHO malaria RDT product testing, 2008–2016 84 Annex S2: Malaria RDT field assessment and anomalies 87 Annex S3: Selection of an appropriate RDT 90 Annex 1: Characteristics of RDTs evaluated in round 7 91 Annex 2: Malaria RDTs: guide to interpretation of results 93 Annex 3: Phase-1 results 108 Annex 4: Phase-2 results 112 Annex 5:  Introducing RDT-based malaria diagnosis into national programmes 145

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Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

figures Figure S1. Figure S2. Figure S3. Malaria RDT performance in phase 2 of rounds 4–7 against wild-type (clinical) samples containing P. falciparum at low (200) and high (2000) parasite density (parasites/µL) and clean-negative samples Malaria RDT performance in phase 2 of rounds 4–7 against wild-type (clinical) samples containing P. vivax at low (200) and high (2000) parasite density (parasites/µL) and clean-negative samples Panel detection score of malaria combination RDTs meeting WHO procurement criteria for false-positive and invalid rates, in phase 2 of rounds 4–7 against wild-type (clinical) samples containing P. falciparum and P. vivax at low parasite density (200 parasites/µL) Mode of action of antigen-detecting malaria RDTs Network of specimen collection, characterization and testing sites Overview of malaria RDT product testing Origin of phase-2 P. falciparum wild-type (clinical) samples Origin of phase-2 P. vivax wild-type (clinical) samples Testing procedure and calculation of panel detection score and band intensity for product A against a sample density of 200 parasites/µL Testing procedure and calculation of panel detection score and band intensity for product A against a sample density of 2000 parasites/µL Classification of incorrect species identification with combination malaria RDTs Explanation of lot agreement calculation

Figure 1. Figure 2. Figure 3. Figure 4a. Figure 4b. Figure 5. Figure 6. Figure 7. Figure 8.

Figure 9. Phase-1 P. falciparum panel detection score of malaria RDTs at low (200) and high (2000) parasite density (parasites/µL) Figure 10. Phase-2 P. falciparum panel detection score of malaria RDTs at low (200) and high (2000) parasite density (parasites/µL) Figure 11. Phase-2 P. vivax panel detection score of malaria RDTs at low (200) and high (2000) parasite density (parasites/µL) Figure 12. Phase-2 P. falciparum panel detection score and positivity rate at 200 parasites/µL Figure 13. Phase-2 P. vivax panel detection score and positivity rate at 200 parasites/µL Figure 14. Phase-2 P. falciparum (P. falciparum test line) false-positive rate against clean-negative samples Figure 15. Phase-2 Plasmodium spp. (pan or P. vivax test line) false-positive rate against clean-negative samples Figure 16. Phase-2 P. falciparum false-positive rate versus P. falciparum panel detection score at low parasite density (200 parasites/µL) Figure 17. Phase-2 P. vivax false-positive rate versus P. vivax panel detection score at low parasite density (200 parasites/µL) Figure 18. Phase-2 P. falciparum panel detection score at low parasite density (200 parasites/µL) during initial and subsequent testing of compulsorily and voluntarily resubmitted malaria RDTs Figure 19. Phase-2 P. vivax panel detection score at low parasite density (200 parasites/µL) during initial and subsequent testing of compulsorily and voluntarily resubmitted malaria RDTs Figure 20. Figure 21. Figure 22. Figure 23. Figure 24. Figure 25. Heat stability of P. falciparum-specific test line of P. falciparum-only tests against a low-density P. falciparum sample (200 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of P. falciparum-specific test line of P. falciparum-only tests against a high-density P. falciparum sample (2000 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of P. falciparum -specific test line in combination tests against a low-density P. falciparum sample (200 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of P. falciparum -specific test line in combination tests against a high-density P. falciparum sample (2000 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of pan line of combination tests against a low-density P. falciparum sample (200 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of pan line of combination tests against a high-density P. falciparum sample (2000 parasites/µL). Positivity rate at baseline and after 60 days’ incubation

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Figure 26. Figure 27. Figure 28. Figure 29. Figure 30. Figure 31. Figure 32. Figure 33. Figure 34. Figure 35. Figure 36. Figure 37. Figure 38.

Heat stability of pan line of combination tests against a low-density P. vivax sample (200 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of pan line of combination tests against a high-density P. vivax sample (2000 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of P. vivax-specific test line in combination tests against a low-density P. vivax sample (200 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Heat stability of P. vivax-specific test line in combination tests against a high-density P. vivax sample (2000 parasites/µL). Positivity rate at baseline and after 60 days’ incubation Percentage of RDTs with various anomalies observed in production lots Adherence to box labelling recommendations Adherence to cassette labelling recommendations Adherence to buffer bottle labelling recommendations Accessory labelling – use of internationally recognized symbols Completeness of information on accessory packaging – transfer device and lancet Completeness of information on accessory packaging – dessicant and alcohol swab Completeness of information included in the instructions for use: product information and intended use, precautions and limitations Completeness of information included in the instructions for use: procedure and performance specifications

Figure AS1.1. Box-and-whisker plot of distribution of P. falciparum HRP2 concentration (ng/mL) in product testing phase 2 (wild-type) panels Figure AS1.2. Box-and-whisker plot of distribution of P. falciparum pLDH concentration (ng/mL) in product testing phase 2 (wild-type) panels Figure AS1.3. Box-and-whisker plot of distribution of P. vivax pLDH concentration (ng/mL) in product testing phase 2 (wild-type) panels Figure AS1.4. Box-and-whisker plot of distribution of P. falciparum aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels Figure AS1.5. Box-and-whisker plot of distribution of P. vivax aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels Figure AS2.1. Malaria RDT anomalies encountered in production lots Figure AS3.1. Selecting an appropriate RDT Figure A5.1. Example of malaria RDT implementation steps and timeline Figure A5.2. Components of the budget for a malaria diagnosis programme

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Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Tables Table S1. Table S2. Table S3. Product resubmissions: WHO malaria RDT product testing rounds 1–7 Malaria RDT phase-2 performance in rounds 4–6 against wild-type (clinical) samples containing P. falciparum and P. vivax at low (200) and high (2000) parasite density (parasites/µL) and clean-negative samples Malaria RDT rounds 4–7 heat stability results on a cultured P. falciparum sample at low (200) and high (2000) parasite density (parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Products evaluated during rounds 1-7 that have been removed from summary results listings Manufacturers and products accepted into round 7 of WHO malaria RDT product testing programme Products due for compulsory resubmission in round 7 Characteristics of Plasmodium spp.-negative samples Malaria antigen concentrations (ng/mL) in round 7 wild-type, low-density (200 parasites/µL) samples Summary of phase-1 performance of 45 malaria RDTs against 20 cultured P. falciparum lines at low (200) and high (2000) parasite density (parasites/µL) Summary of phase-2 performance of 46 malaria RDTs against wild-type (clinical) P. falciparum and P. vivax samples at low (200) and high (2000) parasite density (parasites/µL) and Plasmodium spp.-negative samples Heat stability testing results for 46 malaria RDTs on a cultured P. falciparum sample at low (200) and high (2000) parasite density (parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Heat stability testing results for 27 malaria combination RDTs on a wild-type P. vivax sample at low (200) and high (2000) parasite density (parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Ease-of-use description of 46 malaria RDTs evaluated in round 7 of WHO malaria RDT product testing Percentage distribution of anomalies observed by product in phase 2

Table S4. Table 1a. Table 1b. Table 2. Table 3. Table 4. Table 5. Table 6a.

Table 6b.

Table 7. Table 8.

Table AS1.1. Statistics for P. falciparum HRP2 concentration (ng/mL) in product testing phase 2 (wild-type) panels Table AS1.2. Statistics for P. falciparum pLDH concentration (ng/mL) in product testing phase 2 (wild-type) panels Table AS1.3. Statistics for P. vivax pLDH concentration (ng/mL) in product testing phase 2 (wild-type) panels. Table AS1.4. Statistics for P. falciparum aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels Table AS1.5. Statistics for P. vivax aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels Table AS2.1. Field assessment of RDT packaging, safety and ease-of-use to guide product selection Table A3.1. Table A3.2. Table A4.1. Table A4.2. Table A4.3. Lot variation in positive results against phase-1 P. falciparum culture samples at low (200) and high (2000) parasite density (parasites/µL) Distribution of test band intensity scores (0–4) against phase-1 P. falciparum cultured parasites at low (200) and high (2000) parasite density (parasites/µL) Lot variation in positive results against phase-2 wild-type P. falciparum and P. vivax samples at low (200) and high (2000) parasite density (parasites/µL) Distribution of test band intensity (0–4) scores against phase-2 wild-type P. falciparum samples at low (200) and high (2000) parasite density (parasites/µL) Distribution of pan/P. vivax test band intensity (0–4) scores for phase-2 wild-type P. vivax samples at low (200) and high (2000) parasite density (parasites/µL)

Table A4.4. Phase-2 P. falciparum test line false-positive rates for wild-type P. vivax samples at low (200) and high (2000) parasite density (parasites/µL) Table A4.5. Table A4.6. Table A4.7. Phase-2 pan (or P. vivax) test line false-positive rate for non-P. falciparum infection on phase-2 wild-type P. falciparum samples at low (200) and high (2000) parasite density (parasites/µL) Phase-2 false-positive rate for P. falciparum test line results on all malaria-negative samples Phase-2 false-positive rate for P. falciparum in samples containing non-malarial infectious pathogens

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

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Table A4.8. Table A4.9.

Phase-2 false-positive rate for P. falciparum in samples containing potentially cross-reacting blood immunological factors Phase-2 false-positive rate of pan or P. vivax test line results on all malaria-negative samples

Table A4.10. Heat stability testing results for P. falciparum test line on a P. falciparum sample at low parasite density (200 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.10a. Heat stability testing results for pan test line of combination RDTs on a P. falciparum sample at low parasite density (200 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.11. Heat stability testing results for P. falciparum test line on a P. falciparum sample at high parasite density (2000 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.11a. Heat stability testing results for pan test line of combination RDTs on a P. falciparum sample at high parasite density (2000 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.12. Heat stability testing results for P. falciparum test line on parasite-negative samples. Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.12a. Heat stability testing results for pan or P. vivax test line of combination RDTs on parasite-negative samples. Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.13. Heat stability testing results for P. falciparum test line on P. vivax samples at low parasite density (200 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.14. Heat stability testing results for P. falciparum test line on P. vivax samples at high parasite density (2000 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.15. Heat stability testing results for P. vivax test line on P. falciparum samples at low parasite density (200 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.16. Heat stability testing results for P. vivax test line on P. falciparum samples at high parasite density (2000 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.17. Heat stability testing results for pan or P. vivax test line of combination tests on a P. vivax sample at low parasite density (200 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C Table A4.18. Heat stability testing results for pan or P. vivax test line of combination tests on a P. vivax sample at high parasite density (2000 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°C

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Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Acknowledgements The evaluation reported here was a joint project of the WHO Global Malaria Programme, the Foundation for Innovative New Diagnostics (FIND) and the United States Centers for Disease Control and Prevention (CDC) within the WHO-FIND Malaria RDT Evaluation Programme. The project was financed by FIND through a grant from UNITAID. The project would not have been possible without the cooperation and support of the specimen collection sites and specimen characterization laboratories mentioned, and the authors acknowledge the technical advice from many malaria diagnostic manufacturers and developers. This report of round 7 of WHO malaria RDT product testing was compiled by Jane Cunningham (WHO, Global Malaria Programme, Switzerland), Michelle Gatton (Queensland University of Technology, University of Queensland, Australia), and Kate Kolaczinski (WHO, consultant). The malaria RDT evaluation programme of WHO and FIND are grateful to all those who contributed to the evaluation and to the preparation of this report or previous versions: Salim Abdullah Yong Ah Michael Aidoo Frederic Ariey John Barnwell David Bell Andrea Bosman Qin Cheng Peter Chiodini Jane Cunningham Djibrine Djalle Dany Doung Babacar Faye Dionicia Gamboa Michelle Gatton Jeffrey Glenn Iveth Gonzalez Sandra Incardona Cara Kosack Myat Phone Kyaw Jennifer Luchavez Christian Luna James McCarthy Didier Menard Rathana Meth Claribel Murillo Sina Nhem Bernhards Ogutu 1

Ifakara Health Research and Development Centre, United Republic of Tanzania United States Centers for Disease Control and Prevention, National Center for Global Health, Division of Malaria and Parasitic Diseases, United States of America United States Centers for Disease Control and Prevention, National Center for Global Health, Division of Malaria and Parasitic Diseases, United States of America Institut Pasteur, Cambodia United States Centers for Disease Control and Prevention, National Center for Global Health, Division of Malaria and Parasitic Diseases, United States of America Foundation for Innovative New Diagnostics, Switzerland1 WHO, Global Malaria Programme, Switzerland Army Malaria Institute, Australia Hospital for Tropical Diseases, United Kingdom WHO, Global Malaria Programme, Switzerland Institut Pasteur of Bangui, Central African Republic Institut Pasteur, Cambodia Université Cheikh Anta Diop, Senegal Universidad Peruana Cayetano Heredia Instituto de Medicina Tropical, Peru Queensland University of Technology, Australia United States Centers for Disease Control and Prevention, National Center for Global Health, Division of Malaria and Parasitic Diseases, United States of America Foundation for Innovative New Diagnostics, Switzerland Foundation for Innovative New Diagnostics, Switzerland Médecins sans Frontières, Netherlands Department of Medical Research, Myanmar Research Institute of Tropical Medicine, Philippines Research Institute of Tropical Medicine, Philippines Queensland Institute of Medical Research, University of Queensland, Australia Institut Pasteur, Madagascar; Institut Pasteur, Cambodia Institut Pasteur, Cambodia Centro Internacional de Entrenamiento e Investigaciones Médicas, Colombia Institut Pasteur, National Malaria Centre, Cambodia Kenya Medical Research Institute, Kenya

Currently affiliated with Global Health Technologies Global Good Fund (Intellectual Ventures Lab), United States

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

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Pamela Onyor Wellington Oyibo

Kenya Medical Research Institute, Kenya University of Lagos, Nigeria

Roxanne Rees-Channer Consultant, Foundation for Innovative New Diagnostics, Hospital for Tropical Diseases, United Kingdom Muth Sinuon Johanna B. Sornillo Scott Wilson National Malaria Centre, Cambodia Research Institute of Tropical Medicine, Philippines United States Centers for Disease Control and Prevention, National Center for Global Health, Division of Malaria and Parasitic Diseases, United States of America

Abbreviations CDC ELISA FIND HRP2 ISO PCR PDS pLDH RDT TDR United States Centers for Disease Control and Prevention enzyme-linked immunosorbent assay Foundation for Innovative New Diagnostics histidine-rich protein 2 International Organization for Standardization polymerase chain reaction panel detection score Plasmodium lactate dehydrogenase rapid diagnostic test (for the purposes of this report, immunochromatographic lateral flow devices for the detection of malaria parasite antigens) Special Programme for Research and Training in Tropical Diseases sponsored by UNICEF, UNDP, the World Bank and WHO

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Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

1. Summary of performance of rapid diagnostic tests for malaria: WHO product testing rounds 1–7 1.1. Introduction WHO estimates that 3.2 billion people are at risk for malaria. In 2015, there were an estimated 212 million new cases (with an uncertainty range of 148 million to 304 million) and an estimated 429 000 deaths (with an uncertainty range of 235 000 to 639 000). Approximately 90% of these deaths occurred in sub-Saharan Africa and just over 70% were of children under 5 years. Malaria remains endemic in 91 countries and territories and while parasite-based diagnosis is increasing, national surveys between 2013 and 2015 suggest approximately 31% of suspected malaria cases in sub-Saharan Africa were not confirmed with a diagnostic test, resulting in over-use of antimalarial drugs and poor disease monitoring (1). WHO recommends that malaria case management be based on parasite diagnosis in all cases (2). The use of antigendetecting rapid diagnostic tests (RDTs) is a vital part of this strategy, forming the basis for extending access to malaria diagnosis by providing parasite-based diagnosis in areas where good-quality microscopy cannot be maintained. The number of RDTs available and the scale of their use have increased rapidly over the past few years. However, limitations of field trials and the heterogeneous nature of malaria transmission have limited the availability of the good-quality data on performance that national malaria programmes require to make informed decisions on procurement and implementation, and it is difficult to extrapolate the results of field trials to different populations and times. Therefore, in 2006, the WHO Special Programme for Research and Training in Tropical Diseases (TDR) and the Foundation for Innovative New Diagnostics (FIND) launched a programme to systematically evaluate and compare the performance of commercially available malaria RDTs. The results of WHO’s malaria RDT product testing have been published annually since 2009 and form the basis of the procurement criteria of WHO, other United Nations agencies, the Global Fund to Fight AIDS, Tuberculosis and Malaria, national governments and non-governmental organizations. The data have guided procurement decisions, which, in turn, have shifted markets towards better-performing tests (1) and are driving overall improvements in the quality of manufacturing. WHO’s malaria RDT product testing constitutes the laboratory evaluation component of WHO malaria RDT prequalification, but meeting WHO prequalification criteria has not previously been a requirement for a WHO recommendation on procurement. As of 1 January 2018, WHO prequalification, comprising a dossier and inspections of manufacturing sites as well as a laboratory evaluation, will determine the eligibility of malaria RDTs for procurement. Therefore, all manufacturers that submit products to Round 8 and future rounds will be required also to submit applications for WHO prequalification. RDT sales increased from 46 million in 2008 (before implementation of the product testing programme) to 320 million in 2013 (according to manufacturer sales data). In 2014, the number of diagnostic tests provided (RDTs and microscopy combined) in Africa exceeded the total number of courses of artemisinin-based combination therapy administered in Africa for only the second time. Since 2013, decreasing RDT sales in Asia have led to an overall decrease in global sales (270 million were sold globally in 2015); however, sales in Africa have continued to rise each year since 2008. By 2014, it was confirmed that all 91 countries with ongoing malaria transmission had adopted the WHO policy of testing before administering treatment. Despite these achievements, a large number of cases remain undiagnosed, particularly in the private sector, indicating that some gains are still to be made (1). This summary presents an overview of the results of rounds 4–7 of malaria RDT product testing and key concepts for understanding and using the results. It is published in conjunction with the release of the full report on round 7. With the exception of products that are no longer manufactured and/or are de-listed because of failure to comply with compulsory resubmission requirements, the results of all rounds of testing should be considered as a single data set. The separate, full reports of each round (3–8) should be consulted for further details of methods, product performance and interpretation of the results.

1.2. The WHO product testing programme The RDT evaluations summarized here were performed in collaboration by WHO, TDR, FIND, the United States Centers for Disease Control and Prevention (CDC) and other partners1. All companies that manufacture RDTs according to the ISO 13485:2003 quality system standard were invited to submit 1

See full reports of rounds 1–7 for lists of collaborating partners.

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Summary Rounds 1-7 1

products for evaluation. In each round of testing, products were evaluated against geographically diverse, cryopreserved Plasmodium falciparum and P. vivax clinical samples diluted to 200 and 2000 parasites/µL with consistently comparable concentration ranges of histidine-rich protein II (HRP2), Plasmodium lactate dehydrogenase (pLDH) and aldolase determined by quantitative enzyme-linked immunosorbent assay (ELISA) (Annex S1). In the first round of testing, 41 products from 21 manufacturers were evaluated against prepared blood panels of cultured P. falciparum parasites, while 29, 50, 48, 42, 41 and 46 products from 13, 23, 27, 34, 22 and 27 manufacturers were evaluated in rounds 2, 3, 4, 5, 6 and 7, respectively. Of these 297 products, 293 progressed to testing against panels of patient-derived P. falciparum and P. vivax parasites and a parasite-negative panel. Thermal stability was assessed after 2 months of storage at elevated temperature and humidity, and a rudimentary assessment of ease of use was made. In round 6 and 7, specific observations of RDT anomalies were also systematically recorded. Many manufacturers have decided voluntarily to submit products to one or more rounds of testing, and, in round 5, a requirement was instituted to resubmit products for re-evaluation within 5 years of original testing (Table S1). Of the 293 fully evaluated products in rounds 1–7, 31 have been evaluated twice, 21 have been evaluated three times, two evaluated four times and three evaluated five times. Of the 202 unique products tested in the programme, 65 detect P. falciparum alone, 143 detect and differentiate P. falciparum from non-P. falciparum malaria (either pan-specific or species-specific for P. vivax or P. vivax, ovale and malariae), 10 detect P. falciparum and non-P. falciparum malaria without distinguishing between them, and one product was designed to detect P. vivax only. Manufacturers submitted two lots of each product for evaluation. When the same products (9) were resubmitted in subsequent rounds of testing, the second set of results replaced those from the earlier round. Thus, the performance of some tests in the results below differs from that reported in rounds 1–6. Of the 30 products due for compulsory retesting in round 7, five were submitted (Table S1). Round 3 products that were not resubmitted have been removed from the figures and tables in this summary performance document. Product testing is part of a continuing programme of work to improve the quality of RDTs in use and to ensure reliable malaria diagnosis in areas where malaria is prevalent. The aim of the evaluation is to provide comparative data on the performance of the submitted production lots of each product. Since 2009, these data have guided procurement decisions by WHO, other United Nations agencies and national governments. WHO product testing has constituted the laboratory evaluation component of the WHO prequalification process for malaria RDTs (10), which additionally includes a standardized dossier review and a manufacturing site inspection to ensure safety, quality and performance comprehensively. WHO prequalification of in vitro diagnostics, established in 2008, is used in all United Nations agencies to determine the eligibility for procurement of tests for HIV, hepatitis B and C and syphilis and by national authorities to complement

their national regulatory approvals. WHO prequalification will determine the eligibility of malaria RDTs for procurement as of 1 January 20181. To facilitate this transition, manufacturers with products that currently meet procurement criteria and those submitting to future rounds of lab evaluations are required to submit applications to WHO prequalification. Only those products that meet WHO prequalification requirements by 31 December 2017 will be eligible for WHO procurement. An eigth round of product testing started in February 2017.

1.3. Panel detection score and other results of the evaluation The results (summarized in Figs S1–S3 and Tables S2 and S3) provide comparative data on two lots of products against a panel of parasite samples diluted in blood to a low density (200 parasites/µL) and a higher density (2000 parasites/µL). The former is well below the mean parasite density found in many populations with endemic malaria and is considered close to the threshold that must be detected in order to reliably identify clinical malaria in many settings (11). For the purposes of this report, the main measure of performance is the panel detection score (PDS); for each RDT evaluated, the PDS is measured separately at the lower and the higher parasite densities. The summary figures also show the falsepositive rates against blood samples containing no malaria parasites or known markers of other diseases and the rate of invalid results. The PDS is the percentage of malaria samples in the panel that give a positive result in two RDTs per lot at the lower parasite density or by a single RDT per lot at the higher parasite density. As each sample is tested with RDTs from two lots, for a sample to be positive at the lower parasite density, it must show a positive result in four tests (two RDTs per lot for two lots); at the higher parasite density, it must show a positive result in two tests (one RDT per lot for two lots). Thus, the PDS is a combined measure of positivity rate incorporating inter-test and inter-lot consistency. As all tests performed on each sample must show a positive result for the sample to be considered positive, the PDS for a given RDT will usually be lower than a simple positivity rate per panel, measured by comparing the number of positive tests among all tests performed per panel. The PDS is also different from clinical sensitivity, which is the ability of the test to detect malaria infection in a given population of infected patients. Boxes 1 and 2 illustrate how the PDS is calculated and how it differs from a simple positivity rate for all samples tested and from clinical sensitivity in a population. The PDS for a given RDT is different from the clinical sensitivity of that RDT (also called the true positive rate), which is a measure of the proportion of people known to have the disease who test positive for it. The sensitivity of malaria RDTs is highly dependent on local conditions, including the parasite density in the population; it therefore varies among populations with different levels of transmission, as their level 1

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Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Box 1: Example calculation of panel detection score and positivity rate for product A against a sample density of 200 parasites/µL The first reading was at the minimum time specified by the manufacturer; the second reading was up to 30 min latera. A sample is considered detected only if all first test readings, from both lots, are positive, i.e. readings a, b, c and d must be positive.

Product A Lot 1 Lot 2

Test 1

Test 2

Test 3

Test 4

a Reading 1 a second

b Reading 2 Reading 1 Reading 2

c Reading 1 Reading 2

d Reading 1 Reading 2

Detected if 4 positive first readings

reading results are for internal use only

P. falciparum sample 1 2 3

a

b

c

d

+ + +

+

+ +

+ + +

Sample NOT detected Sample NOT detected Sample detected

In this example, only one of three samples was positive all four times it was tested; the PDS is therefore 1/3 = 33%. The positivity rate is calculated as the percentage of all tests of a particular product that returned a positive test result at the manufacturers’ recommended minimum reading time when tested against a P. falciparum or P. vivax sample. In the above example, the positivity rate is: 9/12 = 75%. The positivity rate is always greater than the PDS, except when the PDS and the positivity rate are both 100%.

Box 2: Performance measures in WHO product testing and in field settings: PDS versus clinical sensitivity WHO Malaria RDT Product Testing Primary performance measure: PDS indicates which products are likely to be more sensitive in the field, particularly in populations with low‐density infections. Malaria endemic setting Performance measure: sensitivity is the proportion of the population studied who have malaria for whom the test is positive. - high, moderate, low transmission - immune, non-immune - vulnerable groups

20

20

0

00

pa

pa

ra s

ra s

ite

ite

s/

s/

μL

μL Patients have varying parasite density. Most RDTs for P. falciparum and P. vivax perform well for a parasite density > 2000 parasites/μL, but clinically significant densities < 200 parasites/μL may be missed. The “overall” test performance will nevertheless be classified as very good in a field evaluation.

Reference panels: two fixed parasite densities allows discrimination in RDT performance.

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Summary Rounds 1-7 3

of immunity affects the parasite density at which they exhibit symptoms that warrant a diagnostic test. Where transmission rates are low, the parasite densities in people with symptoms of malaria are likely to be low, and tests will be less sensitive. Test performance at 200 parasites/µL is therefore particularly important. The results in this report show the comparative performance of RDTs and indicate which products are likely to be more sensitive in the field, particularly in populations with low-density infections. In general, as countries reduce the prevalence of malaria and even move towards malaria elimination, detection of low parasite densities becomes increasingly important in case management. As the high PDS at 2000 parasites/µL indicates, the sensitivity of many of these products is similar in populations with higher parasite densities; therefore, it is not possible to discriminate RDTs with superior performance. An important caveat to estimating field sensitivity from the PDS provided in this report is that the panels used include only parasites known to express the target antigens. While non-expression of the target antigens has not been recorded for aldolase or pLDH, it is known that parasites that infect people in some areas of South America (Peru, Colombia, Brazil), India and Africa (Eritrea, Ghana, Rwanda) do not express HRP2 (12–13 , 33-34). In areas where HRP2-deleted parasites exist, tests for HRP2 will have greatly reduced sensitivity or be incapable of detecting P. falciparum. In such populations, only tests for pLDH or aldolase in P. falciparum parasites will be effective. Heat stability (summarized in Table S3) is vital to maintaining the sensitivity of tests in the field. As a result, for procurement, careful consideration must be given to ensure that the products to be used in areas with high temperatures of transport and storage have demonstrated stability in the product testing programme. Requirements vary among countries; for example, if tests are to be deployed in areas where temperatures rarely rise above 30°C, less emphasis is needed on stability at high temperatures than on other aspects of quality. Ease-of-use requirements depend on the extent of training and the work environment of the users. Particularly in primary health care settings, the simpler the test, the easier it will be to avoid errors in preparation and interpretation. Certain anomalies resulting from defects in production lots or RDT degradation may affect the running of the test or interpretation and may warrant a field safety notice and corrective action. To encourage manufacturers to meet international standards and best practice in the packaging and labelling of malaria RDTs, with the goal of ensuring better, more consistent ease of use, WHO and partners have made recommendations for the instructions for use and labelling of malaria RDTs (14). Evaluation of adherence to the recommendations was introduced in round 7. Detailed results can be found in the report of each evaluation (3–8) and at http://www.who.int/malaria/publications/ diagnostic_testing/en/ (accessed 8 March 2017).

1.4. Summary of outcomes Laboratory-based evaluation provides a comparative, standardized measure of RDT performance for distinguishing between well and poorly performing tests to serve as a basis for procurement decisions by malaria control programmes and to guide United Nations procurement policy. In round 7, the proportion of tests that achieved a PDS ≥ 75% at a density of 200 parasites/µL is slightly lower than in round 6 for both P. falciparum (87.0%%) and P. vivax (70.0%). Several RDTs in the seven rounds of testing consistently detected malaria at a low parasite density (200 parasites/µL), had low false-positive rates, are stable at tropical temperatures, are relatively easy to use and can detect P. falciparum or P. vivax infections or both. Although the performance of the products varied widely at low parasite density (200 parasites/µL) in round 7, all products had a high rate of detection of P. falciparum at 2000 parasites/µL (PDS of 100%), as did the majority of products for P. vivax at 2000 parasites/µL. In all except two of the RDTs submitted to round 7, the HRP2 antigen was used to detect P. falciparum, either alone (41 products) or with Pf-pLDH (3 products). In the two exceptions, Pf-pLDH was used alone. Of the five products that detected Pf-pLDH, two combined Pf-pLDH with HRP2 in the same test line, one had dual test lines for detecting P. falciparum (one HPR2 and one Pf-pLDH test line), and two had only Pf-pLDH. While the dual test line product performed well overall, the line for detecting Pf-pLDH performed considerably less well than the HPR2-detecting test line at 200 µL, with a PDS of 38%. The PDS of the two products with Pf-pLDH alone for detecting P. falciparum at 200 parasites/µL were 75% and 73%. Thus, after seven rounds of testing, the choice of well-performing pLDH-based P. falciparum tests and of pan-only tests remains limited. The test performance of lots in round 7 varied only slightly, with an average difference in positivity rates of 1.5 percentage point (range, 0–4.5%) and 1.0 percentage point (range, 0–3.5%) when tested against 200 parasites/µL wildtype P. falciparum and P. vivax , respectively (Tables A3.1 and A4.1), a pattern also seen in round 6. In previous rounds, however, wide variation was found, indicating the advisability of testing lots after purchase and before use in the field. The frequency of anomalies that can interfere with test interpretation was recorded for the first time in round 6. In round 7, one to five anomalies were found with 33 of the 46 products (Annex S2, Table 8, Fig. 30). Incomplete clearing and a red background were the most common anomalies, seen in 48% and 24% of products, respectively. The next most common anomalies were incomplete migration, failed migration and a red background obscuring the test lines, in 15%, 11% and 11% of products, respectively. Most products (44/46) had anomalies in < 1% of the tests; two products had anomalies in 1.4% of products (Table 8). Overall, fewer types and a lower frequency of anomalies were seen in round 7 than in round 6.

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Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

All except one of the RDTs evaluated in round 7 were in cassette format; the exception was in dipstick format. Only 5 of the 30 RDTs due for compulsory resubmission were submitted for retesting. All met the WHO procurement criteria on initial testing. Two products (one for P. falciparum only and one combination RDT) scored higher in re-testing, with percentage point increases of 7 and 6, respectively, in the PDS at 200 µL against P. falciparum and an increase of 6 percentage points against P. vivax for the combination RDT. Three re-tested products (one P. falciparum only, two combination RDTs) scored lower than in their initial testing, with percentage point decreases of 7, 8 and 16 in the PDS at 200 µL against P. falciparum and a decrease of 91 percentage points (to a score of zero) in the PDS against P. vivax for the combination RDT. Of these three products with diminished performance, two no longer meet the criteria for procurement. Four products showed decreased false-positive rates on re-testing, whereas one had an increase from 0% to 5% at 200 µL.

local malaria transmission and illness where the tests will be used (e.g. Plasmodium spp., target antigen, parasite densities, climate) and other important considerations, including ease of use in the field (Annex S2), training or retraining requirements and lot testing.1 The results in Table S2 indicate WHO prequalification status and are colour-coded to reflect achievement of WHO performance requirements for RDT procurement. A web-based tool that allows filtering of product testing results by various parameters to assist in selecting products with the performance characteristics most suitable for a country’s health programme is available and is maintained by FIND (15 ). This online database has been updated to allow filtering of results by RDT procedural characteristics, such as blood volume requirements, number of buffer drops and time to a result. This will allow identification of products with similar procedures so that, when product replacement is required, another product can be selected with the same or a similar protocol. Use of similar products may reduce the need for user retraining and reduce user error. The results in the product testing reports are presented by product, which are described by their name and “product code”. The same RDT may be sold in a variety of product configurations, such as single or multi-kits, the number of tests per box, with or without certain accessories, and they are assigned a series of distinct product codes on this basis. The reports lists the precise name and product code as provided by the manufacturer for testing. Procurers should contact the manufacturer for a list of product configurations before purchase. Comprehensive guidance on several aspects of procurement can be found in Recommended selection criteria for procurement of malaria rapid diagnostic tests (16), published as a WHO information note in 20162 and Good practices for selecting and procuring rapid diagnostic tests for malaria (16). Guidance on implementation is provided in Universal access to malaria diagnosis (17 ). 1 The WHO-FIND malaria RDT evaluation programme provides lot-testing

1.5. De-listing of products in summary report Products that are due for compulsory resubmission (every 5 years) but are not resubmitted are removed from the summary results listing (Tables S2 and S3) and the online interactive database (15 ) and are featured only in the full round-specific product testing report. They are also not eligible for WHO procurement. Furthermore, a product is de-listed if WHO is notified by the manufacturer that its production has been discontinued. To date, 72 products have been delisted (Table S4).

1.6.  How product testing results can inform RDT procurement and use Accurate diagnosis is vital to good malaria case management, whether based on microscopy or on RDTs. The results of this report should be used to make a short list of RDTs for procurement for use in settings where good microscopy is not available or appropriate. Box 3 lists WHO’s minimum criteria for RDT selection, and Annex S3 provides a step-bystep approach to selecting an RDT, taking into consideration

capacity in two regional laboratories free of charge. Information on the programme and how to access it can be found at: https://www. finddx.org/malaria-rdt-qa/ (accessed 8 March 2017). 2 http://www.who.int/malaria/publications/atoz/rdt-selection-criteria.

pdf (accessed 3 April)

Box 3: WHO selection criteria for the procurement of RDTs Products should be selected in line with the following set of criteria, based on the results of the assessment of the WHO Malaria RDT Product Testing Programme: (A) For the detection of Plasmodium falciparum (Pf) in all transmission settings the panel detection score (PDS) against Pf samples should be at least 75% at 200 parasites/μl. (B) For the detection of Plasmodium vivax (Pv) in all transmission settings the panel detection score (PDS) against Pv samples should be at least 75% at 200 parasites/μl. (C) The false positive rate should be less than 10%. (D) The invalid rate should be less than 5%. Only products meeting performance criteria outlined in A,B,C and D are recommended for procurement As of 1 January, 2018 WHO procurement recommendations for malaria RDTs will change to require WHO prequalification designation1.

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Summary Rounds 1-7 5

Figure S1: Malaria RDT performance in phase 2 of rounds 4–7 against wild-type (clinical) samples containing P. falciparum at low (200) and high (2000) parasite density (parasites/µL) and clean-negative samples 100 90 80 70 60 50 40 30 20 10 0

1.7. Product testing and WHO programme for prequalification of diagnostics and medical devices In the WHO programme for prequalification of diagnostics and medical devices, the results of product testing are used as the laboratory evaluation component of the prequalification process for malaria RDTs. These data are used to set priorities for dossier review and inspection. As of 1 January 2018, WHO prequalification will become a requirement for WHO procurement. Therefore, manufacturers are strongly encouraged to apply.1 Prequalified RDTs are listed in summary tables and at http://www.who.int/diagnostics_laboratory/ evaluations/PQ_list/en/ (accessed 8 March 2017). 1

Panel detection scorea

a Panel

detection score - A sample is considered detected only if all RDTs from both lots read by the first technician, at minimum specified reading time, are positive. - blood samples from healthy volunteers with no known current illness or blood abnormality. * Indicates tests that also detect other non-P. falciparum parasites b Clean-negative

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Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

80 60 40 20 0

200 parasites/µl 2000 parasites/µl False-positive Plasmodium spp. rate (%) Invalid rate (%)

False-positive Plasmodium spp. rate on clean-negative samplesb (%) and invalid rate (%)

100

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Summary Rounds 1-7 7

Figure S2: Malaria RDT performance in phase 2 of rounds 4–7 against wild-type (clinical) samples containing P. vivax at low (200) and high (2000) parasite density (parasites/µL) and clean-negative samples 100 90 80 70 60 50 40 30 20 10 0

a Panel

Panel detection scorea 8

b Clean-negative

detection score - A sample is considered detected only if all RDTs from both lots read by the first technician, at minimum specified reading time, are positive. - blood samples from healthy volunteers with no known current illness or blood abnormality.

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

80 60 40 20 0

200 parasites/µl 2000 parasites/µl False-positive Plasmodium spp. rate (%) Invalid rate (%)

False-positive Plasmodium spp. rate on clean-negative samplesb (%) and invalid rate (%)

100

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Summary Rounds 1-7 9

Figure S3: Panel detection score of malaria combination RDTs meeting WHO procurement criteria for false-positive and invalid rates, in phase 2 of rounds 4–7 against wild-type (clinical) samples containing P. falciparum and P. vivax at low parasite density (200 parasites/μL) 100 80 60 40 20 0 100 95 90 85 80 73 74 69 61 62 32 11 & 12 18 13 4 & 9 8 19 20 & 23 24 5 45, 46 & 47 25 14 6 3 60 39 33 & 38 15 48 56 7 55 37 49 54 26 30 31 21 10

Panel detection score P. vivaxa

92 75

Panel detection score P. vivaxa

2

63 65 64 66 & 67 68

0

20 40 60 80 Panel detection score P. falciparuma

100

75

75

80 85 90 95 Panel detection score P. falciparuma 50 & 51 70 59 52 57 58 27 41 34 40 35 28 22 36 53 29 71 42 & 44 43 17

100

Panel detection score P. vivaxa

79

Panel detection score P. vivaxa

60 40 20 0 0 91 89 90 87 83 86 & 88 85 80 84 82 76

60 40 20 0 75

72

16

1

81 78 77

20 40 60 Panel detection score P. falciparuma

80 85 90 95 Panel detection score P. falciparuma

100

1 Core™ Malaria Pan Pf - MAL - 190024 2 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 3 SD BIOLINE Malaria Ag P.f/Pan - 05FK60 4 Is It... Malaria Pf PAN - MPFPAN050 5 CareStart ™ Malaria Screen RDT - RMAM-05071 6 Aspen® Malaria Ag Pf/Pv - AS0060 7 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 8 NanoSign Malaria pf/pan Ag 3.0 - RMAP10 9 Humasis Malaria P.f/P.v Antigen Test - AMFV-7025 10 RAPID 1-2-3 ® HEMA CASSETTE MALARIA PF/PV TEST - MAL-PFV-CAS/25(100) 11 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 12 One Step Malaria P.F/P.V Test (Cassette) - 523352 13 ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25 14 SD Bioline Malaria Ag P.f/P.v - 05FK80 15 RapiGEN BIOCREDIT Malaria Ag Pf/Pv (HRPII/pLDH) - C40RHA25 16 One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C 17 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 18 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 19 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 20 BioTracer™ Malaria P.f/P.v Rapid Card - 17412 21 PALUTOP +4 optima® - 5499 22 KHB ® Malaria Ag P.f/P.v Rapid Test - KH-R-07-50 23 SD BIOLINE Malaria Ag Pf/ Pan - 05FK66 24 CareStart ™ Malaria Pf/PAN (HRP2/pLDH) Ag COMBO RDT - RMRM(U)-XXX7X 25 Humasis Malaria P.f/Pan Antigen Test - AMAL-7025 26 DIAQUICK Malaria P.f/Pan Cassette - Z11200CE 27 NG-Test MALARIA Pf/Pan (pLDH) - NG-MAL-W23-001 28 Malaria PV/PF (pLDH/HRP2) Antigen Test- Inf-72 29 ATOMORAPID™ MALARIA (PF/PAN) - MMAL01 30 HiSens Malaria Ag P.f/P.v Combo Card - HR3123 31 HiSens Malaria Ag P.f/VOM Combo Card - HR3323 32 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT - RMVM-05072 33 Malaria Pf/Pan One Step Rapid Test - RT 20222 34 Humasis Malaria P.f/Pan Antigen Test - ANMAL-7025 35 Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a 36 Trusty™ Malaria Antigen P.f./p.v. test - A03-12-322 37 Asan Easy Test ® Malaria Pf/Pan Ag - AM4650-K 38 Is ItÖ Malaria Pf/Pv Device - AL030 39 Humasis Malaria P.f/P.v Antigen Test - ANMIV-7025 40 Advanced Quality™ Rapid Malaria Test (Pf/Pan) - ITP11005 41 FirstSign™ ParaView (Pan+Pf) - 2101CB-25 42 Vikia® Malaria Ag Pf/Pan - 412499 43 Malaria Pf/PAN Test - PROMALPFV001 44 ABON™ Plus Malaria P.f/Pan Rapid Test Device (Whole Blood) - IMA-T402 45 Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 46 Biosynex® Malaria Pf/Pv - 0581_K25 a Panel

47 SD Bioline Malaria Ag P.f/P.f/P.v - 05FK120 48 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv - 11108191040 49 Biosynex® Malaria Pf/Pan - 0584_K25 50 First Response® Malaria Ag. pLDH/HRP2 Combo Card Test - I16FRC 51 Malaria Pf (HRPII)/ PV (PLDH) Antigen Detection Test Device - GM006 52 First Response® Malaria Ag Pf/Pv Card Test - PI19FRC 53 ICT MALARIA DUAL TEST - ML03 54 ParaHIT - Total Ver. 1.0 (Device) - 55IC204-10 55 Advantage Malaria Pan + Pf Card - IR231025 56 CareStart ™ Malaria PAN (pLDH) Ag RDT - RMNM(U)-XXX7X 57 Maleriscan® Malaria Pf/PAN (Pv, Pm, Po) 3 Line Antigen Test - MAT-PF/PAN-50 58 GenBody™ Malaria Pf/Pan Ag - MALAG100 59 BIONOTE MALARIA P.f & Pan Ag Rapid Test Kit - RG19-08 60 First Response® Malaria Ag. pLDH/HRP2 Combo Card Test - PI16FRC 61 FalciVax™ - Rapid Test for Malaria Pv/Pf - 503010025 62 Parascreen® - Rapid Test for Malaria Pan/Pf - 503030025 63 QuickProfile™ Malaria Pf/Pan Test - 71063 64 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 65 EzDx™ Malaria Pan/Pf Rapid test detection Kit - RK MAL 001 66 OnSite Malaria Pf/Pan Ag Rapid Test - R0113C 67 One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 68 Coretests® One Step Malaria Pf/Pv Ag Test Device - B42-21/B42-22 69 Advantage Pan Malaria Card - IR013025 70 Meriscreen Malaria Pf/Pan Ag - MHLRPD-01 71 One Step Malaria P.f/Pan Whole Blood Test - W62-C 72 ParaHIT - Total Ver. 1.0 (Dipstick) - 55IC203-10 73 EzDx™ Malaria Pv/Pf Rapid Malaria antigen detection test - RK MAL 003 74 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 75 OnSite Malaria Pf/Pv Ag Rapid Test - R0112C 76 RightSign™ Malaria P.f./Pan Rapid Test Cassette - IMPN-C52 77 CareStart ™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 78 MeDiPro Malaria Ag HRP2/pLDH Combo - IR-0051K 79 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 80 Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016 81 Genedia® Malaria P.f/Pan Ag Rapid Test- 20-0146-01 82 ACCUCARE ONE STEP MALARIA Pf/Pan Antigen Test - MAGC 25 83 Malaria pf (HRP II)/PAN (pLDH) Antigen Detection Test Device - 1-13-101-1 84 ParaHIT® fV Rapid test for P. falciparum and P. vivax Malaria - Device - 55IC402-50 85 AZOG Malaria pf (HRPII)/pf (LDH)/ (PAN-LDH) Antigen Detection Device - MFV-124F 86 AZOG hCG Malaria Detection Test Device - MPT-124 87 Malaria Pf./Pan Antigen (MAL Pf/Pan) Test Kit - A03-18-322 88 Malaria pf (HRP II) / pv (pLDH) Antigen Detection Test Device - 1-13-101-3 89 Malaria pf (pLDH) / PAN-pLDH Test Device - MFV-124 90 Malaria Pf/Pv - GM002 91 Malaria Pf/ PAN - GM004 92 Advantage Mal Card - IR221025

detection score - A sample is considered detected only if all RDTs from both lots read by the first technician, at minimum specified reading time, are positive.

10

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Table S1: Product resubmissions: WHO malaria RDT product testing rounds 1—7 Manufacturer Product name CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria HRP2/PLDH (Pf/VOM) COMBO CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria HRP2/pLDH (Pf/PAN) Combo CareStart™ Malaria PAN (pLDH) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag RDT CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT EzDx™ Malaria Pan/Pf Rapid Test Detection Kit

Product code* RMVM-05072a RMWM(U)-XXX7Xb RMOM(U)-XXX7Xc RMSM-05071d RMNM(U)-XXX7Xe RMPM(U)-XXX7Xf RMLM-05071g RMAM-05071h RK MAL 001

Product resubmission Round Voluntary Compulsory 2, 4, 7 2, 4 1, 7 1, 7 1 2 3 3 4, 5, 6 5 5 5 6 7 7

Access Bio, Inc.

ParaHIT® - f (Device)j 551C104-50 3 7 ARKRAY Healthcare Pvt. ParaHIT® - f (Dipstick)k 551C103-50 3 7 ASAN Pharmaceutical Co., Ltd Asan Easy Test® Malaria Pf/Pan Ag AM4650-K 5, 7 l Malaria pf (HRP II) / (PAN-LDH) Antigen Detection Test Device MFV-124R 1, 3 AZOG Malaria pf (pLDH) / PAN-pLDH Test Device MFV-124 3, 5 Bhat Bio-Tech India (P) Ltd. Maleriscan® Malaria Pf/PAN (Pv, Pm, Po) 3 Line Antigen Test MAT-PF/PAN-50 4, 5 Bioland NanoSign Malaria Pf/Pan Ag RMAP10 3, 4 BIONOTE MALARIA P.f. Ag Rapid Test Kit RG19-11 3, 6 Bionote, Inc. BIONOTE MALARIA P.f & Pan Ag Rapid Test Kit RG19-08 3, 6 Biosynex IMMUNOQUICK® MALARIA falciparum 0502_K25 1 5 Bio Focus Co., Ltd. BioTracerTM Malaria P.f/PAN Rapid Card 17012 5, 6, 7 One Step Malaria Pf Test (cassette) 522352 2, 3, 4 Blue Cross Bio-Medical (Beijing) Co., Ltd. One Step Malaria P.F/P.V Test (Cassette) 523352 4, 5 Onsite Pf Ag Rapid Test R0114C 2, 3, 6 CTK Biotech, Inc. Onsite Malaria Pf/Pan Malaria Ag Rapid Test R0113C 2, 3, 4, 5, 6 Onsite Malaria Pf/Pv Ag Rapid Test R0112C 2, 3, 4, 6 DiaMed - A Division of Bio-Rad OptiMAL-IT 710024 1, 3 Wondfo One Step Malaria Pf/Pan Whole Blood Test W56-C 1, 3 Guangzhou Wondfo Biotech Co. Ltd. One Step Malaria P.f/P.v Whole Blood Test W056-C 5, 6, 7 One Step Malaria P.f Testm W37-C 2, 3, 4, 6, 7 Humasis Co., Ltd. Humasis Malaria Pf/Pan Antigen Test AMAL-7025 4, 5 ICT Malaria Combo Cassette Test ML02 1, 3, 4 ICT INTERNATIONAL ICT Malaria Pf Cassette Test ML01 1, 3 7 ICT Malaria Dual Test ML03 3, 5, 7 Advanced Quality™ One Step Malaria Pf Test ITP11002TC1/TC40 1, 3, 7 5 InTec Products, Inc. Advanced Quality ™One Step Malaria (Pf/Pv) Tri-line Test (whole blood) ITP11003 TC40 3, 6, 7 Advantage Pan Malaria Card IR013025 1 5 J.Mitra & Co. Pvt. Ltd. Advantage Mal Card IR221025 1 5 Advantage P.f Malaria Card IR016025 1 5 Lumiquick Diagnostics Inc. QuickProfileTM Malaria Pf/Pv Antigen Test 71050 6, 7 Paracheck® Pf Device - Rapid test for P. falciparum Malaria (Ver. 3)n 30301025 1, 3, 4 Orchid Biomedical Systems Paracheck® Pf Dipstick - Rapid test for P. falciparum Malaria (Ver.3)n 30302025 1, 3, 4 First Response® Malaria Ag Combo (pLDH/HRP2)o I16FRC25 1, 2, 5 Premier Medical Corporation Ltd. First Response Malaria Ag P. falciparum(HRP2) Card Test I13FRC25 1 5 RapiGEN Inc. BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) C30RHA25 5, 6, 7 SSA Diagnostics & Biotech Systems diagnosticks- Malaria (Pf)Cassette WB KMFC6001 2, 5 SD BIOLINE Malaria Ag 05FK40 1, 3 SD BIOLINE Malaria Ag Pf/Pan 05FK60 1, 3, 5 Standard Diagnostics Inc. SD BIOLINE Malaria Antigen 05FK50 1 5 SD Bioline Malaria Ag P.f (HRP2/pLDH) 05FK90 3, 6 SD Bioline Malaria Ag P.f/P.v 05FK80 2 6 Unimed International Inc. FirstSign™ - ParaView (Pan+Pf) Malaria Test 2101 CB-25 2, 4 Malaria Rapid Combo/Clearview® Malaria Combo VB11p 1, 3 Vision Biotech (Pty) Ltd / Orgenics Malaria Rapid Pf /Clearview ®Malaria Pf VB01 1, 3, 5 (Alere Healthcare (Pty) Ltd subsidaries) Malaria Rapid Dual/Clearview® Malaria Dual Test Device VB20p 1, 3, 5 Malascan™ Device - Rapid test for Malaria Pf/Pan 50402025 1, 3 Parabank™ Device - Rapid test for Malaria Pan 50301025 1, 3 Zephyr Biomedical Systems Parascreen™ Device -Rapid test for Malaria Pan/Pf 50310025; 503030025 (rd 6) 1, 3, 4, 5, 6 Falcivax Rapid Test for Malaria Pv/Pf (device) 50300025; 503010025 (rd 6) 2, 4, 6 * The product code corresponds to a specific configuration of the RDT, kit components and accessories. Therefore, changes to this configuration including the quantity of tests, the contents or the manufacturing site are denoted by a different product code. Often this involves the end portion of the product code; however, the manufacturer should be contacted for full details. a Previously listed with product code G0161 for the Access Bio Inc product. Previously co-listed with G0161-ET, the equivalent Access Bio Ethiopia product. Access Bio Ethiopia products are now listed as separate products from separate manufacturers and not considered resubmissions. b Previously listed with product code G0171 for the Access Bio Inc product. Previously co-listed with G0171-ET, the equivalent Access Bio Ethiopia product. Access Bio Ethiopia products are now listed as separate products from separate manufacturers and not considered resubmissions. c Previously listed with product code G0141 for the Access Bio Inc product. Previously co-listed with G0141-ET, the equivalent Access Bio Ethiopia product. Access Bio Ethiopia products are now listed as separate products from separate manufacturers and not considered resubmissions. d Previously listed with product code G0131/G0131-ET e Previously listed with product code G0111 f Previously listed with product code G0121 g Previously listed with product code G0231 h Previously listed with product code G0181/G0181-ET I Arkray Healthcare Pvt. Ltd. was formerly Span Diagnostics Ltd. j New product codes have been in place since round 3, the previous code was 55IC102-10. k New product codes have been in place since round 3, the previous code was 55IC101-10. l Round 1 product name error : published - Malaria Pf (HRPII)/pv-LDH) Antigen Detection Test Device Code ; corrected product name: Malaria Pf (HRPII/PAN-LDH) Antigen Detection Test Device Code. No change in product code. m In round 2, product did not pass phase 1, therefore results do not feature in summary tables. n Ver.3 was introduced after round 1 o Error in WHO Malaria RDT product testing: round 1 report: product code (II6FRC30) should have been ( I16FRC ), as in round 2 p New company acquisition (Alere™), therefore change in product branding and catalogue numbers; VB011 to VB11 and VB020 to VB20. Manufacturer confirmed compliance with product definition. Ltd.i 11

Advy Chemical Pvt. Ltd. (Affiliate of Bharat Serums & Vaccines Ltd. )

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Summary Rounds 1-7

Pf samplesc

Pv samplesd

Pf samplesc

Pv samplesd

12

Table S2: Malaria RDT phase 2 performance in rounds 4–7 against wild type (clinical) samples containing P. falciparum and P. vivax at low (200) and high (2000) parasite density (parasites/μl) and clean-negative samples Panel detection scorea False positive rates (%) 200 parasites/µl Pf samples Pv samples Pf samples Pv samples False positive non-Pf infectione NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 1.4 0.7 0.0 0.7 1.4 5.0 3.6 0.0 11.4 1.4 0.0 (139) 1.5 2.9 0.0 0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 2.9 (139) 0.7 0.0 2.1 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 1.4 0.0 0.0 1.4 0.0 0.0 1.5 1.4 1.4 4.3 0.0 12.9 1.4 0.0 0.0 1.4 0.0 1.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.0 0.7 0.0 0.0 0.0 0.0 0.7 NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.4 0.0 0.9 (231) 1.3 0.5 0.0 0.9 0.4 0.0 0.4 0.9 0.0 1.0 0.4 1.0 2.2 (231) 1.4 1.7 5.1 (234) 0.0 10.6 (235) 1.0 0.0 0.4 0.4 (231) 0.0 1.3 0.0 0.0 0.0 1.3 0.9 0.0 0.0 0.0 0.5 (207) 0.0

Total false positive ratesb (%) Clean negative samples False positive Plasmodium spp. Infectioni

200 2000 or 5000 parasites/µl parasites/µl Manufacturer False positive Pf infectionf False positive non-Pf infectiong False positive Pf infectionh

2000 parasites/µl

Product

Product code

Meets Invalid WHO rate Round procurement (%)l criteria

Pf only ABON™ Malaria P.f. Rapid Test Device (Whole Blood) Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test j Advantage P.f. Malaria Card Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BIONOTE MALARIA P.f. Ag Rapid Test Kit BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria HRP2 (Pf) CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag RDT ABON Biopharm (Hangzhou) Co. Ltd Advy Chemical Private Limited InTec Products, Inc. J. Mitra & Co. Pvt. Ltd. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bionote,Inc. Bio Focus Co., Ltd. Access Bio, Inc. Access Bio Ethiopia Access Bio, Inc. NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

IMA-402 RKMAL017 ITP11002-TC25 IR016025 05FK140-40-0 AS0015 RG19-11 17912 RMOM(U)-XXX7X RMOM-03091 RMPM(U)-XXX7X

0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.2 0.0 0.0 0.2 0.0 0.7 0.0 0.1 0.2 0.1 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.2 0.2 0.0

4 7 7 5 7 7 6 7 5 7 6 7 7 7 6 5 6 4 6 7 5 7 5 6 7 4 7 7 4 7 6 7 4 4 7 7 6 6 6

No Yes Yes Yes Yes Yes Yes Yes Yesm Yes Yesm Yes Yes Yes No Yesm Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes No No Yesm Yes Yes Yes

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line k

RMSM-05071

careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette EzDx™ Malaria Pf Rapid Malaria antigen detection test First Response® Malaria Ag P. falciparum (HRP2) Card Test First Response® Malaria Ag P. falciparum (HRP2) Card Test FirstSign™ Malaria Pf Humasis Malaria P.f Antigen Test ICT MALARIA P.F. CASSETTE TEST j IMMUNOQUICK® MALARIA falciparum KHB® Malaria Ag (HRP2) Pf Rapid Test Shanghai Kehua Bio-engineering Co.,Ltd. Oscar Medicare Pvt. Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Bhat Bio-Tech India (Pte.) Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Blue Cross Bio-Medical (Beijing) Co., Ltd. Meril Diagnostics Pvt. Ltd. CTK Biotech, Inc. ALLDIAG SA Orchid Biomedical Systems Orchid Biomedical Systems ARKRAY Healthcare Pvt Ltd n ARKRAY Healthcare Pvt Ltd n Hema Diagnostic Systems RapiGEN Inc. Hangzhou Biotest Biotech Co., Ltd. 91.0 89.0 83.7 86.0 93.0 94.9 73.0 75.0 92.0 95.9 70.4 74.0 77.0 93.0 88.0 79.0 79.0

RMO-M05082 W06200 RK MAL 008 I13FRC25 PI13FRC 2100CB-25 ANMPF-7025 ML01 0502_K25 R-409-50-C

32.7 80.0 93.0 89.0 98.0 93.0 88.0 97.0 91.0 96.0 91.0 94.0 Access Bio, Inc. (94/38) WELLS BIO, INC 94.0 DIALAB 86.0 Advy Chemical Private Limited 71.0 Premier Medical Corporation Ltd. 95.0 Premier Medical Corporation Ltd. 91.0 Unimed International Inc. 94.9 Humasis Co., Ltd. 87.0 ICT INTERNATIONAL 94.0 Biosynex 72.0 Shanghai Kehua Bio-engineering Co.,Ltd. 85.0

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016) 99.0 100.0 99.0 99.0 100.0 100.0 100.0 99.0 100.0 100.0 99.0 99.0 (99/92) 100.0 99.0 100.0 100.0 100.0 100.0 100.0 100.0 93.0 99.0 91.8 (98) 100.0 100.0 98.0 99.0 100.0 99.0 99.0 99.0 99.0 98.0 99.0 100.0 100.0 100.0 99.0 100.0

KHB® Malaria Ag P.f Rapid Test

KH-R-06-20

Malaria Antigen Test-Pf Malaria Pf Rapid Test Maleriscan ® Malaria P.f Antigen Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test j One Step Malaria P.F Test (Cassette) One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag OnSite Malaria Pf Ag Rapid Test PALUTOP + pf® Paracheck® Pf-Rapid Test for P.falciparum Malaria Device (Ver.3) Paracheck® Pf-Rapid Test for P.falciparum Malaria Dipstick (Ver.3)j Parahit f® Ver 1.0 - Dipstick j Parahit® f Ver 1.0 - Device j Rapid 1-2-3® Hema® Cassette Malaria PF RapiGEN BIOCREDIT Malaria Ag Pf (HRPII) RightSign® Malaria P.f. Rapid Test Cassette (Whole Blood)

MAG01040 GCMAL(pf)-402a MAT-PF-50 GMDMALPF001 W37-C 522352 MPHRPD-01 R0114C 5531 302030025 302040025 55IC103-50 55IC104-50 MAL-PF-CAS/25 (100) C10RHA25 IMPF-C51

Table S2 (continued) Panel detection scorea False positive rates (%) 200 parasites/µl Pf samples Pv samples Pf samples Pv samples False positive non-Pf infectione False positive Plasmodium spp. Infectioni 0.0 0.0 (231) 0.0 5.2 (230) 0.4 7.3 (234) 0.0 8.7 (231) 0.4 0.0 0.0 0.9 1.3 1.3 (231) 0.0 (207) 0.0 0.0 0.0 0.0 0.7 0.7 0.7 0.0 33.8 2.9 0.0 0.0 0.0 1.5 0.0 13.6 0.0 (138) 0.7 (139) 0.0 0.0 0.0 0.0 (135) 47.9 4.3 0.7 0.5 0.0 0.0 0.5 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (199) 0.0 1.0 0.5 0.0 0.0 1.5 0.0 (199) 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.0 0.0 42.7 1.5 (67) 0.0 0.0 0.0 0.0 0.0 7.1 1.4 1.4 0.0 0.0 0 (68) 0.0 35.7 0.0 0.0 1.7 (231) 3.9 0.5 0.0 0.9 1.7 0.4 0.0 (231) 32.2 (230) 2.1 1.4 0.0 1.9 (207) 2.6 0.0 (235) 10.6 0.9 (235) 0.5 1.3 3.9 1.0 (206) 0.0 81.3 (235) 0.9 0.0 NA NA NA NA 0.0 0.3 0.0 0.3 (389) 1.5 3.5 1.3 1.3 0.5 (399) 0.3 (399) 0.0 (399) 0.0 (390) 0.0 0.0 0.0 0.8 0.0 1.5 1.3 0.0 0.3 0.3 0.3 1.5 0.3 0.0 0.0 0.5 (396) 0.0 0.3 2.0 0.5 (395) 0.0 22.5 0.0 (3.98) 0.3 5.2 0.0 0.0 (139) 0.0 6.7 (134) 0.7 0.0 0.0 0.0 0.0 1.4 (138) 2.9 0.0 0.0 (199) 0.0 0.0 (197) 0.5 0.0 1.0 2.0 1.0 1.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 (69) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4.4 (135) NA NA NA 0.0 2.9 2.9 0.7 NA 0.0

Total false positive ratesb (%) Clean negative samples

200 2000 or 5000 parasites/µl parasites/µl Manufacturer Pf samplesc Pv samplesd Pf samplesc Pv samplesd False positive Pf infectionf False positive non-Pf infectiong False positive Pf infectionh

2000 parasites/µl

Product

Product code

Meets Invalid WHO rate Round procurement (%)l criteria

SD Bioline Malaria Ag P.f (HRP2/pLDH)k Standard Diagnostics, Inc. Standard Diagnostics, Inc. Standard Diagnostics, Inc. Artron Laboratories Inc. ABON Biopharm (Hangzhou) Co. Ltd LAB-CARE Diagnostics (India) PVT. LTD. Advy Chemical Private Limited InTec Products, Inc. J. Mitra & Co. Pvt. Ltd. J. Mitra & Co. Pvt. Ltd. Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. Atomo Diagnostics PTY Limited 0.0 88.2 100.0 100.0 100.0 94.3 71.4 100.0 97.1 29.4 97.1 100.0 100.0 100.0 100.0 97.1 88.6 97.1 97.1 100.0 100.0 100.0 85.3 45.7 97.1 97.1 100.0 68.6 85.7 97.1 0.0 94.3 94.3 26.5 82.9 88.6 74.3 91.4 61.8 54.3 17.1 91.4 62.9 31.4 100.0 91.4 2.9 8.6 2.9 2.9 5.9 37.1 45.7 60.0 94.3 100.0 91.4 71.4 100.0 91.4 22.9 97.1 97.1 100.0 97.1 97.1 100.0 100.0 100.0 100.0 100.0 97.1 NA NA NA NA NA NA NA NA

05FK90

0.0 0.1 0.0 0.7 0.0 0.4 0.0 2.1 0.0 0.2 0.0 0.0 0.1 0.3 0.2 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.3 0.2 0.0 0.0 0.1 0.0 0.2 0.1 0.7 0.1 0.0 0.0 0.8 0.1 0.1 0.2 0.0

6 7 5 4 4 5 7 5 5 5 7 7 7 7 6 4 7 6 7 7 7 5 7 4 5 6 5 6 4 5 5 5 6 7 7 6 4 5 5 4

Yesm Yes Yesm Yes No No No No No Yes Yes No Yes Yes No No Yes No Yes Yes No Yesm Yes No Yes Yes No Yes No No No Yes No No Yes Yes No No No No

05FK130-40-0 05FK50 A03-01-322 100.0 92.0 100.0 100.0 94.0 100.0 98.0 96.0 98.0 98.0 100.0 98.0 (98/37.8) 99.0 100.0 100.0 99.0 100.0 100.0 99.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 96.0 100.0 99.0 98.0 99.0 99.0 100.0 97.0 95.0 94.9

88.0 (87/52) 90.0 95.0 88.8

100.0 (100/97) 100.0 99.0 100.0

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines SD BIOLINE Malaria Ag Pf Trusty™ Malaria Antigen P.f. test Pf and Pan ABON™ Plus Malaria P.f/Pan Rapid Test Device (Whole Blood) ACCUCARE ONE STEP MALARIA Pf/Pan Antigen Test Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Advanced Quality™ Rapid Malaria Test (Pf/Pan) Advantage Mal Card Advantage Malaria Pan + Pf Card Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag j Aspen® Malaria Ag Pf/Pv ATOMORAPID™ MALARIA (PF/PAN) AZOG Malaria pf (HRPII)/pf (LDH)/ (PAN-LDH) Antigen Detection Devicek BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) j BIONOTE MALARIA P.f & Pan Ag Rapid Test Kit Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card j CareStart™ MALARIA Pf/PAN (pLDH) Ag RDT j CareStart™ Malaria Pf/PAN (HRP2/pLDH) Ag COMBO RDT CareStart™ Malaria Screen RDT j Core™ Malaria Pan Pf DIAQUICK Malaria P.f/Pan Cassette EzDx™ Malaria Pan/Pf Rapid test detection Kit First Response® Malaria Ag. pLDH/HRP2 Combo Card Test First Response® Malaria Ag. pLDH/HRP2 Combo Card Test FirstSign™ ParaView (Pan+Pf) GenBody™Malaria Pf/Pan Ag Genedia® Malaria P.f/Pan Ag Rapid Test Humasis Malaria P.f/Pan Antigen Test Humasis Malaria P.f/Pan Antigen Test ICT MALARIA DUAL TEST j Is It... Malaria Pf PAN Is It… Malaria Pf/Pv Device Malaria pf (HRP II)/PAN (pLDH) Antigen Detection Test Device Malaria pf (pLDH) / PAN-pLDH Test Device Malaria Pf./Pan Antigen (MAL Pf/Pan) Test Kit Malaria Pf/ PAN

85.7 66.0 67.0 88.0 30.0 84.0 85.0 69.0 88.0 93.0 90.0 62.2 MFV-124F AZOG, INC. (62/3.1) C32RHA25 RapiGEN Inc. 91.0 RG19-08 BioNote, Inc. 83.0 0584_K25 Biosynex 85.0 17012 Bio Focus Co., Ltd. 96.0 RMLM-05071 Access Bio, Inc. 73.0 RMRM(U)-XXX7X Access Bio, Inc. 90.0 RMAM-05071 Access Bio, Inc. 93.0 MAL-190024 Core Diagnostics Ltd. 99.0 Z11200CE DIALAB GmbH 90.0 RK MAL 001 Advy Chemical Private Limited 78.0 I16FRC Premier Medical Corporation Ltd. 85.0 PI16FRC Premier Medical Corporation Ltd. 82.0 2101CB-25 Unimed International Inc. 87.8 MALAG100 GenBody Inc. 84.0 20-0146-01 Green Cross Medical Science Corp. (Korea) 67.0 AMAL-7025 Humasis, Co., Ltd. 90.0 ANMAL-7025 Humasis Co., Ltd. 89.0 ML03 ICT INTERNATIONAL 85.0 MPFPAN050 Medsource Ozone Biomedicals Pvt. Ltd. 93.0 AL030 Medsource Ozone Biomedicals 88.0 1-13-101-1 United Biotech, Inc. 63.3 MFV-124 AZOG, Inc. 41.0 A03-18-322 Artron Laboratories Inc. 61.0 GM004 Genomix Molecular Diagnostics Pvt.Ltd. 39.8

IMA-T402 MAGC 25 RKMAL016 ITP11005 IR221025 IR231025 05FK60AI-40 IMPN-402 AM4650-K AS0060 MMAL01

(continued)

Summary Rounds 1-7

13

Pf samplesc

Pv samplesd

Pf samplesc

Pv samplesd

14

Table S2: Malaria RDT phase 2 performance in rounds 4–7 against wild type (clinical) samples containing P. falciparum and P. vivax at low (200) and high (2000) parasite density (parasites/μl) and clean-negative samples (continued) Panel detection scorea False positive rates (%) 200 parasites/µl Pf samples Pv samples Pf samples Pv samples False positive non-Pf infectione 0.0 (398) 0.0 (391) 1.3 0.8 0.5 (399) 0.8 (399) 0.0 0.0 (398) 0.3 0.8 2.3 6.5 0.0 2.0 0.8 0.0 1.0 1.0 (399) 0.0 0.0 0.0 1.8 0.0 2.8 (399) 1.3 0.5 0.0 0.3 (391) 0.0 0.5 0.3 0.3 0.5 1.5 (391) 0.8 0.0 0.0 (395) 27.3 (399) 0.0 0.0 (139) 0.0 0.0 0.0 0.0 0.0 0.0 (138) 1.4 0.0 0.0 0.0 0.0 0.7 0.7 0.0 0.0 (135) 6.5 (138) 0.7 0.0 0.0 (137) 5.8 (139) 0.0 0.0 0.0 0.0 0.0 1.4 0.0 2.9 0.7 0.7 (139) 0.0 0.5 0.5 0.0 0.0 0.5 (199) 0.0 0.5 0.5 0.5 (199) 1.0 1.0 (199) 0.0 0.0 0.0 2.0 0.0 1.0 0.0 0.5 0.0 (199) 0.5 0.5 0.5 0.0 0.0 3.1 (195) 3.6 (195) 0.5 0.5 (199) 0.5 (198) 87.4 (199) 3.6 (139) 1.0 4.3 0.0 1.4 3.0 (67) 1.5 0.0 0.0 0.0 5.7 1.4 0.0 (69) 1.4 (69) 1.5 (68) 0.0 (69) 0.0 (69) 0.0 0.0 0.0 0.0 1.4 0.0 0.0 0.0 0.0 1.5 0.0 0.0 1.5 2.9 0.0 0.0 0.0 4.3 (69) 9.3 0.0 4.3 0.7 (138) 0.0 0.0 0.0 0.0 (199) 0.0 0.0 0.0 0.0 (69) 1.5 0.0 0.0 0.4 (232) 0.9 0.5 0.4 15.3 33.2 0.0 0.0 (207) 0.0 0.0 0.0 7.2 0.4 14.0 0.0 1.3 (235) 0.4 0.0 (230) 0.0 (229) 0.0 0.0 0.0 (231) 0.0 0.0 (207) 3.9 1.4 0.5 (207) 0.4 0.0 1.3 1.0 (207) 0.0 0.0 (230) 0.9 (232) 0.9 0.0 (231) 0.0 (203) 3.0 (232)

Total false positive ratesb (%) Clean negative samples False positive Plasmodium spp. Infectioni

200 2000 or 5000 parasites/µl parasites/µl Manufacturer False positive Pf infectionf False positive non-Pf infectiong False positive Pf infectionh

2000 parasites/µl

Product

Product code

Meets Invalid WHO rate Round procurement (%)l criteria

Malaria Pf/Pan One Step Rapid Test MeDiPro Malaria Ag HRP2/pLDH Combo Meriscreen Malaria Pf/Pan Ag NanoSign Malaria pf/pan Ag 3.0 2.9 71.4 97.1 65.7 25.7 14.3 85.7 82.4 61.8 97.1 91.4 100.0 40.0 91.4 5.7 97.1 100.0 91.4 94.3 97.1 100.0 88.6 82.9 77.1 100.0 71.4 79.4 76.5 100.0 91.4 48.6 0.0 74.3 0.0 57.1 51.4 62.9 98.0 98.0 99.0 100.0 100.0 99.0 100.0 98.0 100.0 99.0 100.0 100.0 100.0 100.0 100.0 100.0 92.9 97.0 94.9 99.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 94.1 91.2 100.0 100.0 100.0 26.5 94.3 5.9 100.0 97.1 100.0 100.0 99.0 99.0 100.0 100.0 99.0 100.0 94.0 99.0 97.0 100.0 97.1 91.2 94.1 100.0 100.0 100.0 88.6 97.1 94.3 98.0 91.4 100.0 94.3 SARL NG Biotech, Z.A. NG Biotech Guangzhou Wondfo Biotech Co., Ltd. CTK Biotech, Inc. ARKRAY Healthcare Pvt. Ltd.n ARKRAY Healthcare Pvt. Ltd.n Zephyr Biomedicals Lumiquick Diagnostics, Inc. Hema Diagnostic Systems Hangzhou Biotest Biotech Co. Ltd. Standard Diagnostics Inc. IMACCESS S.A.S InTec Products, Inc. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Core Technology Co., Ltd. Advy Chemical Private Limited Zephyr Biomedicals Premier Medical Corporation Ltd. HBI Co., Ltd. HBI Co., Ltd. Humasis, Co., Ltd. Humasis Co., Ltd. Shanghai Kehua Bio-engineering Co., Ltd. United Biotech, Inc. Genomix Molecular Diagnostics Pvt. Ltd. Genomix Molecular Diagnostics Pvt.Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Nantong Egens Biotechnology Co., Ltd. Bhat Bio-Tech India (P) Ltd. 92.0 75.0 85.0 91.0 91.0 89.0 93.0 78.0 76.0 80.0 85.0 89.8 89.8 92.9 88.0 91.0 60.2 85.0 40.8 89.0 90.0 84.0 77.0 78.0 84.7 76.5 79.0 79.0 92.0 74.0 94.0 86.0 92.0 90.0

Zhejiang Orient Gene Biotech Co., Ltd. Formosa Biomedical Technology Corp. Meril Diagnostics Private Ltd. Bioland Ltd.

89.0 69.4 77.0 92.9

91.4

100.0 99.0 100.0 100.0

100.0 0.0 100.0 100.0

1.0 0.1 0.0 0.0 0.1 0.2 0.0 0.2 0.1 0.0 0.0 0.1 0.0 0.0 0.0 0.3 0.1 0.6 0.3 0.1 0.0 0.1 0.0 0.5 0.0 0.0 0.2 0.1 0.0 0.0 0.1 0.0 0.5 2.5 0.0 0.3 1.3 0.7

5 4 6 4 5 7 6 6 4 4 6 6 7 5 5 5 7 7 7 6 7 7 7 6 6 6 6 4 4 4 6 6 4 5 4 7 6 5

Yes No No Yes No No No Yes Yes No Yes Yes Yes No Yesm No Yes Yes Yes Yes Yes Yesm Yes Yes Yes Yes No Yes Yes Yes Yes No No No No No No No

NG-Test MALARIA Pf/Pan (pLDH)

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

NG-Test MALARIA Pf/Pan (pLDH)

One Step Malaria P.f/Pan Whole Blood Test OnSite Malaria Pf/Pan Ag Rapid Test ParaHIT - Total Ver. 1.0 (Device) ParaHIT - Total Ver. 1.0 (Dipstick) Parascreen® - Rapid Test for Malaria Pan/Pf QuickProfile™ Malaria Pf/Pan Test Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN RightSign™ Malaria P.f./Pan Rapid Test Cassette SD BIOLINE Malaria Ag P.f/Pan Vikia® Malaria Ag Pf/Pan Pf and Pv/Pvom ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test j BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv BioTracer™ Malaria P.f/P.v Rapid Card CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT j careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Coretests® One Step Malaria Pf/Pv Ag Test Device EzDx™ Malaria Pv/Pf Rapid Malaria antigen detection test FalciVax™ - Rapid Test for Malaria Pv/Pf First Response® Malaria Ag Pf/Pv Card Test HiSens Malaria Ag P.f/P.v Combo Card HiSens Malaria Ag P.f/VOM Combo Card Humasis Malaria P.f/P.v Antigen Test Humasis Malaria P.f/P.v Antigen Test KHB® Malaria Ag P.f/P.v Rapid Test Malaria pf (HRP II) / pv (pLDH) Antigen Detection Test Device Malaria Pf (HRPII)/ PV (PLDH) Antigen Detection Test Device Malaria Pf/Pv Malaria Pf/Pv Rapid Test Malaria PV/PF (pLDH/HRP2) Antigen Test Maleriscan® Malaria Pf/PAN (Pv, Pm, Po) 3 Line Antigen Test

RT 20222 IR-0051K MHLRPD-01 RMAP10 NGMAL-W23-001 NGBMAL-W23-005 W62-C R0113C 55IC204-10 55IC203-10 503030025 71063 MAL-PF/Pan-CAS/25 IMPN-C52 05FK60 412499

ITP11003-TC25 C60RHA25 0581_K25 17412 RMVM-03091 RMVM-05072 RMV-M05082 B42-21/B42-22 RK MAL 003 503010025 PI19FRC HR3123 HR3323 AMFV-7025 ANMIV-7025 KH-R-07-50 1-13-101-3 GM006 GM002 GCMAL(pf/pv)-402a Inf-72 MAT-PF/PAN-50

Table S2 (continued) Panel detection scorea False positive rates (%) 200 parasites/µl Pf samples Pv samples Pf samples Pv samples False positive non-Pf infectione False positive Plasmodium spp. Infectioni 1.3 77.1 0.0 0.0 (207) 6.4 22.9 (231) 4.3 4.4 (207) 1.9 0.0 32.0 (231) 0.0 0.5 NA NA NA 0.0 NA NA NA 0.0 0.0 0.4 2.2 0.0 0.3 21.5 0.5 0.0 (399) 2.0 (399) 39.8 0.0 2.5 (399) 0.5 0.0 13.3 0.0 1.3 NA NA NA NA NA NA 0.7 0.0 0.5 0.0 53.6 0.7 1.4 5.7 0.0 0.7 0.0 0.7 0.0 27.4 (135) 1.0 9.0 0.0 0.0 0.5 27.5 0.0 1.0 0.0 0.0 16.0 (194) 0.0 34.3 1.4 0.0 2.9 0.0 1.5 2.9 0.0 0.0 19.4 (67)

Total false positive ratesb (%) Clean negative samples

200 2000 or 5000 parasites/µl parasites/µl Manufacturer Pf samplesc Pv samplesd Pf samplesc Pv samplesd False positive Pf infectionf False positive non-Pf infectiong False positive Pf infectionh

2000 parasites/µl

Product

Product code

Meets Invalid WHO rate Round procurement (%)l criteria

One Step Malaria HRP2/pLDH (P.f/P.v) Test j One Step Malaria P.F/P.V Test (Cassette) One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag OnSite Malaria Pf/Pv Ag Rapid Test ParaHIT®fV Rapid test for P. falciparum and P.vivax Malaria - Device QuickProfile™ Malaria Pf/Pv Antigen Test j RAPID 1-2-3® HEMA CASSETTE MALARIA PF/PV TEST RapiGEN BIOCREDIT Malaria Ag Pf/Pv (HRPII/pLDH) SD Bioline Malaria Ag P.f/P.v Rapid Test Kit for Malaria Ag Pf/Pv - Alere Trueline Malaria Ag Pf/Pv Trusty™ Malaria Antigen P.f./p.v. test Pf, Pf and Pv Guangzhou Wondfo Biotech Co., Ltd. Blue Cross Bio-Medical (Beijing) Co., Ltd. Meril Diagnostics Pvt. Ltd. CTK Biotech, Inc. ARKRAY Healthcare Pvt. Ltd.n Lumiquick Diagnostics Inc. Hema Diagnostic Systems, LLC RapiGEN Inc. Standard Diagnostics, Inc. Alere Medical Private Limited Artron Laboratories Inc. Standard Diagnostics, Inc. ALLDIAG SA 99.0 98.0 99.0 99.0 100.0 55.9 97.1 77.0 61.2 84.0 100.0 0.0 88.6 91.0 82.9p 100.0p 85.0 (84/36) 91.4 100.0 100.0 (100/98) 92.0 92.0 78.0 74.0 63.0 79.0 92.9 92.0 92.0 85.0 88.8 65.7 100.0 85.7 80.0 37.1 88.6 79.4 91.4 94.3 88.6 38.2 100.0 100.0 100.0 98.0 91.0 99.0 100.0 100.0 100.0 98.0 99.0 100.0 100.0 100.0 100.0 85.7 100.0 100.0 100.0 100.0 100.0 100.0

W056-C 523352 MFLRPD-02 R0112C 55IC402-50 71050 MAL-PFV-CAS/25(100) C40RHA25 05FK80 11108191040 A03-12-322

0.0 0.0 0.0 0.2 0.1 0.1 0.0 0.2 0.0 0.0 0.5 0.0 0.0 0.0 0.2 0.0 Performance measure

7 5 7 6 5 7 4 6 6 7 4 6 7 5 4 5

No No Yes No No No Yes Yes Yesm Yes No Yes Yes Yes No Yesm

SD Bioline Malaria Ag P.f/P.f/P.v k

05FK120

Pf, Pv and Pan PALUTOP +4 optima® Pan only Advantage Pan Malaria Card AZOG hCG Malaria Detection Test Device CareStart™ Malaria PAN (pLDH) Ag RDT

5499

IR013025 J. Mitra & Co. Pvt. Ltd. MPT-124 AZOG, INC. RMNM(U)-XXX7X Access Bio, Inc.

NA, not

applicable

Pf, Plasmodium falciparum 

Panel detection score for Pf and Pv 200/µl samples False-positive rates against clean-negatives

Recommended WHO procurement criteria ≥ 75% < 10% Invalid rate < 5% of tests conducted

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

g For combination tests, pan or Pv line, only, positive indicates a false positive non-P. falciparum infection (Round 1, n=158, Round 2, n=200; Round 3, n=198; Pv, Plasmodium vivax  pan, Plasmodium species Round 4, n=196; Round 5, n=200; Round 6, n=200; Round 7, n=200) Pvom, Plasmodium vivax, ovale and malariae h Pf line positive indicates a false positive P. falciparum infection (Round 1, n=40; a A sample is considered detected only if all RDTs from both lots read by the first Round 2, n=80, Round 3, n=70; Round 4, n=68; Round 5, n=70; Round 6, n=70; technician, at minimum specified reading time, are positive b The total number of times a positive result for malaria was generated when it should Round 7, n=70) i Round 1, n=168; Round 2, n=200; Round 3, n=200; Round 4, n=232; Round 5, n=236; not have been c Round 1, n=79; Round 2, n=100; Round 3, n=99; Round 4, n=98; Round 5, n=100; Round 6, n=208; Round 7, n=220 j Product resubmission, results from most recent Round of testing replace previous Round 6, n=100; Round 7, n=100 d Round 1, n=20; Round 2, n=40; Round 3, n=35; Round 4, n=34; Round 5, n=35; results. Refer to Table S1. k PDS presented in the table is based on a positive Pf test line (either HRP2 or Pf-pLDH). The Round 6, n=35; Round76, n=35 e For combination tests, pan or Pv line, only, positive indicates a false positive results in brackets are the PDS based alone on HRP2 and Pf-pLDH test lines, respectively. l Round 1, n=954; Round 2, n=1240; Round 3, n=1204; Round 4, n=1192; non P. falciparum infection (Round 1 n=316; Round 2, n=400; Round 3, n=396; Round 5, n=1214 ; Round 6, n=1210; Round 7, n=1210 Round 4, n=392; Round 5, n=400); Round 6, n=400; Round 7, n=400) m Indicates a WHO prequalified product f Pf line positive indicates a false positive P. falciparum infection (Round 1, n=80; n ARKRAY Healthcare Pvt. Ltd. was formerly Span Diagnostics Ltd.. Round 2, n=160; Round 3, n=140; Round 4, n=136; Round 5, n=140; Round 6, n=140; Round 7, n=140)     

Summary Rounds 1-7

15

16

Table S3: Malaria RDT rounds 4–7 heat stability results on a cultured P. falciparum sample at low (200) and high (2000) parasite density (parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Positive test results for P. falciparum (Pf line) Positive test results for P. falciparum (Pf line) 2000 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 56.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Positive test results for P. falciparum (Pan line) 200 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined 35°C 45°C Baseline 35°C 2000 parasites/µl

Positive test results for P. falciparum (Pan line) 45°C Round

200 parasites/µl Manufacturer Baseline Percentage of tests positive Lots 1 and 2 combined ABON Biopharm (Hangzhou) Co. Ltd Advy Chemical Private Limited InTec Products, Inc. J. Mitra & Co. Pvt. Ltd. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bionote,Inc. Bio Focus Co., Ltd. Access Bio, Inc. Access Bio Ethiopia Access Bio, Inc. Access Bio, Inc. WELLS BIO, INC DIALAB Advy Chemical Private Limited Premier Medical Corporation Ltd. Premier Medical Corporation Ltd. Unimed International Inc. Humasis Co., Ltd. ICT INTERNATIONAL Biosynex Shanghai Kehua Bio-engineering Co., Ltd. Shanghai Kehua Bio-engineering Co.,Ltd. Oscar Medicare Pvt. Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Bhat Bio-Tech India (Pte.) Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Blue Cross Bio-Medical (Beijing) Co., Ltd. Meril Diagnostics Pvt. Ltd. CTK Biotech, Inc. ALLDIAG SA Orchid Biomedical Systems Orchid Biomedical Systems ARKRAY Healthcare Pvt Ltd c ARKRAY Healthcare Pvt Ltd c Hema Diagnostic Systems RapiGEN Inc. Hangzhou Biotest Biotech Co., Ltd. Standard Diagnostics Inc. Standard Diagnostics, Inc. Standard Diagnostics, Inc. Artron Laboratories Inc. 15.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 15.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 96.7 100.0 100.0 17.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Product 35°C 45°C 35°C 45°C

Product code

Percentage of tests positive Lots 1 and 2 combined NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 4 7 7 5 7 7 6 7 5 7 6 7 7 7 6 5 6 4 6 7 5 7 5 6 7 4 7 7 4 7 6 7 4 4 7 7 6 6 6 6 7 5 4

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Pf only tests ABON™ Malaria P.f. Rapid Test Device (Whole Blood) Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test a Advantage P.f. Malaria Card Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BIONOTE MALARIA P.f. Ag Rapid Test Kit BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria HRP2 (Pf) CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line b careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette EzDx™ Malaria Pf Rapid Malaria antigen detection test First Response® Malaria Ag P. falciparum (HRP2) Card Test First Response® Malaria Ag P. falciparum (HRP2) Card Test FirstSign™ Malaria Pf Humasis Malaria P.f Antigen Test ICT MALARIA P.F. CASSETTE TEST a IMMUNOQUICK® MALARIA falciparum KHB® Malaria Ag (HRP2) Pf Rapid Test KHB® Malaria Ag P.f Rapid Test Malaria Antigen Test-Pf Malaria Pf Rapid Test Maleriscan ® Malaria P.f Antigen Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test a One Step Malaria P.F Test (Cassette) One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag OnSite Malaria Pf Ag Rapid Test PALUTOP + pf® Paracheck® Pf-Rapid Test for P.falciparum Malaria Device (Ver.3) Paracheck® Pf-Rapid Test for P.falciparum Malaria Dipstick (Ver.3) Parahit f® Ver 1.0 - Dipstick a Parahit® f Ver 1.0 - Device a

Rapid 1-2-3® Hema® Cassette Malaria PF

RapiGEN BIOCREDIT Malaria Ag Pf (HRPII) RightSign® Malaria P.f. Rapid Test Cassette (Whole Blood) SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) b SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines SD BIOLINE Malaria Ag Pf Trusty™ Malaria Antigen P.f. test

IMA-402 RKMAL017 ITP11002-TC25 IR016025 05FK140-40-0 AS0015 RG19-11 17912 RMOM(U)-XXX7X RMOM-03091 RMPM(U)-XXX7X RMSM-05071 RMO-M05082 W06200 RK MAL 008 I13FRC25 PI13FRC 2100CB-25 ANMPF-7025 ML01 0502_K25 R-409-50-C KH-R-06-20 MAG01040 GCMAL(pf)-402a MAT-PF-50 GMDMALPF001 W37-C 522352 MPHRPD-01 R0114C 5531 302030025 302040025 55IC103-50 55IC104-50 MAL-PFCAS/25 (100) C10RHA25 IMPF-C51 05FK90 05FK130-40-0 05FK50 A03-01-322

Table S3 (continued) Positive test results for P. falciparum (Pf line) Positive test results for P. falciparum (Pf line) 2000 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 90.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 3.3 0.0 0.0 0.0 80.0 46.7 0.0 76.7 50.0 0.0 3.3 80.0 0.0 0.0 100.0 0.0 93.3 100.0 26.7 0.0 3.3 0.0 96.7 0.0 0.0 3.3 0.0 0.0 3.3 93.3 93.1 16.6 13.3 10.0 0.0 0.0 0.0 46.7 0.0 0.0 0.0 10.0 0.0 0.0 0.0 93.3 70.0 0.0 50.0 90.0 16.7 0.0 26.7 0.0 0.0 100.0 6.7 86.7 100.0 80.0 0.0 23.3 10.0 100.0 0.0 0.0 0.0 0.0 0.0 3.3 93.3 96.6 0.0 93.3 3.3 0.0 0.0 0.0 56.7 0.0 6.7 0.0 0.0 0.0 0.0 0.0 26.7 33.3 16.7 10.0 100.0 0.0 0.0 6.7 0.0 0.0 70.0 0.0 53.3 100.0 83.3 0.0 10.0 0.0 70.0 13.3 0.0 13.3 0.0 0.0 13.3 93.3 36.7 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 70.0 100.0 70.0 70.0 100.0 100.0 90.0 100.0 100.0 100.0 20.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 50.0 0.0 100.0 100.0 90.0 100.0 100.0 90.0 60.0 100.0 60.0 100.0 0.0 100.0 100.0 100.0

Positive test results for P. falciparum (Pan line) 200 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined 35°C 45°C Baseline 35°C 45°C 2000 parasites/µl

Positive test results for P. falciparum (Pan line) Round

200 parasites/µl Manufacturer Baseline 35°C 45°C 35°C 45°C Percentage of tests positive Lots 1 and 2 combined ABON Biopharm (Hangzhou) Co. Ltd LAB-CARE Diagnostics (India) PVT. LTD. Advy Chemical Private Limited InTec Products, Inc. J. Mitra & Co. Pvt. Ltd. J. Mitra & Co. Pvt. Ltd. Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. Atomo Diagnostics PTY Limited AZOG, INC. RapiGEN Inc. Bionote,Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. Access Bio, Inc. Core Diagnostics Ltd. DIALAB GmbH Advy Chemical Private Limited Premier Medical Corporation Ltd. Premier Medical Corporation Ltd. Unimed International Inc. GenBody Inc. Green Cross Medical Science Corp. (Korea) Humasis, Co., Ltd. Humasis, Co., Ltd. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. Medsource Ozone Biomedicals United Biotech, Inc. AZOG, Inc. Artron Laboratories Inc. Genomix Molecular Diagnostics Pvt.Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Formosa Biomedical Technology Corp. Meril Diagnostics Private Ltd. Bioland Ltd. SARL NG Biotech, Z.A. 100.0 83.3 100.0 86.7 0.0 100.0 100.0 100.0 100.0 100.0 100.0 96.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 96.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 46.7 10.0 56.7 100.0 100.0 100.0 100.0 100.0 100.0 73.3 100.0 96.7 0.0 100.0 100.0 100.0 100.0 100.0 100.0 96.7 100.0 100.0 100.0 100.0 96.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 93.3 100.0 96.7 56.7 6.7 23.3 100.0 96.7 100.0 100.0 100.0 100.0 10.0 100.0 100.0 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 96.7 100.0 93.3 96.7 100.0 100.0 96.7 100.0 100.0 100.0 100.0 93.3 43.3 100.0 100.0 100.0 100.0 96.7 96.7 66.7 0.0 26.7 96.7 96.7 100.0 100.0 100.0

Product

Product code Lots 1 and 2 combined 0.0 90.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 100.0 100.0 100.0 100.0 40.0 100.0 100.0 90.0 90.0 0.0 100.0 100.0 100.0

Percentage of tests positive

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

Pf and Pan ABON™ Plus Malaria P.f/Pan Rapid Test Device (Whole Blood) ACCUCARE ONE STEP MALARIA Pf/Pan Antigen Test Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Advanced Quality™ Rapid Malaria Test (Pf/Pan) Advantage Mal Card Advantage Malaria Pan + Pf Card Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag a Aspen® Malaria Ag Pf/Pv ATOMORAPID™ MALARIA (PF/PAN) AZOG Malaria pf (HRPII)/pf (LDH)/ (PAN-LDH) Antigen Detection Deviceb BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) a BIONOTE MALARIA P.f.& Pan Ag Rapid Test Kit a Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT a CareStart™ Malaria Pf/PAN (HRP2/pLDH) Ag COMBO RDT CareStart™ Malaria Screen RDT a Core Malaria Pan Pf DIAQUICK Malaria P.f/Pan Cassette EzDx™ Malaria Pan/Pf Rapid test detection Kit First Response® Malaria Ag. pLDH/HRP2 Combo Card Test First Response® Malaria Ag. pLDH/HRP2 Combo Card Test FirstSign™ ParaView (Pan+Pf) GenBody™Malaria Pf/Pan Ag Genedia® Malaria P.f/Pan Ag Rapid Test Humasis Malaria P.f/Pan Antigen Test Humasis Malaria P.f/Pan Antigen Test ICT MALARIA DUAL TEST a Is It... Malaria Pf PAN Is It… Malaria Pf/Pv Device Malaria pf (HRP II)/PAN (pLDH) Antigen Detection Test Device Malaria pf (pLDH) / PAN-pLDH Test Device Malaria Pf./Pan Antigen (MAL Pf/Pan) Test Kit Malaria Pf/ PAN Malaria Pf/Pan One Step Rapid Test MeDiPro Malaria Ag HRP2/pLDH Combo Meriscreen Malaria Pf/Pan Ag NanoSign Malaria pf/pan Ag 3.0 NG-Test MALARIA Pf/Pan (pLDH)

IMA-T402 MAGC 25 RKMAL016 ITP11005 IR221025 IR231025 05FK60AI-40 IMPN-402 AM4650-K AS0060 MMAL01 MFV-124F C32RHA25 RG19-08 0584_K25 17012 RMLM-05071 RMRM(U)-XXX7X RMAM-05071 MAL-190024 Z11200CE RK MAL 001 I16FRC PI16FRC 2101CB-25 MALAG100 20-0146-01 AMAL-7025 ANMAL-7025 ML03 MPFPAN050 AL030 1-13-101-1 MFV-124 A03-18-322 GM004 RT 20222 IR-0051K MHLRPD-01 RMAP10 NG-MAL-W23-001

0.0 30.0 100.0 80.0 80.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 80.0 100.0 100.0 100.0 100.0 10.0 0.0 100.0 100.0 100.0 100.0 90.0 50.0 100.0 90.0 50.0 100.0 0.0 100.0 100.0 100.0

4 5 7 5 5 5 7 7 7 7 6 4 7 6 7 7 7 5 7 4 5 6 5 6 4 5 5 5 6 7 7 6 4 5 5 4 5 4 6 4 5

(continued)

Summary Rounds 1-7

17

18

Table S3: Malaria RDT rounds 4–7 heat stability results on a cultured P. falciparum sample at low (200) and high (2000) parasite density (parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at 35°C and 45°C (continued) Positive test results for P. falciparum (Pf line) Positive test results for P. falciparum (Pf line) 2000 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 90.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 90.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 70.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 90.0 100.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 60.0 100.0 100.0 100.0 100.0 100.0 100.0 53.3 0.0 0.0 0.0 50.0 100.0 100.0 0.0 0.0 0.0 0.0 86.7 0.0 6.7 0.0 0.0 90.0 96.7 0.0 20.0 0.0 0.0 66.7 0.0 0.0 0.0 0.0 93.3 100.0 33.3 100.0 0.0 0.0

Positive test results for P. falciparum (Pan line) 200 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined 100.0 90.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 60.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Positive test results for P. falciparum (Pan line) 2000 parasites/µl Baseline 35°C 45°C Round Percentage of tests positive Lots 1 and 2 combined 100.0 100.0 100.0 100.0 90.0 100.0 100.0 100.0 60.0 100.0 60.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100.0 70.0 100.0 100.0 0.0 100.0 100.0 100.0 100.0 100.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 7 6 6 4 4 6 6 7 5 5 5 7 7 7 6 7 7 7 6 6 6 6 4 4 4 6 6 4 5 4 7 6 5 7 5 7 6 5 7 4 6 6

200 parasites/µl Manufacturer Baseline Percentage of tests positive Lots 1 and 2 combined NG Biotech Guangzhou Wondfo Biotech Co., Ltd. CTK Biotech, Inc. Span Diagnostics Ltd. d Span Diagnostics Ltd. d Zephyr Biomedicals Lumiquick Diagnostics, Inc. Hema Diagnostic Systems Hangzhou Biotest Biotech Co. Ltd. Standard Diagnostics Inc. IMACCESS S.A.S InTec Products, Inc. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Core Technology Co., Ltd. Advy Chemical Private Limited Zephyr Biomedicals Premier Medical Corporation Ltd. HBI Co., Ltd. HBI Co., Ltd. Humasis, Co., Ltd. Humasis, Co., Ltd. Shanghai Kehua Bio-engineering Co., Ltd. United Biotech, Inc. Genomix Molecular Diagnostics Pvt. Ltd. Genomix Molecular Diagnostics Pvt.Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Nantong Egens Biotechnology Co., Ltd. Bhat Bio-Tech India (P) Ltd. Guangzhou Wondfo Biotech Co., Ltd. Blue Cross Bio-Medical (Beijing) Co., Ltd. Meril Diagnostics Pvt. Ltd. CTK Biotech, Inc. Span Diagnostics Ltd. d Lumiquick Diagnostics Inc. Hema Diagnostic Systems, LLC RapiGEN Inc. Standard Diagnostics, Inc. 100.0 93.3 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 83.3 40.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 86.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 90.0 33.3 100.0 100.0 100.0 100.0 100.0 100.0 100.0 96.7 100.0 100.0 58.6 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 83.3 40.0 100.0 96.6 100.0 100.0 100.0 100.0 90.0 96.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 93.3 100.0 100.0 100.0 100.0 100.0 96.7 100.0 96.7 100.0 100.0 46.7 100.0 100.0 100.0 100.0 100.0 96.7

Product 35°C 45°C 35°C 45°C 35°C 45°C

Product code

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

NG-Test MALARIA Pf/Pan (pLDH) One Step Malaria P.f/Pan Whole Blood Test OnSite Malaria Pf/Pan Ag Rapid Test ParaHIT - Total Ver. 1.0 (Device) ParaHIT - Total Ver. 1.0 (Dipstick) Parascreen® - Rapid test for Malaria Pan/Pf QuickProfile™ Malaria Pf/Pan Test Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN RightSign™ Malaria P.f./Pan Rapid Test Cassette SD BIOLINE Malaria Ag P.f/Pan Vikia® Malaria Ag Pf/Pan Pf and Pv/Pvom ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test a BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv BioTracer™ Malaria P.f/P.v Rapid Card CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT a careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Coretests® One Step Malaria Pf/Pv Ag Test Device EzDx™ Malaria Pv/Pf Rapid Malaria antigen detection test FalciVax™ - Rapid Test for Malaria Pv/Pf First Response® Malaria Ag Pf/Pv Card Test HiSens Malaria Ag P.f/P.v Combo Card HiSens Malaria Ag P.f/VOM Combo Card Humasis Malaria P.f/P.v Antigen Test Humasis Malaria P.f/P.v Antigen Test KHB® Malaria Ag P.f/P.v Rapid Test Malaria pf (HRP II) / pv (pLDH) Antigen Detection Test Device Malaria Pf (HRPII)/ PV (PLDH) Antigen Detection Test Device Malaria Pf/Pv Malaria Pf/Pv Rapid Test Malaria PV/PF (pLDH/HRP2) Antigen Test Maleriscan® Malaria Pf/PAN (Pv, Pm, Po) 3 Line Antigen Test One Step Malaria HRP2/pLDH (P.f/P.v) Test a One Step Malaria P.F/P.V Test (Cassette) One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag OnSite Malaria Pf/Pv Ag Rapid Test ParaHIT®fV Rapid test for P. falciparum and P.vivax Malaria - Device QuickProfile™ Malaria Pf/Pv Antigen Test a

NGB-MAL-W23-005 W62-C R0113C 55IC204-10 55IC203-10 503030025 71063 MAL-PF/Pan-CAS/25 IMPN-C52 05FK60 412499

RAPID 1-2-3® HEMA CASSETTE MALARIA PF/PV TEST

RapiGEN BIOCREDIT Malaria Ag Pf/Pv (HRPII/pLDH) SD Bioline Malaria Ag P.f/P.v

ITP11003-TC25 C60RHA25 0581_K25 17412 RMVM-03091 RMVM-05072 RMV-M05082 B42-21/B42-22 RK MAL 003 503010025 PI19FRC HR3123 HR3323 AMFV-7025 ANMIV-7025 KH-R-07-50 1-13-101-3 GM006 GM002 GCMAL(pf/pv)-402a Inf-72 MAT-PF/PAN-50 W056-C 523352 MFLRPD-02 R0112C 55IC402-50 71050 MAL-PFVCAS/25(100) C40RHA25 05FK80

Table S3 (continued) Positive test results for P. falciparum (Pf line) Positive test results for P. falciparum (Pf line) 2000 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined 100.0 100.0 100.0 100.0 NA NA NA NA NA NA NA NA NA 36.7 100.0 100.0 66.7 100.0 100.0 60.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 NA NA NA NA 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 NA NA NA NA NA NA NA NA

Positive test results for P. falciparum (Pan line) 200 parasites/µl Baseline Percentage of tests positive Lots 1 and 2 combined NA NA NA 100.0 100.0 100.0 100.0

Positive test results for P. falciparum (Pan line) 2000 parasites/µl Baseline 35°C 45°C Round Percentage of tests positive Lots 1 and 2 combined NA NA NA 100.0 90.0 100.0 100.0 7 4 6 7 5 4 5

200 parasites/µl Manufacturer Baseline 35°C 45°C 35°C 45°C 35°C 45°C Percentage of tests positive Lots 1 and 2 combined Alere Medical Private Limited Artron Laboratories Inc. Standard Diagnostics, Inc. ALLDIAG SA NA NA NA NA NA NA NA NA NA 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 36.7

Product

Product code

11108191040 A03-12-322

05FK120

Rapid Test Kit for Malaria Ag Pf/Pv - Alere Trueline Malaria Ag Pf/Pv Trusty™ Malaria Antigen P.f./p.v. test Pf, Pf and Pv SD Bioline Malaria Ag P.f/P.f/P.v b Pf, Pv and Pan PALUTOP +4 optima® Pan Only Advantage Pan Malaria Card AZOG hCG Malaria Detection Test Device CareStart™ Malaria PAN (pLDH) Ag RDT

5499

IR013025 J. Mitra & Co. Pvt. Ltd. MPT-124 AZOG, INC. RMNM(U)-XXX7X Access Bio, Inc.

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species  Pvom, Plasmodium vivax, ovale and malariae

a

Indicates results for those products that meet all WHO recommended procurement criteria Product resubmission, results from most recent round of testing replace previous results. Refer to Table S1. b Results presented in the table are based on stability of a Pf test line (either HRP2 or Pf-pLDH). Results based on stability of individual test lines is presented in the following table: c Arkray Healthcare Pvt. Ltd. was formerly Span Diagnostics Ltd. d Span Diagnostics Ltd. is now Arkray Healthcare Pvt. Ltd.

Positive test results for P. falciparum (Pf line) Manufacturer Baseline Percentage of tests positive Lots 1 and 2 combined Access Bio, Inc. Standard Diagnostics, Inc. Standard Diagnostics Inc. 96.7 AZOG, INC. 13.3 3.3 6.7 50.0 10.0

Positive test results for P. falciparum (Pf line) 2000 parasites/µl Baseline 35°C 45°C

Positive test results for P. falciparum (pan line) 200 parasites/µl Baseline 35°C 45°C Percentage of tests positive Lots 1 and 2 combined

Positive test results for P. falciparum (pan line) 2000 parasites/µl Baseline 35°C 45°C Percentage of tests positive Lots 1 and 2 combined Round

Product 35°C 45°C

Product code

200 parasites/µl

Percentage of tests positive Lots 1 and 2 combined

RMSM-05071

05FK120

05FK90

100.0 100.0 100.0 30.0 100.0 93.3 96.7 100.0

100.0 50.0 100.0 30.0 100.0 90.0

100.0 50.0 100.0 30.0 100.0 66.7

100.0 100.0 100.0 100.0 100.0 100.0 100.0

100.0 50.0 100.0 100.0 100.0 100.0 100.0

100.0 50.0 100.0 100.0 100.0 100.0 100.0 50.0

NA NA NA NA NA NA 3.3 3.3

NA NA NA NA NA NA 0.0 0.0

NA NA NA NA NA NA 0.0 0.0

NA NA NA NA NA NA 20.0 20.0

NA NA NA NA NA NA 0.0 0.0

NA NA NA NA NA NA 0.0 0.0

7 7 6 6 6 6 4 4

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - (Pf(HRP2) line) CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - (Pf(pLDH) line) SD Bioline Malaria Ag P.f/P.f/P.v - (PF(HRP2) line) SD Bioline Malaria Ag P.f/P.f/P.v - (PF(pLDH) line) SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) - (PF(HRP2) line) SD BIOLINE Malaria Ag P.f. (HRP2/pLDH)- (PF(pLDH) line) AZOG Malaria pf (HRPII)/pf (LDH)/ (PAN-LDH) Antigen Detection Device - (PF(HRP2) line) AZOG Malaria pf (HRPII)/pf (LDH)/ (PAN-LDH) Antigen Detection Device - (PF(pLDH) line)

MFV-124F

Summary Rounds 1-7

19

Table S4: Products evaluated during rounds 1-7 that have been removed from summary results listings Manufacturer Amgenix International, Inc. Abon Biopharm (Hangzhou) Co. Ltd. (Iverness Medical) Access Bio, Inc. Access Bio Ethiopia ACON Biotech (Hangzhou) Co. Ltd Acon Laboratories, Inc AZOG, Inc Bhat Bio-Tech India (P) Ltd Bioland, Ltd BioNote,Inc. Biosynex

Product name OnSight™ - Malaria Pf Test OnSight™ - ParaQuick-2 (Pv,Pf) Malaria Test OnSight™ - PanScreen (Pan) Malaria Test OnSight™ - ParaQuick (Pan, Pf) Test ABON Malaria Pan/P.f.Rapid Test Device (whole blood) CareStart™ Malaria/Pregnancy (HRP2/pLDH/ HCG) ParaCare Malaria HRP2/pLDH (Pf/Pv) COMBO ParaCare Malaria HRP2/pLDH (Pf/VOM) COMBO Surestep™ Malaria Pf/Pan Rapid Test Device (Whole Blood) Malaria Plasmodium falciparum Rapid Test Device (Whole Blood) Malaria pf (HRP II) / pv (pLDH) Antigen Detection Test Device Malaria pf (HRP II) / (PAN-LDH) Antigen Detection Test Device Maleriscan® Malaria Pf/Pv Nano Sign Malaria Pf Ag NanoSign Malaria Pf/Pv Ag BIONOTE MALARIA P.f&P.v Ag Rapid Test Kit IMMUNOQUICK CONTACT falciparum Immunoquick Malaria +4 IMMUNOQUICK CONTACT Malaria +4 Core™ Malaria Pf Core™ Malaria Pv/Pf Core™ Malaria Pan/Pv/Pf OnSite Pf Ag Rapid Test OptiMAL-IT Malaria Pan test Malaria P.F/Vivax One Step Malaria P.f./Pan Whole Blood Test HiSens Malaria Ag P.f/P.v Card HiSens Malaria Ag Pf/Pv (HRP2/pLDH) Card HiSens Malaria Ag Pf HRP2 Card Hexagon Malaria Hexagon Malaria Combi ICT Malaria Combo ICT MALARIA P.F. One Step Malaria Antigen Strip IND ONE STEP MALARIA ANTIGEN P.f/Pan TEST IND ONE STEP MALARIA ANTIGEN P.f Quickstick Malaria Antigen Test Binax Now Malaria Advantage Malaria Card MD Malaria Pf/Pan(pLDH) test Medisensor Malaria HRP2/pLDH (Pf/Pv) COMBO Medisensor Malaria HRP2/pLDH (Pf/VOM) COMBO Clearview® Malaria pLDH Clearview® Malaria Dual First Response® Malaria Ag pLDH BIOCREDIT Malaria pf(HRP II) Malaria Pf/PAN TestX ParaHIT®-f Dipstick ParaHIT®- f Device ParaHIT - Total (Device) ParaHIT Pan M (dipstick) ParaHIT total (dipstick) diagnosticks- Malaria (Pf) Cassette diagnosticks- Malaria (Pf) Dipstick diagnosticks- Malaria (Pv/Pf) Cassette diagnosticks MALARIA (Pan) Cassette diagnosticks MALARIA (Pan/Pf) Cassette diagnosticks MALARIA (Pan/Pv/Pf) Cassette SD BIOLINE Malaria Ag SD BIOLINE Malaria Ag Pf/ Pf/ Pv SD BIOLINE Malaria Ag Pf/ Pan SD BIOLINE Malaria Ag Pv SD BIOLINE Malaria Ag P.f/Pan SD BIOLINE Malaria Ag P.f/P.v SD BIOLINE Malaria Ag Pf FirstSign – Malaria Pf Card Test FirstSign – ParaView-2 (Pv + Pf) Card Test FirstSign™ - PanCheck (Pan) Malaria Test FirstSign™ - ParaView-3 (Pan+Pv+Pf) Malaria Test Vision Malaria Pf Clearview® Malaria Combo Paramax-3 Rapid Test for Malaria Pan/Pv/Pf (device)

Product code 511-25-DB 537-25-DB 539-25-DB 536-25DB IMA-B402 RRHM(U)-XXX7Xa G0161 G0171 IMA-T402 IMA-402 MFV-124V MFV-124R MAT-50 RMAF10 RMAD10 RG19-12 0519K25 0506_K25 0525K25 MAL-190020 Mal-190022 Mal-190026 R0114C 710024 MAL-W23N-001 172110P-25 W56-C HR2823 HR2923 HR3023 58051 58024 ML02 ML04 820-1 535-10 535-11 IN660050 IR211025 MDMALLDH001 M161 M171 70884025 VB20 I12FRC30 HR0100 PROMALPFV001 551C010-50/25977 551C102-50/25975 55IC202-10/25989 55IC301-10 55IC201-10/25988 KMFC6001 KMFD6007 KMVFC6002 MPNWBC1007.3 MPNFWBC1007.4 MPNVFC1007.5 05FK40 05FK100 05Fk66 05FK70 05FK63b 05FK83c 05FK53d 2102CB-25 2104 CB-25 2103 CB-25 VB01 VB11 50320025

Core Diagnostics CTK Biotech, Inc. DiaMed - A Division of Bio-Rad Dima • Gesellschaft für Diagnostika mbH Diagnostics Automation/Cortez Diagnostics Inc. Guangzhou Wondfo Biotech Co. Ltd. HBI Co., Ltd. Human GmbH ICT INTERNATIONAL IND Diagnostic Inc. Innovatek Medical Inc. Inverness Medical Innovations, Inc. J. Mitra & Co. Pvt. Ltd. Medical Diagnostech (Pty) Ltd Medisensor, Inc. Orgenics Ltd. (Inverness Innovations) Orgenics Ltd.(IS) Premier Medical Corporation Ltd. RapiGen inc. Real World Diagnostics

Span Diagnostics

SSA Diagnostics & Biotech Systems

Standard Diagnostics Inc.

Unimed International

Vision Biotech (Pty) Ltd Zephyr Biomedicals Pf, P. falciparum  a

Pv, P. vivax  Pvom, P. vivax, ovale, malariae  HRP2, histidine-rich protein 2  pLDH, Plasmodium lactate dehydrogenase Previously listed with product code G0221 b Previously co-listed with 05FK60 (multi-use pack), but removed because single pack format (05FK63) not evaluated at CDC c Previously co-listed with 05FK80 (multi-use pack), but removed because single pack format (05FK83) not evaluated at CDC d Previously co-listed with 05FK50(multi-use pack), but removed because single pack format (05FK53) not evaluated at CDC

20

Malaria Rapid Diagnostic Test Performance – Summary results of WHO product testing of malaria RDTs: rounds 1-7 (2008-2016)

2. Executive summary 2.1. Introduction WHO estimates that 3.2 billion people are at risk for malaria. In 2015, there were an estimated 212 million cases (with an uncertainty range of 148 million to 304 million) and an estimated 429 000 deaths (with an uncertainty range of 235 000 to 639 000). Approximately 90% of these deaths occurred in sub-Saharan Africa, and just over 70% were of children under 5 years. Malaria remains endemic in 91 countries and territories, and, while parasite-based diagnosis is increasing, national surveys between 2013 and 2015 suggest approximately 31% of suspected malaria cases in sub-Saharan Africa were not confirmed with a diagnostic test, resulting in over-use of antimalarial drugs and poor disease monitoring (1). WHO recommends that malaria case management be based on parasite diagnosis in all cases (2). The use of antigendetecting RDTs is a vital part of this strategy, forming the basis for extending access to malaria diagnosis by providing parasite-based diagnosis in areas where good-quality microscopy cannot be maintained. The data generated by the WHO and FIND programme to evaluate and compare the performance of commercially available malaria RDTs are guiding procurement decisions, which, in turn, have shifted markets towards better-performing tests and helped to improve the quality of manufacture. Since 2009, these data have guided procurement decisions by WHO, other United Nations agencies and national governments and have formed the laboratory evaluation component of the WHO prequalification process for malaria RDTs. Meeting WHO prequalification criteria has not previously been a requirement for WHO procurement; however, as of 1 January 2018, only those products that meet WHO prequalification requirements will be eligible for WHO procurement.1 This report provides the results of round 7 of product testing, performed at the CDC during 2015–2016, with data on the performance of 46 products. This round adds to the evaluations of rounds 1–6 (3–8), which should be considered as a single evaluation, except that the results for products tested in previous rounds that were resubmitted for testing replace those reported previously. From round to round, the evaluation panels are essentially the same (Annex S1), and the same or slightly modified testing protocols are followed. This report extends the data from previous rounds and therefore increases the number of RDTs available for procurement for which detailed, comparative data are available on aspects of performance relevant to field use. The report provides updated data on the performance of products at least every 5 years, as a result of implementation of the compulsory resubmission policy.

2.2. The WHO product testing programme Product testing is part of the WHO–FIND malaria RDT evaluation programme, which develops methods for evaluation and provides data on antigen-detecting malaria RDTs. The programme is a collaboration among many institutions in malaria-endemic and non-endemic countries, with a global specimen bank and testing performed at the CDC (Fig. 2). All companies that manufacture according to ISO 13485:2003 quality system standards were invited to submit tests for evaluation in the programme. The 46 products from 26 manufacturers were evaluated with prepared blood panels of cultured P. falciparum parasites, patient-derived wildtype P. falciparum and P. vivax parasites and a parasitenegative panel. Observed anomalies were recorded. Thermal stability was assessed after 2 months of storage at elevated temperature and humidity, and a rudimentary assessment of ease of use was recorded. In round 7 a new assessment of compliance with good practices for product labelling and instructions for use was included. As in previous rounds, RDTs are grouped in the tables and figures into those designed to detect P. falciparum only, various combination tests and those that have a line only for pan-specific (or P. vivax-specific) malaria. Manufacturers submitted two lots of each product for evaluation. The 15 products that had been tested in previous rounds comprised five compulsory resubmissions and 10 voluntary resubmissions (Tables 1a,b). The aim of the evaluation is to provide comparative data on the performance of the submitted production lots of each product against samples containing low (200 parasites/µL) and high densities (2000 parasites/µL) of P. falciparum or P. vivax . Because the concentration of target antigens in samples with the same parasite density is variable, the process for selecting the panel is adjusted to ensure that there is no statistically significant difference in mean or median concentrations of HRP2, aldolase and pLDH antigens between panels used in different rounds of testing (Annex S1, Table 3). WHO product testing constitutes the laboratory evaluation component of the WHO prequalification process for malaria RDTs (10), which also includes a standardized dossier review and a manufacturing site inspection to ensure safety, quality and performance comprehensively. WHO prequalification of in vitro diagnostics, established in 2008, is used by all United Nations agencies to determine the eligibility of tests for HIV, hepatitis B and C and syphilis for procurement and by national authorities as a complement to their regulatory approvals. WHO prequalification will determine the eligibility of malaria RDTs for procurement as of 1 January 2018. The results of WHO product testing will continue to be used as the independent laboratory evaluation component of the prequalification process.

1

http://www.who.int/malaria/news/2016/rdt-procurement-criteria/ en/ (accessed 8 March 2017)

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Executive Summary Round 7 21

Compulsory resubmission was introduced in round 5. Products that are due for resubmission (every 5 years) that are not submitted are removed from the summary results (Tables S2 and S3) and the online interactive database and appear only in the full round-specific product testing report. These products will not be eligible for WHO procurement. A product is also de-listed if WHO is notified by the manufacturer that its production has been discontinued.

2.3. Results of the evaluation The results (summarized in Tables 4 and 5 and Figs 9, 10, 11, 14 and 15) provide a comparison of two lots of products against a panel of parasite samples diluted to a low parasite density (200 parasites/µL), considered to be close to the threshold that tests must detect in order to identify clinical malaria reliably in many settings (11), and a higher parasite density (2000 parasites/µL). For the purposes of this report, the main measure of performance is the panel detection score (PDS), the percentage of malaria samples in a panel that give a positive result in two RDTs per lot at the lower parasite density and a single RDT per lot at the higher parasite density. Thus, it is not a measure of clinical sensitivity or of the positivity rate against the panel but rather a combined measure of positivity rate and inter-test and inter-lot consistency. As for products evaluated in previous rounds of product testing, the PDS varied, although much less variation was seen for P. falciparum -only detecting RDTs in round 7. Generally, products with high performance in detecting parasites have low false-positive rates, good thermal stability and low rates of anomalies. Overall, there is no obvious trade-off between the PDS (or positivity rate) and the false-positive rate, which are surrogates for sensitivity and specificity in the field, respectively. The basis for P. falciparum detection by combination RDTs, particularly in samples with low parasite density, is predominantly detection of HRP2 and not pLDH. In other words, it is mainly the HRP2 test band that reacts with P. falciparum containing samples, probably reflecting poorer affinity of the monoclonal pLDH antibodies on the pLDH test band and not HRP2-persistent antigenaemia, as all samples are known to contain P. falciparum (and pLDH). Therefore, when using HRP2 and pan-pLDH (or Pf-pLDH) combination products in the field, it is important to remember that the presence of an HRP2 band combined with the absence of a pLDH band may reflect the lower sensitivity of the pLDH-detecting band in low-density samples and not persistent antigenaemia or successful treatment. In round 7, the results for five products submitted for compulsory retesting showed an average PDS decrease of 3.5 percentage points as compared to the previous evaluation round, for detection of P. falciparum (range, –16 to +7; 2/5 had a better PDS). Only two of these tests also targeted P. vivax at 200 parasites/µL; the mean change in PDS was – 42.9 percentage points (range, –91 to +5). The mean change in the false-positive rate of clean negatives

was – 0.4 percentage points (range, –2.5 to + 1.7%). Two of the five tests had improved false-positive rates (one showed no change, and two showed increases). Overall, most of the differences were decreases in PDS and improvements in false-positivity rates in comparison with previous testing. Among the voluntary resubmissions, 80% (8/10) and 75% (6/8) of products showed the same or better detection of P. falciparum and P. vivax at 200 parasites/µL, respectively. Specifically, in tests for P. falciparum, the mean change in PDS was +9.2 percentage points (range, –8 to +40; n = 10); 8/10 had improved PDS. For P. vivax, the mean change in PDS was +30.7 percentage points (range, –8.6 to +65.7; n = 8), and 6/8 had a better PDS. The mean change in the false-positive rate on clean negatives was 1.9 percentage points (range, –7.3 to + 22.9%; n = 10), while 2/10 had a better false-positive rate. In combination tests, no significant correlation was found between the changes in P. falciparum and P. vivax detection (p = 0.7), suggesting that the changes in the detection of the two parasite species were independent. In round 7, none of the products had very high false-positive rates when tested against clean negatives, as in round 6. These are an improvement from the high rates observed in rounds 4 and 5. In contrast, more products reacted against blood samples containing specific immunological abnormalities (and against samples containing non-Plasmodium infectious agents), and these false-positive rates were higher than those seen in round 5 (Tables A4.6–A4.9). The number of samples evaluated was, however, small, and the clinical significance of these results is limited, although they may be important in certain populations with very low parasite prevalence. There was no notable variation among lots in round 7 (Table A4.1); however, as previous rounds have shown variation in performance between the two lots evaluated, it is still recommended that products be lot-tested before field use. The P. falciparum HRP2 test lines in the majority of products showed good heat (thermal) stability after 2 months’ storage at 45°C and 75% humidity; however, Pf-pLDH test lines showed variable baseline performance and deterioration after incubation at 45°C. For many products, pan-pLDH performance at baseline and after heat stress for detection of the P. falciparum isolate was poor, and it was nearly universally poor against low-parasite-density samples, making it difficult to assess true stability. As in round 6, products were assessed for heat stability against a wild-type P. vivax sample. While most of the products performed well, with high positivity rates after 2 months’ storage at 45°C and 75% humidity, others showed some drop in performance after storage, with little difference between pan-pLDH and P. vivax pLDH in test line stability. The frequencies of anomalies that can interfere with test interpretation were recorded. In round 7, 33 of the 46 products had one to five different types of anomaly (Annex S2, Table 8, Fig. 30). Incomplete clearing and red background (not obscuring the test lines) were the most common anomalies, seen in 48% and 24% of products, respectively. Incomplete

22

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

The clinical sensitivity of an RDT, i.e. the proportion of known cases of the disease with a positive test, is highly dependent on local conditions, including the parasite density in the target population; it therefore varies in populations with different levels of transmission. The comparative performance between RDTs shown in this report give an indication of which products are likely to be more sensitive in the field, particularly for populations with low-density infections. In general, as the malaria prevalence in countries falls and they even move towards malaria elimination, detection of low parasite densities will become increasingly important in case management. As the PDS at 2000 parasites/µL indicates, the sensitivity of many of these products will be similar in populations with higher parasite densities, although a subset of any population will include vulnerable individuals who may develop illness at low parasite densities (e.g. young children, pregnant women, people well protected by bed nets) and must always be taken into account when interpreting RDT results. For areas where significant non-expression of HRP2 is known, the results in this report for HRP2-detecting tests should not be considered to predict sensitivity in the field. Only tests targeting P. falciparum by detection of pLDH or aldolase should be considered. Heat stability (summarized in Tables 6a and 6b) is vital to maintaining the sensitivity of a test in the field. For procurement, therefore, the stability results should be used to ensure that products to be used in areas with high temperatures during transport and storage have demonstrated good stability in the product testing programme. The requirements vary by country; for example, if tests are to be used in areas where the temperature rarely rises above 30°C, stability at high temperatures is less important. The requirements for ease of use depend on the extent of training and the work environment of users. Particularly in primary health care settings, the simpler the test, the easier it should be to avoid errors in preparation and interpretation. In round 7, for the first time, adherence to a list of recommendations on instructions for use and product labelling was assessed (Fig. 31-38). Products generally scored well in this assessment for labelling of the main device and labelling of the device packaging and of the primary product box, with some exceptions, especially in warnings and precautions. The scores for adherence to recommendations on labelling of buffer bottles and other accessories were lower. The instructions for use were highly variable, with some important omissions, particularly on laboratory safety, product performance and interpretation.

The results of product testing are reported by product, with the product name and code. The same RDT may be sold in a variety of configurations, such as single or multi-kits, different numbers of tests per box, with or without certain accessories; and they are assigned a distinct product code on this basis. The reports gives the precise name and product code provided by the manufacturer for testing. Procurers should contact the manufacturer for a list of product configurations prior to purchase. Annex S3 outlines a step-by-step approach to selecting an RDT, taking into consideration local conditions of malaria transmission and illness (e.g. Plasmodium spp., target antigen, parasite density, climate) and other important considerations, such as ease of use in the field and lot testing. RDTs must not be procured without preparation for proper use, including supply chain management and training in test use and disposal and in patient management in response to results. Comprehensive guidance on several aspects of procurement can be found in Recommended selection criteria for procurement of malaria rapid diagnostic tests (16), published as a WHO information note in 2016,1 and guidance on implementation in Universal access to malaria diagnosis (17 ).

1

http://www.who.int/malaria/publications/atoz/rdt-selection-criteria.pdf

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Executive Summary Round 7 23

migration, failed migration and a red background obscuring the test lines were the next most common anomalies, in 15%, 11% and 11% of products, respectively. Most of the products with anomalies (31/33) had anomalies in < 1% of the tests, while two products had anomalies in 1.4% of tests (Table 8). This rate is far lower than in round 6, in which all products had one to six anomalies, and approximately half had a frequency > 2%.

2.4. Use of the results Box 3 lists WHO’s current minimum criteria for selecting RDTs. With the upcoming transition to WHO prequalification as a requirement for malaria RDT procurement, the findings from dossiers and site inspections will also be considered; however, the performance requirements will remain the same. The results in Tables S2, S3 and 5 are colour-coded to reflect achievement of these requirements, as well as current WHO prequalification status (indicated in Table S2). A web-based tool maintained by FIND allows filtering of product testing results by various parameters to assist in selecting products with the performance characteristics most suitable for a country’s health programme (15 ). This online database has been updated to allow filtering of results by RDT procedural characteristics, such as blood volume requirements, number of buffer drops and time to result. This grouping, also indicated in Annex 1, will allow use of the same or similar protocols to identify products, so that, when product replacement is required, another product with the same or similar protocol may be selected. Use of similar products may reduce the need for user retraining and also reduce user error.

3. Background During the past decade, new opportunities for the control of malaria have emerged, including use of long-lasting insecticidal nets, indoor residual spraying of insecticides and artemisinin-based combination therapy. These have been shown to reduce the burden of malaria infection in countries where they are adequately implemented. Therefore, the proportion of febrile episodes attributable to malaria is likely to decrease substantially. Despite WHO’s recommendation for a parasitologically confirmed diagnosis of malaria infection before treatment in all cases (2), diagnoses are still often made on clinical grounds (11); however, in many endemic areas, malaria accounts for a minority of cases of “malaria-like” febrile illness. Microscopy has been the cornerstone of diagnosis and is recommended for malaria diagnosis when its quality can be maintained; however, the need for trained personnel and adequate reagents and equipment limits its availability and accessibility in malaria-endemic areas. Rapid, accurate, accessible diagnostic tools are increasingly required as programmes extend parasite-based diagnosis and the prevalence of malaria decreases. RDTs to detect Plasmodiumspecific antigens (proteins) in whole blood of infected people are an attractive alternative to microscopy. The currently available RDTs come in various formats (dipstick, cassette or hybrids) and contain antibodies bound to specific antigens, such as HRP2 specific to P. falciparum, pan-specific and species-specific pLDH or aldolase specific to all the major Plasmodium species most relevant to human health (P. falciparum, P. vivax, P. malariae, P. ovale) (Fig. 1). To be widely useful, an RDT must be highly sensitive to ensure detection of all clinically significant malaria infections, highly specific to allow monitoring of low malaria prevalence and appropriate management of non-malarial fevers and highly stable to allow transport and storage in ambient conditions in malaria-endemic areas. Published field trials of RDTs show highly variable performance, probably due to poor manufacturing quality, incorrect storage and handling, poor preparation and interpretation, and sometimes poor study methods, analysis and reporting (17–25). In general, diagnostic testing by microscopy or RDT to a level of 200 parasites/µL will reliably detect nearly all clinically relevant infections in malaria-endemic areas (11). The number of RDTs available on the market grew rapidly after their introduction in the late 1990s; sales reported by 41 manufacturers showed a peak of 320 million tests sold in 2013. Since 2013, there has been a global decline, due to decreasing sales in Asia, although sales in Africa have risen every year since 2008 (1). Regulatory control of diagnostics is, however, often weak, and procurement agencies have had considerable difficulty in selecting appropriate RDTs and ensuring their quality. In view of the inconsistency in the results of field studies and the inherent difficulties in assessing large numbers of products in a standardized way in field trials, WHO and partners embarked on a programme in 2002 to evaluate RDTs for malaria, in order to ensure standardized assessment of performance and to guide procurement decisions and regulatory mechanisms. Between 2003 and mid-2012, the programme was managed by WHO and TDR in partnership with FIND. After TDR withdrew its involvement in 2012, the WHO Global Malaria Programme assumed a coordinating role. A steering committee oversees the development of and modifications to standard operating procedures (26, 27 ). A network of specimen collection sites has been established to provide specimens for a global bank at the CDC and to facilitate local quality control (Fig. 2). The reports of the previous six rounds of product testing have been released annually since 2009 (3–8). This seventh report adds data on the performance of 29 new products and updated data on 17 resubmitted RDTs. Testing for round 7 was conducted against an evaluation panel with characteristics similar to those of previous panels in terms of overall antigen concentration, parasite origin and parasite-negative blood samples (Annex S1). Most panel samples were retained from previous rounds, with 19 of 100 P. falciparum, 5 of 35 P. vivax and 17 of 100 negative samples replaced (new) in round 7.

4. Objective The objective of the programme is to evaluate malaria RDTs for performance in order to guide procurement of RDTs for use in the field in malaria-endemic countries.

24

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Figure 1: Mode of action of antigen-detecting malaria RDTs a Bound Ab Lysing agent and labelled Ab Control line (bound Ab)* Test line (bound Ab)*

Mode of action of common malaria RDT format:

Free labelled Ab

Nitrocellulose strip *Not normally visible

Bu er/ ushing agent

b Parasite Ag captured by labelled Ab

Parasitized blood

(b) Blood and buffer, which have been placed on the strip or in the well, are mixed with the labelled antibody and are drawn up the strip across the lines of bound antibody. (c) If antigen is present, some labelled antibody will be trapped on the test line. Other labelled antibody is trapped on the control line.

c

Blood and labelled Ab ushed along strip

Labelled Ab–Ag complex captured by bound Ab of test band

Labelled Ab captured by bound Ab of control band

Captured Ag–labelled Ab complex

Captured labelled Ab

Malaria, countries or areas at riskand of transmission, 2009 Figure 2: Network of specimen collection, characterization testing sites

HTD CDC DRM EHNRI KEMRI IHRDC IPM IPC RITM

CIDEIM IMT

UCAD

IPB UL

QIMR Collection and testing site Specimen characterization Global specimen bank Countries or areas where malaria transmission occurs Countries or areas with limited risk of malaria transmission No malaria This map is intended as a visual aid only and not as a definitive source of information about malaria endemicity. Source: © WHO 2010. All rights reserved.

CDC, Centers for Disease Control and Prevention (Atlanta, United States of America); CIDEIM, Centro Internacional de Entrenamiento y Investigaciones Médicas (Cali, Colombia); DMR, Experimental Medicine Research Division (Department of Medical Research, Yangon, Myanmar); EHNRI, Ethiopian Health and Nutrition Research Institute (Addis Ababa, Ethiopia); HTD, Hospital for Tropical Diseases (London, United Kingdom); IHRDC, Ifakara Health Research and Development Center (Bagamoyo, United Republic of Tanzania); IMT, Instituto de Medicina Tropical (Universidad Peruana Cayetano Heredia, Lima, Peru); IPB, Institut Pasteur de Bangui (Bangui, Central African Republic); IPC, Institut Pasteur du Cambodge (Phnom Penh, Cambodia); IPM, Institut Pasteur de Madagascar (Antananarivo, Madagascar); KEMRI, Kenya Medical Research Institute (Kisumu, Kenya); QIMR, Queensland Institute of Medical Research (Brisbane, Australia); RITM, Research Institute of Tropical Medicine (Manila, Philippines); UCAD, Université Cheikh Anta DIOP (Dakar, Senegal); UL, University of Lagos (Lagos, Nigeria).

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Executive Summary Round 7 25

(a) Dye-labelled antibody (Ab), specific for the target antigen, is present on the lower end of the nitrocellulose strip or in a well provided with the strip. Antibody, also specific for the target antigen, is bound to the strip in a thin (test) line, and either antibody specific for the labeled antibody, or antigen (Ag), is bound at the control line.

5. Materials and methods 5.1. Test selection In July 2015, the WHO–FIND malaria RDT evaluation programme issued a call for expressions of interest to manufacturers of malaria RDTs with information on the requirements for submission of a product to round 7 and the conditions for participation in the evaluation programme (29). Manufacturers of products that had not been retested since round 3 were informed they must resubmit these products; otherwise, the performance characteristics would be removed from the summary results document, which is a compilation of the results of all previous rounds of testing. This rule was introduced in round 5 to ensure that all products were retested < 5 years after the primary submission. Other standard requirements included valid ISO 13485:2003 certification of all manufacturing sites, sufficient quantities of products (1100 tests from each of two lots1), compliance with

1

Manufacturers were requested to supply an additional 500 RDTs per lot voluntarily to support the WHO-FIND evaluation of malaria recombinant antigens.

Table 1a: Manufacturers and products accepted into round 7 of WHO malaria RDT product testing programme Manufacturer Product name Product codea Target antigen(s)

CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDTc Access Bio, Inc. CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line CareStart™ Malaria Screen RDTb CareStart™ Malaria Pf/PAN (pLDH) Ag RDTb Access Bio Ethiopia Advy Chemical Private Limited Alere Medical Private Limited ALLDIAG SA ARKRAY Healthcare Pvt Ltd ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Biosynex DIALAB Guangzhou Wondfo Biotech Co., Ltd. Hangzhou AllTest Biotech Co. Ltd. Hema Diagnostic Systems ICT INTERNATIONAL InTec Products, Inc. Lumiquick Diagnostics Inc. Medical Diagnostech (Pty) Ltd Real World Diagnostics CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test

RMVM-05072 RMSM-05071 RMAM-05071 RMLM-05071 RMOM-03091 RMVM-03091 RKMAL016 RKMAL017

V(pLDH), HRP2 F(pLDH), HRP2 pan(pLDH), HRP2/F(pLDH) pan(PLDH), F(pLDH) HRP2 V(pLDH), HRP2 pan(pLDH), HRP2 HRP2 pan(pLDH), HRP2 V(pLDH), HRP2 pan(pLDH), V(pLDH), HRP2 HRP2 HRP2 HRP2 pan(pLDH), HRP2 V(pLDH), HRP2 HRP2 HRP2 pan(pLDH), HRP2 V(pLDH), HRP2 pan(pLDH), HRP2 HRP2 HRP2 V(pLDH), HRP2 Aldolase, HRP2 HRP2, pan(pLDH) HRP2 HRP2 V(pLDH), HRP2 V(pLDH), HRP2 HRP2 HRP2, V(pLDH) pan(pLDH), HRP2 V(pLDH), HRP2 HRP2

Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) 05FK60AI-40 Rapid Test Kit for Malaria Ag Pf/Pv- Alere Trueline Malaria Ag Pf/Pv 11108191040 PALUTOP +4 optima® PALUTOP + pf® Parahit® f Ver 1.0 - Deviceb Parahit f® Ver 1.0 - Dipstickb Asan Easy Test® Malaria Pf/Pan Aspen® Malaria Ag Pf/Pv Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card BioTracer™ Malaria P.f/PAN Rapid Cardc Biosynex® Malaria Pf/Pv Biosynex® Malaria Pf/Pan DIAQUICK Malaria P.f. Cassette One Step Malaria HRP2 (P.f) Testc One Step Malaria HRP2/pLDH (P.f/P.v) Testc AllTest™ Malaria P.f./Pan Rapid Test Cassette Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN ICT MALARIA DUAL TESTc ICT MALARIA P.F. CASSETTE TESTb ADVANCED QUALITY ™ ONE STEP Malaria (p.f) Testc QuickProfile™ Malaria Pf/Pv Antigen Testc GMD Malaria Pf test Malaria Pf/PAN Test Agc 5499 5531 55IC104-50 55IC103-50 AM4650-K AS0060 AS0015 17912 17012 0581_K25 0584_K25 W06200 W37-C W056-C IMPN-402 ML03 ML01 ITP11002-TC25 71050 GMDMALPF001 PROMALPFV001 MPFPAN050

MAL-PF/Pan-CAS/25 HRP2, pan(pLDH)

ADVANCED QUALITY ™ ONE STEP Malaria (p.f/p.v.) Tri-line Testc ITP11003-TC25

Medsource Ozone Biomedicals Pvt. Ltd. Is It... Malaria Pf PAN Meril Diagnostics Pvt. Ltd.

One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag MFLRPD-02 One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag MPHRPD-01

26

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Table 1a: (continued) Manufacturer Product name Product codea Target antigen(s)

NG Biotech RapiGEN Inc.

NG-Test MALARIA Pf/Pan (pLDH) BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH)c BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Alere™ Malaria Ag P.f careUS™ Malaria Pf (HRP2) Ag careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf Rapid Test Malaria Pf/Pv Rapid Test

NGB-MAL-W23-005 HRP2, pan(pLDH) C32RHA25 C60RHA25 R-409-50-C 05FK130-40-0 05FK140-40-0 RMO-M05082 RMV-M05082 GCMAL(pf)-402a pan(pLDH), HRP2 V(pLDH), F(pLDH) HRP2 HRP2/F(pLDH) HRP2 HRP2 V(pLDH), HRP2 HRP2

Shanghai Kehua Bio-engineering Co., Ltd. KHB® Malaria Ag (HRP2) Pf Rapid Test Standard Diagnostics, Inc.d WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd.

GCMAL(pf/pv)-402a HRP2, V(pLDH)

pLDH, Plasmodium lactate dehydrogenase; HRP2, histidine rich protein 2; V, P. vivax; F, P. falciparum a The product code corresponds to a specific configuration of the RDT, kit components and accessories. Therefore, changes to this configuration including the quantity of tests, the contents or the manufacturing site are denoted by a different product code. Often this involves the end portion of the product code; however, the manufacturer should be contacted for full details. b Indicates previously submitted products which were submitted for compulsory restesting in round 7. c Indicates products which have previously been submitted and were voluntarily resubmitted in round 7. d An Alere company

Table 1b: Products due for compulsory resubmission in round 7 Manufacturer ABON Biopharm (Hangzhou) Co. Ltd Access Bio, Inc. ACON Biotech (Hangzhou) Co. Ltd AZOG, Inc Bioland, Ltd BioNote,Inc. Biosynex Product name ABON Malaria Pan/P.f. Rapid Test Device (Whole Blood) CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria/Pregnancy (HRP2/pLDH/ HCG) CareStart™ Malaria Screen RDT Surestep™ Malaria Pf/Pan Rapid Test Device (Whole Blood) Malaria pf (HRP II) / pv (pLDH) Antigen Detection Test Device Malaria pf (HRP II) / (PAN-LDH) Antigen Detection Test Device Nano Sign Malaria Pf Ag NanoSign Malaria Pf/Pv Ag BIONOTE MALARIA P.f/P.v Ag Rapid Test Kit IMMUNOQUICK CONTACT falciparum IMMUNOQUICK CONTACT MALARIA +4 Core™ Malaria Pf Core Diagnostics CTK Biotech, Inc. DiaMed - A Division of Bio-Rad ICT International J. Mitra & Co. Pvt. Ltd. Orgenics Ltd. Standard Diagnostics Inc. Span Diagnotics Ltd.e Core™ Malaria Pv/Pf Core™ Malaria Pan/Pv/Pf OnSite Pf Ag Rapid Test OptiMAL-IT ICT Diagnostics Malaria P.f Advantage Malaria Card Clearview® Malaria pLDH SD BIOLINE Malaria Ag ParaHIT® - f (Device) ParaHIT® - f (Dipstick) diagnosticks MALARIA (Pan) Cassette SSA Diagnostics & Biotech Systems diagnosticks MALARIA (Pan/Pf) Cassette diagnosticks MALARIA (Pan/Pv/Pf) Cassette Vision Biotech (Pty) Ltd. Guangzhou Wondfo Biotech Co. Ltd. a

Product Code IMA-B402 RMLM-05071b RRHM(U)-XXX7Xc RMAM-05071d IMA-T402 MFV-124V MFV-124R RMAF10 RMAD10 RG19-12 0519K25 0525K25 MAL-190020 Mal-190022 Mal-190026 R0114C 710024 MAL-W23N-001 ML01 IR211025 70884025 05FK40 55IC102-10 55IC101-10 MPNWBC1007.3 MPNFWBC1007.4 MPNVFC1007.5 VB11 VB01 W56-C

Participation in round 7a No Yes No Yes No No No No No No No No No No No No No No Yes No No No Yes Yes No No No No No No

Dima • Gesellschaft für Diagnostika mbH Malaria Pan test

Clearview® Malaria Combo Clearview® Malaria Pf One Step Malaria P.f./Pan Whole Blood Test

The results of the first testing of the products in this list that were not retested in round 7 have been removed from tables S2 and S3 and figs S1 and S2 and are listed in table S4. b Previously listed with product code G0121 c Previously listed with product code G0221 d Previously listed with product code G0231 e Currently listed with product codes 55IC104-50 and 55IC103-50. Span Diagnostics is now ARKRAY Healthcare Pvt.Ltd.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Methods 27

the product definition1, deadlines for document submission and payment of fees. Twenty-seven manufacturers, proposing 45 products, responded to the call, and the products went forward for testing. A further product from one manufacturer was exceptionally accepted as a late entry, directly into phase 2, because of the urgent need for pf-pLDH-based RDTs in areas with a high prevalence of HRP2 deletions. Overall, 46 products from 27 manufacturers were tested in round 7 (Table 1a). Catalogue numbers and verification with manufacturers showed that 15 of the 46 products (33%) had been submitted previously to one or more rounds, including five (11%) scheduled for compulsory resubmission (Table 1b). All 45 products met the minimum performance requirements2 in the initial evaluation against the P. falciparum culture-derived panel (phase 1) and were therefore evaluated fully in phase 2, with the additional product. Of the 46 products that were fully evaluated, 19 are designed to detect P. falciparum alone, 13 to detect and differentiate P. falciparum from non-P. falciparum malaria, 13 to differentiate P. falciparum from P. vivax and one to detect and differentiate P. falciparum, P. vivax and other Plasmodium species. Of these products, five detected P. falciparum pLDH. Three products had separate Pf-pLDH detecting lines and two combined P. falciparum pLDH with HRP2 on the same line. Annexes 1 and 2 give a comprehensive overview of the product characteristics.

5.2. The product testing protocol The testing process is outlined in Fig. 3 and in the Methods manual for product testing of malaria rapid diagnostic tests, version 6 (28). In brief, RDTs from each of two lots of each product were evaluated against a panel of parasite-positive and parasite-negative cryopreserved blood samples. Both lots were also tested for heat (thermal) stability, evaluated after 2 months’ storage at room temperature (21–24°C), 35°C and 45°C. A description of the ease of use of the products was completed on a standard form, and common anomalies were recorded. Evaluation of adherence to recommendations on instructions for use and labelling was introduced in round 7. Products were assessed against a list of preferred and required recommendations on the scope, format and terms used in the instructions for use and on the labelling of the box, the test device, its primary packaging, buffer bottle, other accessories. The testing and all the results were monitored by the WHO– FIND steering committee, and manufacturers were given 30 days to comment on the results for individual products before publication.

5.3. Evaluation panels RDTs were evaluated against three panels: • P. falciparum culture lines (includes a subset, “manufacturer’s panel”) at low (200 parasites/µL) and high parasite density (2000 parasites/µL); • wild-type Plasmodium species (P. falciparum, P. vivax ) from naturally infected humans diluted with parasitenegative samples to low (200 parasites/µL) and high

1

A working definition of a product can be found in Annex 2 (http:// www.who.int/malaria/news/2015/EOI-letter-to-manufacturers-Rd7annex-2jul2015.pdf?ua=1, accessed 8 March 2017). PDS > 80% against high-density (2000 parasites/µL) P. falciparum in culture

2

Figure 3: Overview of malaria RDT product testing RDT product testing flow chart

Panel detection score and false-positive rate Test RDTs against high and low density samples of phase 1 panel

Heat stability Select RDTs from 2 differents lots

Ease-of-use description

Labelling and instruction for use

Blood safety

Labelling

Instruction for use

Proceed to test RDTs against phase 2 panel, if pass phase 1

Place in a 35°C incubator

Place in a 45°C incubator

Initial test (room temperature) 200, 2000 p/µL

Total time to obtain result Number of timed steps

Store for 2 months at 75% humidity In each case, read each result with: Remove and allow RDTs to reach room temperature

Quality of the instructions Additional information • format • blood transfer method • items included in package • language • anomalies

• Box • Cassette packaging • Cassette • Buffer container • Accessories

Technician 1

Technician 2

Completed assessment forms

• Layout • Product information • Intended use • Warnings and precautions • Materials • Storage and stability • Procedure • Limitations • Performance specifications • Bibliography • Contact manufacturer

Prepare RDTs with a 200 p/µL sample

Prepare RDTs with a 2000 p/µL sample

Record results

Record results

Record results

28

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

parasite density (20001 parasites/µL), all samples prepared from isolates that express HRP2; and • a parasite-negative panel (“clean” samples and diseasespecific or blood factor-specific samples). An overview of sample collection and characterization is given in the methods manuals prepared for this purpose (27, 28). Characterization results for each round are available in the reports of previous rounds (3-8). Each panel specimen was characterized for: • species, by duplicate microscopy (two microscopists) and confirmation of mono-species infection by nested polymerase chain reaction (PCR); • antigen concentration, by quantitative ELISA for HRP2, pLDH and aldolase; and • the absence of malaria parasites by nested PCR and confirmatory testing for other diseases in the case of parasite-negative samples. Some of the P. falciparum samples in the global specimen bank were also characterized according to HRP2 sequence by PCR amplification and sequencing. This was not performed on samples collected after 2009, as accumulated evidence indicates that HRP2 variation has no significant effect on RDT sensitivity (30). The geographical origin of all samples was recorded.

culture bank and diluted in O-positive blood from donors in the USA (28).

Wild-type parasite panel The parasite-positive wild-type (clinical) panel consisted of samples from 100 cases of P. falciparum and 35 cases of P. vivax malaria, from 11 collection sites in Africa, Asia and South America (Figs 2, 4a and 4b). Samples were collected from febrile patients and processed by standard methods designed to preserve the target antigen concentration (27 ). After dilution and cryopreservation, the samples were transferred to the global bank (WHO specimen bank) at CDC for further characterization. The concentrations of sample antigens (HRP2, pLDH, aldolase) determined by quantitative ELISA are shown in Table 3. The results are based on 98 P. falciparum samples for pLDH, 99 P. falciparum samples for HRP2 and 100 for aldolase, 34 P. vivax samples for pLDH and 35 P. vivax samples for aldolase. This panel is closely comparable to those of previous rounds (Annex S1).

Negative blood sample panel The negative panel consisted of 52 “clean” parasite-negative samples from donor-derived blood obtained in banks or from volunteers in non-endemic (USA) and endemic areas (Cambodia, Kenya, Madagascar, the Philippines and Senegal) that had been confirmed to be malaria-negative by microscopy and PCR. The negative sample panel also contained 48 parasite-negative samples from donors with diseases that might be used in the differential diagnoses of malaria, that contained blood factors known to be common in the community or that could result in false-positive reactions in immunochromatographic tests (Table 2). All negative control samples were confirmed to be free of Plasmodium parasites by nested-PCR.

Panel composition P. falciparum-cultured parasites panel The programme selected culture-adapted strains of P. falciparum from various geographical locations, including 13 strains with type B HRP2 sequence, five with type A and two with type C (30). All specimens were derived from the CDC 1 Three

(3%) of the 100 high-parasite-density P. falciparum dilution samples contained 5000 rather than 2000 parasites/µL.

Figure 4a: Origin of phase 2 P. falciparum wild-type (clinical) samples (n=100) 50 45 40 No. of samples

Figure 4b: Origin of phase 2 P. vivax wild-type (clinical) samples (n=35) 18

35 30 25 20 15 10 5 0 mb od ite ia d of Repu Ta bli nz c an ia ge ria eg al C an en Re tra pu l bli Ph c ilip pin es Co lom bia Pe ru ya iop ia ma r Ke n Se n an Eth Ni My 0 No. of samples 12

6

mb od ia

Un

Af

ric

Ph ilip pin

Co lom

Ca

Ca

Eth

iop ia

Pe ru

bia

es

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Methods 29

Table 2: Characteristics of Plasmodium spp. negative samples Nature of negative samplea Clean-negativeb Anti-nuclear antibody positive (sera) Anti-mouse antibody positive (plasma) Rheumatoid factor positive (whole blood and sera) Rapid plasma reagin positive (sera) Chagas' disease antibody positive (plasma) Dengue antibody positive (whole blood sera) Leishmaniasis antibody positive (sera) Schistosomiasis antibody positive (whole blood and sera) a

No. 52 12 3 6 6 2 7 4 8

of a set of lot 1 of all products was completed, then a set of lot 2 was tested, until both lots of all products had been tested against all panel samples. Phase 1. A screening step is used to allow selection of RDTs that meet the minimal quality requirements. Products from two lots were evaluated against a panel of 20 culture-derived P. falciparum samples at high (2000 parasites/µL) and low (200 parasites/µL) parasite density, and against 20 clean negative samples. To progress to the full evaluation (phase 2), a product evaluated in phase 1 must achieve a minimum PDS of 80% against the samples containing 2000 parasites/µL and <50% false positive rate against clean negative samples. Phase 2. Products from two lots are evaluated against a panel of diluted clinical blood samples containing wild-type parasites and a parasite-negative panel, evaluated for heat (thermal) stability and assessed for ease of use. Because the number of aliquots were smaller, fewer replicate RDTs were performed. • Performance assessment: The mixed parasite-positive and parasite-negative panel comprised 100 P. falciparum, 35 P. vivax at two parasite densities (200 parasites/µL and 2000 parasites/µL 2) and 100 parasite-negative samples. • Evaluation of heat stability for P. falciparum- detecting products: 15 RDTs from each of two lots were tested against a single culture-derived P. falciparum isolate (Nigeria XII strain, P. falciparum HRP2 sequence type B) with a typical antigen concentration3 at 200 parasites/µL, five RDTs from each lot against P. falciparum Nigeria XII strain at 2000 parasites/µL and four RDTs from each lot against a negative sample, which were all tested at baseline and after RDTs were maintained for 60 days at room temperature (< 25°C), 35°C and 45°C, at 75% humidity. Evaluation of heat stability for P. vivax- detecting products: Four RDTs from each of the two lots were tested against a single wild-type P. vivax sample4 (from Ethiopia) at 200 parasites/µL, two RDTs from each lot against P. vivax at 2000 parasites/µL and four RDTs from each lot against a negative sample, at baseline and after RDTs were 2 3

Whole blood unless indicated. Sera and plasma samples were reconstituted packed cells b Healthy volunteers with no known current illness or blood abnormality

5.4. Product registration Receipt of each shipment of RDTs at the CDC was recorded in a dedicated RDT register. Temperature monitoring devices were offered to manufacturers free of charge to accompany RDT shipments to the CDC. All RDTs were stored at room temperature (21–24°C) immediately, and temperature monitors were labelled with the date of receipt and forwarded for data extraction and analysis, when applicable.

5.5. Specimen panel registration All panel specimens were assigned unique identification numbers at the collection sites and stored in aliquots of 50 µL at –70°C until testing. All data pertaining to specimen identification, storage location and characterization are stored in a secure, dedicated database.

5.6. Test phases The evaluation is divided into two phases. Each lot of RDTs was evaluated independently. Lots 1 and 2 of each product were tested alternately against defined sample sets1, testing 1

Three (3%) of the 100 P. falciparum high parasite density dilution samples contained 5000 parasites/µL rather than 2000. The P. falciparum sample had 18.8 ng/mL of HRP2, 21.1 ng/mL of pLDH and 0.49 ng/mL of aldolase. The P. vivax sample had 143.9 ng/mL of pLDH and 44.4 ng/mL of aldolase.

A sample set usually consists of 13 P. falciparum specimens and 5 P. vivax specimens at 200 parasites/µL and 2000 parasites/µL and 13 malaria-negative samples.

4

Table 3: Malaria antigen concentrations (ng/mL) in round 7 wild-type, low parasite density (200 parasites/µL) samples pLDH HRP2 Aldolase

P. falciparum Mean Median Maximum Minimum Standard deviation 15.9 13.0 53.5 0.2 11.6

P. vivax 16.9 16.6 44.8 1.6 11.2

P. falciparum 11.8 6.8 62.5 0.7 13.0

P. falciparum 1.4 1.3 9.1 0.0 1.3

P. vivax 8.2 8.0 15.1 3.2 3.6

30

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

maintained for 60 days at room temperature (21-24°C), 35°C and 45°C, at 75% humidity. The pLDH concentrations in the samples chosen were above average in order to increase the probability of good RDT baseline reactivity, thereby allowing an interpretable assessment of stability or degradation. • Ease-of-use assessment: After technicians had become familiar with the test device, they jointly described its blood safety characteristics, the quality of the instructions, the number of timed steps and the total time to a result, using a standard reference guide (28). • Assessment of labelling, packaging and instructions for use: Technicians assessed the product components to

determine whether they met each of the recommended or preferred criteria, assessed in the following categories: • labelling of the RDT box (58 criteria assessed); • labelling of the primary cassette packaging (16 criteria assessed); • labelling of the cassette (11 criteria assessed); • labelling of the buffer bottle (15 criteria assessed); • labelling of the accessories (transfer devices, lancets, alcohol swabs and desiccant) (19 criteria assessed); and • content and format of the instructions for use (119 criteria assessed). See supplemental files for full details.

Figure 5: Testing procedure and calculation of panel detection score and band intensity for product A against a sample density of 200 parasites/µL

Product A Lot 1 Lot 2

Test 1

Test 2

Test 3

Test 4

a Reading 1 Reading 2

b Reading 1 Reading 2

c Reading 1 Reading 2

d Reading 1 Reading 2

Detected if 4 positive first readings

Based on the positive results of first test reading (2 tests per lot), the mean band intensity score =a+b+c+d/4 (excluding negative results). a Second

reading results are for internal use only

Figure 6: Testing procedure and calculation of panel detection score and band intensity for product A against a sample density of 2000 parasites/µL The first reading was at the minimum time specified by the manufacturer; the second reading was up to 30 min latera. A sample is considered detected only if all first test readings, from both lots, are positive, i.e. readings a and b must be positive.

Product A Lot 1 Lot 2

Test 1

Test 2

a Reading 1 Reading 2

b Reading 1 Reading 2

Detected if 2 positive first readings a Second

Based on positive results of first test reading (2 tests per lot), in each lot, the mean band intensity score =a+b/2 reading results are for internal use only

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Methods 31

The first reading was at the minimum time specified by the manufacturer; the second reading was up to 30 min latera. A sample is considered detected only if all first test readings, from both lots, are positive, i.e. readings a, b, c and d must be positive.

• RDT anomalies: During testing, technicians regularly reported the RDT anomalies listed below (not all of which were observed in round 7) and in Fig. AS2.1. When anomalies were noted frequently, a photograph was taken of at least one example. • red background • red background obscuring test line(s) • incomplete clearing • incomplete migration • failed migration • ghost test line(s) • patchy, broken test line(s) • diffuse test line(s) • strip misplaced in cassette (shift) • specimen pad not seen in sample window • buffer remains pooled in buffer well

used. The result was recorded by a technician at the minimum specified reading time, and a second technician re-read the result within 30 min for internal monitoring and to obtain information for the manufacturer. Annexes 1 and 2 give a descriptive, illustrated summary of the test characteristics and steps and a guide to interpretation of results.

5.8.  Interpreting the results The results of control and test lines were recorded as negative or positive by each technician. Each test line was read against a standard colour chart and the band intensity graded as 0 (no visible band), 1, 2, 3 or 4 (1 being the weakest colour intensity and 4 being the strongest). If the control line was recorded as “0” (no visible band) by either technician, the test was recorded as invalid. Figs 5 and 6 illustrate the testing sequence at low and high parasite density.

5.7. Performing rapid tests All RDTs were maintained at room temperature (21–24 °C) until first use. When applicable, the desiccant was inspected for colour change, and products were discarded if they were present. Technicians were rotated and blinded to the sample type and to each other’s results. RDTs were labelled with a sample identification number and the date on which test was performed. The tests were used according to the manufacturer’s instructions, except that the recommended volume of blood was transferred by micropipette from the sample tube; co-packaged blood transfer devices were not

5.9. Recording anomalies Anomalies are defined as unexpected features that appear during performance of an RDT. Anomalies have been observed since round 1. After the appearance of each, technicians agreed on terms with which to identify them. During earlier rounds of testing, their presence was recorded informally (and reported to manufacturers), but, since round 6, the frequency of anomalies has been recorded. Some anomalies do not interfere with the interpretation of results, while others may obscure test or control lines and therefore affect the interpretation and create confusion. Manufacturers are encouraged to reduce or eliminate anomalies and to acknowledge them in their instructions for use.

6. Data management Receipt of products was hand-recorded in a RDT register at the CDC as per standard operating procedures. Data associated with specimen collection and characterization were recorded, first on hard-copy report forms as per the standard operating procedure at the collection sites (Fig. 2), the Hospital of Tropical Diseases (quantitative ELISA results) and the CDC (PCR results), then entered directly into Excel, followed by importation into a specially developed database. The results of product panel testing and heat stability testing conducted at the CDC were recorded on report forms by each technician individually, as per the standard operating procedure. The results were entered in duplicate and analysed for discrepancies. All source documents and electronic records of the study data are maintained in secure storage until the conclusion of the evaluation, data analysis and publication of the report. Individual product testing reports and raw data were sent to manufacturers in December 2016 for a 30-day review period before production of the final report.

32

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

7.  Quality assurance Product testing follows standard operating procedures developed during previous testing rounds, which are based on recommendations by expert consultants, with minor modifications by the steering committee before round 7 (28). Overall, the quality of critical steps was controlled as described below. used for internal monitoring. The summarized results were reviewed in detail, and potential discrepancies were identified and cross-checked against source laboratory report forms. All wild-type parasite samples used in phase 2 were randomized with parasite-negative samples and re-labelled. Reading of the RDT results by the first and second technician is blinded.

7.1.  Quality of malaria RDTs and their use All RDTs were stored in a controlled environment at room temperature (21–24 °C). The pouch was opened, and, if applicable, the desiccant was checked for colour change immediately before use. The manufacturer’s instructions were followed, except for use of the blood transfer device provided by the manufacturer: a micropipette was used to ensure the correct blood volume. A temperature monitoring device was offered to manufacturers to be shipped with the RDTs to the testing site (CDC). Lots were analysed at temperatures above and below the manufacturer’s recommended storage conditions.

7.3.  Quality of WHO specimen bank samples Standard operating procedures were established for the preparation of all specimen bank samples (26). Culture lines of parasites and wild-type samples were selected on the basis of previous evidence and data from specific studies. All diluted parasite sample aliquots were stored and transported at –70°C and were used only once within 8 hours of thawing.

7.4.  Quality of the product testing site The Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, is the main operating component of the Department of Health and Human Services of the USA for malaria control and prevention. Laboratories within the Division are accredited by Clinical Laboratory Improvement Amendments and are monitored by an internal quality management system.

7.2.  Quality and objectivity of RDT readings The results were read under good lighting, using standard colour charts by trained technicians tested for visual acuity and were doubly entered into the database. Technicians were rotated, and the readings of a second technician were

8. Ethical considerations Each specimen collection site obtained approval from a WHO research ethics review committee and/or a local institutional review board for specimen collection, transport and archiving of blood samples for the purpose of RDT product testing, lot testing and quality assurance.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Methods 33

9. Data analysis 9.1. Measures of parasite detection: panel detection score and positivity rates As shown in Fig. 5, a product must return four positive test results at the manufacturers’ recommended minimum reading time (two from lot 1, two from lot 2 at the initial reading time) when tested against a parasite density of 200 parasites/µL to contribute to its PDS. When tested against 2000 parasites/µL (Fig. 6), the product must return two positive tests at the manufacturers’ recommended minimum reading time (one from each lot). Thus, the PDS is a measure of inter-test and inter-lot consistency, as well as the ability of the test to detect antigen. The PDS for P. falciparum indicates an RDT result that confirms the presence of P. falciparum when tested against cultured and wild-type P. falciparum samples, while the P. vivax PDS indicates Plasmodium-positive/P. falciparumnegative results when tested with wild-type P. vivax samples. The positivity rate is the percentage of all tests of a particular product that returned a positive result at the manufacturers’ recommended minimum reading time when tested against a P. falciparum or P. vivax sample. percentage of all tests of a particular product that returned a positive test result when it should not have been obtained, when read at the manufacturer’s recommended minimum reading time.

9.2.1  Incorrect species identification A test is considered to have returned an incorrect species result if a positive P. falciparum test line appears when testing a sample containing non-P. falciparum (P. vivax) parasites. Fig. 7 illustrates the various possibilities for incorrect species identification in combination tests. For example, if P. falciparum samples result in only a visible pan-specific (or non-P. falciparum -specific) test line in combination tests, the result is considered to be a false-positive for non-P. falciparum parasites.

9.2.2 False-positive results for Plasmodiumnegative samples Any positive reading of samples with no Plasmodium parasites is considered a false positive. In phase 2, parasite-negative samples are clean negative samples and samples containing other infectious agents (dengue, leishmania, Chagas, schistosoma and rapid plasma reagin, which is indicative of syphilis infection) and immunological factors (rheumatoid factor, anti-nuclear antibodies, anti-mouse antibodies) (Table 2).

9.2. False-positive results False-positive results are analysed and reported as two groups: those with incorrect species identification and those that returned a positive result for samples that do not contain Plasmodium spp. Specifically, the false-positive rate is the

9.3. Band intensity All positive test results were recorded with their band intensity against a standard reference chart, matched closely to

Figure 7: Classification of incorrect species identification with combination malaria RDTs Pf/pan combination tests Panel sample Pf Pv False-positive (Pf) False-positive (Pf) Pf + / Pan Pf + / Pan + Pf - / Pan + False-positive (non-Pf) Pf - / Pan Negative Negative

Pf/Pv combination tests Panel Pf Pv False-positive (Pf) Pf + / Pv Pf + / Pv + False-positive (Pv) False-positive (Pf) Pf - / Pv + False-positive (non-Pf) Pf - / Pv Negative Negative

34

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

line colour. On the basis of the results of the first reader, the distribution of band intensity results is presented as the mean band intensity of positive results. In addition, the intensity was expressed for each possible result (0, 1, 2, 3 or 4) as the percentage recorded at that level1.

9.4. Lot agreement Agreement between test lots is calculated from the number of samples that return a positive result on both RDTs tested in that lot against parasite-positive samples at 200 parasites/µL, and on the single RDT from each lot tested against samples at 2000 parasites/µL. High inter-lot agreement indicates consistency in detecting malaria parasites. When one test is invalid and the other positive, positive agreement is recorded. Fig. 8 shows sample calculations for lot agreement.

samples)2 and mean band intensity (for positive tests only based on the first reading) after the lots were stored at room temperature (21–25°C) and at 35°C and 45°C for 2 months. At some point during the 60-day incubation period for the late entry test (CareStart™ Malaria Pf/PAN (pLDH)- RMLM-05071), the humidity regulator in the 45°C stability chamber was compromised leading to water-soaking of all test boxes. The precise timing of this event and the effect on temperature and humidity are unknown. Testing was still performed because all cassette packaging was intact.

9.7. Anomalies The presence and frequency of commonly observed anomalies – red background, red background obscuring test line(s), incomplete clearing, incomplete migration, failed migration, strip misplaced in cassette (shift), specimen pad not seen in the sample window, ghost test line(s), diffuse test line(s), patchy broken line(s) and buffer remains pooled in buffer well – were routinely recorded for all round-7 products. Photographs and descriptions are shown in Fig. AS2.1.

9.5. Invalid tests Invalid tests are those deemed invalid during testing of both lots, with samples at 200 parasites/µL and 2000 parasites/µL.

9.6.  Heat (thermal) stability The results of heat stability testing are reported as the number of positive tests against one cultured P. falciparum or one wild-type P. vivax parasite sample at 200 and 2000 parasites/µL based on the first reading of two lots at each parasite density (maximum score is 30 (P. falciparum) or eight (P. vivax) against 200 parasites/µL samples and 10 (P. falciparum) or four (P. vivax) against 2000 parasites/µL

9.8. Labelling and instructions for use For each product, technicians recorded whether the product met each of the recommended criteria. The results were pooled for analysis. The proportions of products that met a selection of recommended criteria is presented graphically in Figs 31–38.

2 1

A standard intensity comparison chart is used, which allows matching to the closest of four common colour variants of labelled antibodies used in RDTs, each at four levels of intensity.

Fifteen tests per lot against 200 parasites/µL samples, five tests per lot against 2000 parasites/µL for P. falciparum samples, four tests per lot against 200 parasites/µL samples and two tests per lot against 2000 parasites/µL for P. vivax samples. Invalid results were excluded from the analysis.

Figure 8: Explanation of lot agreement calculation Test results (1= positive, 0 = negative) Lot 1 Test 1 reader 1 Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 1 1 0 0 1 Test 2 reader 1 1 0 1 0 1 Test 1 reader 1 1 0 0 0 1 Lot 2 Test 2 reader 1 1 0 1 0 1 (a) Lot 1 tests 1 Disagree Disagree 0 1 Derived values (1= both positive, 0 = both negative) (b) Lot 2 tests 1 0 Disagree 0 1 (d) (f) Comparison Contribution of lot results to overall 1 Can’t compare Can’t compare 0 1 1 0 0 0 1

PDS = sum (f) / number of samples = 2/5 = 40 Lot 1 PDS = sum (a) / number of samples = 2 / 5 = 40 Lot 2 PDS = sum (b) / number of samples = 2 / 5 = 40 Positivity = number of positive results / total number of tests = 11 / 20 = 55% Agreement between tests = (count number of 0 and 1s in (a) and (b)) / (number of samples x 2 lots) = 7 / 10 = 70% Agreement between lots = (count number of 0 and 1s in (d)) / (number of samples -­ ‐ number of “can’t compare” in (d)) = 3 /3 = 100% Note: reader 1 = Technician 1 in raw data files

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Results 35

10.  ASSOCIATION BETWEEN PARASITE DENSITY AND ANTIGEN CONCENTRATION Malaria RDTs detect parasite-derived antigen. The relation of the concentration of antigen available from the blood sample (after lysis of red cells and parasites) to the peripheral parasite density varies widely because of a series of host and parasite factors (Box 4). In establishing panels for the product testing programme that reflect possible variations in antigen concentration for parasitaemia of 200 parasites/µL, a large number (> 300) of wild-type parasite samples from clinical cases in different geographical areas were analysed by quantitative ELISA for HRP2, pLDH and aldolase. Only samples with antigen values within the 90th percentile for HRP2, pLDH and aldolase were selected for the performance panels. Furthermore, the distribution of antigen levels for HRP2, pLDH and aldolase was compared with that in previous rounds to ensure consistency. No statistically significant differences in average antigen levels between the panels for rounds 1–7 were detected for any of the antigens (p > 0.5, Kruskal-Wallis test). Therefore, the panels used for the product testing rounds can be considered comparable (Annex S1).

Box 4. Explanations for variable antigen concentrations in samples with the same parasite density • variation in antigen expression among isolates • different durations of infections (accumulating antigens) • different parasite growth stages at the time of collection (expressing different levels of antigens) • presence of circulating HRP2 from previous cycles of growth • HRP2 produced by parasites sequestered in the host’s vascular tissues that cannot be accounted for in the estimate of parasite density on the blood slide (29)

11.  evaluation of malaria rapid diagnostic tests in the Laboratory and in the field Despite the strengths of the product testing programme, the evaluations are not completely analogous to field testing of malaria RDTs. In order to compose a panel that could be used to evaluate RDTs reproducibly, blood samples must be diluted, frozen and stored below −70°C; however, blood that has undergone freezing and thawing is lysed and may not have exactly the same characteristics as fresh blood. Another difference from field evaluation is use of a micro-pipette to place blood in the RDT device rather than the blood transfer device provided by the manufacturer. This is necessary because blood is collected from a cryo-tube rather than a finger-prick and because the blood transfer devices provided with the different products vary (31). This technique also ensures the consistency of testing by reducing the likelihood of operator error. As all samples in the panel used for the evaluation are prepared from parasites that express HRP2, the results will not be predictive of field trial results of parasite populations with significant levels of HRP2 deletion (12–13). In addition, the population frequency of blood immunological factors or infectious diseases, which can result in false-positive results, may vary. Therefore, the sensitivity and specificity of an RDT in the field depends on the epidemiological situation. The evaluation reported here does not predict sensitivity or specificity in a given field situation but the rates of detection of target antigens and false-positive results of RDTs against a standardized panel in a controlled, repeatable manner. As the panel is meant to be a close approximation to field samples, the detection rates of different products will be reflected in similar differences in the field. The panel is designed to include a large number of samples that are close to the limit of detection of RDTs (200 parasites/µL) and is therefore likely to discriminate between them more clearly than a field trial. It follows that, in settings where the parasite density is very high, no differences in the PDS or positivity rates of tests or much smaller differences will be observed than those reported against the WHO evaluation panel. Furthermore, where the parasite density is very low, the detection rates may be lower than those reported here.

36

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Field trials have a place in product selection, particularly in determining which of a short-list of products is most appropriate for the technicians and situation of its intended use in a programme (e.g. ease-of-use characteristics). Such trials should have carefully defined objectives and procedures designed to achieve them. Trials to determine the probable field sensitivity and specificity of a product also have a place but require large samples and populations with low

parasite densities if significant differences are to be found between well-performing products; they must also be closely controlled and are therefore expensive. Such trials do not allow comparison of a large number of products. WHO has published recommendations for good practice in malaria field trials (32), which should be followed to improve the reproducibility and quality of the results.

12. Results 12.1. Summary Round 7 of WHO malaria RDT product testing provided results for 46 products evaluated against P. falciparum culture samples, and all the products proceeded to evaluation against wild-type samples collected from parasitaemic patients on three continents and a large panel of parasite-negative samples. Heat stability was assessed at the temperatures commonly encountered in malaria-endemic countries. Thirteen research institutes were engaged in either sample collection or sample characterization to establish the evaluation panels. Between February 2016 and August 2016, approximately 65 000 RDTs were tested at the CDC. The main results are presented in Tables 4 and 5, which group the RDTs by the species they are designed to detect, i.e. P. falciparum only, P. falciparum and all species or P. falciparum and P. vivax. Note that only tests against P. falciparum and P. vivax were evaluated, and the evaluation therefore does not indicate whether a product intended to detect other species, i.e. P. malariae, P. ovale, could do so. PDS values at both high and low parasite concentrations are presented, as are false-positive rates and the percentages of invalid test results. Tests in each category are listed alphabetically, but the results are colour-coded according to WHO-recommended RDT procurement selection criteria (Box 3); WHO prequalification status is also indicated. When choosing an appropriate product, it is important also to review its thermal stability (Tables 6a and 6b) according to the expected conditions of transport and storage in the field. The results of the evaluation are listed below. • The overall range of results against wild-type P. falciparum and negative samples, including P. falciparum PDS, P. falciparum positivity rate and heat stability, were similar to those in rounds 1–6 (3–8), the false-positivity rates and P. vivax PDS and P. vivax positivity rates were similar to those in round 6, and better than in previous rounds. The median PDS for P. falciparum at low parasite densities in round 7 (89.5%) was slightly higher than in rounds 5 and 6 (both 86%) and similar to that seen in round 4 (89.3%). No products in round 7 scored a PDS of 100% for the P. falciparum detecting line. The PDS for P. vivax at low densities has improved consistently since round 1 (median, 30%), the results for rounds 2, 3, 4, 5, 6 and 7 being 75.0%, 51.4%, 61.8%, 65.7%, 82.9% and 90.0%, respectively. Six products achieved 100% PDS on their pan-pLDH and P. vivax pLDH lines when tested against P. vivax but had lower scores for their P. falciparum detecting lines. The median false-positive rate on clean negative samples and samples containing other infectious agents was 0%, while samples containing immunological factors had a median overall false-positive rate of 2.8%. • A number of RDTs consistently detected malaria at a low parasite density (200 parasites/µL), had low false-positive rates, were stable at tropical temperatures, are relatively easy to use and can detect P. falciparum, P. vivax or both. This increases the number of well-performing tests from that in rounds 1–6. • The one P. falciparum -only test detecting pf-pLDH did not meet procurement criteria; however, one combination non-HRP2 detecting RDT met criteria for P. falciparum and P. vivax targeting pf-pLDH and pan-pLDH, respectively. • The performance of products varied at low parasite density (200 parasites/µL), but most showed high detection rates for P. falciparum and P. vivax at 2000 parasites/µL. • All, except two, round-7 products had an HRP2 detecting line, and most of these products achieved a high PDS for P. falciparum detection at low parasite density. • Several combination tests achieved PDS at the upper end of the range for both P. falciparum and P. vivax. (Fig. S3). • There was minimal lot-to-lot variation in the test performance of round-7 products. • Overall, approximately half of the combination tests with Pf and Pan lines in which HRP2 was used for detection of P. falciparum, returned positive results only on the HRP2 band at lower densities of P. falciparum. Results were product-specific, with values ranging from 5% to 89%. Manufacturers’ instructions should therefore classify P. falciparum infections as positive in either the HRP2 test line alone or in combination with the pan-pLDH line.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Results 37

38

Table 4: Summary of phase 1 performance of 45 malaria RDTsa against 20 cultured P. falciparum lines at low (200) and high (2000) parasite density (parasites/µl) Panel detection scoreb (n=20) Manufacturer 200 parasites/µl 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (100/35)d 100.0 100.0 100.0 100.0 100.0 100.0 100.0 95.0 100.0 80.0 100.0 90.0 75.0 100.0 80.0 100.0 80.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 80.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 95.0 100.0 100.0 100.0 100.0 100.0 NA NA NA NA NA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (78) 0.0 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (100/95)d 100.0 100.0 100.0 100.0 100.0 100.0 100.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 (39) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.5 0.0 0.0 0.0 0.0 0.0

False-positive non-Pf infectionc (%) 200 parasites/µl (n=80) 2000 parasites/µl (n=40)

Product 2000 parasites/µl

Product code

Invalid rate (%) (n=120)

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 RMSM-05071 RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc.e Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc.e Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd.

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.5 0.5 0.0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines

MPHRPD-01

5531 55IC103-50 55IC104-50 05FK130-40-0

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091

Table 4: Summary phase-1 performance of 41 malaria RDTs against 20 cultured P. falciparum lines at low (200) and high (2000) parasite density (parasites/µL) (continued) Panel detection scoreb (n=20) Manufacturer 200 parasites/µl 100.0 100.0 100.0 100.0 100.0 90.0 100.0 100.0 100.0 100.0 1.3 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 0.0 0.0 25.0 0.0 0.0 (79) 12.5 0.0 0.0 0.0 0.0 97.5 0.0 0.0 15.0 0.0

False-positive non-Pf infectionc (%) 200 parasites/µl (n=80) 2000 parasites/µl (n=40)

Product 2000 parasites/µl Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Real World Diagnostics Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA

Product code

Invalid rate (%) (n=120) 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0.0 0.0

CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test Malaria Pf/PAN Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv

RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a PROPMALPFPV001 W056-C MFLRPD-02 71050 11108191040

Pf, Pv and Pan PALUTOP +4 optima®

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species a Phase-1 performance tests for CareStart Pf/PAN (pLDH) Ag RDT (RMLM-05071) not conducted b A sample is considered detected only if all RDTs from both lots read by the first technician, at minimum specified reading time, are positive c Pan or Pv line only positive indicates a false positive non P. falciparum infection d Product PDS shown along with PDS for HRP2 band and Pf-pLDH band, respectively e An Alere company

Results

39

40

Table 5: Summary of phase 2 performance of 46 malaria RDTs against wild-type (clinical) P. falciparum and P. vivax samples at low (200) and high (2000a) parasite density (parasites/µl) and Plasmodium spp. negative samples Panel detection scoreb False positive rates (%) 200 parasites/µl Pv samples False positive Pf infectiond (n=140) 0.0 0.0 0.0 0.7 0.0 0.0 2.1 0.0 0.0 5.0 0.0 0.0 (139) 2.9 0.0 NA NA NA NA NA 100.0 98.0 96.0 98.0 98.0 99.0 100.0 99.0 100.0 99.0 98.0 99.0 98.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 94.3 71.4 97.1 100.0 100.0 91.4 100.0 NA NA NA NA NA 0.0 1.3 1.3 0.5 (399) 0.3 (399) 0.0 0.0 0.8 0.0 1.3 0.3 2.0 0.8 (399) 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.4 (138) 0.0 0.0 0.7 0.7 0.0 0.0 0.0 3.6 (139) 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 1.0 2.0 1.0 1.0 0.5 0.0 0.5 0.0 0.5 1.0 0.5 1.0 0.0

200 parasites/µl Manufacturer Pf samples (n=100) Pv samples (n=35) Pv samples (n=35) Pf samples (n=100)a Pf samples False positive non Pf infectionc (n=400) NA NA NA NA NA NA NA NA NA NA NA NA NA NA

2000 parasites/µl Pf samples False positive non-Pf infectionc (n=200)

2000 parasites/µl Pv samples

Product

Product code

Total false positive ratese (%) Clean negative samples

False positive False positive-Pf Plasmodium d infection spp. infection (n=232) (n=70) 0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 1.4 0.0 0.0 1.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.0 0.0 0.0 4.3 0.0 0.0 0.4 0.9 (231) 1.3 0.0 0.4 0.4 0.9 0.0 1.7 0.0 0.0 0.4 (231) 0.0 0.0 0.0 0.0 0.0 0.0 (231) 0.0 0.0 0.9 1.3 1.3 (231) 3.9 0.0 0.9 1.7 0.0 (231) 1.3 3.9 33.2 0.4

Invalid rate (%) (n=1210)

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. NA NA NA NA NA NA NA NA NA NA NA NA NA 45.7 91.4 71.4 100.0 91.4 100.0 85.7 97.1 0.0 94.3 31.4 100.0 25.7 100.0 99.0 100.0 100.0 100.0 99.0 NA NA NA NA NA NA NA NA WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems 67.0 85.0 69.0 88.0 93.0 91.0 85.0 96.0 73.0 93.0 85.0 93.0 92.0 92.0 92.0 74.0 77.0 90.0 73.0 NA NA NA NA NA NA NA NA NA NA NA NA

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091

0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.3 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.2 0.0

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

80.0 93.0 98.0 93.0 97.0 96.0 94.0 (94/38)f 94.0 86.0 94.0 85.0 89.0 86.0 93.0

100.0 99.0 100.0 100.0 99.0 100.0 99.0 (99/92)f 100.0 99.0 100.0 99.0 100.0 99.0 100.0

MPHRPD-01

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

5531 55IC103-50 55IC104-50 05FK130-40-0

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

Table 5: Summary phase-2 performance of 41 malaria RDTs against wild-type (clinical) P. falciparum and P. vivax samples at low (200) and high (2000a) parasite density (parasites/µL) and Plasmodium spp. negative samples (continued) Panel detection scoreb False positive rates (%) 200 parasites/µl Pv samples False positive Pf infectiond (n=140) 0.0 0.0 (139) 0.0 0.0 0.0 0.0 0.0 4.3 0.0 0.7 0.0 0.0 1.3 0.7 0.5 1.0 1.0 (199) 0.0 0.0 2.0 0.0 0.5 (199) 92.5 1.0 0.0 27.5 0.0

200 parasites/µl Manufacturer Pv samples Pf samples (n=100) Pv samples (n=35) Pv samples (n=35) Pf samples (n=100)a Pf samples False positive non Pf infectionc (n=400) 1.0 1.0 (399) 0.0 0.0 1.8 0.0 0.0 22.3 0.3 0.5 39.8 0.0 1.4 (69) 1.5 (68) 0.0 (69) 0.0 0.0 0.0 0.0 7.1 0.0 1.4 0.0 0.0 0.0

2000 parasites/µl Pf samples False positive non-Pf infectionc (n=200)

2000 parasites/µl

Product

Product code

Total false positive ratese (%) Clean negative samples

False positive False positive-Pf Plasmodium infectiond spp. infection (n=232) (n=70) 0.4 0.0 (230) 0.0 (229) 0.0 0.0 (231) 0.0 0.0 (231) 24.6 1.3 0.0 22.9 (231) 0.0 0.0

Invalid rate (%) (n=1210)

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 99.0 91.0 82.9 (82.9/100)g 100.0 (100/100)g 92.0 75.0 85.0 91.0 89.0 93.0 89.0 86.0 92.0 78.0 79.0 85.0 97.1 100.0 91.4 97.1 100.0 88.6 57.1 2.9 65.7 85.7 88.6 88.6 98.0 98.0 99.0 100.0 99.0 100.0 99.0 99.0 100.0 100.0 99.0 98.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 8.6 100.0 100.0 100.0 100.0

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

0.1 0.6 0.3 0.0 0.1 0.0 0.3 0.0 0.0 0.0 0.1 0.0 0.0

PALUTOP +4 optima®

5499

Performance measure

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species a 3 (3%) of the 100 P. falciparum high parasite density dilution samples were at 5000 parasites/µl rather than 2000 b A sample is considered detected only if all RDTs from both lots read by the first technician, at minimum specified reading time, are positive c For combination tests, pan or Pv line, only, positive indicates a false positive non P. falciparum infection d Positive Pf line indicates a false positive P. falciparum infection e The total number of times a positive result for malaria was generated when it should not have been f Product PDS shown along with PDS for HRP2 band and Pf-pLDH band, respectively g Product PDS shown along with PDS for Pv-pLDH band and Pan-pLDH band, respectively

Panel detection score for Pf and Pv 200/µl samples False positive rates against clean negatives Invalid rate < 5% of tests conducted

Recommended WHO procurement criteria ≥ 75% < 10%

Results

41

42

• Only one of two tests met the WHO procurement criterion for detection of P. falciparum with Pf-pLDH alone. This test had a PDS of 75%, a false-positive rate of 0% and an invalid rate of 0.6%. However, the test had diminished performance after incubation at 35°C and 45°C (Figs. 22, 23). The PDS in other Pf-pLDH tests in which HRP2 was used to detect Pf on the same test line, ranged from 90% to 94%, however it cannot be distinguished if this performance results from detection of HRP2, Pf-pLDH or both. Tests that can detect pfhrp2 -deleted parasites are a high priority in malaria-endemic countries with a high prevalence of such parasites (12, 13, 33, 34).

a All

Panel detection scoreb 100 25 50 75 0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

200 (HRP2) 200 (pLDH)

Figure 9: Phase-1 P. falciparum panel detection score of malaria RDTsa at low (200) and high (2000) parasite density (parasites/μL)

2000 (HRP2) 2000 (pLDH) 2000 (Dual antigen)

200 (Dual antigen)

but 2 RDTs target HRP2 for falciparum detection. Two products target only pf-pLDH for falciparum detection (RMLM-05071 and C60RHA25). Two products (RMAM-05071 and 05FK130-40-0) target both HRP2 and pf-pLDH on the same line. One product (RMSM-05071) targets both HRP2 and pf-pLDH on separate lines; for this product HRP2 and pf-pLDH based results are presented separately in table 4. b A sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive.

Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test- RKMAL017 ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test- ITP11002-TC25 ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test- ITP11003-TC25 Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 Alere™ Malaria Ag P.f - 05FK140-40-0 Asan Easy Test® Malaria Pf/Pan Ag- AM4650-K Aspen® Malaria Ag Pf - AS0015 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH)- C32RHA25 Biosynex® Malaria Pf/Pan- 0584_K25 Biosynex® Malaria Pf/Pv- 0581_K25 BioTracer™ Malaria P.f Rapid Card- 17912 BioTracer™ Malaria P.f/PAN Rapid Card- 17012 CareStart™ Malaria Pf (HRP2)- RMOM-03091 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT- RMVM-03091 CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line- RMSM-05071 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT- RMVM-05072 CareStart™ Malaria Screen RDT- RMAM-05071 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 careUS™ Malaria Pf (HRP2) Ag - RMO-M05082 DIAQUICK Malaria P.f. Cassette - W06200 ICT MALARIA DUAL TEST - ML03 ICT MALARIA P.F. CASSETTE TEST- ML01 Is It... Malaria Pf PAN - MPFPAN050 KHB® Malaria Ag (HRP2) Pf Rapid Test - R-409-50-C Malaria Pf Rapid Test- GCMAL(pf)-402a Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a GMD Malaria Pf test- GMDMALPF001 Malaria Pf/PAN Test - PROMALPFV001 One Step Malaria HRP2/pLDH (P.f/P.v) Test- W056-C One Step MalariaHRP2 (P.f) Test- W37-C PALUTOP + pf® - 5531 PALUTOP +4 optima® - 5499 Parahit® f Ver 1.0 - Device - 55IC104-50 QuickProfile™ Malaria Pf/Pv Antigen Test- 71050 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN- MAL-PF/Pan-CAS/25 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv- 11108191040 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag - MPHRPD-01 One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines - 05FK130-40-0 AllTest™ Malaria P.f./Pan Rapid Test Cassette- IMPN-402 Aspen® Malaria Ag Pf/Pv - AS0060 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH)- C60RHA25 Parahit f® Ver 1.0 - Dipstick - 55IC103-50 Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit- RKMAL016

• No consistent pattern was seen in the changing performance of the five compulsorily resubmitted products. The PDS of some of the P. falciparum and P. vivax tests improved over their results in round 3, while that of others decreased. Tables 4 and 5 summarize the performance of malaria RDTs against cultured P. falciparum parasites, blood containing wild-type P. falciparum and P. vivax parasites and Plasmodium spp.-negative samples. Detailed phase-1 and phase-2 results of product testing are given in Annexes 3 and 4, respectively. The data are shown graphically in Figs. 9–19.

a 3

12.2. Phase 1: P. falciparum culture panel

All but one of the products consistently detected 100% of cultured P. falciparum parasites at high parasite density (2000 parasites/µL); the PDS of the exception was 95%. The PDS was more variable (75–100%) at low parasite density (200 parasites/µL) (Fig. 9).

Figure 10: Phase-2 P. falciparum panel detection score of malaria RDTs at low (200) and high (2000a) parasite density (parasites/μL)b,c

b Phase

Panel detection scored 100 25 50 75 0

200 (pLDH)

200 (HRP2)

12.3.1  P. falciparum detection

2000 (pLDH)

2000 (HRP2)

200 (Dual antigen)

2000 (Dual antigen)

(3%) of the 100 P. falciparum high parasite density dilution samples were at 5000 parasites/μL rather than 2000 2 evaluation panel consisted of 100 clinical blood samples containing wild type P. falciparum. RDTs performed = 2 tests x 2 lots at 200 p/μL and 1 test x 2 lots at 2000 p/μL; c All but 2 RDTs target HRP2 for falciparum detection. Two products target only pf-pLDH for falciparum detection (RMLM-05071 and C60RHA25). Two products (RMAM-05071 and 05FK130-40-0) target both HRP2 and pf-pLDH on the same line. One product (RMSM-05071) targets both HRP2 and pf-pLDH on separate lines; for this product HRP2 and pf-pLDH based results are presented separately in table 5. d A sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive.

Alere™ Malaria Ag P.f - 05FK140-40-0 BioTracer™ Malaria P.f Rapid Card - 17912 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart™ Malaria Pf (HRP2) Ag RDT - RMOM-03091 CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - RMSM-05071 careUS™ Malaria Pf (HRP2) Ag - RMO-M05082 ICT MALARIA P.F. CASSETTE TEST - ML01 ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test - ITP11002-TC25 Aspen® Malaria Ag Pf - AS0015 Aspen® Malaria Ag Pf/Pv - AS0060 CareStart™ Malaria Screen RDT - RMAM-05071 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 Is It... Malaria Pf PAN - MPFPAN050 One Step MalariaHRP2 (P.f) Test - W37-C ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C PALUTOP + pf® - 5531 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 PALUTOP +4 optima® - 5499 SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines - 05FK130-40-0 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072 Malaria Pf Rapid Test - GCMAL(pf)-402a Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K DIAQUICK Malaria P.f. Cassette - W06200 GMD Malaria Pf test - GMDMALPF001 Malaria Pf/PAN Test - PROMALPFV001 Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 Biosynex® Malaria Pf/Pan - 0584_K25 Biosynex® Malaria Pf/Pv - 0581_K25 ICT MALARIA DUAL TEST - ML03 KHB® Malaria Ag (HRP2) Pf Rapid Test - R-409-50-C Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv- 11108191040 Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test - RKMAL017 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 Parahit® f Ver 1.0 - Device - 55IC104-50 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 Parahit f® Ver 1.0 - Dipstick - 55IC103-50 CareStart™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag - MPHRPD-01 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016

12.3. Phase 2: wild -type P. falciparum and P. vivax- and Plasmodium spp.negative samples.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

All 46 products in round 7 were designed to detect P. falciparum. As in phase 1, all the tests had very high scores at the high parasite density, with a PDS ≥ 96%. Seventeen of the 19 products specific for P. falciparum alone achieved a PDS ≥ 75% against samples with low parasite density (Table 5, Fig. 10).

Results

43

Only one of two tests met WHO procurement criteria based on detection of P. falciparum with Pf-pLDH alone. This test achieved a PDS of 75%, a false-positive rate of 0% and an invalid rate of 0.6%. The PDS in other Pf-pLDH tests in which HRP2 was used to detect Pf on the same test line, ranged from 90% to 94%, however it cannot be distinguished if this performance results from detection of HRP2, Pf-pLDH or both. Tests that can detect pfhrp2 gene-deleted parasites are a high priority in malaria-endemic countries with a high prevalence of such parasites (12, 13, 33, 34).

12.3.2  P. vivax detection Fig. 11 shows that 25 of 27 (93%) products designed to detect P. vivax consistently detected ≥ 75% at high parasite density (2000 parasites/µL), and 19 (70%) achieved the same threshold of PDS against samples with 200 parasites/µL. The overall detection rate in low-parasite density wild-type P. vivax samples was lower than that for P. falciparum. At a low parasite density (200 parasites/µL), 13 products had a PDS ≥ 90%, and 18 had a PDS < 75% (Table 5, Fig. 11), which is an improvement on round-5 results, in which only eight products had a PDS ≥ 90%, and 19 had a PDS < 75%.

Figure 11: Phase-2 P. vivax panel detection score of malaria RDTs at low (200) and high (2000) parasite density (parasites/μL)a,b 100

75

Panel detection scorec

50

200 (pLDH) 25

200 (Aldolase) 2000 (pLDH) 2000 (Aldolase)

0 Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 Is It... Malaria Pf PAN - MPFPAN050 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo - RMVM-05072 ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25 CareStart™ Malaria HRP2/pLDH (Pf/Pv) Combo - RMVM-03091 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart™ Malaria Screen RDT - RMAM-05071 Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 Aspen® Malaria Ag Pf/Pv - AS0060 Biosynex® Malaria Pf/Pv - 0581_K25 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv- 11108191040 Biosynex® Malaria Pf/Pan - 0584_K25 One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 PALUTOP +4 optima® - 5499 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016 ICT MALARIA DUAL TEST - ML03 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 Malaria Pf/PAN Test - PROMALPFV001 CareStart™ Pf/PAN (pLDH) Ag RDT - RMLM-05071 a Phase-2

evaluation panel consisted of 35 clinical blood samples containing wild type P. vivax; RDTs performed = 2 tests x 2 lots at 200 p/μL and 1 test x 2 lots at 2000 p/μL; b All RDTs target pan-pLDH or pv-pLDH c A sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive.

44

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Panel detection scoreb/Positivity ratec (%) 100 25 50 75 0 Alere™ Malaria Ag P.f - 05FK140-40-0

12.3.4  P. falciparum and P. vivax positivity rate

12.3.3 Combined detection of P. falciparum and P. vivax

Of the 27 pan-specific and combination tests, 19 (70%) had a PDS ≥ 75% for both P. falciparum and P. vivax at a low parasite density (200 parasites/µL) (Table 5). Most products performed well at a high parasite density.

The positivity rate was calculated in addition to the PDS. As expected, the positivity rates were higher than the PDS but mirrored the PDS against wild-type P. falciparum and P. vivax samples (Figs 12 and 13).

a Phase-2

BioTracer™ Malaria P.f Rapid Card - 17912

CareStart™ Malaria Pf (HRP2) - RMOM-03091

BioTracer™ Malaria P.f/PAN Rapid Card - 17012

careUS™ Malaria Pf (HRP2) Ag - RMO-M05082

ICT MALARIA P.F. CASSETTE TEST- ML01

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - RMSM-05071 Aspen® Malaria Ag Pf/Pv - AS0060 Aspen® Malaria Ag Pf - AS0015

ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test - ITP11002-TC25

CareStart™ Malaria Screen RDT - RMAM-05071

careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 Is It... Malaria Pf PAN - MPFPAN050 PALUTOP + pf® - 5531

One Step MalariaHRP2 (P.f) Test - W37-C

ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25

NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25

One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C PALUTOP +4 optima® - 5499

CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091

BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 Malaria Pf Rapid Test - GCMAL(pf)-402a

SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines - 05FK130-40-0

CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072

Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a

Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K GMD Malaria Pf test - GMDMALPF001 Malaria Pf/PAN Test - PROMALPFV001 ICT MALARIA DUAL TEST - ML03

DIAQUICK Malaria P.f. Cassette - W06200

KHB® Malaria Ag (HRP2) Pf Rapid Test - R-409-50-C

Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv- 11108191040 Biosynex® Malaria Pf/Pv - 0581_K25 Biosynex® Malaria Pf/Pan - 0584_K25

12.3.5 Band intensity

Figure 12: Phase-2 P. falciparum panel detection score and positivity rate at 200 parasites/μL a

Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40

Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test - RKMAL017

QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Parahit® f Ver 1.0 - Device - 55IC104-50

One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02

Positivity rate (HRP2)

Positivity rate (pLDH)

Parahit f® Ver 1.0 - Dipstick - 55IC103-50

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25

One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag - MPHRPD-01

Panel detection score (HRP2)

Panel detection score (pLDH)

CareStart™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071

evaluation panel consisted of 100 clinical blood samples containing wild-type P. falciparum. RDTs performed = 2 tests x 2 lots at 200 p/μL and 1 test x 2 lots at 2000 p/μL; b A sample is considered detected only if all RDTs from both lots read by the first technician, at minimum specified reading time, are positive; c The total number of times a test returned a positive result divided by the total number of times it should have (x100).

AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Of the combination RDT products containing a pan test band that gave a positive indication for P. falciparum against low-density P. falciparum samples, 51.6% (2473/4796) gave positive results on both the P. falciparum and pan test

Although RDTs do not provide quantitative results, the technicians graded positive results according to a standard colour chart and calculated the mean band intensity for positive results (Annex 4, Tables A3.2 (for phase 1), A4.2 and A4.3 (for phase 2)). A positive correlation was found between the PDS and band intensity (Spearman rank correlation, r = 0.75, p < 0.001 for the P. falciparum phase-2 panel and r = 0.82, p < 0.001 for the P. vivax panel).

Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016

Results

45

bands, and 47.8% (2292/4796) were positive only on the P. falciparum test band. A small proportion (0.6%, 31/4796) were positive only on the pan test band. When the pan test band in the combination products was positive, the intensity of the band was the same as the P. falciparum test band in 11.2% of tests, while 33.0%, 39.1% and 16.7% of the pan tests bands were one, two and three

intensities lower than the corresponding P. falciparum test bands, respectively. Only 0.1% of tests had a pan band intensity larger than the corresponding P. falciparum test band. When tested at low parasite density, none of the tests achieved 75% with a band intensity > 2 for P. falciparum or P. vivax, although 12 achieved at least 50% with this intensity for P. falciparum and 1 for P. vivax.

Figure 13: Phase-2 P. vivax panel detection score and positivity rate at 200 parasites/μL a

Panel detection scoreb/Positivity ratec (%)

100

75

50

Positivity rate (pLDH)

25

Positivity rate (Aldolase) Panel detection score (pLDH) Panel detection score (Aldolase)

0 Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 Is It... Malaria Pf PAN - MPFPAN050 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 CareStart™ Malaria Screen RDT - RMAM-05071 Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 Aspen® Malaria Ag Pf/Pv - AS0060 Biosynex® Malaria Pf/Pv - 0581_K25 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv- 11108191040 Biosynex® Malaria Pf/Pan - 0584_K25 One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 PALUTOP +4 optima® - 5499 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 ICT MALARIA DUAL TEST - ML03 Malaria Pf/PAN Test - PROMALPFV001 CareStart™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071

a Phase-2

evaluation panel consisted of 35 clinical blood samples containing wild type P. vivax; . RDTs performed = 2 tests x 2 lots at 200 p/μL and 1 test x 2 lots at 2000 p/μL; b A sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive; c The total number of times a test returned a positive result divided by the total number of times it should have (x100).

46

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

12.3.6 False-positive rates

None of the products had a false-positive rate > 10% with 52 clean-negative samples of the P. falciparum test line (Fig. 14); three products had false-positive rates > 10% with pan or P. vivax test lines (Fig. 15). Fifteen products had false-positive rates > 5.6% (for one or both lots), against samples containing

a Phase-2

False-positive rate (%) 0 2 4 6

Figure 14: Phase-2 P. falciparum (P. falciparum test line) false-positive rate against clean-negative samplesa

evaluation panel included 100 Plasmodium spp.-negative samples, of which 52 were clean negatives from healthy volunteers with no known current illness or blood abnormality.

Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit- RKMAL016 Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test- RKMAL017 ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test- ITP11002-TC25 ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test- ITP11003-TC25 Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 Alere™ Malaria Ag P.f - 05FK140-40-0 AllTest™ Malaria P.f./Pan Rapid Test Cassette- IMPN-402 Asan Easy Test© Malaria Pf/Pan Ag- AM4650-K Aspen© Malaria Ag Pf/Pv - AS0060 Aspen© Malaria Ag Pf - AS0015 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH)- C32RHA25 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH)- C60RHA25 Biosynex© Malaria Pf/Pan- 0584_K25 Biosynex© Malaria Pf/Pv- 0581_K25 BioTracer™ Malaria P.f Rapid Card- 17912 BioTracer™ Malaria P.f/PAN Rapid Card- 17012 CareStart™ Pf/PAN (pLDH) Ag RDT - RMLM-05071 CareStart™ Malaria Pf (HRP2) Ag RDT - RMOM-03091 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - RMSM-05071 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072 CareStart™ Malaria Screen RDT - RMAM-05071 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 careUS™ Malaria Pf (HRP2) Ag - RMO-M05082 DIAQUICK Malaria P.f. Cassette - W06200 ICT MALARIA DUAL TEST - ML03 ICT MALARIA P.F. CASSETTE TEST- ML01 Is It... Malaria Pf PAN - MPFPAN050 KHB© Malaria Ag (HRP2) Pf Rapid Test - R-409-50-C Malaria Pf Rapid Test- GCMAL(pf)-402a Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a GMD Malaria Pf test - GMDMALPF001 Malaria Pf/PAN Test - PROMALPFV001 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 One Step MalariaHRP2 (P.f) Test- W37-C One Step Malaria HRP2/pLDH (P.f/P.v) Test- W056-C One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag - MPHRPD-01 One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 PALUTOP + pf© - 5531 PALUTOP +4 optima© - 5499 Parahit f© Ver 1.0 - Dipstick - 55IC103-50 Parahit© f Ver 1.0 - Device - 55IC104-50 QuickProfile™ Malaria Pf/Pv Antigen Test- 71050 Rapid 1-2-3 HEMA© CASSETTE MALARIA PF/PAN- MAL-PF/Pan-CAS/25 SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines - 05FK130-40-0 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv- 11108191040

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

immunological factors. The rates of 9 of these were 5.6–7.4%, and those of a further six were 11.1–24.1% in both lots. These rates are worse than those in round 6 but similar to those in previous rounds. False positivity was seen predominantly for samples containing immunological factors (seven of the eight instances of false positivity > 10%).

Results

47

48

The false-positivity rates for samples containing nonPlasmodium spp. agents were similar to those in round 6. In only four products was the false-positivity rate > 3.3%, and only one had a false positivity rate > 10% (10% and 13%

a Phase-2

False-positive rate (%) 10 20 30 40 0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Figure 15: Phase-2 Plasmodium spp. (pan or P. vivax test line) false-positive rate against clean-negative samplesa

evaluation panel included 100 Plasmodium spp.-negative samples of which 52 were clean negatives, from healthy volunteers with no known current illness or blood abnormality.

Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016 ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25 Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 Asan Easy Test© Malaria Pf/Pan Ag - AM4650-K Aspen©Malaria Ag Pf/Pv - AS0060 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 Biosynex© Malaria Pf/Pan - 0584_K25 Biosynex© Malaria Pf/Pv - 0581_K25 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072 CareStart™ Malaria Screen RDT - RMAM-05071 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 ICT MALARIA DUAL TEST - ML03 Is It... Malaria Pf PAN - MPFPAN050 Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a Malaria Pf/PAN Test - PROMALPFV001 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 PALUTOP +4 optima© - 5499 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Rapid 1-2-3 HEMA© CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv- 11108191040

in each of the two lots); three products had false-positivity rates of 6.7% for one or both lots. False positivity was seen against all four of the samples of infections pathogens used: schistosoma, leishmaniasis, Chagas disease and dengue.

Only 21 samples contained non-Plasmodium infectious agents and 27 samples contained immunological factors. For detailed information on the blood abnormalities and pathogens that generated false-positive results in specific products, see Annex 4 (Tables A4.6–A4.9). Products were assessed for false-positivity rates for species that they were not designed to detect (Tables A4.4 and A4.5). Overall, the rates were low; only two combination products

showed > 10% false positivity for a non-P. falciparum infection when tested against samples of P. falciparum at 200 or 2000 parasites/µL. There was no clear trend of higher false-positive rates in tests with higher PDS, indicating no clear association between the sensitivity and specificity of the tests at these detection thresholds (Figs 16 and 17).

Figure 16: Phase-2 P. falciparum false-positive ratea versus P. falciparum panel detection scoreb at low parasite density (200 parasites/μL)

6 False-positive rate (%)

4

2

0 0 a False-positive

25

50

75

100

P. falciparum PDS at 200 parasites/μL rate is for clean-negatives, only; b A sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive.

Figure 17: Phase-2 P. vivax false-positive ratea versus P. vivax panel detection scoreb at low parasite density (200 parasites/μL)

40 False-positive rate (%) 30 20 10 0 0 a False-positive b A

25 50 75 P. vivax PDS at 200 parasites/μL

100

rate is for clean negatives only. sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Results 49

12.4. Performance of resubmitted products Of the 46 products in round 7, 15 (33%) had been evaluated previously. For six of the resubmissions, this was the second testing, and nine had been tested more than twice. Figs 18 and 19 show the performance in the current and previous testing of products against wild-type P. falciparum and P. vivax at 200 parasites/µL and clean-negative samples that had been resubmitted compulsorily and voluntarily. The change in PDS between the two rounds varied for the five products that had not been tested since round 3 (compulsory resubmissions): two had improved performance against P. falciparum (increases of 6 and 7 percentage points), and three showed worse performance (decreases of 7, 8 and 11 percentage points). The changes in the two pan-detecting products in their ability to detect P. vivax differed from those in round 3: the PDS of one increased by 5 percentage points, while that of the other dropped from 91% in round 3 to 0 in round 7.

Figure 18: Phase-2 P. falciparum panel detection scorea at low parasite density (200 parasites/μL) during initial and subsequent testing of compulsorily and voluntarily resubmitted malaria RDTs False-positive Plasmodium spp. rate on clean-negative samplesb (%) Compulsory retest Voluntary retest Panel detection score (prior submission) Panel detection score (Rd 7) False-positive (prior submission) False-positive (Rd 7) a Panel b Clean-negative

Panel detection scorea 50 Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

detection score - A sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive. blood samples from healthy volunteers with no known current illness or blood abnormality.

For the 10 products that were voluntarily resubmitted for testing, no significant correlation was found between the PDS for P. falciparum at lower parasite density in consecutive submissions (Spearman rank correlation, r = – 0.30, P = 0.405). The median change in detection of P. falciparum was +7.5% (range, –8.0 to 40.0%), which was almost significantly different from zero (Wilcoxon signed rank test, P = 0.052). Most of the products (8/10) detected P. vivax, and detection of this parasite improved overall (median change, 28.6%; range, –8.6 to 65.7%), which was almost statistically significant (Wilcoxon signed rank test, P = 0.058). No statistically significant correlation was found between the PDS of

consecutive submissions against P. vivax at lower parasite density (Spearman rank correlation, r = 0.503, P = 0.20). On re-testing, approximately half of the resubmitted products (7/15) showed no change or an improvement in their falsepositivity rate against clean negative samples; the median change in false-positivity rate was +0.4%. Most of the changes on re-testing were small (< 2.5%), except for two products, in which the false-positivity rate decreased by 7.3% for one product and increased by 22.9% for another. Both of these products were voluntarily resubmitted for testing in Round 7.

Figure 19: Phase-2 P. vivax panel detection scorea at low parasite density (200 parasites/μL) during initial and subsequent testing of compulsorily and voluntarily resubmitted malaria RDTs False-positive Plasmodium spp. rate on clean-negative samplesb (%) 100 90 80 70 60 50 40 30 20 10 0 0 20 40 60 100 80

Panel detection scorea

Compulsory retest

Voluntary retest Panel detection score (prior submission) Panel detection score (Rd 7) False-positive (prior submission) False-positive (Rd 7)

a Panel

b Clean-negative

detection score - A sample is considered detected only if all RDTs from both lots read by the first technician, at the minimum specified reading time, are positive. blood samples from healthy volunteers with no known current illness or blood abnormality.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Results 51

13.  Heat stability 13.1. Summary A single P. falciparum culture sample and single wild-type P. vivax sample were used as the reference samples to test heat stability. Continuous in vitro culture of a wild-type P. vivax sample is difficult, largely because of selective invasion of reticulocytes by the parasite. Round 7 was the second in which the stability of test lines to detect non-P. falciparum parasites was tested. Because of the large number of aliquots used to assess heat stability, fewer replicate RDTs were tested against P. vivax, with four assessed against the 200 parasites/µL sample and two against the 2000 parasites/µL sample, for each of the two lots. The results of heat stability testing are summarized in Tables 6a and 6b, and detailed results are presented in Annex 4 (Tables A4.10– A4.18) and in Figs. 20–29, which show the results for the two lots combined. The maximum obtainable scores were 30 (15 tests per lot) against P. falciparum for 200 parasites/µL and 10 for 2000 parasites/µL (five tests per lot). The maximum score obtainable against P. vivax was 8 for 200 parasites/µL (four tests per lot) and 4 for 2000 parasites/µL (two tests per lot). Confirmatory data on the stability of recent production lots of all tests can be obtained from the manufacturers and through the WHO–FIND lot-testing programme during product selection for procurement of RDTs. Many combination test products had pan lines that poorly detected low-density P. falciparum samples at baseline. Furthermore, tests with a baseline positivity < 100% showed unpredictable variation in positivity rates on subsequent testing, indicating that they were on the borderline of visibility. Two of the three combination tests with good (i.e. scoring at least 28/30) baseline pan line reactivity to the low-density sample showed good detection throughout, while one showed a marked reduction in performance after 2 months at 45 °C. The stability of pan-pLDH-detecting test lines was much poorer than that of HRP2-detecting test lines (Figs 20–25).

13.3.  Plasmodium vivax Testing of the heat stability of P. vivax-detecting lines using a P. vivax clinical sample was introduced in round 6. Many (11/14) of the combination RDTs with a pan-LDH test line were heat stable after 2 months’ storage at 45 °C when tested against a wild-type P. vivax sample. Two of the 11, however, showed some variation in performance under other conditions: one had slightly poorer performance at baseline and after storage at room temperature, and the other had very poor performance after storage at 35 °C. Of the three tests that did not detect 100% of samples after storage at 45 °C, two showed 100% detection at baseline but some decrease after storage at 35 °C and 45 °C (one with only a slight decrease and the other with a more significant decrease). The third of the three tests performed very poorly at baseline (only 2 of 8 samples detected) and did not detect any samples after storage at any temperature. The P. vivax pLDH line appeared to be more stable, 11 of 13 being heat stable under all testing conditions and a further one showing only a slight decrease in detection at 35 °C and 100% detection at 45 °C. The exception was a product in which the P. vivax pLDH line did not detect any of the P. vivax samples at baseline or after storage at room temperature and only slightly better performance after incubation with one of eight samples detected after storage at 35 °C and three of eight samples detected after storage at 45 °C (Figs 26–29). Overall, both P. falciparum and P. vivax detecting products appeared more stable against samples with high (2000 parasites/µL) rather than low (200 parasites/µL) parasite density, as minor deterioration is not apparent at high parasite density.

13.2.  P  lasmodium falciparum All of the 19 P. falciparum -only RDTs with an HRP2 test line were heat stable. Thus, they detected a cultured P. falciparum sample the same number of times when stored at room temperature (< 25°C) or at 35°C or 45°C (with 75% humidity) for 2 months (Fig. 20) as at baseline. One P. falciparum -only detecting product had a line that detected P. falciparum pLDH (in addition to an HRP2 line). Both lines were heat stable. Of the 27 combination tests, 25 had an HRP2-detecting line. Of these, 24 tests were heat stable against a cultured P. falciparum sample. The 25th showed slight deterioration after 2 months’ storage at 45 °C. One of the 24 heat-stable products showed a slight loss in detection when stored at 35 °C but not at 45 °C. The two combination tests with only pLDH-detecting lines for P. falciparum both showed some heat instability: one with a slight decline in performance at 35 °C and then again at 45 °C, and the second with a major decrease in performance at 35 °C and then again at 45 °C.

52

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Table 6a: Heat stability testing results for 46 malaria RDTs on a cultured P. falciparum sample at low (200) and high (2000) parasite density (parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°Ca Positive test results for P. falciparum (Pf line) 200 parasites/µL Manufacturer Baseline 35°C 35°C 35°C 45°C Baseline Lots 1 and 2 combined NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0 30 30 30 30 30 29 30 28 30 30 14 0 23 15 24 0 30 0 30 1 0 11 3 26 25 18 0 29 0 28 0 NA NA NA NA 0 21 0 15 27 8 0 30 2 30 1 NA NA NA NA NA 0 10 5 3 30 2 0 21 0 30 4 NA NA NA NA NA NA NA NA NA NA NA 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 NA NA NA NA NA NA NA NA 10 10 9 10 10 10 10 10 10 10 9

Positive test results for P. falciparum (pan line) 200 parasites/µL 2000 parasites/µL 45°C Baseline Room temp

Positive test results for P. falciparum (Pf line)

Positive test results for P. falciparum (pan line) 2000 parasites/µL Room temp 35°C 45°C

Product Room temp 45°C Baseline Lots 1 and 2 combined NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Product code Room temp

Number of tests positive (max. 30) Number of tests positive (max. 30) Number of tests positive (max. 10) Number of tests positive (max. 10) Lots 1 and 2 combined Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

Lots 1 and 2 combined NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 10 10 10 10 10 10 10 10 9 10 10 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 10 10 10 10 10 10 10 10 10 10 10 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 10 10 10 10 10 10 10 10 10 10 10

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 Access Bio, Inc. (30/30)b (30/30)b (30/30)b (30/30)b WELLS BIO, INC 30 30 30 30 DIALAB 30 30 30 30 ICT INTERNATIONAL 30 30 30 30 Shanghai Kehua Bio-engineering Co., Ltd. 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 29 30 30 30 30 29 30 30 30 30 30 30 30 30 30 30 30 29 (29) 30 30 30 30 30 30 30 30 30 30 30 30 30 29 (29)

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line

RMSM-05071

careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test

10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 (10/10)b (10/10)b (10/10)b (10/10)b 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10

Malaria Pf Rapid Test

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)Zhejiang Orient Gene Biotech Co., Ltd. 402a GMDMALPF001 Medical Diagnostech (Pty) Ltd W37-C Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL

MPHRPD-01

5531 55IC103-50 55IC104-50 05FK130-40-0

RKMAL016

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST

05FK60AI-40

IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03

(continued)

Results

53

54

Table 6a: Heat stability testing results for 46 malaria RDTs on a cultured P. falciparum sample at low (200) and high (2000) parasite density (parasites/µL). Positivity rate at baseline (room temperature) and after 60 days’ incubation at room temperature, 35°C and 45°Ca (continued) Positive test results for P. falciparum (Pf line) 200 parasites/µL 200 parasites/µL Room 45°C Baseline temp 35°C 35°C Lots 1 and 2 combined 28 20 10 NA NA NA NA NA NA NA NA NA NA NA NA 30 NA 30 NA NA NA 30 NA NA NA NA NA 30 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 9 (9) 10 10 10 10 NA NA NA NA NA NA NA NA NA NA NA NA 10

Positive test results for P. falciparum (pan line) 2000 parasites/µL Room 45°C Baseline temp

Positive test results for P. falciparum (Pf line)

Positive test results for P. falciparum (pan line) 2000 parasites/µL

Product Room Baseline temp 35°C Lots 1 and 2 combined 30 30 30 30 17 (29) 30 30 30 30 30 30 30 30 30 30 30 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0 5 0 16 15 26 28 29 28

Product code

Manufacturer

45°C Baseline

Room temp

35°C

45°C Lots 1 and 2 combined 10 10 10 NA NA NA NA NA NA NA NA NA NA NA NA 10 10 10 10 NA NA NA NA NA NA NA NA NA NA NA NA 10 10 10 10 NA NA NA NA NA NA NA NA NA NA NA NA 10

Number of tests positive (max. 30) Number of tests positive (max. 30) Number of tests positive (max. 10) Number of tests positive (max. 10) Lots 1 and 2 combined 30 30 30 30 28 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 26 30 30 30 30 30 30 30 30 30 28

Is It... Malaria Pf PAN

NG-Test MALARIA Pf/Pan (pLDH)

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA

MPFPAN050 Medsource Ozone Biomedicals Pvt. Ltd. NGBNG Biotech MAL-W23-005 MAL-PF/PanHema Diagnostic Systems CAS/25

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag

Malaria Pf/Pv Rapid Test

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/ pv)-402a MDMALLDH004 W056-C

MFLRPD-02

71050

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

11108191040

5499

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species a Positive results presented in the table are based on stability of a positive reader 1 result b Product result shown along with results for HRP2 band and Pf-pLDH band, respectively

Table 6b: Heat stability testing results for 27 combination malaria RDTs on a wild-type P. vivax sample at low (200) and high (2000) parasite density (parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°Ca Positive test results for P. vivax (Pv line) 200 parasites/µL Manufacturer Baseline 35°C 35°C 35°C 45°C Baseline Lots 1 and 2 combined 8 8 8 8 7 8 8 8 0 8 8 8 5 8 NA NA NA NA NA NA NA NA NA 8 8 8 8 7 8 8 8 8 8 NA NA NA 8 NA NA NA 8 NA NA NA 8 8 NA NA NA NA NA NA NA NA NA NA NA NA 8 NA 4 4 4 4 4 4 4 0 4 4 4 4 4 NA 4 4 4 4 4 4 4 0 4 4 4 4 4 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 4 4 4 4 4 4 4 1 4 4 4 4 4 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 4 3 (3) 4 4 4 4 3 (3) 0 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 4 4 4 NA NA NA NA NA NA NA NA NA NA NA NA 4

Positive test results for Plasmodium (pan line) 200 parasites/µL 2000 parasites/µL 45°C Baseline Room temp

Positive test results for P. vivax (Pv line)

Positive test results for Plasmodium (pan line) 2000 parasites/µL Room temp 35°C 45°C

Product Room temp 45°C Baseline Lots 1 and 2 combined NA NA NA NA NA NA NA NA NA NA NA NA NA NA 8 8 8 8 8 8 8 3 8 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 8 8 7 8 8 8 8 8 2 8 8 8 8 7 8 8 8 8 8 0 8 7 8 8 8 8 7 8 8 8 0 8 8 8 7 8 8 8 8 7 4

Product code Room temp

Number of tests positive (max. 8) Number of tests positive (max. 8) Number of tests positive (max. 4) Number of tests positive (max. 4) Lots 1 and 2 combined Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 8 8 8 8 8 8 8 8 8 8 8 8 8 0 8 8 8 8 8 8 8 8 0 8 8 8 8 8 8 8 8 1 8 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Lots 1 and 2 combined 4 4 4 4 4 3 4 4 1 4 4 4 4 4 NA NA NA NA NA NA NA NA NA NA NA NA 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 NA NA NA NA NA NA NA NA NA NA NA NA 4 4 4 4 4 4 4 4 4 2 4 4 4 4 4 NA NA NA NA NA NA NA NA NA NA NA NA 4

RKMAL016

Pf and pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH)

05FK60AI-40

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/PanCAS/25

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C

MFLRPD-02

71050

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

11108191040

5499

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species  Pvom, Plasmodium vivax, ovale and malariae a Positive results presented in the table are based on stability of a positive reader 1 result

Results

55

Figure 20: Heat stability of P. falciparum-specific test line of P. falciparum-only tests against a low-density P. falciparum sample (200 parasites/μL). Positivity rate at baseline and after 60 days’ incubation No. of positive results from two lotsa

30

Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test - RKMAL017 ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test - ITP11002-TC25 Alere™ Malaria Ag P.f - 05FK140-40-0 Aspen© Malaria Ag Pf - AS0015

20

BioTracer™ Malaria P.f Rapid Card - 17912 CareStart ™ Malaria Pf (HRP2) Ag RDT - RMOM-03091 CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - RMSM-05071 careUS™ Malaria Pf (HRP2) Ag - RMO-M05082

10

DIAQUICK Malaria P.f. Cassette - W06200 ICT MALARIA P.F. CASSETTE TEST - ML01 KHB © Malaria Ag (HRP2) Pf Rapid Test - R-409-50-C GMD Malaria Pf test - GMDMALPF001

0

Baseline

RT

35 °C

45 °C

One Step MalariaHRP2 (P.f) Test - W37-C One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag - MPHRPD-01 PALUTOP + pf© - 5531 Parahit© f Ver 1.0 - Device - 55IC104-50 SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines - 05FK130-40-0 Malaria Pf Rapid Test - GCMAL(pf)-402a Parahit f© Ver 1.0 - Dipstick - 55IC103-50

a Maximum

score is 30 (15 tests x 2 lots)

Figure 21: Heat stability of P. falciparum-specific test line of P. falciparum-only tests against a high-density P. falciparum sample (2000 parasites/μL). Positivity rate at baseline and after 60 days’ incubation. No. of positive results from two lotsa

10 8 6 4 2 0

Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test - RKMAL017 ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test - ITP11002-TC25 Alere™ Malaria Ag P.f - 05FK140-40-0 Aspen© Malaria Ag Pf - AS0015 BioTracer™ Malaria P.f Rapid Card - 17912 CareStart ™ Malaria Pf (HRP2) - RMOM-03091 CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - RMSM-05071 careUS™ Malaria Pf (HRP2) Ag - RMO-M05082 DIAQUICK Malaria P.f. Cassette - W06200 ICT MALARIA P.F. CASSETTE TEST - ML01 KHB © Malaria Ag (HRP2) Pf Rapid Test - R-409-50-C Malaria Pf Rapid Test - GCMAL(pf)-402a GMD Malaria Pf test - MDMALPF001 One Step MalariaHRP2 (P.f) Test - W37-C One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag - MPHRPD-01 PALUTOP + pf© - 5531 Parahit f© Ver 1.0 - Dipstick - 55IC103-50 Parahit© f Ver 1.0 - Device - 55IC104-50 SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines - 05FK130-40-0

Baseline

RT

35 °C

45 °C

a Maximum

score is 10 (5 tests x 2 lots);

56

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Figure 22: Heat stability of P. falciparum-specific test line in combination tests against a low-density P. falciparum sample (200 parasites/μL). Positivity rate at baseline and after 60 days’ incubation. ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25 Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K Aspen® Malaria Ag Pf/Pv - AS0060 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 Biosynex® Malaria Pf/Pv - 0581_K25 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072 CareStart ™ Malaria Screen RDT - RMAM-05071 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 ICT MALARIA DUAL TEST - ML03 Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a Malaria Pf/PAN Test - PROMALPFV001 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 PALUTOP +4 optima® - 5499 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv - 11108191040 Biosynex® Malaria Pf/Pan - 0584_K25 CareStart ™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 Is It... Malaria Pf PAN - MPFPAN050 Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016 BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 a Maximum

No. of positive results from two lotsa

30

20

10

0

Baseline

RT

35 °C

45 °C

score is 30 (15 tests x 2 lots)

Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016 ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25 Alere Trueline™ - Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K Aspen® Malaria Ag Pf/Pv - AS0060 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25

No. of positive results from two lotsa

10 8 6 4 2 0

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 Biosynex® Malaria Pf/Pan - 0584_K25 Biosynex® Malaria Pf/Pv - 0581_K25 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart ™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072 CareStart ™ Malaria Screen RDT - RMAM-05071 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 ICT MALARIA DUAL TEST - ML03 Is It... Malaria Pf PAN - MPFPAN050 Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a Malaria Pf/PAN Test - PROMALPFV001 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 PALUTOP +4 optima® - 5499 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv - 11108191040

Baseline

RT

35 °C

45 °C

a Maximum

score is 10 (5 tests x 2 lots)

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Results 57

Figure 23: Heat stability of P. falciparum-specific test line in combination tests against a high-density P. falciparum sample (2000 parasites/μL). Positivity rate at baseline and after 60 days’ incubation.

Figure 24: Heat stability of pan line of combination tests against a low-density P. falciparum sample (200 parasites/μL). Positivity rate at baseline and after 60 days’ incubation. No. of positive results from two lotsa

30

QuickProfile TM Malaria Pf/Pan Test - 71063 Parascreen® - Rapid Test for Malaria Pan/Pf - 503030025 BioTracerTM Malaria Pf/PAN Rapid Card - 17012 First Response ® Malaria Ag. pLDH/HRP2 Combo Card - PI16FRC Is It… Malaria Pf/Pv Device - AL030 Meriscreen Malaria Pf/Pan Ag - MHLRPD-01 EzDxTM Malaria Pan/Pf Rapid Test Detection kit - RK MAL 001 RapiGEN BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C30RHA25 ATOMORAPIDTM Malaria (PF/PAN) - MMAL01 OnSite Malaria Pf/Pan Ag Rapid Test - R0113C BIONOTE MALARIA P.f.& Pan Ag Rapid Test Kit - RG19-08 Humasis Malaria P.f/Pan Antigen Test - ANMAL-7025 One Step Malaria P.f/Pan Whole Blood Test - W62-C

20

10

0

Baseline

RT

35 °C

45 °C

a Maximum

score is 30 (15 tests x 2 lots)

Figure 25: Heat stability of pan line of combination tests against a high-density P. falciparum sample (2000 parasites/μL). Positivity rate at baseline and after 60 days’ incubation. Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016

No. of positive results from two lotsa

10 8 6 4 2 0

Alere Trueline™ - Rapid test kit for Mala ria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K Aspen® Malaria Ag Pf/Pv - AS0060 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 Biosynex® Malaria Pf/Pan - 0584_K25 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart ™ Malaria Screen RDT - RMAM-05071 Is It... Malaria Pf PAN - MPFPAN050 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 PALUTOP +4 optima® - 5499 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25

Baseline

RT

35 °C

45 °C

CareStart ™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 ICT MALARIA DUAL TEST - ML03

a Maximum

score is 10 (5 tests x 2 lots)

Figure 26: Heat stability of pan line of combination tests against a low-density P. vivax sample (200 parasites/μL). Positivity rate at baseline and after 60 days’ incubation. Alere Trueline™ - Rapid test kit for Mala ria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40

No. of positive results from two lotsa

8

Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K Aspen® Malaria Ag Pf/Pv - AS0060 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25 Biosynex® Malaria Pf/Pan - 0584_K25 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart ™ Malaria Screen RDT - RMAM-05071 Is It... Malaria Pf PAN - MPFPAN050 PALUTOP +4 optima® - 5499 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25 CareStart ™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005

6

4

2

0

Baseline

RT

35 °C

45 °C

ICT MALARIA DUAL TEST - ML03 Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402

a Maximum

score is 8 (4 tests x 2 lots)

58

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Figure 27: Heat stability of pan line of combination tests against a high-density P. vivax sample (2000 parasites/μL). Positivity rate at baseline and after 60 days’ incubation Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit - RKMAL016

No. of positive results from two lotsa

4

Alere Trueline™ - Rapid test kit for Mala ria Ag Pf/Pan (HRP-II/pLDH) - 05FK60AI-40 AllTest™ Malaria P.f./Pan Rapid Test Cassette - IMPN-402 Asan Easy Test® Malaria Pf/Pan Ag - AM4650-K

3

Aspen® Malaria Ag Pf/Pv - AS0060 Biosynex® Malaria Pf/Pan - 0584_K25 BioTracer™ Malaria P.f/PAN Rapid Card - 17012 CareStart ™ Malaria Pf/PAN (pLDH) Ag RDT - RMLM-05071 CareStart ™ Malaria Screen RDT - RMAM-05071

2

1

ICT MALARIA DUAL TEST - ML03 Is It... Malaria Pf PAN - MPFPAN050 NG-Test MALARIA Pf/Pan (pLDH) - NGB-MAL-W23-005 Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN - MAL-PF/Pan-CAS/25

0

Baseline

RT

35 °C

45 °C

PALUTOP +4 optima® - 5499 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) - C32RHA25

a Maximum

score is 4 (2 tests x 2 lots)

Figure 28: Heat stability of P. vivax-specific test line in combination tests against a low-density P. vivax sample (200 parasites/µL). Positivity rate at baseline and after 60 days’ incubation. ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25

No. of positive results from two lotsa

8

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 Biosynex® Malaria Pf/Pv - 0581_K25 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02 PALUTOP +4 optima® - 5499 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv - 11108191040 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072

6

4

2

Baseline a Maximum

RT

35 °C

45 °C

Malaria Pf/PAN Test - PROMALPFV001

score is 8 (4 tests x 2 lots)

Figure 29: Heat stability of P. vivax-specific test line in combination tests against a high-density P. vivax sample (2000 parasites/μL). Positivity rate at baseline and after 60 days’ incubation. ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test - ITP11003-TC25

No. of positive results from two lotsa

4

Biosynex© Malaria Pf/Pv - 0581_K25 CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-03091 careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag - RMV-M05082 One Step Malaria HRP2/pLDH (P.f/P.v) Test - W056-C One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag - MFLRPD-02

3

2

PALUTOP +4 optima© - 5499 QuickProfile™ Malaria Pf/Pv Antigen Test - 71050 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv - 11108191040

1

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) - C60RHA25 Malaria Pf/Pv Rapid Test - GCMAL(pf/pv)-402a CareStart ™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT - RMVM-05072

0

Baseline

RT

35 °C

45 °C

Malaria Pf/PAN Test - PROMALPFV001

a Maximum

score is 4 (2 tests x 2 lots)

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Results 59

14.  description of Ease of use, anomalies, Labelling and instructions for use 14.1. Ease of use After becoming proficient in using a product, two technicians submitted a joint agreed assessment of its usability. The results, which are a description of the product with emphasis on aspects considered important for ease of use in the field, are presented in Table 7. The assessment did not include a comparison of blood transfer devices, which are critical to both the safety and the accuracy of the testing procedure and pose a significant challenge to many users. These may vary by manufacturer in many products. Procurement decisions should be based on which transfer devices are best suited for the intended users, which should be discussed with the manufacturer before procurement. It is strongly recommended that RDT packaging, contents, safety and ease of use be assessed in the field as part of product selection (Annex S2, Table AS2.1).

14.3. Labelling and instructions for use Adherence to a list of recommendations for instructions for use and product labelling were assessed for the first time in Round 7. Figs 31–38 show the percentages of products that adhered to the recommendations, grouped by theme. Generally good adherence was found to the recommendations for labelling of the main package (Fig. 31) and the device (Fig. 32), with exceptions in the guidance on storage conditions and the inclusion of appropriate warning labels. Labelling of the buffer bottle (Fig. 33) and accessories (Figs 34–36) met only a few recommendations (see below). The instructions for use were highly variable, and many recommendations, including critical ones, were not met. An important area of divergence from the recommendations was for laboratory safety. For example, none of the blood transfer devices carried labels indicating that they were for single use only, and 59% of lancet packages had no indication that those with damaged packaging should not be used (Fig. 35). The instructions for use of less than 10% of products advised disposal of tests in biohazard waste containers, and those of less than 20% advised disposal of lancets in sharps containers (Fig. 38). Only 26% of the instructions advised that a new pair of gloves should be used at each step (Fig. 38). Important omissions were also found in basic product information: 28% of instructions for use did not mention that some necessary materials were not included in the kit (Fig. 37), and 33% did not list limitations of product. In terms of product specifications, nearly all the instructions listed the diagnostic sensitivity and specificity of the product, but few mentioned analytical sensitivity or specificity or gave information on parasite densities and reference methods (Fig. 37). Adherence to recommendations for describing procedures was also variable. While all gave good guidance on the interpretation of line combinations for positive results, fewer than half advised that a faint line should be considered a positive result (Fig. 38).

14.2. Anomalies In round 7, technicians regularly recorded anomalies from a list of problems encountered with some production lots evaluated in past rounds of testing and at WHO–FIND lottesting laboratories. Since March 2012, these observations have been included in all WHO–FIND lot testing reports and were recorded as part of product testing for the first time in round 5. Table 8 shows the percentage of tests per product in which specific anomalies were observed and the frequency of tests with an anomaly in each product. Generally, users should be aware of major anomalies that may be encountered in production lots (Fig. AS2.1), as they can affect interpretation of RDT results. In round 7, 33 of the 46 products had between one and five different types of anomaly; in 13 products, no anomaly was seen (Table 8, Fig. 30). Incomplete clearing and red background (not obscuring test lines) were the most common anomalies, seen in 48% and 24% of products, respectively. Incomplete migration, failed migration and a red background obscuring the test lines were seen next most often, in 15%, 11% and 11% of products, respectively. In most (31) of the 33 products with anomalies, they were found in < 1% of the tests; in two products, anomalies occurred in 1.4% of tests (Table 8). This rate is much lower than that in round 6, when all products had between one and six anomalies and approximately half had a frequency > 2%.

60

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Figure 30: Percentage of RDTs with various anomalies observed in production lots 100 80 60

Percentage of products

1-2% frequency 40 20 0

<1% frequency Not seen

Any anomaly

Patchy broken test lines

Incomplete clearing

Red background

Failed migration

Red background obsuring test line

Type of anomaly

Strip misplaced in cassette (shift)

Incomplete migration

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Results 61

62

Percent 100 50 0 100 50 0

Pr od

Percent

100 4 85 11 13 100 100 4 96 24 76 2 2 98 98 78 22 87 7 4 89

U re ses co in gn te iz rn ed at sy ion m all bo y ls 100

Figure 31: Adherence to box labelling recommendations

a: Standard of box labelling

le C gi om bi lit pli y es st an wi da th rd

100

In cl ud

es

co m m

Percent 50 0

100 2 9 91 98

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

c: Completeness of information displayed on the product box 30

63

37

11

59

7 93

30

70

63

37

No

b: Completeness of product name (as on box)

Yes

Pr uc od tc uc od tn e am (a nd e sy m bo l) In te nd ed N In o. us vi of tro e te di st ag s Le in no ga ki st t lm ic ( an sy Le m uf ga bo ac lm l) t u an re Le r's uf a ga na ct lm ur m er e an 's uf a ac dd tu re Lo re ss tn r's um C Ex on be pi ta r( ra ct an tio d n sy da m te bo (a l) nd Q sy M ua a m te nt bo ria ity l) ls of p m St r ov at or id er ag ed W ia e ar ls c ni p o ro ng nd vi s iti de on or d s pr (s ec ym au bo tio ls ns ) (s ym bo ls ) 89 9 2

er ci al In cl na u m de In e cl s ud "M es In al cl ar an ud ia tig " es e In n t ar cl o ud ge rA es te g d ta sp rg ec et ie ed s a nt U ni i g qu en e /s fo rp ro du ct

Partially

15 85

Figure 32: Adherence to cassette labelling recommendations a: Completeness of information displayed on the cassette packaging 100

2 98

30

17 83

17 83

2 41

2 50

26 43

91

Percent

70 50

57

48 30

0

9

Pr od uc tn In Le am vi In ga tro e te lm di nd ag an ed no uf us ac st e i tu c (s re ym r's bo na Lo l) m tn e um ( o Ex rl be pi og r( ra o) a tio n d n sy St da or m te bo ag (a l) e nd W co ar sy nd ni m ng iti bo on s/ l) s pr (s ec ym au bo tio ls ns ) (s ym bo ls )

No Partially Yes

b: Standard of cassette labelling 100 11 61

c: Completeness of information displayed on the cassette 100 7 9 85 11 11 78

Percent

50

Percent 26 2

50

0

P or rod ab uc br t n ev am ia e tio n

be an lled d bu spe ffe ci r w me el n ls

Labeling legibility Low Medium High No response

0 No Partially Yes

La

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

63

Figure 33: Adherence to buffer bottle labelling recommendations a: Standard of buffer bottle labelling 100

13 26 61

Percent

50

0

Use of internationally recognized symbols

b: Completeness of information displayed on the buffer bottle 100

26 74

70

52

26 74

9 91

35

4 30

24 4 72

28

100

Percent

50

65

65

72

48 30

0

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ym

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(n

ls No Not applicable Partially Yes

io

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Figure 34: Accessory labelling – use of internationally recognized symbols 100

Ex pi

C

ra

tio

nt

n

72

9 13 39

da

te

9 4 48

no

78

Percent

50

W

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26 0

39

39 22

2 Blood transfer device Lancet Alcohol swab Dessicant

64

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

ns No Yes

te

m

s

(s

Not applicable Accessory not included

)

Figure 35: Completeness of information on accessory packaging – blood transfer device and lancet a: Blood transfer device 100

80

87

85

85

98

Percent

50 No Not applicable Yes

20 0

4 13 15 11 2

de

100

y na nt Inte m ifi n e ca de tio d n us by e na an m d e qu Lo an tn tit um y be in O di u r ca te tio r p n ac (s ka Si ym g ng bo e le l) us e (s ym bo l) id e b: Lancet

vi ce

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30

20 41

28 33

28 33

33

22 39

59

30 Percent 50

28 2 No Yes Accessory not included

39

39

39

39

39

39

39

0

de

en In m tif ten e ic d at ed io n us by e na an m d e Lo tn um be r Ex pi qu r a an tio tit n y da in O te di u ca te tio r p n ac (s ka ym g Si ng bo e le l) us e ( -n sy m ot D bo to am l) be ag us ed ed pa (s cka ym g bo e l)

Ac c vi

es

ce

id

so

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na

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

65

Figure 36: Completeness of information on accessory packaging – dessicant and alcohol swab a: Dessicant 100

22 78

48

100

37

Percent

50

43 52 No Not applicable Yes

20 0

de

vi ce

100

or y na id m en In e tif ten ic d at e io d n us W by e ar na an ni m d ng e (te xt C or ol sy ou m rc bo ha ls ng ) e in te rp re ta tio n

Ac

ce ss

b: Alcohol swab

61

61

61

22 39

24 37

30

17 43

50

30 11 No Yes Accessory not included

Percent

50

39

39

39

39

39

39

39

39

0

de 66

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

An

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ss or en In y na tif ten ,p i m c d ro at e e io d du n u ct se b y an n an d co am d e nc en tra tio n Lo tn um Ex be qu pi r an ra tit t io y n in O da di u te ca te tio r p n a Si (s ck ng ym ag le bo e us -n l) e ot D (s ym to am be ag bo l) us ed ed pa (s ck ym ag bo e l) id

vi

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Ac

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Figure 37: Completeness of information included in the IFU: intended use and precautions and limitations a: Product information and Intended use 100

b: Precautions and Limitations

100

13 87

100

100

100

100

28

9 91

100

11 89

37

7 93

33

72 Percent 50 Percent 50

63

67

No Yes 0 0

As io sa n ec y bu ct im pr i of en tn nc m ot ip ty an le pe pr uf ov r ac e id qu tu ed ire re (a rd t le te as ch to ni ca ne la ) ss is ta nc e

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Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

67

68

R oo m te m pe ra tu re Percent 50 0

Pr C on fir 100 50 0

ep a

An Percent

100

re

fin

m

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ge

72 28

13

87

11 89 74 26

4 11

85

11 4 85 11 100 89

4 96 9 91

50 50

a: Performance Specifications

b: Test Procedure

17 83 93 7 4 96 100 50 11 39

91

9 11 52

37

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

al yt (d ical et s ec en tio sit An n ivi lim ty al yt it) ic al sp ec D ia ifi gn ci ty os tic se ns D iti ia vi gn ty os tic sp Pa ec ra ifi ci re site ty fe d re e nc ns D e itie m s fo iffe et a r 4 re ho nd Pl nt s ds as p m ec od ific iu at m io sp ns p.

9 91 4 96

No

Yes

Partially

Figure 38: Completeness of information included in the IFU – procedure and performance specifications.

go fore o u P ra ut d co se nd on nd iti us ne o e of w g n lo a lc ve U oh se s ol o fb D U s w is s lo ab po Set od e o sa co fl t ra an li D u nt ns n is ce po do b fe t sa ios w r de n af li r e v n N ea ty ic eg bi e di sh oh at ng a i a rp za t Po ve im s re r si su d w con e In te tive ltas t rp al te aine re res ll co r in ul ta e tnt t co ai Al ion a ne ll ll of lin mb in r d in e e at co iffe co i r o m m en ns bi bi F tp C na on ollo nat o t s io si w ns itiv ions de in e g f rf or re ac ai s in tio nt va ults n te lid fo st ri lin nv res e ul al as t i po d re su si tiv lt e re su lt Not applicable

46

54

Table 7: Ease-of-use description of 46 malaria RDTs included in round 7 Blood safetya Buffer Discoloured Blood transfer device Mixing wells involved Retractable needle Strip Exposed Score (max. 3) Mixing wells involved Retractable needle Strip Exposed Score (max. 3)

Instruction qualityb

Product Format

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 2 2 2 4 0 1 2 2 2 4 1 1 1 1 0 1 2 3 2 2 1 1 2 2 4 5 25 25 20 15 NA 1 2 2 1 20 2 4 no no no yes yes NA 1 2 1 1 20 no 1 3 0 1 2 2 1 15 yes 2 4 NA 1 2 2 1 20 no 2 4 1 1 3 2 1 15 no 2 5 0 1 2 2 1 15 yes 2 4 0 1 2 2 1 30 no 2 4 0 1 2 2 1 20 no 2 4 pipette 0 0 1 1 2 2 2 2 1 1 20 20 no no 2 2 4 4 0 1 2 2 1 20 no 2 4 cassette cassette cassette cassette 0 1 0 1 1 1 2 3 2 2 2 2 1 1 1 20 20 20 no no yes cassette cassette cassette loop loop loop inverted cup pipette pipette 2 2 2 4 5 4 NA 1 2 2 1 20 no pipette cassette 2 4 English English English English English

RKMAL017

Advy Chemical Private Limited

ITP11002-TC25 InTec Products, Inc. AS0015 Aspen Laboratories Pvt. Ltd. 17912 Bio Focus Co., Ltd.

Combined score (max. 5) Number of timed steps Total time to result Desiccant with colour indicator (yes/no) Container does not puncture Does not flow freely Insufficient volume Empty (bottle or vial)

Language of instruction English English English, German English English English English English English English, French English English English English English English English English English English English

Product code

Manufacturer

Items included in RDT boxc

Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet

CareStart™ Malaria Pf (HRP2) Ag RDT

RMOM-03091

Access Bio Ethiopia

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line RMSM-05071 careUS™ Malaria Pf (HRP2) Ag" RMO-M05082

Access Bio, Inc. WELLS BIO, INC

DIAQUICK Malaria P.f. Cassette

W06200

DIALAB

GMD Malaria Pf test

MDMALPFH005 Medical Diagnostech (Pty) Ltd

ICT MALARIA P.F. CASSETTE TEST

ML01

ICT INTERNATIONAL

KHB® Malaria Ag (HRP2) Pf Rapid Test

pipette cassette inverted cassette cup inverted cassette cup pipette pipette pipette loop cassette cassette cassette cassette

Malaria Pf Rapid Test

One Step Malaria HRP2 (P.f) Test

Shanghai Kehua BioR-409-50-C engineering Co., Ltd. Zhejiang Orient Gene Biotech GCMAL(pf)-402a Co., Ltd. Guangzhou Wondfo Biotech W37-C Co., Ltd.

Alcohol Swab / Lancet

One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag

GMDMALPF001 Meril Diagnostics Pvt. Ltd.

PALUTOP + pf®

5531

ALLDIAG SA

Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device

55IC103-50 55IC104-50

ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd

Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet

Alere™ Malaria Ag P.f.

05FK140-40-0

Standard Diagnostics, Inc.

SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines 05FK130-40-0

Standard Diagnostics, Inc.

pipette dipstick pipette cassette inverted cassette cup inverted cassette cup 4 1 20 no

Pf and Pan 1 1 1 1 1 1 1 NA 1 2 NA 0 1 1 2 2 NA 1 2 NA 1 2 0 1 2 2 2 2 2 2 2 0 1 2 2 2 2 2 2 2 2 2 Alcohol Swab / Lancet 4 4 4 4 4 4 1 1 1 1 1 1 20 20 30 30 20 15 no no no no yes no Alcohol Swab / Lancet

CareStart™ Malaria Screen RDT

RMAM-05071

Access Bio, Inc.

CareStart™ Malaria Pf/PAN (pLDH) Ag RDT

RMLM-05071

Access Bio, Inc.

RKMAL016

Advy Chemical Private Limited

inverted cassette cup inverted cassette cup pipette cassette loop cassette

Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) Asan Easy Test® Malaria Pf/Pan Ag BioTracer™ Malaria P.f/PAN Rapid Card

05FK60AI-40

Alere Medical Private Limited

AM4650-K 17012

ASAN Pharmaceutical Co., Ltd Bio Focus Co., Ltd.

Alcohol Swab / Lancet

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) loop cassette loop cassette inverted cassette cup

Biosynex® Malaria Pf/Pan

0584_K25

Biosynex

Results

69

Mixing wells involved Retractable needle

Strip Exposed

Score (max. 3)

Mixing wells involved Retractable needle

Strip Exposed

Score (max. 3)

Discoloured

Blood transfer device

Format

AllTest™ Malaria P.f./Pan Rapid Test Cassette IMPN-402 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 NA 1 2 2 NA 0 1 1 2 2 2 2 2 2 2 NA 1 2 1 1 3 4 4 4 NA 0 1 1 2 2 2 2 2 2 4 4 1 1 1 1 1 1 0 1 2 2 1 2 4 0 1 2 2 1 2 4 15 20 20 30 20 30 20 20 NA 1 2 2 1 15 2 4 no yes no no no no no no no 1 1 3 2 1 20 no 2 5 NA 1 2 2 1 30 no 2 4 0 1 2 2 1 20 no 2 4 0 1 2 2 1 20 no 2 4 NA 1 2 2 1 30 no 2 4 0 1 2 2 1 30 yes 2 4 NA 1 2 2 1 20 yes x 2 4 loop pipette pipette pipette 0 1 2 2 1 30 no 2 4 0 1 2 2 1 20 no pipette 2 4 cassette

Hangzhou AllTest Biotech Co. Ltd. 1 NA 1 2 2 1 10 no pipette cassette 2 4

Combined score (max. 5) Number of timed steps Total time to result Desiccant with colour indicator (yes/no) Container does not puncture Does not flow freely Insufficient volume Empty (bottle or vial)

English English English Alcohol Swab / Lancet Alcohol Swab / Lancet

MAL-PF/PanRapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN CAS/25

Hema Diagnostic Systems

ICT MALARIA DUAL TEST

ML03

ICT INTERNATIONAL

inverted cassette cup cassette cassette cassette cassette inverted cassette cup loop cassette

Is It... Malaria Pf PAN

MPFPAN050

Medsource Ozone Biomedicals Pvt. Ltd.

English English English English English English English English Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet

NGBNG Biotech NG-Test MALARIA Pf/Pan (pLDH) MAL-W23-005 BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) C32RHA25 RapiGEN Inc. Pf and Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag RMVM-05072 Access Bio, Inc. Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag RMVM-03091 Access Bio Ethiopia Combo RDT Alere Medical Private Rapid Test Kit for Malaria Ag Pf/Pv- Alere 11108191040 Limited Trueline Malaria Ag Pf/Pv Aspen® Malaria Ag Pf/Pv AS0060 Aspen Laboratories Pvt. Ltd.

Biosynex® Malaria Pf/Pv

0581_K25

Biosynex

loop cassette inverted cassette cup pipette loop pipette pipette pipette pipette pipette pipette cassette cassette cassette cassette cassette cassette cassette cassette

One Step Malaria HRP2/pLDH (P.f/P.v) Test

W056-C

Guangzhou Wondfo Biotech Co., Ltd.

English English English English English English English English

Language of instruction English, French

70

Table 7: Ease-of-use description of 46 malaria RDTs included in round 7 (continued) Blood safetya Buffer Instruction qualityb

Product

Product code

Manufacturer

Items included in RDT boxc

Alcohol Swab / Lancet Alcohol Swab / Lancet Alcohol Swab / Lancet

ITP11003-TC25 InTec Products, Inc.

71050 Lumiquick Diagnostics Inc. PROMALPFV001 Real World Diagnostics

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) 1 NA 1 2 2 2 4 1 20 no loop cassette

ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test QuickProfile™ Malaria Pf/Pv Antigen Test Malaria Pf/PAN Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag

MFLRPD-02

Meril Diagnostics Pvt. Ltd.

Alcohol Swab / Lancet

Malaria Pf/Pv Rapid Test

C60RHA25 RMV-M05082 GCMAL(pf/pv)402a

RapiGEN Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd.

Pf and Pv and Pan

PALUTOP +4 optima®

5499

ALLDIAG SA

Pf, Plasmodium falciparum 

IFU, instructions

Pv, Plasmodium vivax  pan, Plasmodium species  for use a Mixing wells involved; Yes=0; No=1; retractable needle: yes=1; no=0; strip exposed, not within card or cassette: exposed =0, covered=1 b No diagrams=0; diagram of results=1; diagram of result and method=2 c Procurers should verify which accessories accompany test kits with the manufacturer and ensure they procure the appropriate products.

Table 8: Percentage distribution of anomalies observed by product in phase 2

Product

Product code

Manufacturer

Percentage of tests with specified anomaly Percentage Red Strip of tests with Red background Incomplete Incomplete Failed misplaced at least one background obsuring test clearing migration migration in cassette anomaly line(s) (shift) 0.1 0.2 0.1 0.0 0.1 0.1 0.2 1.4 0.1 0.2 0.1 0.0 0.0 0.0 0.2 0.0 0.0 0.2 0.1 0.0 0.2 0.0 0.1 0.6 0.0 0.0 0.2 0.5 0.1 0.5 0.0 0.8 0.2 0.2 0.2 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.2 0.2 0.0 0.5 0.0 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.4 0.0 0.0 0.0 0.3 0.0 0.1 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.2 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.1 0.1 0.8 0.0 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1

Patchy broken test line 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 RMSM-05071 RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc.

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd.

MPHRPD-01

5531 55IC103-50 55IC104-50 05FK130-40-0

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

ITP11003-TC25

Results

71

72

Table 8: Percentage distribution of anomalies observed by product in phase 2 (continued)

Product

Product code

Manufacturer

Percentage of tests with specified anomaly Percentage Red Strip of tests with Red background Incomplete Incomplete Failed misplaced at least one background obsuring test clearing migration migration in cassette anomaly line(s) (shift) 0.0 0.2 0.6 0.2 0.1 0.7 0.1 0.0 0.3 1.4 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.2 0.1 0.4 0.1 0.0 0.0 0.6 0.1 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.3 0.5 0.0 0.0 0.2 0.0 0.1 0.0 0.2 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Patchy broken test line 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.1

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

15. Discussion of key findings This report describes the performance of many of the commercially available malaria antigen-detecting RDTs manufactured under the ISO 13485:2003 quality standard. For malaria RDTs to improve the management of febrile illness in malaria-endemic areas, they must have adequate: • sensitivity, to detect nearly all clinically significant cases of malaria; • specificity, to accurately discriminate non-malarial febrile illness from malaria in order to ensure appropriate management and accurate disease monitoring; • stability, to maintain accuracy after transport and storage in ambient conditions; and • ease-of-use, and adequate labelling and instructions for use to ensure safe, correct preparation and accurate interpretation of results. Malaria RDTs were evaluated in terms of these four requirements in order to assist national malaria control programmes and other procurement agencies in selecting products appropriate for their needs. The evaluation constitutes the laboratory component of the WHO programme for prequalification of in vitro diagnostics. The panel used ensured successful discrimination between the RDTs evaluated. A number of products showed a high rate of antigen detection, a low false-positive rate and good heat stability. These attributes are essential for tests used as a basis for decisions about malaria treatment in the populations of most malaria-endemic countries. Overall, the mean PDS against low-density P. falciparum samples in round 7 was 87.2%, slightly higher than in round 6 (83.6%) and continuing the pattern of improvements in each round.1 For P. vivax tests, the mean PDS of 76.8% is the highest achieved so far.2 The median false-positive rate was 0%, which is lower than in round 6 (0.5%). Overall, a high level of performance has been maintained in P. falciparum -only tests, and improved performance has been seen in P. vivaxdetecting RDTs. As previously, too few Pf-pLDH-based RDTs were submitted for evaluation: only three were assessed in round 7. The mean PDS (at 200 parasites/µL) was 62% (range, 38–75%) in rounds 2–6 (17 products) and 2.0–88.9% in rounds 2–7. Five products tested in round 3 of the programme were resubmitted for testing in round 7. Two performed better 5 years after initial testing, but three performed less well, and two of these no longer met the WHO criteria for procurement. The evaluation is performed against a standardized panel of cultured P. falciparum and frozen blood samples by experienced technicians in a research laboratory and is not 1

therefore a field evaluation of the accuracy of RDTs in a specific epidemiological context in the hands of the intended users. The panel is designed to mimic fresh blood samples from actual cases as closely as possible, while allowing direct comparison of a large number of products simultaneously, with control for confounding factors, and is calibrated to a level likely to discriminate differences in the performance of various products. The discussion points below should therefore be taken into account in interpreting the results.

15.1. Panel detection score and its relation to sensitivity Evaluation of the RDTs against the phase-2 wild-type parasite panel with a parasite density of 200 parasites/µL (Figs 10 and 11) revealed a range of frequency and consistency of antigen detection between products, recorded as the PDS. As expected, testing at higher parasite density (2000 parasites/µL) resulted in smaller differences in performance. As two tests from two different lots were tested at 200 parasites/µL and as all four tests had to be positive in order for a sample to be considered “detected” by an RDT, a positive result indicates the ability of a product to detect the target antigen in the sample and to do this consistently (both tests from both lots). A parasite density of about 200 parasites/µL should be detected to ensure high field sensitivity for clinically significant malaria infection in many malaria-endemic populations (11). The PDS in the panels used in this evaluation differs from the test sensitivity in clinical settings for five main reasons. (i) The performance of different lots or batches of the same product may vary. Variation in lot performance is an issue for all diagnostics; therefore, the results found in the evaluation may not predict the results for subsequent RDT lots. It is important to test lots before their distribution in the field to ensure that the expected performance is maintained (section 16.2). (ii) In clinical settings, patients show wide variation in parasite density, the range depending on the local epidemiology of the disease. The parasite density in the population tested affects the clinical sensitivity of a test. The PDS against a test panel of blood samples diluted to 200 parasites/µL is likely to underestimate the clinical sensitivity of an RDT in areas where symptomatic patients have much higher parasite densities. Many tests that show only moderate detection of the 200-parasites/µL panel may perform well in such settings, as indicated by the better PDS of most products against the panel at 2000 parasites/µL. The small differences in PDS seen in Figs S1, S2 and 9–11 and Tables 4 and 5 found among the better-performing RDTs in this evaluation are unlikely to result in noticeable differences in clinical sensitivity, and other issues, such as required storage conditions, stability, cost, experience and training

The PDS values for P. falciparum in rounds 1, 2, 3, 4 and 5 were 67.2%, 69.9%, 75.5%, 81.6% and 81.0%, respectively. 58.9%, 47.1%, 51.3%, 61.3% and 70.7%, respectively.

2 The PDS values for P. vivax in rounds 1, 2, 3 , 4, 5 and 6 were 36.0%,

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of the intended users, ease of use (Annex S2) and manufacturing capacity, may be equally important in test selection. Consideration of the parasite density in target populations and the probable sensitivity of RDTs in the field indicates that, even in areas with high transmission and strong malaria immunity, the population may include individuals with a low parasite density but clinically significant infection (e.g. young children, pregnant women, people who regularly use bed nets, immigrants and people with reduced immunity). The ability to detect low parasite-density infections reliably, therefore, remains important. As some countries move towards elimination of malaria, population immunity will decrease and/or clinical cases may be detected earlier, and it could become increasingly important to use diagnostic tests that detect low parasite density (i.e. with a high PDS against samples with 200 parasites/µL). (iii) The performance of tests against the challenge panel may not always predict sensitivity in clinical testing, e.g. when antigen expression by certain parasite populations differs greatly from that in the panel. For example, P. falciparum strains in some areas of Africa (Eritrea (33), Democratic Republic of the Congo), India (13) and South America (34) do not express HRP2 antigens because of gene deletions (12–13). If a significant proportion of parasites in a given area do not express HRP2 and HRP3, leading to false negative results, tests to detect other target antigens (e.g. pLDH or aldolase) must be used. To date, parasite populations with a high frequency of non-expression of target antigens have been identified in several countries in South America (12) and in Eritrea (33, 34). The reactivity of the non-HRP2, Pf-specific test lines against phase 1 and 2 Pf (HRP2-containing) samples is currently the best predictor of how well these RDTs would detect pfhrp2-negative parasites. In most cases, the Pf panel detection score for products based on pf-pLDH-specific test lines is < 75, the cut-off for procurement. In round 7, one combination test met the procurement criterion, with a PDS of 75 against 200 parasites/µL Pf samples. For a summary of options and test performance in round 7 and previous rounds, refer to the WHO interim guidance on investigating false-negative RDTs and pfhrp2/3 gene deletions.1 (iv) The conditions under which RDTs are transported and stored can alter their sensitivity in the field. The tests evaluated in round 7 were shipped and stored under conditions intended to safeguard them from degradation by high temperature or other extreme conditions. If such precautions are not taken with purchased RDTs, loss of performance could result. The ambient temperature of storage conditions varies widely in the settings in which these tests are commonly used, as does the temperature during transport; therefore, the requirements for the heat stability of a product will differ. Tests should be transported and stored well within the temperature range recommended by the manufacturer (see Annex 1) and extremes of temperature avoided (32, 35 ). 1

(v) Diagnostic sensitivity and specificity depend on the quality of preparation and interpretation of the tests. Highly trained technicians tested all the products in this evaluation. In clinical settings, malaria RDTs are often used by health workers with limited training and supervision; therefore, simple design and clearly interpretable results are required to ensure translation of the technical proficiency of a product into accurate diagnoses in the field (36).

15.2. False-positive rate and specificity False-positive rates are reported against a panel of 52 clean-negative samples taken from blood donated in lowtransmission settings by people without symptoms of malaria. In addition, false-positive rates were calculated with a smaller number of samples with specific characteristics that affect the likelihood of a false-positive result from an immunodiagnostic test (e.g. rheumatoid factor, anti-nuclear antibody) or that may be significant in a specific population in a malaria-endemic area (e.g. leishmaniasis, dengue). The importance of these results depends on the intended area of use. High false-positive rates with samples of blood from dengue patients, for example, might not be a significant factor in regions in which dengue does not occur. In view of the small number of samples in each category in this evaluation, the results should be considered primarily a guide to potential cross-reactions, which should be closely monitored if they are relevant to the target population. In general, it is preferable to procure a product with a low rate of false-positive reactions. In the case of many diagnostic tests, a trade-off must be made between a preference for a high rate of antigen detection (sensitivity) and a low false-positive rate (specificity). The context in which the test will be used will guide the relative importance of these two factors in the choice of one product over another. Overall, in this evaluation, there was no correlation between a lower PDS (loss of sensitivity) and a low false-positive rate (high specificity). A number of products had both a high PDS and a low false-positive rate.

15.3. Reactivity of combination HRP2 and pan-pLDH test lines against P. falciparum samples Instructions for the use of P. falciparum/pan and pan/P. falciparum combination tests classify P. falciparum infections as either HRP2 test line-positive alone or in combination with the pan-pLDH line. Combination tests that return only a positive HRP2 test line may be incorrectly interpreted as false positives for malaria infection secondary to persistent (HRP2) antigenaemia. The results in this report clearly indicate that most combination tests in which HPR2 is used for the detection of P. falciparum return positive results only on the HRP2 band at lower densities of P. falciparum (Table A4.2). When both the HRP2 and the pan test bands were positive, the mean band intensity was significantly lower on the pan test

http://apps.who.int/iris/bitstream/10665/208819/1/WHO_HTM_ GMP_2016.4_eng.pdf (accessed 8 March 2017).

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band than on the HRP2 test band. Therefore, it is important to reinforce adherence to the manufacturer’s instructions for use (Annex 2) and to emphasize that for combination HRP2/pan-pLDH tests, a HRP2 test line-positive alone may well be attributed to the poor reactivity of pan-pLDH lines.

15.5. Ease-of-use description The sensitivity and specificity of RDTs depend on the quality of preparation and interpretation. In general, a simpler format with fewer steps or fewer required extraneous materials is likely to be prepared and interpreted more reliably. Thus, cassette-format RDTs are generally more reliably prepared and interpreted than products in dipstick format (39). The extra cost of this format may be offset by the advantages of greater accuracy and, in some cases, less additional equipment required to perform them. The method by which blood is transferred from the patient to the test is important for the safety of the user and for the accuracy of the volume transferred. Devices for blood transfer are supplied with RDTs but vary widely in design and accuracy (31). The performance of blood transfer devices was not formally assessed in this evaluation, as blood was transferred from a tube with a micropipette to ensure that the volume specified by the manufacturer was used. Procurement programmes for RDTs should consider the adequacy of the blood transfer device supplied, including the experience of health workers and the cost and time required for retraining. It may be appropriate to discuss with manufacturers the possibility of changing the blood transfer device from that usually supplied. The clarity of results is important for interpreting tests. A clearly visible (intense) test line is less likely to be overlooked than a line that is barely visible. While reading proficiency and adequate workplaces should be ensured, some health workers might have suboptimal vision or work in inadequate lighting. Although the intensity of the test band was found to be correlated with the PDS of RDTs, PDS is determined only from a positive or negative result under ideal working conditions. Thus, it is important when selecting RDTs also to consider the relative intensity of the test bands, with a preference for intense bands (i.e. an intensity > 2). The importance of format and the simplicity of the test design depend on the intended users. Trained laboratory technicians can handle a complicated procedure more reliably than village volunteers with limited supervision. In all cases, proficiency-based training and adequate supervision should be included in any RDT-based diagnostic programme, and clear instructions should be provided in a language and format appropriate for the user (40, 41). Annex S2 provides guidance on conducting a field-based ease-of-use assessment (Table AS3.1).

15.4.  Heat (thermal) stability The RDTs evaluated were held for 2 months at room temperature (21–25°C) and at 35°C and 45°C at 75% humidity and tested to evaluate stability at these temperatures as compared with baseline detection. The importance of thermal stability depends on the conditions under which a product will be transported and stored. Thus, stability at high temperatures is vital if an RDT is to be stored at clinics in a country where the ambient temperature can reach 45°C in the hot season but is less critical in a high-altitude or cooler environment where the temperature rarely rises above 35°C. Many commercially available RDTs indicate 30°C or 40°C as the maximal storage temperature (Annex 1). Higher temperatures were tested in this evaluation because malaria-endemic countries often have maximum ambient temperatures of 35°C, although use of cool storage can allow storage of products below this temperature. When RDTs are likely to be transported and stored at high ambient temperatures, heat (thermal) stability must be considered a significant factor in ensuring sensitivity. High humidity accelerates the degradation of malaria RDTs and other lateral flow tests. All the products in this evaluation were packaged in individual envelopes containing desiccant and designed to be moisture-proof. This allows the user to open the envelope of a test at the time of use, limiting exposure to high humidity. During the stability-testing phase of this evaluation, the RDTs were stored at 75% humidity. The packaging should, if in good condition, protect the contents from exposure to high humidity during storage. The results presented here provide an assessment of both the stability of the RDT and the quality of its packaging. Several P. falciparum -detecting products were highly stable at the temperatures and times used in the evaluation. In this round, as in previous ones, pan-specific lines (pLDH) performed less well at baseline and were less stable than HRP2 test lines, so that it was difficult to assess postincubation stability. When tested against P. vivax, many of the pan-pLDH lines were highly stable at all temperatures and times tested. In most products, the P. vivax pLDH lines were also highly stable. These results for P. vivax are an improvement over round 6. While the temperature and humidity were held constant in this evaluation, temperatures in the field fluctuate with the time of day and season. Two months’ storage at a set temperature cannot accurately predict long-term stability under field conditions, but loss of sensitivity for parasite detection over this period indicates that significant sensitivity will be lost if RDTs are stored at similar or higher temperatures for a significant period of their storage time and the likelihood of greater susceptibility to degradation during short exposure to much higher temperatures, such as during transport (37, 38).

15.6. Labelling and instructions for use The labelling on primary packaging (the box), device packaging and the device itself was generally consistent and adhered to most of the recommendations. A notable exception was that almost all products failed to include warning labels on the boxes and cassette packaging. Much poorer adherence to the recommendations and less consistency among products was seen in labelling of buffers and other accessories.

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Adherence to the recommendations for instructions for use was variable. Product information and intended use were generally included, with notable exceptions, such as the failure to list all the materials required but not provided. Other aspects of the instructions often did not meet the recommendations; for example, the instructions for over one third of the products did not include precautionary notes on the use of damaged products or product limitations. With regard to performance, the instructions for most products covered diagnostic sensitivity and specificity, but very few included analytical sensitivity and specificity or issues of parasite density and reference methods. Adherence to the recommendations for information on procedures was generally poor, particularly for safety practices and interpretation: fewer than half the product instructions advised that a faint line should be considered a positive result. Wide differences in how information is presented to users can affect the ease and consistency of use and potentially affect proper use. There is considerable scope for improvement in the instructions for use of currently recommended products.

manufacturing standards should minimize the likelihood of inconsistencies due to poor practice in the manufacturing process. Culture-based panels that are subsets of the phase-1 panel used in this evaluation are available as reference standards for manufacturers against which to set their lot-release criteria.1

15.9. Selecting RDTs: target antigens, species and sensitivity Target antigens The malaria RDTs evaluated detect one or more of three parasite antigens, HRP2, pLDH and aldolase, in various combinations. HRP2 is present only in P. falciparum, whereas aldolase and pLDH are present in all four species and may be used as pan or all-species targets. Some tests use differences in pLDH sequences between species as a means to differentiate P. falciparum from P. vivax and other species. There is considerable overlap in the PDS of products that target the different antigens in this evaluation. While the products with the highest PDS for P. falciparum targeted HRP2, a number of pLDH-detecting products had high PDS against P. vivax. The thermal stability of tests that target these different antigens also overlapped for samples with high parasite density. In choosing an RDT, account should be taken of the target antigen: HRP2-detecting RDTs should not be used in areas where false negative RDT rates due to non-expression of HRP2 is common (> 5%) (33, 34). Five P. falciparum RDT products were evaluated in round 7 that detected P. falciparum with Pf-pLDH, two combination tests had only Pf-pLDH, and three had HRP2 as well. Of the three with both HRP2 and Pf-pLDH, two combined the two antigens on a single test line, and the other had two separate test lines to detect P. falciparum. Only one of the three products with separate pf-pLDH test lines met WHO procurement criteria with a P. falciparum PDS of 75% at 200p/µl. However, the pf-pLDH test lines on all three products performed well at 2000p/µl (PDS range: 92-100%). Detection of Pf-pLDH is known to be less sensitive than detection of HRP2 at low parasite densities, and low-density infections with HRP2-deleted P. falciparum parasites could therefore be missed. Tests that detect only HRP2 (without pLDH or aldolase lines) will be of limited use where non-falciparum malaria is common. pLDH (and possibly aldolase) RDTs may have further advantages when antigen persistence (common with HRP2) result in a high false-positive rate in areas where early retesting in the weeks immediately after treatment is common. As mentioned in section 2.3, however, combination tests with both HRP2 and pan test lines should not be used for discriminating between acute infection and persistent antigenaemia, as the overall reactivity of pan test lines is much lower than that of HRP2 test lines, particularly at low parasite density.

15.7.  Anomalies in RDT production lots Anomalies that affected interpretation of the results were encountered with variable frequency in the production lots submitted for evaluation. A glossary of RDT anomalies has been prepared (Fig. AS2.1) on the basis of the experience of several rounds of product testing, with 4095 lots tested in the WHO–FIND lot testing programme. This glossary may be used in RDT training programmes to illustrate potential problems with some production lots and how to report them accurately. As many of the anomalies are infrequent, they might not be picked up in manufacturers’ quality control or lot release procedures; therefore, this information is also useful for manufacturers that wish to improve their processes.

15.8. Inter-lot variation Only two production lots of each product were evaluated in the testing programme. Malaria RDTs are complex biological products made up of components that are commonly supplied from different sources and are subject to a variety of conditions during manufacture that may affect the quality of the final product. All manufacturers that entered this evaluation provided at least one current ISO 13485:2003 certificate for a manufacturing facility. This standard is designed to ensure consistency in the quality of the final product, if correctly implemented. The results presented here indicate that interlot variation does occur, and WHO strongly recommends that a sample of RDTs from each production lot be tested before their dissemination to the field, to ensure that they meet an appropriate standard. This can be facilitated by WHO through two WHO-recognized lot-testing facilities (section 16.2). Inter-test variation will be detected to some extent by routine lot testing. Ensuring that manufacturers follow good

1 http://www.who.int/malaria/areas/diagnosis/rapid-diagnostic-tests/

malaria_specimen_bank/en/

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Species-specific vs non-species-specific RDTs RDTs are mainly tools for making clinical decisions, but their role in surveillance has grown dramatically. If all infections are managed in the same way, ie. with artemisinin-based combination therapy, there is no clinical advantage of having an RDT that can distinguish falciparum from non-falciparum infection: a pan-only test would suffice. If treatment of the two infections is different, however, distinguishing between falciparum and non-falciparum infection is a priority, and a combination test must be used (Pf/Pan). When the results of RDTs are used for species-specific monitoring, a speciesspecific RDT is preferable (Pf/Pv). No currently available RDT can specifically identify P. malariae or P. ovale infections. Furthermore, pan-species and Pvom tests are not evaluated against these, as there is no source of suitable mono-species infections. Published data suggest, however, that the sensitivity of RDTs for detecting these species is significantly poorer than that for detecting P. falciparum and P. vivax (42).

been commercialized with claims of an analytical sensitivity of 0.05–0.08 ng/mL of HRP2 (46). This is approximately 10 times the detection limit of the best conventional RDTs that detect the samples in the product testing panel. (Annex S1). The current performance panels cannot discriminate between products that can detect samples with antigen concentrations comparable to < 200 parasites/µL (considered to be highly sensitive) and those that detect only > 200 parasites/µL (conventional RDTs). Therefore, as expected, the performance of the highly sensitive RDT in round 7 was similar to that of other high-performing conventional RDT able to detect the majority of clinically significant infections. As for other high sensitive tests, the use of the high-sensitive HRP2-based RDT evaluated in round 7 is not recommended for malaria clinical case management, as it is anticipated to lead to the problems listed below: I) Detection of low levels of HRP2 antigen concentrations associated with low density falciparum infections may be associated with decreased specificity of diagnosis of clinical malaria. Since the association between antigenemia and parasitemia and fever varies from place to place, season to season, their use may potentially lead to misdiagnosis and overtreatment of fever, as malaria. ii) Persistent HRP2 antigenemia over longer period following successful treatment may also cause more false positive clinical cases. iii) If highly sensitive diagnostic tests are used for clinical case management or surveys, there is a potential threat of antimalarial stock outs due to increased test positivity caused by low density, asymptomatic infections. iv) If end-users abruptly see an unexpected increase in the number of malaria cases following the introduction of a highly sensitive RDT, this may undermine their confidence in conventional malaria RDTs as case management tools for acute febrile illness. More research is needed to determine the clinical consequences of submicroscopic infections, their contribution to onward disease transmission and the role of highly sensitive diagnostic tests in surveillance for targeting malaria elimination.

RDT sensitivity and the role of highly sensitive diagnostic tools RDTs are considered to be tools to detect symptomatic malaria infections, with ≥ 200 parasites/µL (11); however, the threshold of parasitaemia associated with symptoms depends on both transmission intensity and individual immunity to malaria. In a review of parasite densities in various epidemiological settings (43), the best estimate of the proportion of symptomatic people with a parasite density >200 parasites/µL who seek care at a health facility was 90-95% for P. falciparum and approximately 85% (range, 78-92%) for P. vivax. The performance panels used in product testing challenge the RDTs to consistently detect samples with antigen concentrations at the 200 parasites/µL threshold, corresponding to minimal HRP2 antigen concentrations of 0.59-0.80ng/mL and expected to detect the majority of clinically symptomatic malaria infections in endemic settings. The individual and public health benefits of detecting and treating submicroscopic or very-low-density parasitaemia are poorly understood and would require rigorous risk-benefit analysis (44,45). Nonetheless, highly sensitive tests like PCR and LAMP have been used for surveillance and focus investigation in lowtransmission areas, and a highly sensitive HRP2-based RDT (Alere™ Malaria Ag Pf (05FK140), Standard Diagnostics) has

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16. USING RESULTS TO ENSURE HIGHQUALITY DIAGNOSIS IN THE FIELD This report provides data to guide malaria control programmes in selecting products that are likely to perform to a high standard in the context in which the programme operates. The report does not provide a list for procurement but should aid potential buyers by providing comparative data on the performance of the available products. Final product selection requires that these data be considered systematically, taking into account the distribution of parasite density in the target population in whom the tests will be used, the experience and training of the intended users and other criteria such as climate and transport/storage conditions, price and supply aspects, and others. Box 3 lists WHO’s current minimum RDT selection criteria, as endorsed by the Malaria Policy Advisory Committee, and Tables S2, S3 and 5 are colourcoded to reflect these minimum performance criteria for product selection. As WHO prequalification will become a requirement as of 1 January 2018, the prequalification status of each product is also indicated. A web-based tool for filtering product testing results by various parameters is available on the FIND website and has now been updated to allow rapid identification of products with the same blood volume, number of buffer drops and time until reading.1 Annex 1 groups products according to similar procedure characteristics. Furthermore, an algorithm to guide selection is given in Annex S3, and detailed guidance was published by WHO in Recommended selection criteria for procurement of malaria rapid diagnostic tests, Good practices for selecting and procuring rapid diagnostic tests for malaria (16) and Universal access to malaria diagnostic testing (17). While malaria RDTs can be used in a number of settings, the greatest impact on public health will ensue from extending access to accurate, parasite-based diagnoses of malaria to regions and populations where good-quality microscopybased analysis is impractical to maintain. This will allow implementation of WHO recommendations on universal parasite-based diagnosis before antimalarial therapy (2) and currently applies to most people at risk for malaria in endemic countries (1). In many settings where RDTs have been introduced, the true rate of parasitaemia has been found to be considerably lower than expected, so that health systems can reduce wastage of antimalarial medicines and focus on appropriate management of non-malarial causes of fever, including early pneumonia and sepsis. In order for an RDT programme to have its full potential public health impact, it must therefore address not only malaria but also the management of other common and severe febrile illnesses that occur locally in the differential diagnosis of malaria (46).

16.1. WHO prequalification The WHO programme for prequalification of in vitro diagnostics promotes access to good-quality in vitro diagnostic tests by applying the principles of a comprehensive regulatory assessment. This includes inspection of the manufacturer’s quality management system, assessment of technical documentation (dossier review) and an independent performance evaluation. The results of the WHO malaria product testing programme fulfill the performance evaluation component of the prequalification process. Twelve malaria RDT products have been prequalified.2 Prequalification has not been a requirement for eligibility for United Nations procurement tenders for malaria RDTs, as it is for other RDTs, such as for HIV; however, WHO prequalification will determine the eligibility of malaria RDTs for procurement after 31 December 2017. WHO product testing will continue to be the independent performance laboratory evaluation component of the prequalification process. Round 8 of product testing is under way All manufacturers who submit products to round 8 are required also to submit applications for WHO prequalification.

16.2. Beyond procurement Diagnostic tests are usually used at the start of a health system intervention, and their use is based on the assumption that appropriate patient management, based on testing, will follow. Thus, successful introduction of RDTs requires careful planning beyond rational procurement to ensure consistent supplies of all the necessary materials (including gloves, sharps disposal containers and supplies required for further case management), training of users, community sensitization and monitoring of diagnostic quality and results. This extends malaria management to management of other febrile diseases and health service delivery systems and requires integration with other health programmes. While this report does not provide a list for procurement, it provides information to guide procurement of RDTs within this framework. Factors beyond the performance characteristics reported here, however, must influence procurement decisions. An example of an algorithm, including an ease-of-use assessment, is provided in Annexes S2 and S3 to guide decisions. Details of implementation will vary widely between programmes, depending on local capacity and needs. Further recommendations on budgeting, planning and implementation can be found in Annex 5 and in the relevant WHO guidance document (17 ). 2

1

An interactive guide designed to short-list tests according to programme needs, based on the performance of tests in rounds 3–6 of the WHO product testing programme can be found at: https:// www.finddx.org/malaria/interactive-guide/ (accessed 8 March 2017).

http://www.who.int/diagnostics_laboratory/evaluations/pq-list/ malaria/public_report/en/ (accessed 8 March 2017).

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16.3. Post-market surveillance: lot verification Post-market surveillance confirms manufacturer compliance with quality expectations and is an important component of any quality assurance scheme. Specifically for malaria RDTs, post-market surveillance ensures that the quality reported in product testing is found in what is available on the market to the user. Post-market surveillance can be performed proactively through lot verification (described next), which is recommended to all procurers, or reactively through completion of a “WHO user complaint form for reporting problems and/or adverse events related to diagnostic products” and submitted to the following email address: diagnostics@ who.int. As a complement to product testing, WHO and FIND currently support laboratories that perform continued quality assurance of RDTs in the form of lot testing. This programme responds to requests from all purchasers, including national malaria programmes, manufacturers and procurement bodies, to assess the quality of RDT lots before shipment from the production facility or, when they arrive in a country, before distribution to the field and for clinical use. Testing is performed against parasite-positive and -negative panels prepared and characterized in the same way as the panels used in this evaluation. A number of national institutions have also developed this capacity, and, more recently, several countries have begun pilot-testing malaria recombinant antigen panels to monitor trends in lot performance. Lot testing reassures countries that the product they have

purchased performs to a high standard and helps to ensure that manufacturers produce consistently good lots and improve their products. The results support decisions for accepting or rejecting lots. Lot testing provides information about the adequacy of RDTs for clinical use, their stability over their shelf life and any anomalies observed during testing that may also be encountered in the field. Countries and manufacturers ship 100–150 RDTs to regional, WHO-recognized lot testing centres, where they are evaluated against a small panel of parasites at low density and against negative samples (Fig. 2). They are subsequently incubated at a temperature close to the manufacturer’s specified storage temperature and retested 6 months before expiry. Initial results are available after 5 days, and definitive results after subsequent confirmatory tesing, if required. Details of the protocol can be found in the methods manual for lot testing (27 ). As lot-to-lot variation has previously been noted in many products, purchasers are encouraged to participate in the lot-testing programme to confirm the quality of RDT lots prior to use. Certain anomalies resulting from defects in production lots or RDT degradation, or even defects of some kit accessories, may affect the running of the test or interpretation and may warrant a field safety notice and corrective action. In such instances, a special lot testing service can be provided, which is determined case by case. Lot testing is free of charge, but the requester must cover shipping costs, including related tax and duties. To access lot testing through the WHO-FIND programme, contact christian.nsanzabana@finddx.org and cc: Malaria_rdt@ who.int at least 2 weeks before RDTs are ready for shipment.

17. Conclusions This report adds to the large data set on malaria RDT performance published regularly since 2009 (3–8 ). The product testing programme continues to be an authoritative source in the field of malaria RDT evaluations in terms of the number of products evaluated, its independence and its comprehensiveness. New laboratory methods have been developed and validated to support parasite characterization, and this work has generated new findings on variation in antigen content at similar parasite densities and in the structure and expression of histidine-rich proteins. Round 7 introduced a new component of the product evaluation: examining the labelling and instructions for use associated with each product in a standardized manner, to demonstrate their performance against a set of standards for these components. Publication of the results of past WHO product testing rounds has affected the procurement practices of countries and procurement agencies and contributed to a shift in the malaria RDT market towards better-performing products (1, 48). The report of round 7 adds to the number of well-performing RDTs for which comprehensive performance data are now available including the first high-sensitive RDT and provides updated data on 15 product resubmissions.

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18. References 1. World malaria report 2016. Geneva: World Health Organization; 2016. 2. Guidelines for the treatment of malaria. 3rd edition. Geneva: World Health Organization; 2015. 3. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 1 (2008). Geneva: World Health Organization; 2009. 4. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 2 (2009). Geneva: World Health Organization; 2010. 5. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 3 (2010–11). Geneva: World Health Organization; 2011. 6. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 4 (2012). Geneva: World Health Organization; 2012. 7. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 5 (2013). Geneva: World Health Organization; 2014. 8. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 6 (2014– 2015). Geneva: World Health Organization; 2015. 9. Informal consultation on laboratory methods for quality assurance of malaria rapid diagnostic tests. Manila: WHO Regional Office for the Western Pacific; 2004 (RS/2004/GE/26(PHL). 10. Prequalification of in vitro diagnostics . Geneva: World Health Organization (http://www.who.int/diagnostics_ laboratory/evaluations/en/, accessed 8 March 2017). 11. Parasitological confirmation of malaria diagnosis. Report of a WHO technical consultation. Geneva, 6–8 October 2009. Geneva: World Health Organization; 2010. 12. Gamboa D, Ho MF, Bendezu J, Torres K, Chiodini PL, Barnwell JW, et al. A large proportion of P. falciparum isolates in the Amazon region of Peru lack pfhrp2 and pfhrp3: implications for malaria rapid diagnostic tests. PLoS One 2010:5:e8091. 13. Bharti PK, Chandel HS, Ahmad A, Krishna S, Udhayakumar V, Singh N. Prevalence of pfhrp2 and/or pfhrp3 gene deletion in Plasmodium falciparum population in eight highly endemic states in India. PLoS One 2016;11:e0157949. 14. Jacobs J, Barbé B, Gillet P, Aidoo M, Serra-Casas E, Van Erps J, et al. Harmonization of malaria rapid diagnostic tests: best practices in labelling including instructions for use. Malar J 2014;13:505.

15. Malaria RDT interactive guide. Geneva: Foundation for Innovative New Diagnostics (https://www.finddx.org/ malaria/interactive-guide/, accessed 8 March 2017). 16. Good practices for selecting and procuring rapid diagnostic tests for malaria. Geneva: World Health Organization; 2011. 17. Universal access to malaria diagnostic testing: an operational manual. Geneva: World Health Organization; 2011(revised 2013). 18. Kolaczinski J, Mohammed N, Ali I, Ali M, Khan N, Ezard N, et al. Comparison of the OptiMAL rapid antigen test with field microscopy for the detection of Plasmodium vivax and P. falciparum: considerations for the application of the rapid test in Afghanistan. Ann Trop Med Parasitol 2004;98:15–20. 19. Richter J, Gobels K, Muller-Stover I, Hoppenheit B, Haussinger D. Co-reactivity of plasmodial histidinerich protein 2 and aldolase on a combined immunochromographic-malaria dipstick (ICT) as a potential semi-quantitative marker of high Plasmodium falciparum parasitaemia. Parasitol Res 2004;94:384–385. 20. Mai Huong NM, Davis TM, Hewitt S, Huong NV, Uyen TT, Nhan DH, et al. Comparison of three antigen detection methods for diagnosis and therapeutic monitoring of malaria: a field study from southern Vietnam. Trop Med Int Health 2002;7:304–308. 21. Mason DP, Kawamoto F, Lin K, Laoboonchai A, Wongsrichanalai C. A comparison of two rapid field immunochromatographic tests to expert microscopy in the diagnosis of malaria. Acta Trop 2002;82:51–59. 22. van den Broek I, Hill O, Gordillo F, Angarita B, Hamade P, Counihan H, et al. Evaluation of three rapid tests for diagnosis of P. falciparum and P. vivax malaria in Colombia. Am J Trop Med Hyg 2006;75:1209–1215. 23. McMorrow M, Masanja MI, Abdulla SM, Kahigwa E, Kachur SP. Challenges in routine implementation and quality control of rapid diagnostic tests for malaria – Rufiji District, Tanzania. Am J Trop Med Hyg 2008;79:385–390. 24. Wanji S, Kimbi HK, Eyong JE, Tendongfor N, Ndamukong JL. Performance and usefulness of the Hexagon rapid diagnostic test in children with asymptomatic malaria living in the Mount Cameroon region. Malar J 2008;7:89. 25. Willcox ML, Sanogo F, Graz B, Forster M, Dakouo F, Sidibe O, et al. Rapid diagnostic tests for the homebased management of malaria, in a high-transmission area. Ann Trop Med Parasitol 2009;103:3–16. 26. Belizario VY, Pasay CJ, Bersabe MJ,de leon WU, Guererro DM, Bugaoisan VM. Field evaluation of malaria rapid diagnostic tests for the diagnosis of P. falciparum and non-P. falciparum infections. Southeast Asian J Trop Med Public Health 2005;36:552–561.

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27. Methods manual for laboratory quality control testing of malaria rapid diagnostic tests, version 8. Geneva: World Health Organization; 2016. 28. Methods manual for product testing of malaria rapid diagnostic tests (version 6). Geneva: World Health Organization; 2014. 29. Call for expressions of interest for round 7 of the WHO Malaria Rapid Diagnostic Test Product Testing Programme (http://www.who.int/malaria/news/2015/ rdt_call_for_testing_round7/en/ (accessed 10 March 2017). 30. Baker J, Ho MF, Pelecanos A, Gatton M, Chen N, Abdullah S, et al. Global sequence variation in the histidine-rich proteins 2 and 3 of Plasmodium falciparum: implications for the performance of malaria rapid diagnostic tests. Malar J 2010;9:129. 31. Hopkins H, Oyibo W, Luchavez J, Mationg ML, Asiimwe C, Albertini A, et al. Blood transfer devices for malaria rapid diagnostic tests: evaluation of accuracy, safety and ease of use. Malar J 2011;10:30. 32. Methods for field trials of malaria rapid diagnostic tests . Manila: World Health Organization Regional Office for the Western Pacific; 2009. 33. Berhane A, Mihreteab S, Mohammed S, Embaye G, Hagos F, Zehaie A, et al. PfHRP2 detecting malaria RDTs: alarming false negative results in Eritrea. Poster 879. In: 65th annual meeting of the American Society for Tropical Medicine and Hygiene. Oakbrook Terrace, IL; 2016. 34. Cheng Q, Gatton M, Barnwell J, Chiodini P, McCarthy J, Bell D, et al. Plasmodium falciparum parasites lacking histidine-rich protein 2 and 3: a review and recommendations for accurate reporting. Malaria J 2014;13:283. 35. Transporting, storing and handling malaria rapid diagnostic tests at central and peripheral storage facilities . Manila: World Health Organization Regional Office for the Western Pacific; 2009. 36. Training materials for the use of malaria RDTs. Geneva: Foundation for Innovative Diagnostics; 2011 (http:// www.who.int/malaria/areas/diagnosis/rapid-diagnostic-tests/job-aids/en/, accessed 10 March 2017). 37. Jorgensen P, Chanthap L, Rebueno A, et al., Malaria rapid diagnostic tests in tropical climates: the need for a cool chain. Am J Trop Med Hyg 2006;74(5):750–754. 38. Chiodini PL, Bowers K, Jorgensen P, Tsuyuoka R, Bell D. The heat stability of Plasmodium lactate

dehydrogenase-based and histidine-rich protein 2-based malaria rapid diagnostic tests. Trans R Soc Trop Med Hyg 2007;101:331–337. 39. Rennie W, Phetsouvanh R, Lupisan S, Vanisaveth V, Hongvanthong B, Phompida S, et al. Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance. Trans R Soc Trop Med Hyg 2007;101:9–18. 40. Harvey SA, Jennings L, Chinyama M, Masaninga F, Mulholland K, Bell DR. Improving community health worker use of malaria rapid diagnostic tests in Zambia: package instructions, job aid and job aid-plus-training. Malar J 2008;7:160. 41. Tavrow P, Knebel E, Cogswell L. Using quality design to improve malaria rapid diagnostic tests in Malawi. In: Operations research results 1(4). Bethesda, MD: United States Agency for International Development; 2000. 42. Heutmekers M, Gillet P, Maltha J, Scheirlinck A, Cnops L, Bottieau E, et al. Evaluation of the rapid diagnostic test CareStart pLDH Malaria (Pf-pLDH/panpLDH) for the diagnosis of malaria in a reference setting. Malar J 2012;11:204. 43. Parasitological confirmation of malaria diagnosis: WHO technical consultation, Geneva, 6–8 October 2009. Geneva: World Health Organization; 2009. 44. Lindblade KA, Steinhardt L, Samuels A, Kachur SP, Slutsker L. The silent threat: asymptomatic parasitemia and malaria transmission. Expert Rev Anti-infect Ther 2013;11:623–639. 45. Chen I, Clarke SE, Gosling R, Hamainza B, Killeen G, et al. (2016) “Asymptomatic” Malaria: A Chronic and Debilitating Infection That Should Be Treated. PLOS Medicine 13(1): e1001942.  46. Malaria Ag P.f Ref: 05Fk140. Instructions for use. San Diego, CA: Alere. 47. D’Acremont V, Kilowoko M, Kyungu E, Philipina S, Sango W, Kahama-Maro J, et al. Beyond malaria – causes of fever in outpatient Tanzanian children. N Engl J Med. 2014;370:809–817. 48. Incardona S, Serra-Casas E, Champouillon N, Nsanzabana C, Cunningham J, Gonzalez IJ. Global survey of malaria rapid diagnostic test (RDT) sales, procurement and lot verification practices: assessing the use of the WHO-FIND Malaria RDT Evaluation Programme (2011–2014). Malaria Journal 2017; 16:196

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Discussion 81

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Annexes

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Annexes 83

Annex S1: Characteristics of evaluation panels used in rounds 1–7 of WHO malaria RDT product testing, 2008–2016 Currently, the basis for diagnosing malaria with antigendetecting RDTs is the detection in a patient’s blood of one or more target malaria antigens, including HRP2 (P. falciparum only), pLDH (Plasmodium spp.pan-pLDH), P. falciparum (Pf-pLDH), non-falciparum (Pv-pLDH, Pvom-pLDH) and aldolase (all Plasmodium spp). The antigen concentration in samples with the same parasite density varies. Therefore, the concentrations of malaria antigens in the samples that comprise evaluation panels must be consistent in successive rounds of WHO malaria RDT product testing to ensure that the results of each round are highly comparable (statistically equivalent). Therefore, antigen concentrations were quantified in triplicate in all panel samples, including dilution pairs of 200 and 2000 parasites/µL, by quantitative ELISA. Only results that were consistent in the triplicate runs and showed a value factor between the 200 and the 2000 parasites/µL dilutions close to 10 were considered acceptable and eligible for the performance evaluation panel. In some instances, the antigen concentration was below the detection limit of the ELISA, particularly for aldolase, which is present in malaria parasite samples at much lower concentrations than the other two antigens. Samples that gave inconsistent results for more than one of the three antigens were excluded from the panel. Despite careful standardization of procedures, the tables and figures below show a wide variation in antigen concentrations for the same parasite density. There are a number of possible explanations, including differences in the level of antigen expression by isolates; different durations of infection (accumulating antigens); different parasite growth stages at the time of collection (expressing different levels of antigen); the presence of circulating HRP2 from previous growth cycles; and HRP2 produced by parasites sequestered in the host’s vascular tissues that cannot be accounted for in the estimate of parasite density on the blood slide. Before each round of WHO malaria RDT product testing, the distribution of HRP2, pLDH and aldolase concentrations at 200 parasites/µL dilution of the wild-type P. falciparum and wild-type P. vivax samples selected for the phase-2 panels were systematically compared with those in the previous round to ensure there was no statistically significant difference. The figures and tables below show the distribution of antigen concentrations in all six performance evaluation panels. No statistically significant differences were seen (Kruskal-Wallis test; p > 0.5), confirming that the results of each new round are additive (and comparable) to the previous ones. In the following box and whisker plots, the end of whiskers represent minimum and maximum values; the box represents middle 50% of data and the line through box represents median values; the crosses represent the mean values.

Figure AS1.1: Box-and-whisker plot of distribution of P. falciparum HRP2 concentration (ng/mL) in product testing phase 2 (wildtype) panels. Round 7 Round 6 Round 5 Round 4 Round 3 Round 2 Round 1 0.5 1 2 4 8 16 32 64 128

P. falciparum HRP2 concentration (ng/ml)

Figure AS1.2: Box-and-whisker plot of distribution of P. falciparum pLDH concentration (ng/mL) in product testing phase 2 (wildtype) panels. Round 7 Round 6 Round 5 Round 4 Round 3 Round 2 Round 1 0.25 0.5 1 2 4 8 16 32 64

P. falciparum pLDH concentration (ng/ml)

Figure AS1.3: Box-and-whisker plot of distribution of P. vivax pLDH concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 7 Round 6 Round 5 Round 4 Round 3 Round 2 Round 1 1

P. vivax pLDH concentration (ng/ml)

2

4

8

16

32

64

Figure AS1.4: Box-and-whisker plot of distribution of P. falciparum aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 7 Round 6 Round 5 Round 4 Round 3 Round 2 Round 1 0.125 0.25 0.5 1 2 4 8 16

P. falciparum aldolase concentration (ng/ml)

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Figure AS1.5: Box-and-whisker plot of distribution of P. vivax aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 7 Round 6 Round 5 Round 4 Round 3 Round 2 Round 1 1 2 4 8 16

P. vivax aldolase concentration (ng/ml)

Table AS1.1: Statistics for P. falciparum HRP2 concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 1 Number of Minimum 25% percentile Median 75% percentile Maximum Mean Std. Deviation a

Round 2 99 0.62 1.90 6.76 16.91 73.70 12.70 15.75

Round 3 99 0.62 2.10 6.83 17.37 66.70 12.77 15.19

Round 4 98 0.62 2.97 6.98 15.65 62.48 12.72 14.72

Round 5 99 0.59 2.15 6.76 15.31 62.48 11.65 13.25

Round 6 99 0.67 2.48 8.12 15.51 62.48 12.15 13.29

Round 7 99 0.67 2.15 6.76 16.99 62.48 11.83 13.01

valuesa

78 0.80 2.90 9.57 18.94 73.70 15.28 16.98

The number of values is the number of samples for which consistent ELISA results were obtained.

Table AS1.2: Statistics for P. falciparum pLDH concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 1 Number of valuesa Minimum 25% percentile Median 75% percentile Maximum Mean Std. Deviation a

Round 2 93 0.19 6.27 10.31 20.10 47.15 13.71 10.90

Round 3 92 0.19 6.23 11.18 22.70 47.15 15.08 11.72

Round 4 92 0.19 6.20 10.92 21.28 53.53 14.97 11.98

Round 5 94 0.19 6.90 12.24 23.05 43.02 15.53 11.43

Round 6 98 0.19 7.04 11.85 20.36 53.53 15.61 12.00

Round 7 98 0.19 7.20 12.99 21.51 53.53 15.93 11.60

74 0.71 6.68 11.95 23.75 47.15 15.31 11.47

The number of values is the number of samples for which consistent ELISA results were obtained.

Table AS1.3: Statistics for P. vivax pLDH concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 1 Number of valuesa Minimum 25% percentile Median 75% percentile Maximum Mean Std. Deviation a

Round 2 37 1.64 8.40 17.00 29.69 47.90 20.24 13.27

Round 3 33 1.64 7.30 19.78 31.89 47.90 20.99 13.55

Round 4 32 1.64 6.96 17.50 29.84 47.90 20.00 13.00

Round 5 34 1.64 6.26 13.22 23.42 47.90 16.84 12.59

Round 6 34 1.64 6.72 15.17 23.14 44.79 16.90 11.78

Round 7 35 1.64 6.86 16.62 44.79 16.87 11.17 22.89

20 5.10 8.10 12.65 27.40 44.40 17.38 11.57

The number of values is the number of samples for which consistent ELISA results were obtained.

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Table AS1.4: Statistics for P. falciparum aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 1 Number of Minimum 25% percentile Median 75% percentile Maximum Mean Std. Deviation a

Round 2 98 0.00 0.74 1.49 2.25 9.90 1.79 1.66

Round 3 99 0.00 0.67 1.40 2.23 9.90 1.76 1.69

Round 4 97 0.00 0.64 1.25 2.25 9.08 1.72 1.68

Round 5 98 0.00 0.52 1.17 2.07 7.74 1.52 1.52

Round 6 99 0.00 0.44 1.18 2.02 9.08 1.50 1.61

Round 7 99 0.00 0.59 1.25 1.88 9.08 1.43 1.34

valuesa

77 0.00 0.84 1.58 2.25 9.90 1.93 1.73

The number of values is the number of samples for which consistent ELISA results were obtained.

Table AS1.5: Statistics for P. vivax aldolase concentration (ng/mL) in product testing phase 2 (wild-type) panels. Round 1 Number of valuesa Minimum 25% percentile Median 75% percentile Maximum Mean Std. Deviation a

Round 2 40 1.70 4.11 6.15 8.47 13.40 6.81 3.15

Round 3 34 1.70 4.07 6.10 8.32 13.30 6.45 2.90

Round 4 33 1.70 4.41 6.16 9.10 15.00 6.86 3.23

Round 5 35 3.21 5.55 6.86 9.43 15.00 7.78 3.30

Round 6 35 1.70 4.94 6.54 9.68 15.08 7.74 3.69

Round 7 35 3.21 5.27 7.96 10.52 15.08 8.22 3.61

20 3.21 4.02 6.33 8.47 13.15 6.73 2.89

The number of values is the number of samples for which consistent ELISA results were obtained.

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Annex S2: Malaria RDT field assessment and anomalies Fig. AS2.1 shows examples of observations and anomalies encountered and routinely recorded for RDTs in round 7 of WHO Malaria RDT Product Testing at the CDC. Most of these anomalies would not invalidate the results, as reactivity in the control and test line areas is still visible, but they may pose challenges to health workers in interpreting the results. Furthermore, they should be reported to manufacturers. An extended list of notable observations on RDT packaging, kit accessories (buffer vials, desiccants) and instructions for use is being prepared for use in both product testing and lot testing in the WHO-FIND Malaria RDT Evaluation Programme. Table AS2.1: Field assessment of RDT packaging, safety and ease-of-use to guide product selection Date of assessment Commercial name Product code Lot number(s) Yes Packaging and accessories The RDT box is in good condition RDTs are in individual sealed package The correctly indicated number of RDTs are in the box Desiccant is included in each individual RDT package An expiry date is visible on each RDT package All required accessories are included in the correct quantities (RDT, buffer, blood transfer device, alcohol swab, lancet, gloves, test tubes (for dipsticks, only) Instructions Instructions are included Instructions are in the national language(s) The instructions are for the correct product The instructions include figures displaying all possible interpretations of the RDT results The text and figures are accurate and consistent (specifically order of test lines and results interpretation) Preparation and procedure The test package is easy to open It is easy to write on the test device The test lines on the device are clearly labelled It is easy to use the device for blood collection It is easy to open the buffer bottle or vial The buffer bottle or vial have sufficient volume for testing all RDTs in the box The buffer bottle or vial dispenses even drops It is easy to fill the sample well correctly with the provided blood transfer device It is easy to fill the buffer well correctly (no overflow) The buffer and sample flow well along the test strip Result interpretation Control and test lines Control line is clear Test line(s) are clear Good clearance of blood by time of reading Steps and reading time Reading time <30 min Two or fewer timed steps Was one or more of the last 10 tests you performed invalid (no control line)? If YES, how many? Safety Are there mixing wells (risk of blood splash)? Retractable needle for finger prick? Is the RDT in a cassette format (unexposed strip)? Have waste disposal safety concerns been addressed? (If no, please describe) NA, not

No

NA

Problems /Comments

If no, what is not included:

If no, number of tests in the box affected:

applicable

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Annexes 87

Figure AS2.1 illustrates examples of RDT observations/anomalies encountered and routinely recorded during round 6 of WHO Malaria RDT Product Testing at the CDC. In most cases, these anomalies do not invalidate the results, as reactivity in the control and test line areas are still visible, but they may pose challenges to health workers interpreting the results. Furthermore, they should be reported to manufacturers. An expanded list of notable observations concerning RDT packaging, kit accessories (buffer vials, desiccants) and instructions for use, is under development for use in both product testing and lot testing activities of the WHO-FIND Malaria RDT Evaluation Programme. Figure AS2.1: Malaria RDT anomalies encountered in production lots

a) Observations on the test strip Red background C T1 T2

Background staining is relatively common. In this example, the result is positive as test lines are positive; however, a more intense red background may obscure weak positive test lines, giving false-negative results. In this example, the result is positive as the test line is visible. Poor clearing of blood may obscure weak positive test lines, giving false-negative results.

Incomplete clearing

C

T

b) Observations of flow problems Failed migration C T

Blood and buffer did not run the length of the strip

Incomplete migration

C

T1

One portion of the nitrocellulose near the test band was not absorptive and remained dry during wicking, creating irregular migration of blood/buffer with red background. In this example, the result is positive, as the test line is clearly visible.

c) Observations on test lines Ghost test lines C T1 T2 T3

White lines on a stained background. In this example, the result is negative, as the test line is not dark and is thus not visible. The test line is visible but interrupted (broken).

Patchy broken test line(s)

C

T1 T2

Diffuse test line(s) C T

Test line wider than control, without clearly defined edge.

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Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

d) RDT structural problems Strip misplaced in the cassette (shift) Strip can be seen only partially in the results window.

Buffer remains pooled in the buffer well



Specimen pad not seen in sample window

C T1 T2

Normally, the colour of the conjugated antibody can be seen in the sample window (commonly purple, pink or blue). The buffer is not completely absorbed and this may result in failed migration or incomplete clearing.

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Annexes 89

Annex S3: Selection of an appropriate RDT Figure AS3.1: How to select of an appropriate RDT

Step 1.1 Define setting of use

What? target parasite species and antigena Pf-only or mixed Pf/non-Pf infections: - HRP2 - pLDH-Pf; pLDH-pan Pf and non-Pf infections (single species)b: - HRP2, aldolase; HRP2, pLDH-pan - HRP2, pLDH-Pv; HRP2, pLDH-Pvom - HRP2, pLDH-pan; pLDH-Pv - pLDH-Pf, pLDH-pan; pLDH-Pf, pLDH-Pv - pLDH-Pf, pLDH-Pvom

P. vivax, only: - aldolase - pLDH-pan - pLDH-Pv

**Pf without HRP2 – Do not use exclusively HRP2-based RDTsc

Where?

Exposure to high temperature e.g. tropical environment OR temperature-controlled environment, including during transport and storage Laboratory personnel OR health workers outside laboratories

Who?

Step 1.2 Review RDT performance

WHO RDT product testing resultsd and apply WHO recommended RDT selection criteriae - Panel detection score - False-positivity rate - Invalid rate - Ease-of-use - Thermal stability Sensitivity and specificity based on high-quality field studies in relevant populations

Generate short-list of RDTs

Step 1.3 Apply national guidelines and experience in use of RDTs

National malaria treatment guidelines In-country experience, ease-of-use assessments (Annex S2), availability of training materials - Price - Manufacturer: production capacity, lead times, heat stability data and storage conditions - Delivery schedules (e.g. staggered deliveries), box size, shelf life - Registration requirements of national regulatory authorities - Product lot testing results - Overall budget requirements (Annex 5)

Step 1.4 Other considerations

or mixed Pf/non-Pf infections: Most areas of sub-Saharan Africa and lowland Papua New Guinea; Pf and non-Pf infections (single species): Most endemic areas of Asia and the Americas and isolated areas of the Horn of Africa; Mainly P. vivax-only: areas of East Asia, central Asia, South America, and some highland areas elsewhere b Tests with a P. falciparum-specific line and pan-specific line will not distinguish P. falciparum-only infections from mixed P. falciparum infections. Distinguishing P. falciparum from mixed P. falciparum-vivax infections is important only if a full course of primaquine is routinely given for infections due to P. vivax. This must be weighed against the loss of ability to detect P. malariae and P. ovale if a test has only P. falciparum- and P. vivax-specific lines. Inclusion of further test lines (e.g. Pf-Pv-pan-pLDH) to detect these increases the complexity of test interpretation. A programme should prioritize these various advantages and disadvantages according to local conditions in the initial stage of making procurement decisions. c P. falciparum parasites lacking HRP2 +/- HRP3 genes have been identified with high frequency in parts of South America, Africa (Eritrea, Democratic Republic of the Congo, Ghana) and India (1–6). d See references (7–12). e WHO RDT procurement criteria (13) : http://www.who.int/malaria/publications/atoz/rdt_selection_criteria/en/ (accessed 14 June 2017).

a Pf-only

For a comprehensive guide to procurement of malaria RDTs extending beyond selection to quantification, budgeting, technical specifications, management of tenders, contracts, supply management and monitoring of supplier performance and managing product variations, see reference in the full report (16).

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Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Annex 1: Characteristics of RDTs evaluated in round 7 Sequence and type of bound antibodyb C T1 T2 T3

Manufacturer (type A-J) RMVM-05072 RMSM-05071 RMAM-05071 RMLM-05071 RMOM-03091 RMVM-03091 RKMAL016 RKMAL017 Pan pLDH Pv pLDH Pan pLDH HRP2 HRP2 HRP2 Pan pLDH Pan pLDH HRP2 HPR2 Pan pLDH Pv pLDH Pan pLDH HRP2 HRP2 Pv pLDH Aldolase HRP2 HRP2 HRP2 HRP2 Pv pLDH Pv pLDH MDMALPFH005 MDMALLDH004 HRP2 HRP2 Pv pLDH HRP2 HRP2 HRP2 HRP2 Pan pLDH Pan pLDH HRP2 HRP2 HPR2 HRP2 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 HRP2 5 8 4 4 3 3 4 4 4 4 4 4 4 3 3 5 5 3 3 3 4 4 8 4 5 2 Pv pLDH HRP2 5 2 20 20 25 25 30 20 20 20 20 15 15 20 15 15 10 20 30 15 20 20 20 30 30 HRP2 5 4 30 HRP2 5 4 30 05FK80I-40 5499 5531 55IC104-50 55IC103-50 AM4650-K AS0060 AS0015 17912 17012 0581_K25 0584_K25 W06200 W37-C W056-C IMPN-402 MAL-PF/Pan-CAS/25 ML03 ML01 ITP11002-TC25 71050 HRP2 5 4 20 30 30 30 30 30 30 30 30 30 30 20 20 30 30 30 30 30 20 30 30 Pan pLDH HRP2 5 4 20 30 Pv pLDH HRP2 5 2 20 HRP2 5 2 20 1 1 3 3 5 5 1 1 9 9 5 2 2 3 3 7 7 3 7 7 10 2 11 12 2 2 2 5 5 Pan pLDH 5 2 20 1 Pan pLDH 5 2 20 1 Pf pLDH 5 2 20 1 J C C A E C A C E G A A A C C A A C E C A A E C D D A A E E A F Pv pLDH HRP2 5 2 20 1 E

Product name

Product code

C

T1

T2

T3

Required volume of whole Buffer blood drops (µl) Minimum time to resultsc (mins) Maximum reading time (mins) Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Dipstick Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette

RecomResults mended Protocol Interpreta- Format storage groupf tiond typee temperature Shelf-life (°Celcius) (months) 1-40 1-40 1-40 4-30 1-40 1-40 2-40 2-40 1-40 1-40 4-30 4-45 4-40 4-40 1-30 2-40 2-40 1-40 1-40 2-30 2-30 2-30 1-35 1-35 2-30 4-30 4-40 4-40 2-40 2-40 4-30 4-40 4-40 24 24 24 24 36 36 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 18 24 24

Access Bio, Inc.

CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo

Access Bio, Inc.

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line

Access Bio, Inc.

CareStart™ Malaria Screen

Access Bio, Inc.

CareStart™ Pf/PAN (pLDH) Ag RDT

HRP2 HRP2 + Pf pLDH Pf pLDH

Access Bio Ethiopia

CareStart™ Malaria HRP2 (Pf)

Access Bio Ethiopia

CareStart™ Malaria HRP2/pLDH (Pf/Pv) Combo

Advy Chemical Private Limited

Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit

Advy Chemical Private Limited

Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test

Alere Medical Private Limited

Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) 05FK60AI-40

Alere Medical Private Limited

SD Bioline Malaria Ag Pf/Pv

ALLDIAG SA

PALUTOP +4 optima®

ALLDIAG SA

PALUTOP + pf®

ARKRAY Healthcare Pvt Ltd

Parahit® f Ver 1.0 - Device

ARKRAY Healthcare Pvt Ltd

Parahit f® Ver 1.0 - Dipstick

ASAN Pharmaceutical Co., Ltd

Asan Easy Test® Malaria Pf/Pan Ag

Aspen Laboratories Pvt. Ltd.

Aspen® Malaria Ag Pf/Pv

Aspen Laboratories Pvt. Ltd.

Aspen® Malaria Ag Pf

Bio Focus Co., Ltd.

BioTracer™ Malaria P.f Rapid Card

Bio Focus Co., Ltd.

BioTracer™ Malaria P.f/PAN Rapid Card

Biosynex

Biosynex® Malaria Pf/Pv

Biosynex

Biosynex® Malaria Pf/Pan

DIALAB

DIAQUICK Malaria P.f. Cassette

Guangzhou Wondfo Biotech Co., Ltd.

One Step Malaria HRP2 (P.f) Test

Guangzhou Wondfo Biotech Co., Ltd.

One Step Malaria HRP2/pLDH (P.f/P.v) Test

Hangzhou AllTest Biotech Co. Ltd.

AllTest™ Malaria P.f./Pan Rapid Test Cassette

Hema Diagnostic Systems

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

ICT INTERNATIONAL

ICT MALARIA DUAL TEST

ICT INTERNATIONAL

ICT MALARIA P.F. CASSETTE TEST

InTec Products, Inc.

ADVANCED QUALITY ™ ONE STEP Malaria (p.f) Test

InTec Products, Inc.

ADVANCED QUALITY ™ ONE STEP Malaria (p.f/p.v.) Tri-line Test ITP11003-TC25

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Lumiquick Diagnostics Inc.

QuickProfile™ Malaria Pf/Pv Antigen Test

Medical Diagnostech (Pty) Ltd

MD Malaria Pf

Medical Diagnostech (Pty) Ltd

MD Malaria Pf/Pv (pLDH) Test

(continued)

Annexes

91

92

Annex 1: Characteristics of RDTs evaluated in round 6 (continued) Sequence and type of bound antibodyb C T1 T2 T3

Manufacturer (type A-J) MPFPAN050 Pv pLDH HRP2 HRP2 Pan pLDH Pv pLDH 5 5 5 5 HRP2 5 Pv pLDH 5 f

Product name Pan pLDH HRP2 5 Pan pLDH HRP2 Pf pLDH 4 4 4 2 2 3 3 20 20 20 20 30 30 20 15 15 20 5 4 30 30 5 4 30 30 5 4 30 30 5 5 5 7 7 3 1 1 2 2 4 20 30 3 5 4 20 30 3 HRP2 5 3 20 25 2 C E A D C E A A A A E A F

Product code

C

T1

T2

T3

Required volume of whole Buffer blood drops (µl) Minimum time to resultsc (mins) Maximum reading time (mins)

Recommended Results storage Protocol Interpreta- Format groupf tiond typee temperature Shelf-life (°Celcius) (months) Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette Cassette 2-40 2-30 2-30 2-40 1-40 1-40 4-30 1-40 1-30 1-40 1-40 2-30 2-30 24 18 18 24 24 24 24 24 12 42 24 24 24

Medsource Ozone Biomedicals Pvt. Ltd.

Is It... Malaria Pf PAN

Meril Diagnostics Pvt. Ltd.

Meril Diagnostics Pvt. Ltd. C32RHA25 C60RHA25 R-409-50-C 05FK130-40-0 05FK140-40-0 RMO-M05082 RMV-M05082 GCMAL(pf)-402a GCMAL(pf/pv)-402a e

NG Biotech

One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag MFLRPD-02 One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria MPHRPD-01 Pf HRP-II Ag NG-Test MALARIA Pf/Pan (pLDH) NGB-MAL- W23-005

RapiGEN Inc.

BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH)

RapiGEN Inc.

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH)

Shanghai Kehua Bio-engineering Co., Ltd. KHB® Malaria Ag (HRP2) Pf Rapid Test

Standard Diagnostics, Inc. HRP2 Pv pLDH HRP2 HRP2 5

SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines

Standard Diagnostics, Inc.

Alere™ Malaria Ag P.f

HRP2 HRP2 + Pf pLDH HRP2

WELLS BIO, INC

careUS™ Malaria Pf (HRP2) Ag

WELLS BIO, INC

careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag

Zhejiang Orient Gene Biotech Co., Ltd. Formats include: cassette (A); card (B); hybrid (C), dipstick (D); or other (E). Each product should ideally be accompanied by all required materials (lancet, pipette, etc.) particularly when used at the village health worker level; however, this is often not the case and the contents depend on the request of the procuring agent.

Malaria Pf Rapid Test

Zhejiang Orient Gene Biotech Co., Ltd.

Malaria Pf/Pv Rapid Test

a

pLDH , plasmodium lactate dehydrogrenase; HRP2, histidine rich protein 2; pv, P. vivax; pf, P. falciparum b Sequence when test held in a horizontal position and the sample well is at the far right and control line, far left c From placement of buffer, or from ‘intermediate’ step, if applicable d See Annex 2

Products have been assigned into different groups based on their procedural characteristics, specifically, blood volume (µL), number of buffer drops and minimum reading time (minutes). The groups are as follows: group 1: 5µL, 2 drops, 20 mins; group 2: 5µL, 3 drops, 20 mins; group 3: 5µL, 4 drops, 20 mins; group 4: 5µL, 2 drops, 30 mins; group 5: 5µL, 4 drops, 30 mins; group 6: 5µL, 3 drops, 15 mins; group 7: 5µL, 4 drops, 15 mins; group 8: 10µL, 3 drops, 10 mins; group 9: 8µL, 4 drops, 25 mins; group 10: 5µL, 3 drops, 10 mins ; group 11: 5µL, 5 drops, 30 mins; group 12: 5µL, 5 drops, 15 mins.

A Cassette C T1 T2

B Card

C Cassette hybrid

D Dipstick

E Other

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

C

T

S

A

Pf P C

  Sample and mixing wells

C

C

T

S

T1 T2

Annex 2: Malaria RDTs: guide to interpretation of results Type A: Guide to results of generic Pf malaria RDTs Results window: C=control line; T=test line with bound HRP2 or Pf-specific pLDH antibody.

C

T

Negative results: One line ‘C’ appears in the results window. C T

Positive results:  P. falciparum infection. Two lines ‘C’ and ‘T’ appear in the results window. Test is positive even if the test line is faint. C T

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T C T

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Annexes 93

Type B: Guide to results of generic major Plasmodium species (pan) malaria RDTs Results window: C=control line; T=test line with bound pan-specific pLDH or aldolase antibody.

C

T

Negative results: One line ‘C’ appears in the results window. C T

Positive results: P  lasmodium species (P. falciparum, P. vivax, P. malariae, P. ovale) infection. Two lines ‘C’ and ‘T’ appear in the results window. Test is positive even is the test line is faint. C T

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T C T

94

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Type C: Guide to results of generic pan-Pf malaria RDTs Results window:  C=control line; T1=test line with bound pLDH or aldolase antibody; T2=test line with bound HRP2 and/or Pf-specific pLDH antibody.

C

T1 T2

Negative results: Only one line ‘C’ appears in the results window. C T1 T2

Positive results: P. falciparum: Two lines ‘C’ and ‘T2” appear in the results window. C T1 T2

Non-falciparum infection (P. vivax, P. ovale, P. malariae) or mixed infection: Two lines ‘C’ and ‘T1” appear in the results window. C T1 T2

P. falciparum or mixed infection. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 C T1 T2

C T1 T2 C T1 T2

Annexes Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) 95

Type D: Guide to results of generic Pf-pan malaria RDTs Results window:  C=control line; T1=test line with bound HRP2 or Pf-specific LDH antibody; T2=test line with bound pLDH or aldolase antibody.

C

T1 T2

Negative results: Only one line ‘C’ appears in the results window. C T1 T2

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2

Non-falciparum infection (P. vivax, P. ovale, P. malariae) or mixed infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2

P. falciparum or mixed infection. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 C T1 T2

C T1 T2 C T1 T2

96

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Type E: Guide to results of generic Pv-Pf malaria RDTs Results window:  C=control line; T1=test line with bound P. vivax-specific pLDH; T2=test line with bound HRP2 or Pf-specific pLDH antibody.

C

T1 T2

Negative results: Only one line ‘C’ appears in the results window. C T1 T2

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2

P. vivax infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2

P. falciparum and P. vivax mixed infection. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 C T1 T2

C T1 T2 C T1 T2

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Annexes 97

Type F: Guide to results of generic Pf-Pv malaria RDTs Results window:  C=control line; T1= test line with bound HRP2 or Pf-specific pLDH antibody; T2=test line with bound P. vivax-specific pLDH.

C

T1 T2

Negative results: Only one line ‘C’ appears in the results window. C T1 T2

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2

P. vivax infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2

P. falciparum and P. vivax mixed infection. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 C T1 T2

C T1 T2 C T1 T2

98

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Type G: Guide to results of generic pan-Pv-Pf malaria RDTs Results window:  C=control line; T1=test line with bound pLDH or aldolase antibody; T2=test line with bound P. vivax-specific pLDH; T3=test line with bound HRP2 or Pf-specific pLDH antibody

C

T1 T2 T3

Negative results: Only one line ‘C’ appears in the results window. C T1 T2 T3

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T3’ appear in the results window. C T1 T2 T3

P. vivax infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2 T3

P. falciparum with or without mixed infection with P. ovale or P. malariae. Three lines ‘C’, ‘T1’ and ‘T3’ appear in the results window. C T1 T2 T3

P. falciparum and P. vivax mixed infection. Three lines ‘C’, ‘T2’ and ‘T3’ appear in the results window. C T1 T2 T3

P. falciparum and P. vivax mixed infection with or without P. ovale and/or P. malariae infection. Four lines ‘C’, ‘T1’, ‘T2’ and ‘T3’ appear in the results window. C T1 T2 T3

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Annexes 99

 P. vivax with or without P. ovale and/or P. malariae infection. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2 T3

P. malariae with or without P. ovale and/or P. vivax infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2 T3

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

10 0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Type H: Guide to results of generic vom1-Pf malaria RDTs Results window:  C=control line; T1= test line with bound pLDH specific for non-P. falciparum (P. vivax, P. ovale and P. malariae); T2=test line with bound HRP2 or Pf-specific pLDH antibody

C

T1 T2

Negative results: Only one line ‘C’ appears in the results window. C T1 T2

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2

P. falciparum mixed infection (with P. vivax, P. ovale and/or P. malariae). Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2

Non-P. falciparum infection (P. vivax, P. ovale and P. malariae) or mixed infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 C T1 T2

C T1 T2 C T1 T2

1

vom, P. vivax, P. ovale, P. malariae

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Annexes 101

Type I: Guide to results of generic Pv malaria RDTs Results window: C=control line; T=test line with bound P. vivax-specific pLDH.

C

T

Negative results: Only one line ‘C’ appears in the results window. C T

Positive results: P  . vivax infection. Two lines ‘C’ and ‘T’ appear in the results window. C T

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T C T

10 2

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Type J: Guide to results of generic Pf-Pf malaria RDTs Results window:  C=control line; T1= test line with bound pLDH specific for P. falciparum; T2=test line with bound HRP2.

C

T1 T2

Negative results: Only one line ‘C’ appears in the results window. C T1 T2

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2

P. falciparum infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2

P. falciparum infection. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 C T1 T2

C T1 T2 C T1 T2

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Annexes 103

Type K: Guide to results of generic Pv-Pf-Pf malaria RDTs Results window:  C=control line; T1= test line with bound P. vivax-specific pLDH; T2=test line with bound HRP2 or Pf-specific pLDH antibody; T3=test line with bound HRP2 or Pf-specific pLDH antibody. If an RDT has bound HRP2 antibodies on T2, T3 will have bound Pf-specific pLDH and vice versa (T2 Pf antigen target ≠ T3 Pf antigen target).

C

T1 T2 T3

Negative results: Only one line ‘C’ appears in the results window. C T1 T2 T3

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T3’ appear in the results window. C T1 T2 T3

P. falciparum infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2 T3

P. falciparum infection. Three lines ‘C’, ‘T2’ and ‘T3’ appear in the results window. C T1 T2 T3

P. falciparum infection and P. vivax mixed infection. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2 T3

P. falciparum infection and P. vivax mixed infection. Three lines ‘C’, ‘T1’ and ‘T3’ appear in the results window. C T1 T2 T3

10 4

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

 P. falciparum infection and P. vivax mixed infection. Four lines ‘C’, ‘T1’, ‘T2’ and ‘T3’ appear in the results window. C T1 T2 T3

P. vivax infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2 T3

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

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Annexes 105

Type L: Guide to results of generic pan-Pf-Pf malaria RDTs Results window:  C=control line; T1= test line with bound PAN-pLDH or aldolase antibody; T2=test line with bound HRP2 or Pf-specific pLDH antibody; T3=test line with bound HRP2 or Pf-specific pLDH antibody. If an RDT has bound HRP2 antibodies on T2, T3 will have bound Pf-specific pLDH and vice versa (T2 Pf antigen target ≠ T3 Pf antigen target)

C

T1 T2 T3

Negative results: Only one line ‘C’ appears in the results window. C T1 T2 T3

Positive results: P. falciparum infection. Two lines ‘C’ and ‘T2’ appear in the results window. C T1 T2 T3

P. falciparum infection. Two lines ‘C’ and ‘T3’ appear in the results window. C T1 T2 T3

P. falciparum infection. Three lines ‘C’, ‘T2’ and ‘T3’ appear in the results window. C T1 T2 T3

P. falciparum infection with or without mixed infection with P. vivax, P. ovale and/or P. malariae. Three lines ‘C’, ‘T1’ and ‘T2’ appear in the results window. C T1 T2 T3

P. falciparum infection with or without mixed infection with P. vivax, P. ovale and/or P. malariae. Three lines ‘C’, ‘T1’ and ‘T3’ appear in the results window. C T1 T2 T3

10 6

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

 P. falciparum infection with or without mixed infection with P. vivax, P. ovale and/or P. malariae. Four lines ‘C’, ‘T1’, ‘T2’ and ‘T3’ appear in the results window. C T1 T2 T3

Non-P. falciparum infection (P. vivax, P. ovale, P. malariae) or mixed infection. Two lines ‘C’ and ‘T1’ appear in the results window. C T1 T2 T3

Invalid results:  No ‘C’ line appears in the results window. Repeat the test with a new RDT if no control line appears. C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

C T1 T2 T3 C T1 T2 T3

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Annexes 107

10 8

Annex 3: Phase-1 results P. falciparum samples (n=20) Total positive results returned Manufacturer Lot 1 Test 1 Test 2 No. positive agreementsb (max=20) Test 1 Test 2 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 19 20 20 20 20 18 20 20 20 20 20 20 20 18 20 16 20 20 20 20 20 20 20 20 20 17 20 18 18 20 16 20 20 20 20 20 20 20 19 20 19 20 20 17 20 20 20 18 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 18 20 19 20 18 20 20 20 20 20

Table A3.1: Lot variability in positive resultsa against phase-1 P. falciparum culture samples at low (200) and high (2000) parasite density (parasites/µL)

Product Lot 2

Product code

200 parasites/µL

2000 parasites/µL Lot 1 No. positive agreementsb (max=20) 20 20 20 20 20 20 20 20 20 20 20 20 20 20 19 20 19 20 20 16 20 19 20 16 20 20 20 20 20

Lot 2 Test 1 Test 2

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 RMSM-05071 RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. ICT INTERNATIONAL 20 18 20 18 20

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd.

20 20 20 20 20 20 20 20 20 20 20 20 20 20

20 20 20 20 20 20 20 20 20 20 20 20 20 20

20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 19 (19) 20 20 20 20 20 20 20 20 20

MPHRPD-01

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST

5531 55IC103-50 55IC104-50 05FK130-40-0

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMAM-05071 ML03

Table A3.1 (continued) P. falciparum samples (n=20) Total positive results returned Manufacturer Lot 1 Test 1 Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Real World Diagnostics Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 20 20 20 20 20 20 18 (19) 20 20 20 20 20 20 20 19 (19) 20 20 20 19 (19) 20 20 20 20 20 20 20 20 20 20 20 17 (18) 20 20 20 20 20 20 20 19 (19) 20 20 20 18 20 20 20 20 20 20 20 18 20 20 20 17 20 20 20 20 20 20 20 20 20 20 20 16 20 20 20 20 20 20 20 18 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

Product Lot 2 No. positive agreementsb (max=20) Test 1 Test 2 No. positive agreementsb (max=20) Test 1 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

Product code Lot 1 Test 2

200 parasites/µL

2000 parasites/µL Lot 2 Test 2 20 19 20 20 20 20 20 20 20 20 20 20 20 20 20 20

MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test Malaria Pf/PAN Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a PROPMALPFPV001 W056-C MFLRPD-02 71050 11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species  a Results are based on the first reader’s interpretation according to manufacturer’s instructions. b Number of samples that returned a positive result for both tests. Where one test was invalid and the other positive, positive agreement was recorded.

Annexes

109

11 0

Table A3.2: Distribution of test band intensity (0-4) scores against phase-1 P. falciparum cultured parasites at low (200) and high (2000) parasite density (parasites/μl) 200 parasites/µl Manufacturer 0a 1 26.3 7.5 0.0 7.5 0.0 0.0 1.3 48.8 0.0 16.3 0.0 10.0 0.0 6.3 11.3 43.8 0.0 45.0 36.3 2.5 45.0 1.3 12.5 6.3 5.0 0.0 12.5 0.0 0.0 2.5 2.5 70.0 57.5 62.5 28.8 70.0 41.3 45.0 48.8 57.5 58.8 43.8 2.5 31.3 16.3 26.3 21.3 47.5 16.3 45.0 36.3 30.0 30.0 0.0 8.8 1.3 10.0 6.3 23.8 1.3 13.8 18.8 18.8 10.0 2.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 41.3 48.8 58.8 65.0 42.5 1.3 5.0 28.8 16.3 0.0 0.0 1.3 0.0 0.0 0.0 0.0 51.3 3.8 0.0 0.0 2.5 0.0 0.0 2.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 48.8 61.3 30.0 26.3 15.0 1.3 0.0 0.0 0.0 0.0 0.0 2.5 5.0 0.0 10.0 5.0 2.5 17.5 0.0 0.0 0.0 10.0 0.0 0.0 0.0 0.0 0.0 0.0 50.0 40.0 10.0 0.0 0.0 0.0 7.5 22.5 27.5 42.5 0.0 25.0 30.0 20.0 30.0 7.5 27.5 5.0 10.0 0.0 27.5 5.0 0.0 5.0 5.0 61.3 25.0 3.8 0.0 0.0 0.0 7.5 92.5 92.5 77.5 70.0 50.0 100.0 65.0 62.5 77.5 50.0 92.5 72.5 95.0 80.0 100.0 72.5 95.0 100.0 95.0 95.0 17.5 70.0 47.5 48.8 11.3 40.0 33.8 2.5 12.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.5 20.0 5.0 97.5 80.0 95.0 NA NA NA NA NA NA NA NA NA NA NA NA 98.8 76.3 96.3 56.3 41.3 50.0 96.3 31.3 8.8 96.3 20.0 12.5 0.0 0.0 2.5 17.5 77.5 2.5 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA 1.3 23.8 3.8 43.8 57.5 48.8 3.8 68.8 83.8 3.8 77.5 38.8 43.8 16.3 0.0 0.0 0.0 2.5 97.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 1.3 1.3 0.0 0.0 7.5 0.0 2.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 61.3 52.5 8.8 65.0 25.0 18.8 12.5 30.0 41.3 21.3 53.8 43.8 0.0 10.0 50.0 6.3 21.3 37.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.5 0.0 0.0 7.5 0.0 0.0 42.5 7.5 0.0 20.0 0.0 0.0 55.0 92.5 100.0 72.5 100.0 100.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 17.5 0.0 5.0 0.0 0.0 0.0 0.0 0.0 0.0 17.5 0.0

2000 parasites/µl Percentage distribution of Pf test band intensityb (n=40) 0a 1 2 3 4 1 2 3 4 0a 0a 1 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 77.5 0.0 72.5 20.0 7.5 2.5 50.0 0.0 0.0 67.5 2.5

200 parasites/µl Percentage distribution of pan test band intensityb (n=80)

2000 parasites/µl Percentage distribution of pan test band intensityb (n=40) 2 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 5.0 100.0 22.5 80.0 92.5 97.5 50.0 95.0 60.0 15.0 97.5

Product 2 3 4

Product code

Percentage distribution of Pf test band intensityb (n=80)

3 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5.0 40.0 0.0 0.0

4 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

RKMAL017 Advy Chemical Private Limited ITP11002-TC25 InTec Products, Inc. 05FK140-40-0 Standard Diagnostics, Inc. AS0015 Aspen Laboratories Pvt. Ltd. 17912 Bio Focus Co., Ltd. RMOM-03091 Access Bio Ethiopia 0.0 Access Bio, Inc. 38.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.3 0.0 5.0 0.0 2.5 8.8 0.0 0.0 0.0 5.0 0.0 0.0 0.0 0.0 0.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd.

RMSM-05071

RMO-M05082 W06200 ML01

KHB® Malaria Ag (HRP2) Pf Rapid Test

R-409-50-C

Malaria Pf Rapid Test

GCMAL(pf)402a

GMDMALPF001 Medical Diagnostech (Pty) Ltd W37-C Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd.

MPHRPD-01

5531 55IC103-50 55IC104-50 05FK130-40-0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

RKMAL016

GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/ Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN

05FK60AI-40

IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMAM-05071 ML03 MPFPAN050

Table A3.2 (continued) 200 parasites/µl Manufacturer 0a 1 1.3 0.0 40.0 40.0 20.0 0.0 0.0 0.0 0.0 100.0 81.3 18.8 0.0 0.0 0.0 0.0 15.0 43.8 31.3 23.8 2.5 0.0 0.0 2.5 95.0 38.8 51.3 8.8 1.3 0.0 2.5 22.5

2000 parasites/µl Percentage distribution of Pf test band intensityb (n=40) 0a 1 2 3 4 1 2 3 4 1 2 75.0 85.0

200 parasites/µl Percentage distribution of pan test band intensityb (n=80) 0a 0a 3 0.0 0.0

2000 parasites/µl Percentage distribution of pan test band intensityb (n=40) 4 0.0 0.0

Product 2 3 4

Product code

Percentage distribution of Pf test band intensityb (n=80)

NG-Test MALARIA Pf/Pan (pLDH) Diagnostic Systems 0.0

NGB-MALW23-005 NG Biotech 0.0

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

MAL-PF/PanHema CAS/25 0.0 10.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.8 0.0 0.0 0.0 0.0 41.3 43.8 15.0 0.0 0.0 0.0 5.0 0.0 61.3 30.0 8.8 0.0 0.0 0.0 7.5 12.5 63.8 23.8 0.0 0.0 0.0 0.0 30.0 70.0 92.5 95.0 22.5 60.0 13.8 0.0 0.0 2.5 5.0 42.5 50.0 NA NA NA 22.5 0.0 11.3 50.0 62.5 33.8 23.8 16.3 2.5 0.0 0.0 0.0 0.0 0.0 2.5 7.5 25.0 92.5 72.5 NA NA NA NA NA NA NA 72.5 0.0 48.8 41.3 10.0 0.0 0.0 0.0 5.0 95.0 NA NA NA NA NA NA NA NA 5.0 NA NA NA NA NA NA 0.0 62.5 8.8 2.5 5.0 0.0 26.3 73.8 52.5 58.8 50.0 1.3 16.3 28.8 23.8 28.8 0.0 1.3 16.3 12.5 21.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 32.5 0.0 0.0 0.0 0.0 65.0 15.0 7.5 5.0 2.5 2.5 85.0 92.5 95.0 97.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 5.0 61.3 28.8 5.0 0.0 0.0 2.5 5.0 92.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Real World Diagnostics Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA

ITP11003-TC25 InTec Products, Inc.

NA NA NA NA NA NA NA NA NA NA NA NA 0.0

NA NA NA NA NA NA NA NA NA NA NA NA 70.0

NA NA NA NA NA NA NA NA NA NA NA NA 30.0

NA NA NA NA NA NA NA NA NA NA NA NA 0.0

Malaria Pf/Pv Rapid Test

C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)402a PROPMALPFPV001 W056-C

MFLRPD-02

71050

Malaria Pf/PAN Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species  a Denotes no band visible b Calculations include invalid tests

Annexes

111

11 2

Annex 4: Phase-2 results P. falciparum samples (n=100) Total positive resultsa returned 200 parasites/µL Lot 1 Test 1 No. positive Test 2 agreementsc Test 1 (max=100) Test 2 Test 1 89 97 99 98 99 99 96 98 90 96 90 93 90 96 87 95 81 87 94 77 90 76 93 98 93 91 75 88 73 89 (99) 97 (99) 90 (99) 89 77 92 78 94 95 94 88 93 77 80 94 100 82 85 94 98 86 84 94 77 89 83 95 (99) 98 94 87 78 83 84 96 97 95 87 (99) 92 90 88 94 79 98 80 81 92 73 88 76 93 (99) 94 93 85 91 96 95 93 87 91 90 87 100 100 100 100 99 99 100 100 100 100 99 98 99 98 100 100 99 100 99 100 100 100 100 100 100 100 99 97 99 100 99 100 96 88 95 98 91 99 98 92 97 97 88 97 100 99 100 100 100 100 94 98 99 98 99 100 NA NA NA NA NA NA NA NA NA NA NA NA NA 24 35 28 35 33 35 34 NA NA NA NA NA NA NA NA NA NA NA NA NA 26 35 32 35 34 35 34 95 99 97 99 97 97 98 96 99 99 98 100 97 98 99 96 98 95 97 98 100 100 100 99 100 99 100 100 100 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 22 35 28 35 32 (34) 35 33 87 84 85 81 100 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 29 32 29 35 34 (34) 35 33

Table A4.1: Lot variation in positive results against phase-2 wild-type P. falciparum and P. vivax samples at low (200) and high (2000) parasite density (parasites/µL) P. vivax samples (n=35) Total positive resultsa returned 2000b parasites/μl 200 parasites/µL Lot 1 No. positive Test 2 agreementsc Test 1 (max=35) Lot 2 Lot 2 Lot 2 Lot 1 No. positive c Test 2 agreements Test 1 (max=100)

Product

Product code

Manufacturer

2000 parasites/μl Lot 2 Test 2 Lot 1 No. positive c Test 2 agreements Test 1 (max=35) NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 23 35 30 35 35 35 32 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 21 32 27 35 34 (34) 35 31 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 35 35 35 35 35 35 35

RKMAL017 98 100 98 100 98 95

Advy Chemical Private Limited

87

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 35 35 35 35 35 35 35

ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091

InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line careUS™ Malaria Pf (HRP2) Ag

RMSM-05071 Access Bio, Inc.

DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST

KHB® Malaria Ag (HRP2) Pf Rapid Test

Malaria Pf Rapid Test

GMD Malaria Pf test

One Step Malaria HRP2 (P.f) Test 79 95 84 83 96 81 90

RMO-M05082 WELLS BIO, INC 98 W06200 DIALAB 93 ML01 ICT INTERNATIONAL 97 Shanghai Kehua Bio-engineering 94 R-409-50-C Co., Ltd. GCMAL(pf)- Zhejiang Orient Gene Biotech 96 402a Co., Ltd. GMDMALPF001 Medical Diagnostech (Pty) Ltd 88 (99) Guangzhou Wondfo Biotech 97 W37-C Co., Ltd.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

MPHRPD-01

Meril Diagnostics Pvt. Ltd.

5531 55IC103-50 55IC104-50 05FK130-40-0

ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc.

RKMAL016

Advy Chemical Private Limited

One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette

05FK60AI-40 Alere Medical Private Limited

IMPN-402

Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan

AM4650-K AS0060 C32RHA25 0584_K25

Hangzhou AllTest Biotech Co. Ltd. 78 ASAN Pharmaceutical Co., Ltd 93 (99) Aspen Laboratories Pvt. Ltd. 98 (99) RapiGEN Inc. 92 (99) Biosynex 90

Table A4.1 (continued) P. falciparum samples (n=100) Total positive resultsa returned 200 parasites/µL Lot 1 Test 1 99 87 97 94 98 97 96 95 94 97 94 93 100 100 35 35 35 97 95 95 (99) 95 93 (99) 99 99 24 22 (34) 16 (34) 95 95 95 95 94 99 100 35 35 35 35 25 35 35 20 35 97 85 96 92 97 78 95 90 97 90 97 92 98 88 97 89 97 83 96 87 99 100 99 99 100 100 100 99 35 2 35 21 34 1 35 21 34 0 35 17 35 1 35 17 35 1 33 19

P. vivax samples (n=35) Total positive resultsa returned 2000b parasites/μl 200 parasites/µL Lot 1 Test 1 No. positive Test 2 agreementsc Test 1 (max=35) 35 0 33 15 35 18 35

Product Lot 2 Test 2 Lot 2 Lot 2 No. positive Test 2 agreementsc Test 1 (max=100) Lot 1 No. positive c Test 2 agreements Test 1 (max=100)

Product code

Manufacturer

2000 parasites/μl Lot 2 Test 2 34 29 35 35 35 33 35 34 26 34 35 35 34 35

Lot 1 No. positive c Test 2 agreements Test 1 (max=35)

BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST

17012 RMLM-05071 RMAM-05071 ML03

Is It... Malaria Pf PAN

MPFPAN050

Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd.

NG-Test MALARIA Pf/Pan (pLDH)

NGB-MALW23-005

NG Biotech

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

MAL-PF/PanHema Diagnostic Systems CAS/25 99 85 (99) 94 96 94 97 94 90 97 85 91 93 93 92 96 91 89 88 94 87 87 86 82 85 83 80 83 86 94 94 96 95 94 88 (99) 90 90 87 92 94 93 90 99 (99) 100 100 100 100 99 99 94 96 97 95 100 91 90 98 95 95 99 100 100 99 99 100 100 99 99 100 98 95 97 96 95 100 100 35 35 35 33 7 30 34 34 35 30 89 (99) 89 82 (98) 89 88 92 88 86 82 86 97 (99) 99 99 100 35 34 97 96 97 94 93 100 98 35 35 34 (34) 35 34 35 35 30 4 30 33 35 32 32

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) ITP11003-TC25 InTec Products, Inc. Tri-line Test

35 34 (34) 34 34 35 35 29 1 28 33 34 32 30

34 35 33 35 35 33 27 11 29 31 31 34 32

35 35 34 35 35 33 29 7 29 34 35 32 33

34 35 32 35 35 31 23 5 27 31 31 32 31

35 35 35 35 35 35 35 6 35 35 35 35 35

34 (34) 33 (33) 34 (34) 35 35 35 35 6 35 35 35 35 35

C60RHA25 0581_K25

RapiGEN Inc. Biosynex

RMVM-03091 Access Bio Ethiopia

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT

RMVM-05072 Access Bio, Inc.

careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag RMV-M05082 GCMAL(pf/pv)Malaria Pf/Pv Rapid Test 402a MDMALLDH004 MD Malaria Pf/Pv (pLDH) Test

One Step Malaria HRP2/pLDH (P.f/P.v) Test 85 91 92 94

W056-C

WELLS BIO, INC 97 Zhejiang Orient Gene Biotech 96 Co., Ltd. Medical Diagnostech (Pty) Ltd 90 (99) Guangzhou Wondfo Biotech 94 Co., Ltd.

MFLRPD-02

Meril Diagnostics Pvt. Ltd.

71050

Lumiquick Diagnostics Inc.

One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

11108191040 Alere Medical Private Limited

5499

ALLDIAG SA

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species a Results are based on the first reader’s interpretation according to manufacturer’s instructions. b 3 (3%) of the 100 P. falciparum high parasite density dilution samples were at 5000 parasites/µL rather than 2000 c Number of samples that returned a positive result for both tests. Where one test was invalid and the other positive, positive agreement was recorded. d Results presented in the table are based on a positive Pf test line (either HRP2 or Pf-pLDH).

Annexes

113

11 4

Table A4.2: Distribution of test band intensity scores (0-4) against phase-2 wild-type P. falciparum samples at low (200) and high (2000) parasite density (parasites/µl)

Product

Product code Manufacturer

200 parasites/µl Percentage distribution of Pf test band intensityc (n=400) 0a 1 2 3 4 13.8 25.0 34.0 21.8 2.5 0.8 2.8 1.0 1.3 3.0 46.8 34.5 18.8 2.0 8.5 2.8 8.8 5.0 9.8 12.0 29.6 29.8 18.8 0.5 (399) (399) (399) (399) (399) 0.5 0.5 2.0 0.5 4.0 4.5 0.5 11.0 27.0 61.5 4.5 18.0 76.5 22.5 25.5 48.0 22.5 25.0 48.0 NA NA NA NA 21.0 28.0 48.5 NA NA NA NA NA NA 7.5 30.0 62.0 NA NA NA NA NA NA NA NA 6.5 26.0 66.5 NA NA NA 3.8 3.3 0.5 0.0 0.0 0.0 0.5 18.8 38.5 30.8 8.3 0.0 NA NA NA NA NA NA NA 15.5 35.8 25.3 18.5 0.0 0.0 9.5 20.0 70.5 NA NA NA NA NA NA NA NA NA NA NA NA 18.8 28.3 29.8 14.5 0.5 1.0 7.5 18.5 72.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 7.5 26.8 26.3 37.5 25.0 40.3 21.5 4.8 13.3 31.8 29.0 23.3 0.0 0.5 0.0 0.5 1.0 0.0 1.0 10.0 88.5 16.5 26.0 56.0 4.0 19.5 76.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 5.0 30.5 63.5 1.0 0.0 NA NA NA NA NA NA NA NA 15.0 26.0 28.3 27.8 0.5 0.0 4.0 14.5 81.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 4.5 20.5 10.8 9.0 22.5 38.8 27.3 26.8 28.8 43.5 31.0 7.0 37.3 23.8 26.8 36.3 0.0 0.0 0.5 0.0 0.5 0.5 0.0 0.0 0.0 9.0 90.5 11.0 27.0 61.5 2.5 22.5 74.5 2.5 13.5 84.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 14.0 39.5 29.8 14.3 0.5 1.5 5.0 24.0 69.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 5.5 0.0 1.5 18.5 24.0 56.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

2000b parasites/μl 200 parasites/µl 2000b parasites/μl 200 parasites/µl Percentage distribution Percentage distribution of Percentage distribution of Percentage distribution of Pf test band intensityc pan test band intensityc pan test band intensityc of Pv test band intensityc (n=200) (n=400) (n=200) (n=400) 0a 1 2 3 4 0a 1 2 3 4 0a 1 2 3 4 0a 1 2 3 4

2000b parasites/μl Percentage distribution of Pv test band intensityc (n=200) 0a 1 2 3 4 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Advy Chemical Private Limited

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen RKMAL017 Detection Test ADVANCED QUALITY™ ONE STEP ITP11002-TC25 Malaria (p.f) Test

InTec Products, Inc.

05FK140-40-0 AS0015 17912 RMOM-03091

Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band

RMSM-05071

Access Bio, Inc.

careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST

RMO-M05082 W06200 ML01

KHB® Malaria Ag (HRP2) Pf Rapid Test R-409-50-C

WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bioengineering Co., Ltd.

Malaria Pf Rapid Test

GCMAL(pf)402a

GMD Malaria Pf test

One Step Malaria HRP2 (P.f) Test

Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech GMDMALPF001 (Pty) Ltd Guangzhou Wondfo W37-C Biotech Co., Ltd.

One Step Test for Malaria Pf HRP-II Ag MPHRPD-01 MERISCREEN Malaria Pf HRP-II Ag

Meril Diagnostics Pvt. Ltd. 16.8 27.0 35.5 17.5

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) 18.5 35.3 33.8 7.0 22.0 27.3 36.5 13.0 9.8 21.3 29.8 40.0 8.8 0.3 14.0 31.8 36.0 8.5 1.0 2.5 1.3 0.0 5.5 0.5 3.0 1.0 0.5 22.0 24.5 48.0 95.8 9.5 4.3 28.5 60.5 50.3 44.8 26.0 33.5 35.0 79.3 20.0 7.5 20.0 70.5 42.0 52.0 0.0 5.0 0.8 6.0 10.5 25.0 63.0 28.0 58.5 13.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.5 58.5 25.0 3.0 6.0 2.5 2.0 0.0 10.0 67.5 19.5 38.5 51.5 4.0 10.0 67.5 19.0 6.0 75.0 15.0 0.0 0.0 0.0 1.0 2.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 5.8 22.6 26.3 32.3 13.0 1.0 (399) (399) (399) (399) (399) 2.8 20.3 40.3 28.0 8.8 1.0

5531 55IC103-50 55IC104-50

ALLDIAG SA 3.0 12.3 29.3 28.5 27.0 ARKRAY Healthcare Pvt Ltd 16.8 33.3 33.8 14.5 1.8 ARKRAY Healthcare Pvt Ltd 15.3 33.8 33.8 15.5 1.8

PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines

05FK130-40-0

Standard Diagnostics, Inc. 5.5

NA NA NA NA NA

NA NA NA NA NA

NA NA NA NA NA

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test RKMAL016 Detection Kit Alere Trueline™ – Rapid test kit for Malaria 05FK60AI-40 Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test IMPN-402 Cassette

Asan Easy Test® Malaria Pf/Pan Ag

AM4650-K

Aspen® Malaria Ag Pf/Pv

AS0060

Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd.

Table A4.2 (continued)

Product

Product code Manufacturer

200 parasites/µl Percentage distribution of Pf test band intensityc (n=400) 0a 1 2 3 4 6.5 11.3 25.6 27.8 28.8 0.5 (399) (399) (399) (399) (399) 0.5 2.5 0.0 1.0 0.0 1.0 1.0 0.5 0.0 5.5 19.0 75.5 61.8 36.3 2.0 0.0 0.0 2.5 20.0 70.0 7.5 0.0 NA 4.0 22.0 72.5 58.3 35.3 6.5 0.0 0.0 2.5 29.0 62.0 6.5 0.0 NA NA NA 3.5 22.5 72.5 14.5 74.0 11.5 0.0 0.0 2.0 3.5 70.0 22.5 2.0 NA NA NA NA NA NA NA NA NA NA NA 12.0 3.5 38.0 3.0 5.0 23.5 23.0 42.0 13.0 21.0 62.0 73.0 19.0 83.5 72.0 81.8 14.8 87.0 9.8 81.5 18.0 0.3 62.5 22.8 13.0 0.0 55.8 33.8 15.8 2.8 0.0 0.0 0.0 0.8 0.0 0.0 0.0 0.0 0.0 0.0 5.0 2.0 9.0 1.0 4.5 39.0 2.0 58.5 1.0 36.0 53.0 3.0 50.0 40.5 32.5 0.0 43.5 45.5 55.0 4.5 0.0 5.5 0.0 9.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 4.0 16.5 78.5 52.3 41.5 6.3 0.0 0.0 3.5 16.5 62.0 18.0 0.0 NA NA NA NA NA NA 11.0 2.3 12.5 3.3 8.3 4.3 4.0 11.5 31.0 29.3 23.8 0.0 15.5 31.3 31.8 17.5 1.0 17.5 28.3 32.3 17.8 0.5 23.5 10.3 45.3 14.0 14.3 36.0 25.8 35.5 26.3 32.8 23.3 6.3 39.5 22.3 6.8 0.0 26.5 30.0 25.0 19.8 0.0 0.5 0.0 0.5 1.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

2000b parasites/μl 200 parasites/µl 2000b parasites/μl 200 parasites/µl Percentage distribution Percentage distribution of Percentage distribution of Percentage distribution of Pf test band intensityc pan test band intensityc pan test band intensityc of Pv test band intensityc (n=200) (n=400) (n=200) (n=400) 0a 1 2 3 4 0a 1 2 3 4 0a 1 2 3 4 0a 1 2 3 4

2000b parasites/μl Percentage distribution of Pv test band intensityc (n=200) 0a 1 2 3 4 NA NA NA NA NA NA NA NA NA

BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) C32RHA25

RapiGEN Inc.

Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST

0584_K25 17012 RMLM-05071 RMAM-05071 ML03

Is It... Malaria Pf PAN

MPFPAN050

Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd.

NG-Test MALARIA Pf/Pan (pLDH)

NGBMAL-W23-005

NG Biotech

Rapid 1-2-3 HEMA® CASSETTE MALARIA MAL-PF/PanCAS/25 PF/PAN 3.3 12.3 56.1 31.6 0.0 0.0 2.0 (399) (399) (399) (399) (399) 2.0 1.0 0.5 0.0 0.5 0.0 0.5 2.0 1.5 2.0 0.5 1.0 3.0 8.0 12.5 36.0 49.0 29.5 61.0 21.0 31.5 46.0 NA NA NA 6.0 29.0 63.0 NA NA NA NA NA 6.5 18.0 74.5 NA NA NA NA NA NA NA 21.0 74.5 14.0 53.3 32.0 10.5 20.5 68.0 NA NA NA NA NA NA NA NA NA 0.8 2.5 12.5 84.5 NA NA NA NA 8.0 17.5 74.0 NA NA NA NA NA NA NA NA NA NA NA NA 0.0 3.0 15.0 81.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 13.5 21.0 64.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 3.5 33.0 53.0 10.0 NA NA NA NA NA NA NA 9.8 3.3 5.5 3.3 5.8 9.8 12.0 29.6 29.8 18.8 0.5 (399) (399) (399) (399) (399) 4.5 15.5 24.0 34.3 23.5 11.3 25.0 33.5 27.3 9.5 5.8 12.0 27.3 31.5 23.5 0.5 13.3 31.5 37.8 8.0 1.0 3.0 0.5 2.8 0.0 23.3 34.5 27.3 10.5 0.0 15.0 37.0 26.8 15.5 1.0 15.5 23.0 27.3 31.0 0.0 19.0 29.5 25.0 21.0 0.5 18.5 24.8 27.0 26.5 0.0 22.0 35.0 25.8 7.5 0.5 NA NA NA NA NA NA NA NA NA NA NA 16.0 35.3 31.5 14.0 1.0 0.5 4.5 25.0 69.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Hema Diagnostic Systems 4.5

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria ITP11003-TC25 (p.f/p.v.) Tri-line Test

InTec Products, Inc.

99.0 99.0

1.0 1.0 NA 100.0 0.0 NA 100.0 0.0 NA 98.3 1.8 NA 100.0 0.0 NA 100.0 0.0 NA NA NA NA 77.8 20.3 99.8 99.5 0.2 0.5 60.3 36.3 NA 100.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 3.5 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

0.0 0.0

99.0 99.0

0.5 1.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 98.0 2.0 0.0 100.0 0.0 0.0 0.0 0.0 99.5 7.5 99.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 29.0 59.5 1.0 0.0 100.0 0.0 0.0 72.5 24.5 0.0 100.0 0.0 0.0 0.0 3.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.5 4.0 0.0 0.0 0.0 0.0

0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) C60RHA25

RapiGEN Inc.

Biosynex

Biosynex® Malaria Pf/Pv 0581_K25 CareStart™ Malaria Pf/Pv (HRP2/pLDH) RMVM-03091 Ag Combo RDT

Access Bio Ethiopia

CareStart™ Malaria Pf/Pv (HRP2/pLDH) RMVM-05072 Ag. Combo RDT

Access Bio, Inc.

careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag RMV-M05082 GCMAL(pf/pv)Malaria Pf/Pv Rapid Test 402a

WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech MD Malaria Pf/Pv (pLDH) Test MDMALLDH004 (Pty) Ltd Guangzhou Wondfo One Step Malaria HRP2/pLDH (P.f/P.v) Test W056-C Biotech Co., Ltd. One Step Test for Malaria Pf/Pv Ag MFLRPD-02 Meril Diagnostics Pvt. Ltd. MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test 71050 Lumiquick Diagnostics Inc. Rapid Test Kit for Malaria Ag Pf/Pv-Alere Alere Medical Private 11108191040 Trueline Malaria Ag Pf/Pv Limited Pf, Pv and Pan PALUTOP +4 optima® 5499 ALLDIAG SA

36.0 47.0 13.5 99.3

0.8

0.0

0.0

0.0 100.0 0.0

0.0

0.0

0.0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species a Denotes no visible band b 3 (3%) of the 100 P. falciparum high parasite density dilution samples were at 5000 parasites/μl rather than 2000 c Calculations include invalid tests

Annexes

115

11 6

Table A4.3: Distribution of test band intensity scores (0-4) for phase-2 wild-type P. vivax samples at low (200) and high (2000) parasite density (parasites/µl) 200 parasites/µl 2000 parasites/µl 200 parasites/µl 2000 parasites/µl 200 parasites/µl 2000 parasites/µl

Product 0a 1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA 0.0 0.0 98.6 1.4 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 98.6 1.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 1.4 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 98.6 1.4 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 100.0 100.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Product code 2 3 4 0a 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 0a 0a 0a 4 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Manufacturer

Percentage distribution Percentage distribution of Percentage distribution of Percentage distribution Percentage distribution Percentage distribution of Pf test band intensityb of Pf test band intensityb pan test band intensityb pan test band intensityb of Pv test band intensityb of Pv test band intensityb (n=140) (n=70) (n=140) (n=70) (n=140) (n=70) 0a NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

1 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

2 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

3 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

4 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

RKMAL017 100.0 0.0 100.0 99.3 100.0 100.0 99.3 98.6 100.0 0.0 100.0 0.0 95.0 5.0 100.0 0.0 100.0 0.0 97.1 100.0 0.0 0.7 2.9 0.0 0.7 0.0 0.7 0.0 0.0

Advy Chemical Private 100.0 0.0 Limited

ITP11002-TC25 InTec Products, Inc.

05FK140-40-0 Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. AS0015 17912 Bio Focus Co., Ltd. RMOM-03091 Access Bio Ethiopia

RMSM-05071

Access Bio, Inc.

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST

RMO-M05082 W06200 ML01

KHB® Malaria Ag (HRP2) Pf Rapid Test R-409-50-C

WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bioengineering Co., Ltd.

Malaria Pf Rapid Test

GMD Malaria Pf test

One Step Malaria HRP2 (P.f) Test

G C M A L ( p f ) - Zhejiang Orient Gene 402a Biotech Co., Ltd. Medical Diagnostech GMDMALPF001 (Pty) Ltd Guangzhou Wondfo W37-C Biotech Co., Ltd.

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) 100.0 0.0 100.0 0.0 100.0 0.0 100.0 0.0 98.6 0.0 100.0 0.0 0.0 0.0 0.7 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 27.1 66.4 2.1 6.4 39.3 55.7 15.0 70.7 14.3 0.0 2.9 0.0 30.0 65.7 17.9 75.0 39.3 58.6 0.0 2.9 0.0 4.3 4.3 2.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 0.0 0.0 0.0 52.9 42.9 2.9 11.4 71.4 17.1 31.4 61.4 1.4 4.3 4.3 7.1 58.6 40.0 60.0 35.7 54.3 41.4 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

One Step Test for Malaria Pf HRP-II MPHRPD-01 Ag MERISCREEN Malaria Pf HRP-II Ag

Meril Diagnostics Pvt. Ltd. 99.3

ALLDIAG SA 100.0 0.0 ARKRAY Healthcare Pvt Ltd 100.0 0.0 ARKRAY Healthcare Pvt Ltd 100.0 0.0

PALUTOP + pf® 5531 Parahit f® Ver 1.0 - Dipstick 55IC103-50 Parahit® f Ver 1.0 - Device 55IC104-50 SD BIOLINE Malaria Ag P.f. (HRP2/ 05FK130-40-0 pLDH) 2 Lines

Standard Diagnostics, Inc. 100.0 0.0

RKMAL016

NA NA NA NA NA NA

NA NA NA NA NA NA

NA NA NA NA NA NA

05FK60AI-40

IMPN-402

AM4650-K AS0060

Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd.

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/ pLDH)

C32RHA25

RapiGEN Inc.

Table A4.3 (continued) 200 parasites/µl 2000 parasites/µl 200 parasites/µl 2000 parasites/µl 200 parasites/µl 2000 parasites/µl

Product 0a 1 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 39.3 58.6 2.1 0.0 0.0 0.0 14.3 64.3 21.4 NA 0.0 0.0 95.7 4.3 0.0 0.0 0.0 31.4 53.6 15.0 0.0 0.0 0.0 11.4 65.7 22.9 0.0 NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 11.4 79.3 7.1 2.1 0.0 0.0 4.3 32.9 62.9 NA NA NA NA NA 0.0 0.0 0.0 100.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.7 61.4 33.6 44.3 46.4 8.6 0.7 2.9 0.0 1.4 0.0 0.0 4.3 0.0 5.7 92.9 61.4 32.9 1.4 NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 96.4 3.6 0.0 0.0 0.0 21.4 50.0 25.7 2.9 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 100.0 0.0 0.0 97.1 1.4 0.0 1.4 0.0 0.0 0.0 0.0 5.0 0.0 67.1 27.1 0.7 10.7 73.6 15.0 0.0 0.7 0.0 0.0 0.0 0.0 28.6 60.0 11.4 1.4 30.0 68.6 NA NA NA NA NA NA NA NA NA NA NA NA

Product code 2 3 4 0a 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 NA NA NA NA NA NA NA NA

Manufacturer 0a 0a 0a 0a 2 NA NA NA NA NA NA NA NA

Percentage distribution Percentage distribution of Percentage distribution of Percentage distribution Percentage distribution Percentage distribution of Pf test band intensityb of Pf test band intensityb pan test band intensityb pan test band intensityb of Pv test band intensityb of Pv test band intensityb (n=140) (n=70) (n=140) (n=70) (n=140) (n=70) 3 NA NA NA NA NA NA NA NA

4 NA NA NA NA NA NA NA NA

0584_K25 17012 99.3 100.0 0.0 100.0 0.0 100.0 0.0 96.4 3.6 0.7

Biosynex Bio Focus Co., Ltd.

100.0 0.0 99.3 0.0

Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST

RMLM-05071

Access Bio, Inc.

RMAM-05071 ML03

Is It... Malaria Pf PAN

MPFPAN050

Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd.

NG-Test MALARIA Pf/Pan (pLDH)

NGBNG Biotech MAL-W23-005

Rapid 1-2-3 HEMA® CASSETTE MALARIA MAL-PF/PanHema Diagnostic Systems 100.0 0.0 PF/PAN CAS/25 100.0 0.0 100.0 0.0 100.0 0.0 100.0 0.0 100.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 98.6 0.0 1.4 0.0 0.0 NA NA NA 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA 0.0 0.0 92.9 7.1 0.0 0.0 0.0 NA NA NA NA NA NA NA 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA 18.6 70.7 10.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA 0.7 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA NA 0.0 0.0 0.0 98.6 1.4 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.0 0.0 0.0 0.0 98.6 1.4 0.0 0.0 0.0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 32.9 67.1

ITP11003-TC25 InTec Products, Inc.

0.7 0.7 2.9 0.7 0.0 2.9

12.9 77.9 0.0

8.6 49.3 48.6 47.1 49.3 32.9 60.7 2.1 0.7 5.7 65.7 28.6 32.1 60.0 15.0 65.0 20.0 79.3 18.6 2.1 15.7 70.0 14.3 5.7 3.6 5.0 9.3 51.4 40.0 67.9 28.6 42.9 48.6 49.3 39.3 4.3 0.0 0.0 0.0 2.9 0.0 3.6 2.1

0.0 1.4 0.0 0.0 3.6 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0

1.4 2.9 1.4 0.0 0.0 0.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 82.9 15.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

2.9 0.0

40.0 55.7 1.4 95.7 14.3 71.4 12.9 7.1 0.0 8.6 40.0 52.9 5.7 94.3 32.9 58.6 38.6 51.4 10.0 0.0 1.4 0.0 44.3 45.7 10.0 8.6 71.4 20.0 45.7 48.6 5.7 11.4 71.4 17.1 21.4 38.6 40.0

C60RHA25

RapiGEN Inc.

0581_K25

Biosynex

RMVM-03091

Access Bio Ethiopia

RMVM-05072

Access Bio, Inc.

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/ pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/ pLDH) Ag

RMV-M05082

WELLS BIO, INC

GCMAL(pf/pv)- Zhejiang Orient Gene Malaria Pf/Pv Rapid Test 100.0 0.0 402a Biotech Co., Ltd. Medical Diagnostech MD Malaria Pf/Pv (pLDH) Test 95.7 4.3 MDMALLDH004 (Pty) Ltd One Step Malaria HRP2/pLDH (P.f/P.v) Guangzhou Wondfo W056-C 100.0 0.0 Test Biotech Co., Ltd. One Step Test for Malaria Pf/Pv Ag MFLRPD-02 Meril Diagnostics Pvt. Ltd. 99.3 0.7 MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test 71050 Lumiquick Diagnostics Inc. 100.0 0.0 Alere Medical Private Rapid Test Kit for Malaria Ag Pf/Pv-Alere 100.0 0.0 11108191040 Limited Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® 5499 ALLDIAG SA 99.3 0.7

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species  a Denotes no visible band b Calculations include invalid tests

Annexes

117

11 8

Table A4.4: Phase 2 P. falciparum test line false-positive rates for wild-type P. vivax samples at low (200) and high (2000) parasite density (parasites/µl) P. vivax samples (n=35) Manufacturer Lot 1 (n=70) Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems 0.0 0.0 0.0 0.0 2.9 (69) 0.0 0.0 1.4 0.0 0.0 0.0 0.0 4.3 (69) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 (69) 0.0 0.0 0.0 1.4 0.0 0.0 0.0 2.9 0.0 0.0 1.4 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.4 (138) 0.0 0.0 0.7 0.7 0.0 0.0 0.0 3.6 (139) 0.0

Product Lot 2 (n=70) Overall (n=140) Lot 1 (n=35) Lot 2 (n=35)

Product code

200 parasites/µl False positive Pf infectiona (%)

2000 parasites/µl False positive Pf infectiona (%) Overall (n=70)

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 0.0 5.7 0.0 0.0 2.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.0 0.0 0.0 5.7 0.0

0.0 0.0 0.0 1.4 0.0 0.0 0.0 2.9 0.0 0.0 4.3 0.0 0.0 (69) 2.9 0.0

0.0 0.0 0.0 0.7 0.0 0.0 0.7 1.4 0.0 0.0 5.0 0.0 0.0 (139) 2.9 0.0

0.0 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.0 0.0 2.9 0.0 0.0 2.9 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.0 0.0 0.0 2.9 0.0

0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 0.0 1.4 0.0 0.0 1.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.0 0.0 0.0 4.3 0.0

MPHRPD-01

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

5531 55IC103-50 55IC104-50 05FK130-40-0

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

Table A4.4 (continued) P. vivax samples (n=35) Manufacturer Lot 1 (n=70) InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0.0 1.4 0.7 0.0 0.0 0.0 0.0 (69) 0.0 0.0 0.0 0.0 0.0 7.1 0.0 1.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.0 0.0 0.0 0.0 0.0 0.0 (139) 0.0 0.0 0.0 0.0 0.0 4.3 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 8.6 0.0 2.9 0.0 0.0 2.9 (34) 3.0 (33) 0.0 (34) 0.0 0.0 0.0 0.0 5.7 0.0 0.0 0.0 0.0

Product Lot 2 (n=70) Overall (n=140) Lot 1 (n=35) Lot 2 (n=35)

Product code

200 parasites/µl False positive Pf infectiona (%)

2000 parasites/µl False positive Pf infectiona (%) Overall (n=70) 1.4 (69) 1.5 (68) 0.0 (69) 0.0 0.0 0.0 0.0 7.1 0.0 1.4 0.0 0.0 0.0

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

Pf, Plasmodium falciparum 

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

a

Pv, Plasmodium vivax  pan, Plasmodium species Pf positive line indicates a false-positive P. falciparum infection

Annexes

119

12 0

Table A4.5: Phase 2 pan (or P. vivax) test line false-positive rate for non-P. falciparum infection on phase 2 wild-type P. falciparum samples at low (200) and high (2000) parasite density (parasites/µl) P. falciparum samples (n=100) Manufacturer Lot 1 (n=200) Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited 1.5 1.0 (199) 0.0 0.0 1.5 0.0 0.0 21.5 0.5 1.0 45.0 0.0 0.5 1.0 0.0 0.0 2.0 0.0 0.0 23.0 0.0 0.0 34.5 0.0 1.0 1.0 (399) 0.0 0.0 1.8 0.0 0.0 22.3 0.3 0.5 39.8 0.0 1.0 1.0 (99) 0.0 0.0 2.0 0.0 0.0 (99) 92.0 1.0 0.0 24.0 0.0 0.0 2.5 1.0 0.5 0.0 (199) 0.0 0.0 1.0 0.0 1.0 0.0 1.0 0.5 0.0 0.0 0.0 1.5 0.5 (199) 0.5 0.0 0.0 0.5 0.0 1.5 0.5 3.0 1.0 (199) 0.0 0.0 1.3 1.3 0.5 (399) 0.3 (399) 0.0 0.0 0.8 0.0 1.3 0.3 2.0 0.8 (399) 0.0 0.0 1.0 2.0 1.0 2.0 0.0 0.0 1.0 0.0 1.0 1.0 1.0 1.0 0.0

Product Lot 2 (n=200) Overall (n=400) Lot 1 (n=100)

Product code

200 parasites/µl False positive non-Pf infection (%) Lot 2 (n=100) 0.0 1.0 2.0 1.0 0.0 1.0 0.0 0.0 0.0 0.0 1.0 0.0 1.0 0.0 1.0 1.0 0.0 0.0 2.0 0.0 1.0 93.0 1.0 0.0 31.0 0.0

2000a parasites/µl False positive non-Pf infection (%) Overall (n=200) 0.0 1.0 2.0 1.0 1.0 0.5 0.0 0.5 0.0 0.5 1.0 0.5 1.0 0.0 1.0 1.0 (199) 0.0 0.0 2.0 0.0 0.5 (199) 92.5 1.0 0.0 27.5 0.0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) ALLDIAG SA 0.0 1.0 1.0 0.5 0.5 0.8 0.0 1.0 0.0 0.0

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® - Pv-pLDH band PALUTOP +4 optima® - Pan-pLDH band

5499

0.0 0.5

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species  a 3 (3%) of the 100 P. falciparum high parasite density dilution samples were at 5000 parasites/μl rather than 2000

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Annexes 121

12 2

Table A4.6: Phase-2 false-positive rate for P. falciparum test line results on all malaria-negative samples Percentage of false positive Pf test lines on cleana negative samples Lot 1 (n=116) Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia 0.9 Access Bio, Inc. 0.0 1.7 0.0 1.7 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.0 0.0 (115) 0.0 0.0 0.9 0.9 1.7 (115) 0.0 0.0 0.9 0.0 0.0 (115) 1.7 0.0 0.0 0.0 0.0 1.7 0.9 0.0 0.0 0.9 0.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (231) 0.0 0.0 0.4 1.3 1.3 (231) 0.0 0.0 0.9 0.4 0.0 (231) 0.9 0.0 0.0 0.0 0.0 0.0 0.0 3.3 0.0 0.0 0.0 1.7 0.0 0.0 0.0 (115) 0.0 0.9 0.0 1.7 0.0 0.0 0.4 (231) 0.0 0.0 0.0 6.7 0.0 0.0 3.3 0.0 3.3 0.0 0.0 0.0 0.0 3.3 0.0 3.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. 0.0 0.4 0.0 0.0 0.0 0.0 1.7 0.0 3.3 0.0 0.0 3.3 0.0 1.7 0.0 0.0 0.0 0.0 1.7 0.0 0.0 3.3 0.0 3.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.3 0.0 0.0 0.0 3.3 0.0 0.0 1.7 0.0 1.7 1.7 0.0 0.0 0.0 1.7 0.0 0.0 0.9 1.7 (115) 2.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.9 0.0 0.4 0.9 (231) 1.3 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.7 0.0 0.0 14.8 0.0 3.7 3.7 0.0 3.7 1.9 11.1 0.0 0.0 3.7 7.4 0.0 0.0 11.1 14.8 5.6 0.0 3.7 0.0 1.9 3.7 0.0 1.9 0.0 3.7 3.7 5.6 0.0

Product Lot 2 (n=116) Overall (n=232) Lot 1 (n=30) Lot 2 (n=30) Overall (n=60) Lot 1 (n=54)

Product code

Manufacturer

Percentage of false positive Pf test lines on samples containing non-Plasmodium spp. infectious agentsb Lot 2 (n=54) 5.6 1.9 0.0 14.8 0.0 5.6 3.7 0.0 3.7 1.9 9.3 0.0 0.0 5.6 7.4 1.9 0.0 18.5 14.8 3.7 0.0 0.0 0.0 3.7 3.7 1.9 3.7 0.0 5.6 5.6 5.6 0.0

Percentage of false positive Pf test lines on samples containing immunological factorsc Overall (n=108) 4.6 0.9 0.0 14.8 0.0 4.6 3.7 0.0 3.7 1.9 10.2 0.0 0.0 4.6 7.4 0.9 0.0 14.8 14.8 4.6 0.0 1.9 0.0 2.8 3.7 0.9 2.8 0.0 4.6 4.6 5.6 0.0

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

MPHRPD-01

5531 55IC103-50 55IC104-50 05FK130-40-0

RKMAL016

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN

05FK60AI-40

IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050

Table A4.6 (continued) Percentage of false positive Pf test lines on cleana negative samples Lot 1 (n=116) NG Biotech Hema Diagnostic Systems 0.0 0.9 0.4 0.0 0.0 0.0 1.9 6.0 1.7 3.9 10.0 13.3 11.7 22.2 24.1 3.7

Product Lot 2 (n=116) Overall (n=232) Lot 1 (n=30) Lot 2 (n=30) Overall (n=60) Lot 1 (n=54) Lot 2 (n=54)

Product code

Manufacturer

Percentage of false positive Pf test lines on samples containing non-Plasmodium spp. infectious agentsb

Percentage of false positive Pf test lines on samples containing immunological factorsc Overall (n=108) 23.1 2.8

NG-Test MALARIA Pf/Pan (pLDH)

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

NGBMAL-W23-005 MAL-PF/PanCAS/25 InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.9 (115) 0.4 (231) 0.0 0.0 0.0 0.0 0.0 3.3 0.0 0.0 0.0 1.7 0.0 0.0 0.0 0.0 (114) 0.0 (115) 0.0 0.0 0.0 0.0 6.0 0.0 0.0 0.0 (114) 0.0 0.0 (115) 0.0 0.0 (115) 4.3 0.0 0.0 (230) 0.0 (229) 0.0 0.0 (231) 0.0 0.0 (231) 5.2 0.0 3.3 3.3 0.0 0.0 0.0 0.0 (28) 6.7 0.0 0.0 0.0 0.0 0.0 6.7 0.0 0.0 0.0 1.7 1.7 0.0 0.0 3.3 0.0 (58) 3.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.9 0.0 1.9 3.7 1.9 1.9 1.9 13.0 0.0 1.9 3.7 3.7 0.0

Pf and Pv 3.7 0.0 5.6 1.9 1.9 3.7 0.0 11.1 0.0 0.0 3.7 0.0 0.0 2.8 0.0 3.7 2.8 1.9 2.8 0.9 12.0 0.0 0.9 3.7 1.9 0.0

ITP11003-TC25

C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C

MFLRPD-02

71050

ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Triline Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum 

Pv, Plasmodium vivax  pan, Plasmodium spp.  a Blood samples from healthy volunteers with no known current illness or blood abnormality b See Table A4.7 for details c See Table A4.8 for details

Annexes

123

12 4

Table A4.7: Phase 2 false-positive rate for P. falciparum in samples containing specific non-malarial infectious pathogens Percentage of false positives for Plasmodium spp. by infectious pathogen Manufacturer Chagas Lot 1 (n=4) Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems 0.0 25.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 7.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 7.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 7.1 0.0 0.0 0.0 0.0 0.0 21.4 0.0 0.0 0.0 25.0 0.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 7.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 12.5 0.0 0.0 0.0 12.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Product Dengue Lot 1 (n=14) Lot 2 (n=14) Lot 1 (n=8) Lot 2 (n=8) Leishmaniasis Lot 2 (n=4)

Product code

Schistosomiasis Lot 1 (n=4) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Lot 2 (n=4) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091

CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

MPHRPD-01

5531 55IC103-50 55IC104-50 05FK130-40-0

RKMAL016

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

05FK60AI-40

IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

Table A4.7 (continued) Percentage of false positives for Plasmodium spp. by infectious pathogen Manufacturer Chagas Lot 1 (n=4) InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 (3) 25.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 7.1 0.0 0.0 0.0 0.0 (13) 7.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 12.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Product Dengue Lot 1 (n=14) Lot 2 (n=14) Lot 1 (n=8) Lot 2 (n=8) Lot 1 (n=4) Leishmaniasis Lot 2 (n=4)

Product code

Schistosomiasis Lot 2 (n=4) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species 

Annexes

125

12 6

Table A4.8: Phase 2 false-positive rate for P. falciparum in samples containing potentially cross-reacting blood immunological factors Percentage of false positives for Plasmodium spp. by blood immunological factor Manufacturer Anti-mouse antibodies Lot 1 (n=6) Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems 0.0 33.3 0.0 0.0 0.0 0.0 16.7 0.0 0.0 0.0 50.0 0.0 33.3 16.7 0.0 0.0 0.0 16.7 33.3 0.0 33.3 0.0 0.0 33.3 33.3 0.0 16.7 33.3 0.0 16.7 33.3 50.0 0.0 66.7 33.3 33.3 0.0 16.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 33.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4.2 0.0 25.0 0.0

Product Anti-nuclear antibodies Rheumatoid factor Lot 2 (n=6)

Product code

Rapid plasma reagin (RPR) positive

Lot 1 (n=24) Lot 2 (n=24) Lot 1 (n=12) Lot 2 (n=12) Lot 1 (n=12) Lot 2 (n=12)

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

33.3 0.0 0.0 66.7 0.0 33.3 33.3 0.0 33.3 16.7 50.0 0.0 0.0 33.3 33.3 0.0 0.0 41.7 50.0 0.0 0.0 0.0 0.0 0.0 16.7 0.0 0.0 0.0 16.7 16.7 0.0 0.0 8.3 0.0

33.3 16.7 0.0 66.7 0.0 33.3 33.3 0.0 33.3 16.7 50.0 0.0 0.0 33.3 33.3

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 8.3 0.0 0.0 0.0 0.0

4.2 0.0 0.0 0.0 0.0 4.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4.2 0.0

0.0 0.0 0.0 33.3 0.0 0.0 0.0 0.0 0.0 0.0 8.3 0.0 0.0 0.0 16.7

0.0 0.0 0.0 33.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.7 0.0 0.0 50.0 50.0 0.0 0.0 0.0 0.0 8.3 0.0 8.3 0.0 0.0 25.0 8.3 0.0 0.0 25.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 8.3 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0

MPHRPD-01

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

5531 55IC103-50 55IC104-50 05FK130-40-0

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

Table A4.8 (continued) Percentage of false positives for Plasmodium spp. by blood immunological factor Manufacturer Anti-mouse antibodies Lot 1 (n=6) InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.7 33.3 16.7 16.7 16.7 16.7 0.0 0.0 33.3 33.3 33.3 0.0 33.3 16.7 16.7 33.3 0.0 0.0 0.0 0.0 33.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 12.5 0.0 4.2 0.0 0.0 0.0 0.0 4.2 0.0 0.0 0.0 0.0 16.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 8.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Product Anti-nuclear antibodies Rheumatoid factor Lot 2 (n=6)

Product code

Rapid plasma reagin (RPR) positive

Lot 1 (n=24) Lot 2 (n=24) Lot 1 (n=12) Lot 2 (n=12) Lot 1 (n=12) Lot 2 (n=12) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.7 0.0 0.0 0.0 0.0 0.0

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species 

Annexes

127

12 8

Table A4.9: Phase 2 false-positive rate of pan or P. vivax test line results on all malaria-negative samples Percentage of false positive pan test lines on "clean"a negative samples Lot 1 (n=116) Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0.0 0.0 19.0 1.7 0.0 23.3 0.0 0.0 0.0 (115) 21.6 0.9 0.0 22.6 (115) 0.0 0.0 0.0 0.9 0.0 (114) 0.0 (115) 0.0 0.0 0.0 0.0 0.0 0.0 (114) 0.0 0.0 (115) 0.0 0.4 0.0 (230) 0.0 (229) 0.0 0.0 (231) 0.0 0.0 (231) 20.3 1.3 0.0 22.9 (231) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (28) 20.0 0.0 0.0 53.3 0.0 0.0 0.0 37.9 27.6 32.8 46.7 46.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.7 0.0 0.0 36.7 0.0 0.0 0.0 46.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (58) 18.3 0.0 0.0 45.0 0.0 0.0 0.0 0.0 0.0 0.0 (115) 4.3 0.0 0.0 1.7 0.0 (115) 0.9 3.4 0.9 0.0 0.9 3.4 0.0 0.0 0.9 0.0 0.0 4.3 0.4 0.0 0.4 (231) 3.9 0.0 0.0 1.3 0.0 (231) 0.4 3.9 0.0 0.0 0.0 0.0 0.0 0.0 3.3 0.0 3.3 16.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.3 3.3 0.0 0.0 0.0 0.0 0.0 0.0 1.7 0.0 3.3 10.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5.6 0.0 3.7 0.0 13.0 5.6 20.4 5.6 68.5 7.4 16.7 0.0 3.7 5.6 11.1 1.9 1.9 37.0 0.0 0.0 64.8 0.0 0.0 3.7

Product Lot 2 (n=116) Overall (n=232) Lot 1 (n=30) Lot 2 (n=30) Overall (n=60) Lot 1 (n=54)

Product code

Manufacturer

Percentage of false positive non-Pf test lines on samples containing nonPlasmodium spp. infectious agentsb Lot 2 (n=54) 0.0 0.0 1.9 1.9 1.9 1.9 3.7 0.0 14.8 9.3 18.5 9.3 81.5 7.4 14.8 0.0 3.7 3.7 11.1 0.0 1.9 46.3 0.0 0.0 61.1 0.0 0.0 3.7

Percentage of false positive non-Pf test lines on samples containing immunological factorsc Overall (n=108) 0.0 0.0 0.9 0.9 3.7 0.9 3.7 0.0 13.9 7.4 19.4 7.4 75.0 7.4 15.7 0.0 3.7 4.6 11.1 0.9 1.9 41.7 0.0 0.0 63.0 0.0 0.0 3.7

RKMAL016

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN

05FK60AI-40

NG-Test MALARIA Pf/Pan (pLDH)

Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN

IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGBMAL-W23-005 MAL-PF/PanCAS/25

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)Malaria Pf/Pv Rapid Test 402a MD Malaria Pf/Pv (pLDH) Test MDMALLDH004 One Step Malaria HRP2/pLDH (P.f/P.v) Test W056-C One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag MFLRPD-02 QuickProfile™ Malaria Pf/Pv Antigen Test 71050 Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv 11108191040 Pf, Pv and Pan PALUTOP +4 optima® - Pv-pLDH band 5499 PALUTOP +4 optima® - Pan-pLDH band

NA, not applicable Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species  a Blood samples from healthy volunteers with no known current illness or blood abnormality b See Table A4.7 for details c See Table A4.8 for details

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Annexes 129

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC 15 13 15 15 15 15 0 0 0 0 0 0 2.9 1.0 3.0 3.0 2.6 3.0 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.0 2.9 2.0 2.9 2.8 3.0 3.0 3.0 1.4 3.0 3.0 2.9 3.1 3.5 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.4 3.0 2.0 2.9 3.0 3.0 2.9 3.4 1.5 3.6 3.0 2.9 3.1 3.7 3.0 1.0 3.0 3.0 3.1 3.1 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 3.0 1.5 2.0 2.8 15 15 15 15 0 0 0 0 3.0 2.0 2.4 3.0 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15 0 2.3 15 0 2.9 15 0 2.2 3.6 1.9 2.0 3.0 2.0 3.0 2.0 2.9 2.7 3.1 2.9 3.0 1.3 3.1 3.0 3.0 3.0 3.0 3.0 1.0 3.0 3.7 3.0 3.9 15 15 15 15 15 15 15 15 15 15 15 15 15 14 15 15 13 15 15 15 11 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

MPHRPD-01

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

5531 55IC103-50 55IC104-50 05FK130-40-0

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 2.0 3.0 2.0 2.0 2.7 1.9 3.0 2.1 2.9 3.0 3.0 2.0 3.0 1.4 3.0 3.0 3.0 3.0 3.0 3.0 1.0 2.0 3.0 3.0 2.9 15 15 14 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 4 15 15 15 15 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 2.0 3.8 2.3 2.2 2.9 2.0 3.0 2.3 2.7 3.0 3.3 2.0 2.9 1.3 3.1 3.0 3.0 3.0 3.1 3.0 1.0 2.0 2.9 3.0 3.0 15 15 15 15 15 15 15 15 15 15 15 14 15 13 15 15 15 15 15 15 13 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3.0 3.0 3.9 3.0 3.1 3.9 2.9 1.8 3.8 2.8 3.3 3.0 3.0 2.8 3.0 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3.0 3.0 4.0 3.0 3.3 3.5 3.6 1.0 3.4 3.0 3.9 3.0 3.3 3.4 3.0 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.9 3.0 3.7 2.9 3.0 3.9 3.0 1.2 4.0 2.0 3.5 2.9 3.0 3.4 2.9 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.1 3.0 3.6 3.0 3.0 3.6 3.0 1.1 3.5 2.0 3.0 2.9 3.0 2.9 2.9 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3.0 3.0 3.4 3.0 3.0 3.4 3.1 1.4 3.6 1.6 3.5 3.0 3.0 2.8 3.0 15 15 15 15 15 15 15 15 15 15 15 15 14 15 15

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.5 2.9 3.6 3.0 3.0 3.4 3.0 1.1 3.1 2.0 3.1 3.0 2.9 3.0 3.0 2.0 3.1 2.0 2.0 3.0 1.9 3.0 2.0 2.9 2.9 3.1 2.0 3.0 1.4 3.0 3.0 3.0 3.0 3.0 3.0 1.0 1.8 3.0 3.0 3.0 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 14 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.9 3.1 3.9 2.9 3.0 3.9 4.0 1.8 3.9 3.0 3.9 3.0 3.2 3.4 3.2 2.4 4.0 2.5 2.1 2.9 2.1 3.0 2.0 3.1 2.7 3.3 3.0 3.0 1.4 3.9 3.0 3.7 3.3 3.5 3.0 1.0 3.0 3.6 3.7 3.7 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3.0 3.0 3.7 3.0 3.1 3.5 3.1 1.1 3.4 3.0 2.9 3.0 3.0 3.0 2.9 2.4 3.0 2.0 2.0 2.9 1.9 3.0 2.1 3.0 3.0 3.0 3.0 3.0 1.6 3.0 2.9 2.9 3.0 3.0 3.0 1.0 3.0 2.9 2.9 3.0

13 0

Table A4.10: Heat stability testing results for P. falciparum test line on a P. falciparum sample at low parasite density (200 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=15) Manufacturer Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) 35°C 45°C Room temperature Lot 1 (n=15) Lot 2 (n=15)

Product

Product code

Table A4.10 (continued) Baseline testing Lot 1 (n=15) Manufacturer Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) Lot 1 (n=15) 35°C 45°C Room temperature Lot 2 (n=15)

Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® ALLDIAG SA 15 0 3.0 15 0 3.2 15 0 3.2 15 0 2.9 15 0 3.1 15 0 3.0 15

GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited

5499

ND, not determined Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

Table A4.10a: Heat stability testing results for pan test line of combination RDTs on a P. falciparum sample at low parasite density (200 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=15) Lot 2 (n=15) Manufacturer 35°C Lot 1 (n=15) Lot 2 (n=15) 45°C Lot 1 (n=15) Lot 2 (n=15) Room temperature Lot 1 (n=15) Lot 2 (n=15)

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf, Pv and Pan PALUTOP +4 optima® Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems ALLDIAG SA 15 0 1.9 15 0 1.0 15 0 14 0 10 0 12 0 15 0 15 1 14 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND 1.0 ND 1.0 ND 1.0 ND 1.0 ND 1.0 1.0 1.0 1.0 ND 0 0 0 13 15 12 0 15 0 15 0 14 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND ND ND 1.0 1.0 1.0 ND 1.0 ND 1.0 ND 1.0 1.1 ND 0 15 0 8 12 7 0 15 1 15 0 15 13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) ND 1.0 ND 1.0 1.0 1.0 ND 1.0 1.0 1.0 ND 1.0 1.4 ND 1.6 0 6 0 7 15 1 0 15 1 15 1 13 13 0 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND 1.0 ND 1.0 1.0 1.0 ND 1.0 1.0 1.0 1.0 1.0 1.2 ND 1.0 0 10 0 0 15 0 0 6 0 15 2 13 10 1 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND 1.0 ND ND 1.0 ND ND 1.0 ND 1.0 1.0 1.0 1.4 1.0 1.8 0 0 5 3 15 2 0 15 0 15 2 15 10 9 15

ND, not determined Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

Annexes

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND ND 1.0 1.0 1.0 1.0 ND 1.0 ND 1.0 1.0 1.0 1.2 1.0 1.0 0 7 3 11 10 8 0 15 0 13 0 14 4 5 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND 1.0 1.0 1.0 1.0 1.0 ND 1.0 ND 1.0 ND 1.0 1.3 1.0 2.0 0 4 0 15 15 10 0 14 0 15 0 15 11 0 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND 1.0 ND 1.0 1.0 1.0 ND 1.0 ND 1.0 ND 1.0 1.3 ND 1.0

Product

Product code

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 15 15 15 15 15 15 0 0 0 0 0 0 3.1 3.1 3.0 2.7 2.9 3.0 15 15 15 15 15 15 0 0 0 0 0 0 3.1 3.9 3.0 3.0 2.9 2.9 15 15 15 15 15 15 0 0 0 0 0 0 3.0 3.4 3.0 2.7 3.0 3.0 15 15 15 15 15 15 0 0 0 0 0 0 3.0 3.0 2.9 2.1 2.0 3.0 15 15 15 15 15 15 0 0 0 0 0 0 3.0 3.1 3.0 2.1 2.9 3.0 15 15 15 15 15 15 0 0 0 0 0 0 3.0 3.0 3.0 2.0 2.9 3.0 15 15 15 15 15 15 0 0 0 0 0 0 0 3.1 3.6 3.4 2.7 2.7 3.2 3.9 15 15 15 15 15 15 15 0 0 0 0 0 0 0 3.0 3.1 2.9 2.9 3.0 3.0 3.0

Product

Product code

131

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. 5 5 5 5 5 0 0 0 0 0 4.0 2.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.6 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.8 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 4.0 4.0 4.0 4.0 5 5 5 5 0 0 0 0 4.0 4.0 4.0 4.0 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 4.0 5 0 3.8 5 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 3.6 4.0 4.0 4.0 3.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

MPHRPD-01

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

5531 55IC103-50 55IC104-50 05FK130-40-0

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4.0 4.0 4.0 4.0 4.0 3.8 4.0 4.0 4.0 4.0 4.0 4.0 4.0 3.2 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 3.8 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.8 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 1.6 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 3.8 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 3.8 4.0 4.0 4.0 4.0 4.0 3.8 4.0 4.0 4.0 4.0 4.0 4.0 3.2 4.0 4.0 4.0 4.0 4.0 3.2 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.8 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 3.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 4.0 4.0 4.0

13 2

Table A4.11: Heat stability testing results for P. falciparum test line on a P. falciparum sample at high parasite density (2000 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=5) Manufacturer Lot 2 (n=5) Lot 1 (n=5) Lot 2 (n=5) Lot 1 (n=5) Lot 2 (n=5) 35°C 45°C Room temperature Lot 1 (n=5) Lot 2 (n=5)

Product

Product code

Table A4.11 (continued) Baseline testing Lot 1 (n=5) Manufacturer Lot 2 (n=5) Lot 1 (n=5) Lot 2 (n=5) Lot 1 (n=5) Lot 2 (n=5) Lot 1 (n=5) 35°C 45°C Room temperature Lot 2 (n=5)

careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® ALLDIAG SA 5 0 4.0 5 0 4.0 5 0 4.0 5 0 4.0 5 0 4.0 5 0 4.0 5

RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited

5499

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

Table A4.11a: Heat stability testing results for pan test line of combination RDTs on a P. falciparum sample at high parasite density (2000 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=5) Manufacturer Lot 2 (n=5) Lot 1 (n=5) 35°C Lot 2 (n=5) 45°C Lot 1 (n=5) Lot 2 (n=5) Room temperature Lot 1 (n=5) Lot 2 (n=5)

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf, Pv and Pan PALUTOP +4 optima® Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems ALLDIAG SA 5 0 2.8 5 0 2.0 5 5 5 4 5 5 5 5 5 5 5 4 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.2 1.0 2.0 2.0 2.0 1.6 2.0 1.8 2.0 1.0 2.0 1.2 2.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 1.0 2.0 2.0 2.0 2.0 2.0 1.0 3.0 1.6 2.0 1.6 2.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 1.6 2.0 2.0 2.0 1.8 2.0 1.0 2.4 1.2 2.0 1.8 2.0 3.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 2.0 2.0 2.0 2.0 1.8 2.0 1.0 2.0 1.4 2.0 1.0 2.0 2.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 2.0 2.0 2.0 2.0 1.0 2.0 1.0 3.0 2.0 2.0 2.0 2.0 3.0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

Annexes

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 1.2 1.6 2.0 1.6 2.0 2.0 1.0 2.0 1.8 2.0 1.6 2.0 2.4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 2.0 2.0 2.0 2.0 1.8 2.0 1.2 2.0 1.0 2.0 1.0 2.0 3.0 5 5 5 5 5 5 5 5 4 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 2.0 2.0 2.0 2.0 1.8 2.0 1.0 2.0 1.0 2.0 1.0 2.0 2.0

Product

Product code

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 5 5 5 5 5 5 5 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 4 0 0 0 0 0 0 1 4.0 3.8 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 4.0 4.0 3.8 4.0 4.0 4.0 4.0 4.0 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0

Product

Product code

133

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. positive

No. positive

No. positive

No. invalid

No. positive

No. positive

No. positive

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

RMSM-05071

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0

No. positive

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C MPHRPD-01 5531 55IC103-50 55IC104-50 05FK130-40-0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

No. positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25

No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

13 4

Table A4.12: Heat stability testing results for P. falciparum test line on parasite-negative samples. Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=4) Manufacturer Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) 35°C 45°C Room temperature Lot 1 (n=4) Lot 2 (n=4)

Product

Product code

Table A4.12 (continued) Baseline testing Lot 1 (n=4) No. invalid No. invalid No. invalid No. invalid No. invalid No. invalid No. invalid No. positive No. positive No. positive No. positive No. positive No. positive No. positive

35°C Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4)

45°C

Room temperature Lot 2 (n=4) No. positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0

Lot 2 (n=4)

Product

Product code

Manufacturer

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

Annexes

135

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. positive

No. positive

No. positive

No. invalid

No. positive

No. positive

No. positive

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25 InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited 0 0 0 0 0 0 0 2 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0

Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems

0 0 0 0 0 0 0 0 1 0 0 0 4 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0 0 2 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 1 2 4 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

No. positive

0 0 0 0 0 0 0 0 0 0 0 0 4 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0 0 3 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 3 1 3 0 0 0 0 0 0 0 0 2 0 0 3 0

0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 1 0 0 3 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

No. positive 0 0 0 0 0 0 0 0 0 0 0 1 3 0 0 0 0 0 0 0 0 3 0 0 3 0 0 0 0 0 0 0 0 0

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® - Pv-pLDH band PALUTOP +4 optima® - Pan-pLDH band ALLDIAG SA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5499

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

13 6

Table A4.12a: Heat stability testing results for pan or P. vivax test line of combination RDTs on parasite-negative samples. Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=4) Manufacturer Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) 35°C 45°C Room temperature Lot 1 (n=4) Lot 2 (n=4)

Product

Product code

Table A4.13: Heat stability testing results for P. falciparum test line on P. vivax samples at low parasite density (200 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=4) No. invalid No. invalid No. invalid No. invalid No. invalid No. invalid No. positive No. positive No. positive No. positive No. positive No. positive No. positive

35°C Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) No. invalid

45°C

Room temperature Lot 2 (n=4) No. positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Lot 2 (n=4)

Product

Product code

Manufacturer

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MPHRPD-01

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN

5531 55IC103-50 55IC104-50 05FK130-40-0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050

(continued)

Annexes

137

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. positive

No. positive

No. positive

No. invalid

No. positive

No. positive

No. positive

NGB-MAL-W23-005 NG Biotech MAL-PF/Pan-CAS/25 Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0

0 0

0 0

0 0

0 0

0 0

0 0

No. positive

0 0

0 0

0 0

0 0

0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

No. positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

13 8

Table A4.13: Heat stability testing results for P. falciparum test line on P. vivax samples at low parasite density (200 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C (continued) Baseline testing Lot 1 (n=4) Manufacturer Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) 35°C 45°C Room temperature Lot 1 (n=4) Lot 2 (n=4)

Product

Product code

Table A4.14: Heat stability testing results for P. falciparum test line on P. vivax samples at high parasite density (2000 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=2) No. invalid No. invalid No. invalid No. invalid No. invalid No. invalid No. positive No. positive No. positive No. positive No. positive No. positive No. positive

35°C Lot 1 (n=2) Lot 2 (n=2) Lot 1 (n=2) Lot 2 (n=2) Lot 1 (n=2) No. invalid

45°C

Room temperature Lot 2 (n=2) No. positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Lot 2 (n=2)

Product

Product code

Manufacturer

RKMAL017 ITP11002-TC25 05FK140-40-0 AS0015 17912 RMOM-03091 Access Bio, Inc. WELLS BIO, INC DIALAB ICT INTERNATIONAL Shanghai Kehua Bio-engineering Co., Ltd. Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. ALLDIAG SA ARKRAY Healthcare Pvt Ltd ARKRAY Healthcare Pvt Ltd Standard Diagnostics, Inc. Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Advy Chemical Private Limited InTec Products, Inc. Standard Diagnostics, Inc. Aspen Laboratories Pvt. Ltd. Bio Focus Co., Ltd. Access Bio Ethiopia

RMSM-05071

RMO-M05082 W06200 ML01 R-409-50-C GCMAL(pf)-402a GMDMALPF001 W37-C

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 2 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MPHRPD-01

Pf only Adv Dx™ Malaria Pf Rapid Malaria Antigen Detection Test ADVANCED QUALITY™ ONE STEP Malaria (p.f) Test Alere™ Malaria Ag P.f Aspen® Malaria Ag Pf BioTracer™ Malaria P.f Rapid Card CareStart™ Malaria Pf (HRP2) Ag RDT CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - HRP2 band CareStart™ Malaria Pf (HRP2/pLDH) Ag Combo 3-Line - Pf-pLDH band careUS™ Malaria Pf (HRP2) Ag DIAQUICK Malaria P.f. Cassette ICT MALARIA P.F. CASSETTE TEST KHB® Malaria Ag (HRP2) Pf Rapid Test Malaria Pf Rapid Test GMD Malaria Pf test One Step Malaria HRP2 (P.f) Test One Step Test for Malaria Pf HRP-II Ag MERISCREEN Malaria Pf HRP-II Ag PALUTOP + pf® Parahit f® Ver 1.0 - Dipstick Parahit® f Ver 1.0 - Device SD BIOLINE Malaria Ag P.f. (HRP2/pLDH) 2 Lines Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN

5531 55IC103-50 55IC104-50 05FK130-40-0

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050

(continued)

Annexes

139

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. positive

No. positive

No. positive

No. invalid

No. positive

No. positive

No. positive

NGB-MAL-W23-005 NG Biotech MAL-PF/Pan-CAS/25 Hema Diagnostic Systems InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0

0 0

0 0

0 0

0 0

0 0

0 0

No. positive

0 0

0 0

0 0

0 0

0 0

0 0 0 0 0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

No. positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima®

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

14 0

Table A4.14: Heat stability testing results for P. falciparum test line on P. vivax samples at high parasite density (2000 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C (continued) Baseline testing Lot 1 (n=2) Manufacturer Lot 2 (n=2) Lot 1 (n=2) Lot 2 (n=2) Lot 1 (n=2) Lot 2 (n=2) 35°C 45°C Room temperature Lot 1 (n=2) Lot 2 (n=2)

Product

Product code

Table A4.15: Heat stability testing results for P. vivax test line on P. falciparum samples at low parasite density (200 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Manufacturer No. invalid No. invalid No. invalid No. invalid No. invalid No. invalid No. positive No. positive No. positive No. positive No. positive No. positive No. positive

35°C

45°C

Room temperature

Lot 1 (n=15) Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) No. invalid No. positive 0 0 0 0 0 0 0 1 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 0 No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0

Product

Product code

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 0 13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 1 10 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 11 0 0 0 0 0 0 0 0 0 0 0 0 0

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

Annexes

141

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. invalid

No. positive

No. positive

No. positive

No. invalid

No. positive

No. positive

No. positive

Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited ALLDIAG SA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 5 0 0 0 0 0

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

No. positive

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 5 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

No. positive 0 0 0 0 0 0 0 5 0 0 0 0 0

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

No. invalid 0 0 0 0 0 0 0 0 0 0 0 0 0

14 2

Table A4.16: Heat stability testing results for P. vivax test line on P. falciparum samples at high parasite density (2000 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=5) Manufacturer Lot 2 (n=5) Lot 1 (n=5) Lot 2 (n=5) Lot 1 (n=5) Lot 2 (n=5) 35°C 45°C Room temperature Lot 1 (n=5) Lot 2 (n=5)

Product

Product code

Table A4.17: Heat stability testing results for pan or P. vivax test line of combination tests on a P. vivax sample at low parasite density (200 parasites/µl). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=4) Manufacturer Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) Lot 2 (n=4) Lot 1 (n=4) 35°C 45°C Room temperature Lot 2 (n=4)

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25 InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited 4 4 4 4 4 4 4 0 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 2.0 2.0 2.0 2.0 2.0 2.0 1.3 0.0 1.0 1.5 1.0 2.0 4 4 4 4 4 4 4 0 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 2.0 2.0 1.0 1.8 2.0 1.5 2.0 0.0 1.0 2.0 1.0 1.8 4 4 4 4 4 4 4 0 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 2.0 2.0 2.0 2.0 2.0 2.0 1.8 0.0 1.0 1.8 1.8 2.0 4 4 4 4 4 4 4 1 4 4 4 3 0 0 0 0 0 0 0 0 0 0 0 0 2.0 2.0 1.3 1.3 2.0 1.3 1.0 1.0 1.0 1.0 1.0 1.0 4 4 4 4 4 4 4 0 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 2.0 2.0 1.0 2.0 2.0 1.5 1.5 0.0 1.8 1.3 2.0 2.0 4 4 4 4 4 4 4 3 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0

Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® - Pv-pLDH band PALUTOP +4 optima® - Pan-pLDH band 4 4 3 4 4 4 4 4 0 4 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 1.0 2.0 2.0 1.8 2.0 2.0 0.0 2.0 1.0 2.0 1.3 1.5 4 4 4 4 4 4 4 4 2 4 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 1.5 1.0 2.0 2.0 1.0 1.5 2.0 1.0 2.0 1.0 2.0 1.5 2.0 0 4 4 4 3 4 4 4 0 4 4 4 3 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 2.0 1.0 2.0 2.0 2.0 1.0 2.0 0.0 2.0 1.0 2.0 1.0 2.0 4 4 4 4 4 4 4 4 0 4 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 1.5 1.0 2.0 2.0 1.3 1.8 2.0 0.0 2.0 1.0 2.0 1.0 2.0 4 4 4 4 3 4 4 4 0 4 4 4 1 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 2.0 1.0 1.8 1.7 1.0 1.0 2.0 0.0 2.5 1.0 2.0 1.0 1.8 4 4 4 4 4 4 4 4 0 4 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 1.5 1.0 1.3 2.0 1.0 1.0 2.0 0.0 2.0 1.0 2.0 1.0 1.8 2.0 2.0 1.0 1.5 2.0 1.0 1.3 1.0 1.0 1.0 1.0 1.5 ALLDIAG SA 4 4 0 0 2.0 2.0 4 4 0 0 1.8 2.0 4 4 0 0 2.0 2.0 4 4 0 0 1.0 2.0 4 4 0 0 1.3 2.0 4 4 0 0 1.8 2.0

5499

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

ND, not determined Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

Annexes

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 3 4 4 4 4 4 4 4 0 4 3 4 4 4 4 4 4 4 4 4 4 0 4 4 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 1.8 1.0 2.0 2.0 2.5 1.5 2.0 0.0 2.5 1.0 2.0 1.0 1.5 2.0 2.0 2.0 2.0 2.3 2.0 1.0 0.0 1.0 2.0 1.0 1.8 2.0 2.8 4 4 3 4 4 4 4 4 0 4 4 4 4 4 4 4 4 4 4 4 4 0 4 4 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.0 1.3 1.0 2.0 1.8 1.0 1.0 2.0 0.0 2.0 1.0 2.0 1.0 2.0 2.0 2.0 1.8 2.0 2.0 1.8 1.0 0.0 1.0 1.3 1.0 1.0 1.0 2.0

Product

Product code

143

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

RKMAL016 05FK60AI-40 IMPN-402 AM4650-K AS0060 C32RHA25 0584_K25 17012 RMLM-05071 RMAM-05071 ML03 MPFPAN050 NGB-MAL-W23-005 MAL-PF/Pan-CAS/25 InTec Products, Inc. RapiGEN Inc. Biosynex Access Bio Ethiopia Access Bio, Inc. WELLS BIO, INC Zhejiang Orient Gene Biotech Co., Ltd. Medical Diagnostech (Pty) Ltd Guangzhou Wondfo Biotech Co., Ltd. Meril Diagnostics Pvt. Ltd. Lumiquick Diagnostics Inc. Alere Medical Private Limited 2 2 2 2 2 2 2 0 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 3.0 4.0 4.0 4.0 3.0 0.0 3.0 3.0 3.0 3.0 2 2 2 2 2 2 2 0 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 3.5 4.0 3.0 3.0 4.0 3.0 3.0 0.0 3.0 3.5 3.0 3.0 2 2 2 2 2 2 2 0 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 4.0 4.0 3.5 3.5 4.0 3.5 3.0 0.0 2.5 3.0 3.0 3.0 2 2 2 2 2 2 2 1 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 3.5 4.0 2.5 3.0 3.5 2.5 3.0 1.0 2.5 3.0 2.0 3.0 2 1 2 2 2 2 2 0 2 2 2 2 0 1 0 0 0 0 0 0 0 0 0 0 3.5 4.0 3.0 3.0 4.0 3.0 3.0 0.0 3.0 2.5 2.5 3.5 2 2 2 2 2 2 1 0 2 2 2 2

Advy Chemical Private Limited Alere Medical Private Limited Hangzhou AllTest Biotech Co. Ltd. ASAN Pharmaceutical Co., Ltd Aspen Laboratories Pvt. Ltd. RapiGEN Inc. Biosynex Bio Focus Co., Ltd. Access Bio, Inc. Access Bio, Inc. ICT INTERNATIONAL Medsource Ozone Biomedicals Pvt. Ltd. NG Biotech Hema Diagnostic Systems

ITP11003-TC25 C60RHA25 0581_K25 RMVM-03091 RMVM-05072 RMV-M05082 GCMAL(pf/pv)-402a MDMALLDH004 W056-C MFLRPD-02 71050 11108191040

Pf and Pan Adv Dx™ Malaria Pan/Pf Rapid Test Detection Kit Alere Trueline™ – Rapid test kit for Malaria Ag Pf/Pan (HRP-II/pLDH) AllTest™ Malaria P.f./Pan Rapid Test Cassette Asan Easy Test® Malaria Pf/Pan Ag Aspen® Malaria Ag Pf/Pv BIOCREDIT Malaria Ag Pf/Pan (HRPII/pLDH) Biosynex® Malaria Pf/Pan BioTracer™ Malaria P.f/PAN Rapid Card CareStart™ Malaria Pf/PAN (pLDH) Ag RDT CareStart™ Malaria Screen RDT ICT MALARIA DUAL TEST Is It... Malaria Pf PAN NG-Test MALARIA Pf/Pan (pLDH) Rapid 1-2-3 HEMA® CASSETTE MALARIA PF/PAN Pf and Pv ADVANCED QUALITY™ ONE STEP Malaria (p.f/p.v.) Tri-line Test BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) Biosynex® Malaria Pf/Pv CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag Combo RDT CareStart™ Malaria Pf/Pv (HRP2/pLDH) Ag. Combo RDT careUS™ Malaria Combo Pf/Pv (HRP2/pLDH) Ag Malaria Pf/Pv Rapid Test MD Malaria Pf/Pv (pLDH) Test One Step Malaria HRP2/pLDH (P.f/P.v) Test One Step Test for Malaria Pf/Pv Ag MERISCREEN Malaria Pf/Pv Ag QuickProfile™ Malaria Pf/Pv Antigen Test Rapid Test Kit for Malaria Ag Pf/Pv-Alere Trueline Malaria Ag Pf/Pv Pf, Pv and Pan PALUTOP +4 optima® - Pv-pLDH band PALUTOP +4 optima® - Pan-pLDH band 2 2 2 2 2 2 2 2 1 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3.0 3.0 2.0 4.0 4.0 3.0 3.0 4.0 1.0 4.0 3.0 3.5 2.5 3.0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.5 3.0 3.0 3.5 4.0 3.0 3.0 4.0 1.0 4.0 2.0 4.0 3.0 3.0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.5 3.0 3.0 3.5 3.5 3.0 3.5 4.0 1.0 4.0 3.0 3.5 2.5 3.0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.0 3.0 3.0 3.0 3.0 3.0 3.0 2.0 1.0 3.5 2.0 2.5 2.0 3.0 2 2 2 2 2 2 2 2 1 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.5 4.0 3.0 3.0 4.0 2.0 3.0 3.5 1.0 4.0 2.0 3.5 2.0 3.0 2 2 2 2 2 2 2 2 1 2 2 2 2 2 ALLDIAG SA 2 2 0 0 3.0 3.0 2 2 0 0 3.0 4.0 2 2 0 0 3.0 4.0 2 2 0 0 3.0 3.0 2 2 0 0 3.0 4.0 2 2

5499

Pf, Plasmodium falciparum  Pv, Plasmodium vivax  pan, Plasmodium species

No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity No. positive No. invalid Mean band intensity 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 1.0 4.0 2.0 3.5 2.0 3.0 3.0 4.0 3.0 3.0 4.0 3.0 2.0 0.0 3.0 2.0 3.0 3.0 3.0 4.0 2 2 2 2 2 1 2 2 0 2 2 2 2 2 2 2 2 2 2 2 2 0 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.5 3.5 3.0 3.0 4.0 3.0 3.0 3.5 0.0 4.0 3.0 4.0 2.0 3.0 4.0 4.0 3.0 2.0 4.0 3.0 3.0 0.0 3.0 3.5 3.0 3.0 4.0 4.0 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 0 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2.0 3.0 3.0 3.0 3.0 3.0 3.0 4.0 1.0 4.0 2.0 4.0 2.0 3.0 3.5 3.5 3.0 3.0 4.0 3.0 3.0 0.0 2.5 3.0 2.5 3.0 3.0 4.0

14 4

Table A4.18: Heat stability testing results for pan or P. vivax test line of combination tests on a P. vivax sample at high parasite density (2000 parasites/µL). Positivity rate at baseline (room temperature) and after 60 days incubation at room temperature, 35°C and 45°C Baseline testing Lot 1 (n=15) Manufacturer Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) Lot 1 (n=15) Lot 2 (n=15) 35°C 45°C Room temperature Lot 1 (n=15) Lot 2 (n=15)

Product

Product code

Annex 5: Introducing RDT-based malaria diagnosis into national programmes Introduction of parasite-based diagnosis at small clinics and at village level for case management poses many challenges, not only of logistics but also in managing the health-seeking and health-providing behaviour of patients and health workers. These can be addressed by a clear, time-bound strategic plan covering planning, implementation, monitoring and evaluation of the diagnosis programme, which must begin well before RDTs are procured. Furthermore, funding for the programme must include a significant component for planning and coordination, sensitization, information, education and communication, training, quality assurance, monitoring, supervision and logistics, in addition to procurement. In the absence of such funding, much of the expenditure on RDTs will be wasted, and loss of confidence in RDT-based diagnosis can hinder strengthening of appropriate malaria case management. A focal person or persons should be available to coordinate the overall implementation plan and to ensure that the various agencies involved understand the process and their own roles. Examples of successful wide-scale introduction of malaria RDTs by various national programmes and comprehensive technical guidance on achieving universal access to malaria diagnostic testing have been reported (14–15 ). Figures A5.1 and A5.2 give examples of the steps and timelines for RDT implementation and budget components for a malaria diagnosis programme, respectively. These will have to be modified considerably for each programme.

Key challenges Changing past thinking that “fever equals malaria unless proven otherwise”. Introducing RDTs will disprove this statement. To have an impact on malaria diagnosis and treatment, RDTs must be seen to provide an accurate diagnosis by both health workers and patients, that is, they must be as good or better than those relied on previously. A health worker requires a good alternative to antimalarial medicines for the management of parasite-negative febrile patients. To achieve and maintain confidence in RDT-based diagnosis, a good quality assurance system must be in place. There must be satisfactory education of health workers and widespread community sensitization. Health workers should have understanding of other causes of fever in order to devise appropriate management algorithms for parasite-negative cases.

Changing and enforcing regulatory requirements At the national level, regulation might be required to control the importation and use of malaria RDTs, and new procedures for storage, distribution and inventory management, such as those used for medicines, might be necessary.

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14 6 Written MoH endorsement Written MoH endorsement Written MoH endorsement Dependent on registration process Determine site Commence testing

Figure A5.1. Example of malaria RDT implementation steps and timelinea

RDT IMPLEMENTATION TIMELINE

Coordinating group

Appoint malaria diagnosis coordinator(s)

Policy recommendations

Programme planning

Guidelinesb

Case management of fever of unknown origin

Case management of malaria

RDT (and microscopy) quality assurance

RDT transport and storage

Decide districts for initial / phased implementation

Fever management algorithm

Community sensitization

General health care providers’ education

Determine / designate transport and storage methods

Regulatory issues

Define collaborative roles (NMP and regulatory body)

Write/adopt regulatory guidelines

Create RDT registry for reference

Dsseminate regulatory criteria

Product selection, supply chain management

Select several products

Samples for ease-of-use assessment

Final decision on RDT

Negotiate specifications with manufacturer

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

Competitive bidding and procurement

Receive first batch (of staggered delivery)

Distribution to field

Procure gloves

Procure sharps boxes

Procure other associated materials

RDT quality control

Write sentinel site SOP

Set up/engage field-based quality control monitoring sites

Decide on lot-testing site

Post-marketing surveillancec

Figure A5.1 (continued) May be conducted earlier, or already in place

Training

Conduct case management training for fever

Modify RDT instructions and training manual

Field-test modified training/instructions

Training of trainers and supervisors

Health worker training

Advocacy, communication, social mobilization

Engaging civil society organizations

Community sensitization

Engaging opinion leaders

General health care education

Monitoring and evaluation

Develop/adopt appropriate record forms

Define methods for capturing different indicators

Integrate RDTs into the routine health information management system

Plan for a post-introduction programme review

Malaria Rapid Diagnostic Test Performance – Results of WHO product testing of malaria RDTs: round 7 (2015–2016)

MoH, ministry of health; NMP, national malaria programme a Adapted with permission from FIND and Uganda National Malaria Control Programme b May already be in place c Sentinel site microscopy, possibly positive control wells in future

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Figure A5.2. Components of the budget for a malaria diagnosis programmea Component Activities specific to microscopy Activities specific to RDTs Activities for management of malaria and non-malaria fevers Fever management algorithm Other tests used at primary care level

Preparation of technical guidelines, standard operating procedures and checklists Guidelines Standard operating procedures for diagnostic testing Other standard operating procedures Training material Checklists for supervision Procurement and supply of commodities Diagnostic tests Medicines Other commodities Distribution of commodities to the field Quality management system Pre-shipment testing Training of focal people Monitoring the quality management system Training of health workers Training of tutors Training of health workers Training of supervisors Supervision Supervisory visits Laboratory visitsb Health facility visits Communication on other causes of fever Advocacy, communication and social mobilization Design of strategies and material Dissemination of key messages Monitoring and evaluation Updating the health information management system Train health workers in the new health information management system a Adapted b For

Laboratory supervisionb Microscopy performance Proficiency testing, validation of routine slide results Training manual for microscopy Laboratory visitsb

RDT transport and storage RDT performance RDT storage Training manual for RDTs Health facility visits

Training manuals for integrated management of fevers

Microscopes and related supplies

RDT kits

Urine dipsticks, haemoglobin meter, haematocrit meter, glucometer Antibiotics, zinc, inhaled salbutamol, rehydration salts

Artemisinin-based combination therapy Gloves, lancets, alcohol, cotton-wool, timers, sharps boxes All items listed above Lot-testing Quality management system for focal people Quality monitoring supervision visits and compilation of health information management data

Expert microscopists Microscopists Laboratory supervisorsb

Tutors for RDT performance outside laboratories and clinical management of fever cases Health workers Clinical supervisors Clinicians

Communication on the need for malaria testing Through each delivery channel Add row for RDTs in laboratory report and column for malaria test results in clinicians’ book Training of person in charge or focal person for reporting on health information management in health facilities

Column for other test results in clinicians’ book

with permission (14) simplicity, activities specific to laboratories are listed under ‘Microscopy’, although both microscopy and RDT are generally performed in laboratories.

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References 1. Gamboa D, Ho MF, Bendezu J, Torres K, Chiodini PL, Barnwell JW, et al. A large proportion of P. falciparum isolates in the Amazon region of Peru lack pfhrp2 and pfhrp3: implications for malaria rapid diagnostic tests. PLoS One, 2010:5:e8091. 2. Bharti PK, Chandel HS, Ahmad A, Krishna S, Udhayakumar V, Singh N. Prevalence of pfhrp2 and/or pfhrp3 gene deletion in Plasmodium falciparum population in eight highly endemic states in India. PLoS One 2016;11:e0157949. 3. Berhane A, Mihreteab S, Mohammed S, Embaye G, Hagos F, Zehaie A, et al. PfHRP2 detecting malaria RDTs: alarming false negative results in Eritrea. Poster 879. In: 65th annual meeting of the American Society for Tropical Medicine and Hygiene. Oakbrook Terrace, IL; 2016. 4. Cheng Q, Gatton M, Barnwell J, Chiodini P, McCarthy J, Bell D, et al. Plasmodium falciparum parasites lacking histidine-rich protein 2 and 3: a review and recommendations for accurate reporting. Malaria J 2014;13:283. 5. Parr JB, Verity R, Doctor SM, Janko M, Carey-Ewend K, Turman BJ, et al. Pfhrp2-deleted Plasmodium falciparum parasites in the Democratic Republic of Congo: a national cross-sectional survey. J Infect Dis. 2016;. doi:10.1093/infdis/ jiw538 6. Amoah LE, Abankwa J, Oppong A. Plasmodium falciparum histidine rich protein-2 diversity and the implications for PfHRP 2: based malaria rapid diagnostic tests in Ghana. Malaria Journal. 2016;15:101. doi:10.1186/s12936-016-1159-z. 7. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 1 (2008). Geneva: World Health Organization; 2009. 8. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 2 (2009). Geneva: World Health Organization; 2010. 9. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 3 (2010–11). Geneva: World Health Organization; 2011. 10. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 4 (2012). Geneva: World Health Organization; 2012. 11. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 5 (2013). Geneva: World Health Organization; 2014. 12. Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 6 (2014–2015). Geneva: World Health Organization; 2015. 13. Recommended selection criteria for procurement of malaria rapid diagnostic tests. Geneva: World Health Organization; 2016. 14. Universal access to malaria diagnostic testing: an operational manual. Geneva: World Health Organization; 2011. 15. Thiam S, Thior M, Faye B, Ndiop M, Diouf ML, Diouf MB, et al. Major reduction in anti-malarial drug consumption in Senegal after nation-wide introduction of malaria rapid diagnostic tests. PLoS One 2011;6:e18419.

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