Malaria Rapid Diagnostic Test Performance

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Malaria Rapid Diagnostic Test Performance

Summary results of WHO Malaria RDT

Product Testing: Rounds 1-3 (2008-2011)

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Test Performance

Summary results of WHO Malaria RDT

Product Testing: Rounds 1-3 (2008-2011)

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TDR/RDT/11.1

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Su m m ar

1. Summary performance of malaria rdtS: WHo product teSting:

roundS 1-3

1.1. introduction

The World Health Organization estimates that half the world’s population are at risk of malaria, with 225 million people developing clinical malaria in 2009 (78% in Africa), and 781,000 deaths (91% in Africa, most being children). Malaria remains endemic in 106 countries, and while parasite-based diagnosis is increasing, most suspected cases of malaria are still not properly identified, resulting in over-use of anti- malarial drugs and poor disease monitoring.

¹

WHO recommends that malaria case management be based on parasite-based diagnosis in all cases

²

. The use of antigen- detecting rapid diagnostic tests (RDTs) forms a vital part of this strategy, forming the backbone of expansion of access to malaria diagnosis as they provide parasite-based diagnosis in areas where good quality microscopy cannot be maintained.

The number of RDTs available, and the scale of their use, has rapidly increased over the past few years. However, limitations of comparative field trials and the heterogeneous nature of malaria transmission and epidemiology has limited the availability of good quality performance data that national malaria programmes require to make informed decisions on procurement and implementation, and limits the ability to extrapolate results of field trials to different populations and time periods. To this end in 2006, the World Health Organization (WHO), Special Programme for Research and Training in Tropical Diseases (TDR) and the Foundation for Innovative New Diagnostics (FIND) launched an evalua- tion programme to assess the comparative performance of commercially available malaria RDTs. This data is guiding procurement decisions and helping to drive improvement in the quality of manufacturing. The results of the first and second rounds of Product Testing were published in 2009 and 2010, and now form the basis of procurement criteria of WHO and UN agencies and national governments.

This Summary presents an overview of the results of the first, second and third rounds of WHO Product Testing of malaria antigen-detecting RDTs completed in 2008, 2009 and 2011 respectively, and is published in conjunction with the release of the results of Round 3. The results of the three rounds of testing should be considered as a single data set. Concerning products re-submitted for evaluation, the results of earlier rounds are replaced by subsequent rounds and therefore only one set of results per product feature in

1 World Malaria Report 2010. Geneva, World Health Organization, 2010.

2 Guidelines for the Treatment of Malaria, Second Edition. Geneva,

World Health Organization, 2010.

this summary. Separate full reports of all rounds should be consulted for further detail on product performance, and on the interpretation and use of these results.

1.2. the WHo product testing programme

The RDT evaluations summarized here were performed as a collaboration between WHO, TDR, FIND, the US Centers for Disease Control and Prevention (CDC) and other partners

³

. All companies manufacturing under ISO 13485:2003 Quality System Standard were invited to submit up to 3 tests for evaluation under the programme. In the first round of testing, 41 products from 21 manufacturers were evaluated against prepared blood panels of cultured Plasmodium falciparum parasites, while 29 products from 13 manufacturers were evaluated in Round 2. In Round 3, 50 products were evaluated from 23 manufacturers, including 23 products re-submitted from earlier rounds (Table S3). Of these 120 total products, 118 progressed to testing against panels of patient-derived P. falciparum and P. vivax parasites, and a parasite-negative panel. Thermal stability was assessed after two months of storage at elevated temperature and humidity, and a descriptive ease of use assessment was recorded. Of the 118 fully evaluated products, 25 have been evaluated in more than one round.

Of the 95 unique products tested by the programme, 29 detect P. falciparum alone, 57 detect and differentiate P. falciparum from non-P. falciparum malaria (either pan-specific or species- specific), 8 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. Where the same products

⁴

have been re-submitted in subsequent rounds of testing, the latter results replace results published from the earlier round.

Thus, the performance of many tests in the results below differ from those published in the Round 1 and Round 2 reports.

The evaluation is designed to provide comparative data on the performance of the submitted production lots of each product.

Such data will be used to guide procurement decisions of WHO and other UN agencies and national governments. Product testing is part of a continuing programme of work to improve the quality of RDTs that are used, and to support broad imple- mentation of reliable malaria diagnosis in areas where malaria is prevalent. A fourth round of product testing began in June 2011.

3

See full reports of Rounds 1, 2 and 3 for full list of collaborating partners.

4

Working definition of a product can be found here on page 13: http://

www.wpro.who.int/internet/resources.ashx/RDT/docs/pdf_version/

web3_QARDTreport.pdf (accessed 8 September 2011)

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1.3. results of the evaluation

The results (summarized in Figures S1 and S2 and Tables S1 and S2) provide comparative data on two lots of products against a panel of parasite samples diluted to a low parasite density (200 parasites/µl) and a higher parasite density (2000 or 5000 parasites/µl). The former is well below the mean parasite density found in many populations with endemic malaria, and considered close to the threshold that tests must detect to reliably identify clinical malaria in many settings.

⁵

For the purposes of this report, the main measure of perform- ance is the ‘panel detection score (PDS)’

⁶

; the percentage of malaria samples in the panel giving a positive result by 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 RDT clinical sensitivity, or positivity rate against the panel but rather a combined measure of positivity rate, along with inter-test and inter-lot consistency. The figures also show the false-positive rates against blood samples containing no malaria parasites or known markers of other diseases, and the rate at which invalid results occurred.

The clinical sensitivity of an RDT to detect malaria is highly dependent on the local conditions, including parasite density in the target population. Sensitivity of a test will therefore differ between populations with differing levels of transmission, as their different level of immunity will affect the parasite density at which they exhibit symptoms warranting a diagnostic test.

Where transmission rates are low, parasite densities in people with symptoms of malaria are likely to be lower, resulting in tests having a lower sensitivity. For this reason, test perform- ance at 200 parasites/µl is particularly important. The results in this report show comparative performance between RDTs, and give an indication of which products are likely to provide higher sensitivity in the field, particularly in populations with low-density infections. In general, as countries reduce malaria prevalence and even move towards malaria elimination, detection of low parasite densities becomes increasingly important in case management. As the detection rate 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, those well protected by bed nets) and must always be taken into account when interpreting RDT results. An important caveat when predicting field sensitivity from the PDS provided in this report is that the panels used in this evaluation only include 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 infecting people in some areas of South America do not express HRP2

⁷

. In areas where HRP2-deleted parasites exist, HRP2-detecting

5 Parasitological Confirmation of Malaria Diagnosis. Report of a WHO

technical consultation Geneva, 6–8 October 2009. Geneva, World Health Organization, 2010. ISBN 978 92 4 159941 2

6

Termed ‘Detection Rate’ in the full report of Round 1, published in 2009. See the Round 3 report for a full explanation of the panel detection score (PDS).

7

Gamboa D et al. PLoS One, 2010: 5(1): e8091

tests will have greatly reduced sensitivity or be incapable of detecting P. falciparum. In such populations, only tests detecting pLDH in P. falciparum parasites will be effective in diagnosing falciparum malaria.

Heat stability (summarized in Table S2) is vital to maintaining sensitivity of the test in the field. As a result, for procurement, it is essential that careful consideration be given to stability results to ensure that products to be used in areas with high temperatures of transport and storage have demonstrated stability in the product testing programme. Requirements will vary between countries: for example, if tests are to be deployed in areas where temperatures rarely rise above 30°C, less emphasis may be placed on stability at high temperatures compared to other aspects of test quality.

Ease of use requirements will also vary, depending on the extent of training and the work environment of the end-users.

Particularly in primary health care settings, the simpler the tests, the easier it will be to avoid errors in preparation and interpretation.

Detailed results of the evaluations can be found in the reports of each evaluation,

⁸

and at www.wpro.who.int/sites/rdt.

An interactive guide to assist in selecting products with performance characteristics most suitable for a particular country health programme is found on the FIND website.

⁹

8 Malaria Rapid Diagnostic Test Performance : Results of WHO product testing of malaria RDTs: Round 1 (2008). Geneva, World

Health Organization, 2009. ISBN 978 92 4 1598071; Malaria Rapid

Diagnostic Test Performance : Results of WHO product testing of malaria RDTs: Round 2 (2009). Geneva, World Health Organization,

2010. ISBN 978 92 4 1599467

9

Malaria RDT Interactive Guide : http://www.finddiagnostics.org/

programs/malaria/find_activities/product_testing/malaria-rdt- product-testing/index.jsp (accessed 8 Sept.2011)

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Su m m ar

1.4. Summary of outcomes

This laboratory-based evaluation provides a comparative measure of RDT performance in a standardized way to distinguish between well and poorly performing tests to inform procurement decisions of malaria control programmes and guide UN procurement policy.

Overall, an improvement was noted in the performance of products re-submitted to Round 3 (Table S3), indicating product improvement by the manufacturers. Furthermore, the proportion of tests achieving a PDS (>75%) at 200 parasites/µl is higher than that seen in previous reports.

Several RDTs from the three rounds of testing demonstrated consistent detection of malaria at low parasite densities (200 parasites/µl), have low false positive rates, are stable at tropical temperatures, are relatively easy to use, and can detect P. falciparum, P. vivax infections, or both.

Performance between products varied widely at low parasite density (200 parasites/µl); however, the majority of products showed a high level of detection at 2000 or 5000 parasites/µl.

P. falciparum tests targeting HRP2 antigen demonstrated the highest detection rates, but some tests targeting pLDH also exhibited high detection rates.

Test performance varied between lots, and widely between similar products, confi rming the advisability of lot-testing post-purchase and prior to use in the fi eld.

The results underscore the need for manufacturers to have adequate reference materials for product development and lot-release. The WHO-FIND Malaria RDT Evaluation Programme, in collaboration with the CDC, offers quality standard panels to manufacturers to assist in this process.

1.5. use of these results

Accurate diagnosis is vital to good malaria case management, whether based on microscopy or RDTs. The results of this report should be used to short-list RDTs for procurement for use in cases where good microscopy is not available or appropriate. Additionally, it is imperative that procurement decisions based on these results take into consideration local conditions of malaria transmission and illness where the tests will be used (e.g. Plasmodium species, target antigen variation, parasite densities, climate), as well as other important considerations, including fi eld-based ease of use assessments, and training/retraining requirements.

Furthermore, in order to ensure that the high performance demonstrated by the lots evaluated in the product testing programme is maintained, it is recommended that each lot of RDTs is also tested in a standardized way prior to dispersal to the fi eld.

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Procurement of RDTs must not occur without programmatic and infrastructure preparation for proper use, including supply chain management, training on test usage and disposal, and training on patient management in response to results. The main report provides an algorithm (Annex 5a) to assist in this decision-making process and comprehensive guidance on several aspects of procurement can be found in

‘Good Practices for selecting and procuring rapid diagnostic tests for malaria’.

¹¹

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The WHO-FIND Malaria RDT Evaluation Programme provides lot-testing capacity in a number of regional laboratories free of charge, and can be accessed through Malaria_rdt@who.int and

info@fi nddiagnostics.org.

11

Good Practices for selecting and procuring rapid diagnostic tests for malaria, Geneva, World Health Organization, 2011 ISBN 9789241501125

Reference to any company or product in this report, particularly in any of the fi gures or tables, does not in any way imply an endorsement, Reference to any company or product in this report, particularly in any of the fi gures or tables, does not in any way imply an endorsement, certifi cation, warranty of fi tness or recommendation by WHO of any company or product for any purpose, and does not imply preference over certifi cation, warranty of fi tness or recommendation by WHO of any company or product for any purpose, and does not imply preference over products of a similar nature that are not mentioned. WHO furthermore does not warrant that: (1) any list of companies or products is complete products of a similar nature that are not mentioned. WHO furthermore does not warrant that: (1) any list of companies or products is complete and/or error free; and/or that (2) any products listed are of acceptable quality, have obtained regulatory approval in any country, or that their use and/or error free; and/or that (2) any products listed 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 but not limited to patent laws. Inclusion in this report is otherwise in accordance with the national laws and regulations of any country, including but not limited to patent laws. Inclusion in this report does not furthermore imply any approval by WHO of the products in question (which is the sole prerogative of national authorities). Any lists does not furthermore imply any approval by WHO of the products in question (which is the sole prerogative of national authorities). Any lists of RDTs are not an exhaustive list of malaria RDTs. Such lists reﬂ ect those products which have been submitted for evaluation in Round 3 of the of RDTs are not an exhaustive list of malaria RDTs. Such lists reﬂ ect those products which have been submitted for evaluation in Round 3 of the WHO Malaria RDT Product Testing Programme. The fact that certain products are not included in any list means that they have not or not yet WHO Malaria RDT Product Testing Programme. The fact that certain products are not included in any list means that they have not or not yet been submitted for evaluation in the WHO Malaria RDT Product Testing Programme and does not indicate anything in respect of such products’

been submitted for evaluation in the WHO Malaria RDT Product Testing Programme and does not indicate anything in respect of such products’

performance. WHO will not accept any liability or 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 whatsoever included in this report. This report

may not be used by manufacturers and suppliers for commercial or promotional purposes.

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Figure S1: Malaria RDT performance in Phase 2 of Rounds 1-3 against wild-type (clinical) samples containing P. falciparum at low (200) and high (2000 or 5000) parasite densities (parasites/µl) and clean-negative samples

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.

b clean-negative - blood samples from healthy volunteers with no known current illness or blood abnormality.

*indicates tests that also detect other non-P. falciparum parasites. (see Figure S2)

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Su m m ar Figure S2: Malaria RDT performance in Phase 2 of Rounds 1-3 against wild-type (clinical) samples containing P. vivax

at low (200) and high (2000 or 5000) parasite densities (parasites/µl) and clean-negative samples

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.

b clean-negative - blood samples from healthy volunteers with no known current illness or blood abnormality.

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Ta bl e S 1: M al ari a R DT P ha se 2 p er fo rm an ce i n R ou nd s 1 -3 a ga in st w ild t yp e ( cl in ic al ) s amp le s c on ta in in g P. f al ci par um an d P. v iv ax a t lo w ( 20 0) an d hi gh ( 20 00 o r 5 00 0) p ar asi te d en si tie s ( par asi te s/ µl ) an d c le an n eg at iv e s amp le s Pr od uc t Ca ta lo gu e nu m be r M an uf ac tu re r Pa ne l D et ec tio n Sc or e

a

Fa lse p os iti ve r at es (% ) To ta l f al se p os iti ve ra te s

b

(% ) In va lid ra te (% ) (n =1 20 4) Ro un d

20 0 pa ra sit es /µ l 20 00 o r 50 00 pa ra sit es /µ l 20 0 pa ra sit es /µ l 20 00 o r 50 00 pa ra sit es /µ l Cl ea n- ne ga tiv e sa m pl es

Pf sam

ple

c s

Pv sam

ple

d s

Pf sam

ple

c s

Pv sam

ple

d s

Pf s am pl es Pv s am pl es Pf s am pl es Pv s am pl es Fa ls e po si tiv e no n- Pf in fe ct io n

e

Fa ls e po si tiv e Pf in fe ct io n

f

Fa ls e po si tiv e no n- Pf in fe ct io n

g

Fa ls e po si tiv e Pf in fe ct io n

h

Fa lse p os iti ve

Plasmodium spp.

In fe ct io n

i Pf only Advanced Quality™ One Step Malaria P.f TestjITP11002TC40InTec Products, Inc.93.9N/A100.0N/AN/A40.0N/A35.738.50.13 Advanced Quality™Malaria (p.f) POCTITP11002TC1InTec Products, Inc.57.0N/A100.0N/AN/A12.5N/A17.516.10.01 Advantage P.f. Malaria CardIR016025J. Mitra & Co. Pvt. Ltd.97.5N/A100.0N/AN/A1.3N/A2.50.00.01 BIONOTE MALARIA P.f. Ag Rapid Test Kit RG19-11Bionote,Inc.85.9N/A99.0N/AN/A0.0N/A1.42.00.13 CareStart™ Malaria HRP2 (Pf)G0141Access Bio, Inc.98.7N/A98.7N/AN/A5.0N/A7.52.40.01 CareStart™ Malaria HRP2/pLDH Pf testG0181Access Bio, Inc.98.0N/A100.0N/AN/A0.6N/A1.33.00.02 Clearview® Malaria P.f.jVB01Vision Biotech (Pty) Ltd83.8N/A100.0N/AN/A0.0N/A0.00.00.03 Core™ Malaria Pf MAL-190020Core Diagnostics97.0N/A100.0N/AN/A0.0N/A0.01.0 (198)0.33 diagnosticks- Malaria (Pf) Cassette KMFC6001SSA Diagnostics & Biotech Systems59.0N/A99.0N/AN/A1.9N/A2.6 (77)7.00.92 diagnosticks- Malaria (Pf) Dipstick KMFD6007SSA Diagnostics & Biotech Systems80.0N/A99.0N/AN/A2.5N/A3.82.00.02 First Response® Malaria Ag HRP2I13FRC30Premier Medical Corporation Ltd.100.0N/A100.0N/AN/A0.0N/A0.03.00.01 FirstSign™ – Malaria Pf Card Test--Unimed International, Inc.31.7N/A86.1N/AN/A12.5N/A15.02.4 (166)0.01 Hexagon Malaria58051Human GmbH39.2N/A94.9N/AN/A7.9 (76)N/A2.54.2 (167)1.21 HiSens Malaria Ag Pf HRP2 Card HR3023HBI Co., Ltd.87.0N/A100.0N/AN/A0.0N/A0.01.00.12 ICT Diagnostics Malaria P.f.jML01ICT Diagnostics86.9N/A98.0N/AN/A0.0N/A0.00.00.03 IMMUNOQUICK CONTACT falciparum 0519K25Biosynex81.8N/A100.0N/AN/A3.6 (139)N/A1.44.0 (199)0.33 Immunoquick Malaria Falciparum0502_K25Biosynex91.1N/A100.0N/AN/A0.0N/A0.00.60.01 MalariaPlasmodium falciparum Rapid test Device (Whole blood)IMA-402ACON Laboratories, Inc.92.4N/A100.0N/AN/A0.0N/A0.00.00.01 NanoSign Malaria Pf Ag RMAF10Bioland, Ltd84.9N/A100.0N/AN/A0.0N/A0.00.00.33 One Step Malaria P.F Test (cassette)j522352Blue Cross Bio-Medical (Beijing) Co., Ltd.67.7N/A97.0N/AN/A0.0N/A2.91.00.23 One Step Malaria P.f TestjW37-CGuangzhou Wondfo Biotech Co. Ltd.60.6N/A98.0N/AN/A0.7 (139)N/A0.00.00.23 OnSight™ - Malaria Pf Test511-25-DBAmgenix International, Inc.74.0N/A99.0N/AN/A8.1N/A2.511.00.02 OnSite Pf Ag Rapid TestjR0114CCTK Biotech, Inc.85.9N/A100.0N/AN/A0.7N/A0.03.50.03 Paracheck® Pf Device- Rapid test for P. falciparum Malaria Ver. 3j30301025Orchid Biomedical Systems96.0N/A99.0N/AN/A0.0 (138)N/A1.5 (68)1.50.93 Paracheck® Pf Dipstick- Rapid test for P. falciparum Malaria Ver. 3j30302025Orchid Biomedical Systems89.9N/A98.0N/AN/A0.0N/A1.40.50.03 ParaHIT® - f (Device)j55IC102-50Span Diagnostics Ltd.84.9N/A100.0N/AN/A0.0N/A0.00.00.03 ParaHIT® -f (Dipstick)j55IC101-50Span Diagnostics Ltd.80.8N/A99.0N/AN/A0.0N/A1.42.50.03 SD BIOLINE Malaria Ag P.f. (HRP2/pLDH)k05FK90Standard Diagnostics Inc.87.9N/A100.0N/AN/A0.0N/A0.02.00.03 SD BIOLINE Malaria Ag Pf05FK50Standard Diagnostics, Inc.97.5N/A98.7N/AN/A0.0N/A0.02.40.01 Pf and Pan ABON Malaria Pan/P.f. Rapid Test Device IMA-B402ABON Biopharm (Hangzhou) Co. Ltd.69.70.099.062.90.00.00.00.00.00.03 Advantage Mal CardIR221025J. Mitra & Co. Pvt. Ltd.62.0100.0100.0100.02.50.00.00.04.20.01 Binax Now Malaria TestIN660050Inverness Medical Innovations, Inc.91.110.0100.085.00.33.8 (79)0.0 (157)5.00.00.31 BIONOTE MALARIA P.f.& Pan Ag Rapid Test Kit RG19-08Bionote,Inc.93.988.699.0100.00.00.00.00.03.0 (199)0.13 CareStart™ Malaria/Pregnancy Combo (pLDH/HRP2/HCG) GO221Access Bio, Inc.83.894.3100.097.12.31.4 (139)0.0 (194)1.40.00.23 CareStart™ Malaria HRP2/pLDH (Pf/PAN) COMBOG0131Access Bio, Inc.97.590.0100.095.00.31.30.02.53.00.01 CareStart™ Malaria pLDH 3 Line Test GO121Access Bio, Inc.88.991.4100.0100.01.30.76.10.00.50.03 CareStart™ Malaria Screen GO231Access Bio, Inc.86.988.6100.0100.01.82.10.00.02.5 (199)0.13

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Su m m ar

Pr od uc t Ca ta lo gu e nu m be r M an uf ac tu re r Pa ne l D et ec tio n Sc or e

a

Fa lse p os iti ve r at es (% ) To ta l f al se p os iti ve ra te s

b

(% ) In va lid ra te (% ) (n =1 20 4)

20 0 pa ra sit es /µ l 20 00 o r 50 00 pa ra sit es /µ l 20 0 pa ra sit es /µ l 20 00 o r 50 00 pa ra sit es /µ l Cl ea n- ne ga tiv e sa m pl es

Pf sam

ple

c s

Pv sam

ple

d s

Pf sam

ple

c s

Pv sam

ple

d s

Pf s am pl es Pv s am pl es Pf s am pl es Pv s am pl es Fa ls e po si tiv e no n- Pf in fe ct io n

e

Fa ls e po si tiv e Pf in fe ct io n

f

Fa ls e po si tiv e no n- Pf in fe ct io n

g

Fa ls e po si tiv e Pf in fe ct io n

h

Fa lse p os iti ve

Plasmodium spp.

In fe ct io n

i Clearview® Malaria CombojVB11Vision Biotech (Pty) Ltd82.85.7100.091.40.05.70.55.73.50.0 Clearview® Malaria Dual Test DevicejVB20Vision Biotech (Pty) Ltd69.748.698.094.30.00.7 (139)0.01.41.00.2 diagnosticks MALARIA (Pan/Pf) Cassette MPNFWBC1007.4SSA Diagnostics & Biotech Systems98.051.4100.097.10.0 (394)0.00.00.0 (69)2.50.3 First Response® Malaria pLDH/HRP2 Combo TestjI16FRC30Premier Medical Corporation Ltd.84.075.0100.0100.00.00.00.00.00.00.0 FirstSign™ - ParaView (Pan+Pf) Malaria Test2101 CB-25Unimed International Inc.85.080.099.0100.00.00.6 (159)0.5 (199)0.025.50.2 Hexagon Malaria Combi58024Human GmbH46.80.097.550.00.00.0 (79)0.0 (157)2.6 (38)3.0 (167)0.7 HiSens Malaria Ag P.f/P.v Card HR2823HBI Co., Ltd.20.015.094.0100.00.00.00.00.00.00.0 HiSens Malaria Ag Pf/Pv (HRP2/pLDH) CardHR2923HBI Co., Ltd.84.075.099.0100.00.00.00.00.00.50.0 ICT Diagnostics Malaria CombojML02ICT Diagnostics84.98.698.091.40.03.60.05.72.50.0 ICT Diagnostics Malaria Dual ML03ICT Diagnostics78.860.099.097.10.5 (394)0.00.01.40.5 (199)0.3 IMMUNOQUICK CONTACT MALARIA +4 0525K25Biosynex75.817.198.094.31.8 (395)5.1 (138)0.00.02.00.3 Immunoquick Malaria +40506_K25Biosynex93.730.098.7100.00.0 (314)0.00.0 (157)0.00.60.0 Malaria P.F/Vivax17211OP-25Diagnostics Automation/Cortez Diagnostics, Inc.73.6 (53)0.0 (15)94.9 (39)30.8 (13)1.0 (97)0.0 (30)2.1 (48)0.0 (18)1.6 (64)67.5 Malaria Pan Test MAL-W23N-001Dima • Gesellschaft für Diagnostika mbH54.60.097.048.62.815.70.017.144.00.0 Malaria pf (HRP II) / (PAN-pLDH) Antigen Detection Test DevicejMFV-124RAZOG, Inc.95.00.0100.094.30.0 (395)7.98.10.05.5 (199)0.3 Malaria pf (pLDH) / PAN-pLDH Test Device MFV-124AZOG, Inc.2.05.770.797.10.0 (394)0.0 (139)0.00.00.0 (198)0.4 Malascan™ Device - Rapid test for Malaria Pf/Panj50402025Zephyr Biomedical Systems82.857.197.0100.01.0 (392)0.7 (136)1.0 (194)0.0 (68)1.0 (195)1.9 NanoSign Malaria Pf/Pan Ag RMAP10Bioland, Ltd77.80.0100.091.40.02.90.0 (197)2.90.50.0 NanoSign Malaria Pf/Pv Ag -RMAD10Bioland, Ltd6.18.689.9100.00.50.0 (139)0.00.00.00.1 One Step Malaria Antigen Strip820-1IND Diagnostic Inc.1.30.067.160.02.23.81.90.01.8 (167)0.0 One Step Malaria P.f/Pan TestjW56-CGuangzhou Wondfo Biotech Co. Ltd.37.485.795.0100.08.4 (383)0.0 (137)0.0 (194)0.0 (68)4.1 (195)2.4 OnSight™ – ParaQuick (Pan, Pf) Test536-25DBAmgenix International, Inc.59.550.0100.0100.00.01.30.00.00.00.0 OnSite Pf/Pan Malaria Ag Rapid Test R0113CCTK Biotech, Inc.83.885.7100.0100.01.30.00.00.027.50.0 OptiMAL-IT 710024Diamed - A Division of Bio-Rad50.597.196.068.61.50.00.520.3 (69)2.0 (198)0.5 ParaHIT® total (dipstick)55IC201-10Span Diagnostics Ltd64.010.099.097.50.00.00.00.07.00.0 Parahit-Total Device Rapid test for P. falciparum and Pan malarial species.25989Span Diagnostics Ltd.35.40.093.750.00.0 (315)0.00.02.50.00.2 Parascreen™ Device - Rapid test for Malaria Pan/Pf50310025Zephyr Biomedical Systems89.945.797.088.61.0 (394)2.10.0 (197)7.13.5 (199)0.4 Quickstick Malaria Antigen Test--Innovatek Medical Inc.1.30.067.160.02.23.81.90.01.8 (167)0.0 SD BIOLINE Malaria Ag P.f/Panj05FK60Standard Diagnostics Inc.92.997.199.0100.00.5 (394)0.00.50.03.5 (199)0.3 SD BIOLINE Malaria Agj05FK40Standard Diagnostics Inc.16.297.193.9100.00.80.00.00.00.00.0 Surestep™ Easy Malaria Pf/Pan Rapid Test Device IMA-T402ACON Biotech (Hangzhou) Co. Ltd.83.80.0100.0100.00.00.00.00.01.00.0 Pf and Pv Advanced Quality™ One Step Malaria P.f/P.v Tri-Line Test ITP11003 TC40InTec Products, Inc.86.90.0100.05.715.7 (395)5.78.1 (197)4.318.50.2 Advantage Malaria Card IR211025J. Mitra & Co. Pvt. Ltd.77.831.499.0100.00.50.70.00.00.00.0 BIONOTE MALARIA P.f.& P.v. Ag Rapid Test Kit RG19-12Bionote,Inc.92.997.198.0100.00.30.71.5 (197)0.04.00.0 CareStart™ Malaria HRP2/PLDH (Pf/Pv) COMBOG0161Access Bio, Inc.90.090.0100.0100.00.30.60.00.00.50.0 CareStart™ Malaria HRP2/PLDH (Pf/VOM) COMBOG0171Access Bio, Inc.89.080.0100.0100.01.30.00.50.00.50.0

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Pr od uc t Ca ta lo gu e nu m be r M an uf ac tu re r Pa ne l D et ec tio n Sc or e

a

Fa lse p os iti ve r at es (% ) To ta l f al se p os iti ve ra te s

b

(% ) In va lid ra te (% ) (n =1 20 4) Ro un d

20 0 pa ra sit es /µ l 20 00 o r 50 00 pa ra sit es /µ l 20 0 pa ra sit es /µ l 20 00 o r 50 00 pa ra sit es /µ l Cl ea n- ne ga tiv e sa m pl es

Pf sam

ple

c s

Pv sam

ple

d s

Pf sam

ple

c s

Pv sam

ple

d s

Pf s am pl es Pv s am pl es Pf s am pl es Pv s am pl es Fa ls e po si tiv e no n- Pf in fe ct io n

e

Fa ls e po si tiv e Pf in fe ct io n

f

Fa ls e po si tiv e no n- Pf in fe ct io n

g

Fa ls e po si tiv e Pf in fe ct io n

h

Fa lse p os iti ve

Plasmodium spp.

In fe ct io n

i Core™ Malaria Pv/PfMAL-190022Core Diagnostics98.060.0100.097.10.30.00.00.04.00.13 diagnosticks- Malaria (Pv/Pf) CassetteKMVFC6002SSA Diagnostics & Biotech Systems91.045.099.0100.00.3 (399)0.60.00.02.00.12 Falcivax Rapid Test for Malaria Pv/Pf (device)50300025Zephyr Biomedicals92.045.0100.0100.00.01.30.00.0 (79)4.50.22 FirstSign™ – ParaView-2 (Pv + Pf) Card Test2102CB-25Unimed International, Inc.48.10.098.785.01.03.8N/A5.00.0 (167)0.01 Malaria pf (HRP II) / pv (pLDH) Antigen Detection Test Device MFV-124VAZOG, Inc.79.80.0100.020.00.01.40.00.00.0 (199)0.13 Maleriscan® Malaria Pf/Pv MAT-50Bhat Bio-Tech India (P) Ltd52.00.097.060.01.8 (399)2.532.52.5 (79)1.5 (199)0.42 OnSight™ - ParaQuick-2 (Pv,Pf) Malaria Test537-25-DBAmgenix International, Inc.92.037.5100.0100.00.51.90.00.03.50.12 OnSite Malaria Pf/Pv Ag Rapid TestjR0112CCTK Biotech, Inc.84.997.1100.0100.05.30.06.10.028.00.03 SD BIOLINE Malaria Ag Pf/Pv05FK80Standard Diagnostics, Inc.96.095.0100.0100.00.00.0 (159)0.0 (199)0.03.50.22 Pf, Pv and Pan Core™ Malaria Pan/Pv/Pf MAL-190026Core Diagnostics92.911.499.094.30.3 (391)0.0 (137)0.0 (197)1.43.5 (198)1.03 diagnosticks MALARIA (Pan/Pv/Pf) CassetteMPNVFC1007.5SSA Diagnostics & Biotech Systems93.911.499.094.30.0 (389)0.0 (139)0.0 (196)2.9 (69)4.0 (199)1.13 FirstSign™ - ParaView-3 (Pan+Pv+Pf) Malaria Test2103 CB-25Unimed International Inc.89.045.0100.0100.00.0 (399)2.50.00.024.50.12 Paramax-3 Rapid Test for Malaria Pan/Pv/Pf (device)50320025Zephyr Biomedicals93.045.0100.0100.00.0 (396)0.0 (159)0.0 (199)0.037.0 (198)0.72 Pan only Advantage Pan Malaria CardIR013025J. Mitra & Co. Pvt. Ltd.72.2100.0100.0100.0N/AN/AN/AN/A1.80.01 CareStart™ Malaria pLDH (PAN)G0111Access Bio, Inc.92.4100.0100.0100.0N/AN/AN/AN/A6.60.01 Clearview® Malaria pLDHj70884025Orgenics Ltd. 81.885.799.0100.0N/AN/AN/AN/A13.50.53 diagnosticks MALARIA (Pan) Cassette MPNWBC1007.3SSA Diagnostics & Biotech Systems16.254.392.9100.0N/AN/AN/AN/A0.00.33 First Response® Malaria Ag pLDHI12FRC30Premier Medical Corporation Ltd.31.092.598.0100.0N/AN/AN/AN/A0.00.02 FirstSign™ - PanCheck (Pan) Malaria Test2104 CB-25Unimed International Inc.25.082.587.0100.0N/AN/AN/AN/A2.50.22 OnSight™ - PanScreen (Pan) Malaria Test539-25-DBAmgenix International, Inc.22.077.596.0100.0N/AN/AN/AN/A2.50.22 Parabank™ Device - Rapid test for Malaria Panj50301025Zephyr Biomedical Systems17.262.990.9100.0N/AN/AN/AN/A0.50.23 Pv only SD BIOLINE Malaria Ag Pv05FK70Standard Diagnostics, Inc.N/A92.5N/A100.00.3N/A1.0N/A1.00.02 Pf: Plasmodium falciparumPv: Plasmodium vivaxpan:Plasmodium species a A sample is considered detected only if all RDTs from both lots read by the first technician, at minimum specified reading time, are positive b The total number of times a positive result for malaria was generated when it should not have been c Round 1, n=79; Round 2, n=100; Round 3, n=99 d Round 1, n=20; Round 2, n=40; Round 3, n=35 e For combination tests, Pan or Pv line, only, positive indicates a false positive P. falciparum infection (Round 1 n=316; Round 2, n=400; Round 3, n=396) f Pf line positive indicates a false positive P. falciparum infection (Round 1, n=80; Round 2, n=160; Round 3, n=140) ^gFor combination tests, Pan or Pv line, only, positive indicates a false positive P. falciparum infection (Round 1, n=158, Round 2, n=200; Round 3, n=198) h Pf line positive indicates a false positive P. falciparum infection (Round 1, n=40; Round 2, n=80, Round 3, n=70) i Round 1, n=168; Round 2, n=200; Round 3, n=200 j Product resubmission, results from most recent round of testing replace previous results. Refer to Table S3. k PDS presented in the table is based on a positive pf test line (either pf-HRP2 or pf-pLDH). P. falciparum PDS based on individual test lines was : pf-pLDH (17.2% at 200p/µl; 97% at 2000p/µl) and pf-HRP2 (87.9% at 200p/µl; 100% at 2000p/µl)

Detection rate (%)≥9585-9450-84< 50 False positive rate (%)<22-56 -10>10 Invalid rate (%)<1% of tests conducted1-2% of tests conducted2-5% of tests conducted>5% of tests conducted

Ta bl e S 1 (c on tin ue d)

(12)

Su m m ar

Ta bl e S 2: M al ari a R DT R ou nd s 1 -3 h ea t s ta bi lit y r es ul ts o n a c ul tu re d P. f al ci par um s amp le a t lo w ( 20 0) an d h ig h ( 20 00 ) p ar asi te d en si ty ( par asi te s/ µl ). Po si ti vi ty r at e a t b as el in e, an d a ft er 6 0 d ay s i nc ub at io n a t 3 5° C an d 4 5° C Pr od uc t Ca ta lo gu e nu m be r M an uf ac tu re r

Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P f lin e) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P f lin e) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P an li ne ) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P an li ne 20 0 pa ra sit es /µ l 20 00 p ar as ite s/ µl 20 0 pa ra sit es /µ l 20 00 p ar as ite s/ µl Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d

Pf only Advanced Quality™ One Step Malaria P.f TestaITP11002TC40InTec Products, Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Advanced Quality™Malaria (p.f) POCTITP11002TC1InTec Products, Inc.80.095.090.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Advantage P.f. Malaria CardIR016025J. Mitra & Co. Pvt. Ltd.95.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A BIONOTE MALARIA P.f. Ag Rapid Test Kit RG19-11Bionote,Inc.100.0100.086.7100.090.080.0N/AN/AN/AN/AN/AN/A CareStart™ Malaria HRP2 (Pf)G0141Access Bio, Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A CareStart™ Malaria HRP2/pLDH Pf testG0181Access Bio, Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Clearview® Malaria P.f.aVB01Vision Biotech (Pty) Ltd100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Core™ Malaria Pf MAL-190020Core Diagnostics100.0100.096.7100.0100.0100.0N/AN/AN/AN/AN/AN/A diagnosticks- Malaria (Pf) Cassette KMFC6001SSA Diagnostics & Biotech Systems95.070.055.095.095.095.0N/AN/AN/AN/AN/AN/A diagnosticks- Malaria (Pf) Dipstick KMFD6007SSA Diagnostics & Biotech Systems100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A First Response® Malaria Ag HRP2I13FRC30Premier Medical Corporation Ltd.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A FirstSign™ – Malaria Pf Card Test--Unimed International, Inc.20.015.00.0100.090.095.0N/AN/AN/AN/AN/AN/A Hexagon Malaria58051Human GmbH50.035.060.095.0100.0100.0N/AN/AN/AN/AN/AN/A HiSens Malaria Ag Pf HRP2 Card HR3023HBI Co., Ltd.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A ICT Diagnostics Malaria P.f.aML01ICT Diagnostics100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A IMMUNOQUICK CONTACT falciparum 0519K25Biosynex100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Immunoquick Malaria Falciparum0502_K25Biosynex100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A MalariaPlasmodium falciparum Rapid test Device (Whole blood)IMA-402ACON Laboratories, Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A NanoSign Malaria Pf Ag RMAF10Bioland, Ltd96.7100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A One Step Malaria P.F Test (cassette)a522352Blue Cross Bio-Medical (Beijing) Co., Ltd.63.30.00.0100.0100.0100.0N/AN/AN/AN/AN/AN/A One Step Malaria P.f TestaW37-CGuangzhou Wondfo Biotech Co. Ltd.100.093.390.0100.0100.0100.0N/AN/AN/AN/AN/AN/A OnSight™ - Malaria Pf Test511-25-DBAmgenix International, Inc.100.095.090.0100.0100.065.0N/AN/AN/AN/AN/AN/A OnSite Pf Ag Rapid TestaR0114CCTK Biotech, Inc.96.7100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Paracheck® Pf Device- Rapid test for P. falciparum Malaria Ver. 3a30301025Orchid Biomedical Systems100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Paracheck® Pf Dipstick- Rapid test for P. falciparum Malaria Ver. 3a30302025Orchid Biomedical Systems100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A ParaHIT® - f (Device)a55IC102-50Span Diagnostics Ltd.100.096.7100.0100.0100.090.0N/AN/AN/AN/AN/AN/A ParaHIT® -f (Dipstick)a55IC101-50Span Diagnostics Ltd.100.0100.056.7100.0100.0100.0N/AN/AN/AN/AN/AN/A SD BIOLINE Malaria Ag P.f. (HRP2/pLDH)b05FK90Standard Diagnostics Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A SD BIOLINE Malaria Ag Pf05FK50Standard Diagnostics, Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Pf and Pan ABON Malaria Pan/P.f. Rapid Test Device IMA-B402ABON Biopharm (Hangzhou) Co. Ltd.100.080.090.0100.0100.0100.00.00.00.00.00.00.0 Advantage Mal CardIR221025J. Mitra & Co. Pvt. Ltd.100.0100.055.095.0100.095.055.045.040.0100.0100.0100.0 Binax Now Malaria TestIN660050Inverness Medical Innovations, Inc.100.0100.0100.0100.0100.095.05.00.00.095.095.075.0 BIONOTE MALARIA P.f.& Pan Ag Rapid Test Kit RG19-08Bionote,Inc.100.0100.096.7100.0100.0100.00.00.00.0100.0100.090.0 CareStart™ Malaria/Pregnancy Combo (pLDH/HRP2/HCG) GO221Access Bio Inc100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0 CareStart™ Malaria HRP2/pLDH (Pf/PAN) COMBOG0131Access Bio, Inc.100.095.0100.0100.0100.0100.0100.095.0100.0100.0100.0100.0 CareStart™ Malaria pLDH 3 Line Test GO121Access Bio, Inc.100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

(13)

Pr od uc t Ca ta lo gu e nu m be r M an uf ac tu re r

Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P f lin e) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P f lin e) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P an li ne ) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P an li ne ) Ro un d 20 0 pa ra sit es /µ l 20 00 p ar as ite s/ µl 20 0 pa ra sit es /µ l 20 00 p ar as ite s/ µl Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d

CareStart™ Malaria Screen GO231Access Bio, Inc.100.0100.093.3100.0100.0100.0100.0100.093.3100.0100.0100.03 Clearview® Malaria ComboaVB11Vision Biotech (Pty) Ltd100.0100.0100.0100.0100.0100.00.00.00.090.020.00.03 Clearview® Malaria Dual Test DeviceaVB20Vision Biotech (Pty) Ltd100.0100.096.7100.0100.0100.00.00.00.050.090.020.03 diagnosticks MALARIA (Pan/Pf) Cassette MPNFWBC1007.4SSA Diagnostics & Biotech Systems100.0100.096.7100.0100.0100.00.00.00.0100.090.090.03 First Response® Malaria pLDH/HRP2 Combo TestaI16FRC30Premier Medical Corporation Ltd.100.0100.0100.0100.0100.0100.085.055.055.0100.0100.0100.02 FirstSign™ - ParaView (Pan+Pf) Malaria Test2101 CB-25Unimed International Inc.100.0100.0100.0100.0100.0100.095.040.040.0100.0100.0100.02 Hexagon Malaria Combi58024Human GmbH65.055.050.0100.085.095.00.00.00.00.00.00.01 HiSens Malaria Ag P.f/P.v Card HR2823HBI Co., Ltd.35.00.05.0100.0100.0100.00.00.00.035.00.00.02 HiSens Malaria Ag Pf/Pv (HRP2/pLDH) CardHR2923HBI Co., Ltd.100.0100.0100.0100.0100.0100.0100.0100.095.0100.0100.0100.02 ICT Diagnostics Malaria ComboaML02ICT Diagnostics100.0100.096.7100.0100.090.00.00.00.090.030.00.03 ICT Diagnostics Malaria Dual ML03ICT Diagnostics100.0100.093.3100.0100.0100.00.00.00.0100.080.00.03 IMMUNOQUICK CONTACT MALARIA +4 0525K25Biosynex100.0100.0100.0100.0100.0100.00.00.00.050.050.0100.03 Immunoquick Malaria +40506_K25Biosynex100.0100.0100.0100.0100.0100.00.00.00.0100.080.080.01 Malaria P.F/Vivax17211OP-25Diagnostics Automation/Cortez Diagnostics, Inc.65.015.020.065.045.05.00.00.00.00.00.00.01 Malaria Pan Test MAL-W23N-001Dima • Gesellschaft für Diagnostika mbH60.033.323.3100.0100.090.013.353.340.010.060.040.03 Malaria pf (HRP II) / (PAN-pLDH) Antigen Detection Test DeviceaMFV-124RAZOG, Inc.100.0100.0100.0100.0100.0100.00.00.00.00.00.00.03 Malaria pf (pLDH) / PAN-pLDH Test Device MFV-124AZOG, Inc.3.30.00.040.010.00.00.00.00.00.00.00.03 Malascan™ Device - Rapid test for Malaria Pf/Pana50402025Zephyr Biomedical Systems96.7100.096.7100.0100.0100.00.00.06.7100.0100.0100.03 NanoSign Malaria Pf/Pan Ag RMAP10Bioland, Ltd100.0100.0100.0100.0100.090.00.00.00.00.00.00.03 NanoSign Malaria Pf/Pv Ag RMAD10Bioland, Ltd0.00.00.020.00.00.00.00.00.00.00.00.03 One Step Malaria Antigen Strip820-1IND Diagnostic Inc.15.00.00.065.050.00.015.00.00.065.050.05.01 One Step Malaria P.f/Pan TestaW56-CGuangzhou Wondfo Biotech Co. Ltd.46.713.326.7100.0100.0100.00.036.773.370.080.0100.03 OnSight™ – ParaQuick (Pan, Pf) Test536-25DBAmgenix International, Inc.100.090.060.0100.0100.0100.00.00.00.0100.0100.095.01 OnSite Pf/Pan Malaria Ag Rapid Test R0113CCTK Biotech, Inc.100.0100.0100.0100.0100.0100.03.366.783.3100.0100.080.03 OptiMAL-IT 710024Diamed - A Division of Bio-Rad0.00.00.0100.090.00.00.00.00.0100.090.00.03 ParaHIT® total (dipstick)55IC201-10Span Diagnostics Ltd55.085.055.0100.0100.095.010.00.00.050.045.070.02 Parahit-Total Device Rapid test for P. falciparum and Pan malarial species25989Span Diagnostics Ltd.65.075.025.095.0100.0100.05.00.00.00.00.00.01 Parascreen™ Device - Rapid test for Malaria Pan/Pf50310025Zephyr Biomedical Systems100.0100.0100.0100.0100.0100.00.00.00.090.0100.0100.03 Quickstick Malaria Antigen Test--Innovatek Medical Inc.15.00.00.065.050.00.015.00.00.065.050.05.01 SD BIOLINE Malaria Ag P.f/Pana05FK60Standard Diagnostics Inc.100.096.7100.0100.0100.0100.00.00.00.0100.070.090.03 SD BIOLINE Malaria Aga05FK40Standard Diagnostics Inc.0.00.00.0100.080.090.00.00.00.080.020.090.03 Surestep™ Easy Malaria Pf/Pan Rapid Test Device IMA-T402ACON Biotech (Hangzhou) Co. Ltd.100.0100.0100.0100.0100.0100.00.00.00.00.00.00.03 Pf and Pv Advanced Quality™ One Step Malaria P.f/P.v Tri-Line Test ITP11003 TC40InTec Products, Inc.96.7100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A3 Advantage Malaria Card IR211025J. Mitra & Co. Pvt. Ltd.100.096.796.7100.0100.0100.0N/AN/AN/AN/AN/AN/A3 BIONOTE MALARIA P.f.& P.v. Ag Rapid Test Kit RG19-12Bionote,Inc.100.096.7100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A3 CareStart™ Malaria HRP2/PLDH (Pf/Pv) COMBOG0161Access Bio, Inc.100.0100.095.0100.0100.0100.0N/AN/AN/AN/AN/AN/A2

Ta bl e S 2 (c on tin ue d)

(14)

Su m m ar

Pr od uc t Ca ta lo gu e nu m be r M an uf ac tu re r

Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P f lin e) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P f lin e) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P an li ne ) Pe rc en t po sit iv e te st r es ul ts fo r

P. falciparum

(P an li ne 20 0 pa ra sit es /µ l 20 00 p ar as ite s/ µl 20 0 pa ra sit es /µ l 20 00 p ar as ite s/ µl Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C Ba se lin e 35 °C 45 °C N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve N um be r of t es ts p os iti ve Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d Lo ts 1 a nd 2 c om bi ne d

CareStart™ Malaria HRP2/PLDH (Pf/VOM) COMBOG0171Access Bio, Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A Core™ Malaria Pv/PfMAL-190022Core Diagnostics100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A diagnosticks- Malaria (Pv/Pf) CassetteKMVFC6002SSA Diagnostics & Biotech Systems100.095.095.0100.0100.095.0N/AN/AN/AN/AN/AN/A Falcivax Rapid Test for Malaria Pv/Pf (device)50300025Zephyr Biomedicals100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A FirstSign™ – ParaView-2 (Pv + Pf) Card Test2102CB-25Unimed International, Inc.95.070.00.0100.095.075.0N/AN/AN/AN/AN/AN/A Malaria pf (HRP II) / pv (pLDH) Antigen Detection Test Device MFV-124VAZOG, Inc.100.0100.096.7100.0100.0100.0N/AN/AN/AN/AN/AN/A Maleriscan® Malaria Pf/Pv MAT-50Bhat Bio-Tech India (P) Ltd100.060.030.0100.090.095.0N/AN/AN/AN/AN/AN/A OnSight™ - ParaQuick-2 (Pv,Pf) Malaria Test537-25-DBAmgenix International, Inc.100.0100.0100.0100.0100.085.0N/AN/AN/AN/AN/AN/A OnSite Malaria Pf/Pv Ag Rapid TestaR0112CCTK Biotech, Inc.100.0100.0100.0100.0100.0100.0N/AN/AN/AN/AN/AN/A SD BIOLINE Malaria Ag Pf/Pv05FK80Standard Diagnostics, Inc.100.0100.0100.0100.0100.095.0N/AN/AN/AN/AN/AN/A Pf, Pv and Pan Core™ Malaria Pan/Pv/Pf MAL-190026Core Diagnostics100.0100.0100.0100.090.0100.00.00.00.080.050.070.0 diagnosticks MALARIA (Pan/Pv/Pf) CassetteMPNVFC1007.5SSA Diagnostics & Biotech Systems96.7100.093.3100.0100.0100.00.00.00.070.00.050.0 FirstSign™ - ParaView-3 (Pan+Pv+Pf) Malaria Test2103 CB-25Unimed International Inc.100.0100.0100.0100.0100.0100.060.050.015.0100.090.0100.0 Paramax-3 Rapid Test for Malaria Pan/Pv/Pf (device)50320025Zephyr Biomedicals100.0100.0100.0100.0100.0100.0100.025.030.0100.095.0100.0 Pan Only Advantage Pan Malaria CardIR013025J. Mitra & Co. Pvt. Ltd.N/AN/AN/AN/AN/AN/A50.065.070.0100.0100.0100.0 CareStart™ Malaria pLDH (PAN)G0111Access Bio, Inc.N/AN/AN/AN/AN/AN/A100.0100.090.0100.0100.0100.0 Clearview® Malaria pLDHa70884025Orgenics Ltd. N/AN/AN/AN/AN/AN/A96.793.3100.0100.0100.0100.0 diagnosticks MALARIA (Pan) Cassette MPNWBC1007.3SSA Diagnostics & Biotech SystemsN/AN/AN/AN/AN/AN/A0.00.00.080.0100.080.0 First Response® Malaria Ag pLDHI12FRC30Premier Medical Corporation Ltd.N/AN/AN/AN/AN/AN/A50.080.055.0100.0100.0100.0 FirstSign™ - PanCheck (Pan) Malaria Test2104 CB-25Unimed International Inc.N/AN/AN/AN/AN/AN/A25.05.010.0100.0100.0100.0 OnSight™ - PanScreen (Pan) Malaria Test539-25-DBAmgenix International, Inc.N/AN/AN/AN/AN/AN/A5.035.015.0100.0100.0100.0 Parabank™ Device - Rapid test for Malaria Pana50301025Zephyr Biomedical SystemsN/AN/AN/AN/AN/AN/A0.00.00.090.0100.0100.0 Pv only SD BIOLINE Malaria Ag Pv05FK70Standard Diagnostics, Inc.N/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A Pf: Plasmodium falciparumPv: Plasmodium vivaxpan:Plasmodium species a Product resubmission, results from most recent round of testing replace previous results. Refer to Table S3. b Results presented in the table are based on stability of a pf test line (either pf-HRP2 or pf-pLDH). Results based on stability of individual test lines on 200p/µl and 2000p/µl samples were, respectively : pf-pLDH (0%; 33.3% detected at baseline and 0% ; 33.3% detecte incubation at 35°C, 45°C) and pf-HRP2 (100%; 100% at baseline and 100%; 100% post 60 d incubation at 35°C, 45°C)

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Ta bl e S 3: Pr od uc t R es ub m is si on s: W H O M al ari a R DT P ro du ct T es tin g - R ou nd s 1 -3 M an uf ac tu re r In iti al T es tin g Su bs eq ue nt T es tin g Ro un d Pr od uc t N am e Ca ta lo gu e N o Ro un d Pr od uc t N am e Ca ta lo gu e N o

AZOG, Inc.1Malaria Pf (HRPII)/pv-LDH) Antigen Detection Test DeviceaMFV-124R3Malaria pf (HRP II) / (PAN-LDH) Antigen Detection Test DeviceMFV-124R Blue Cross Bio-Medical (Beijing) Co., Ltd.2One Step Malaria Pf Test (cassette)5223523One Step Malaria P.F Test (cassette)522352 CTK Biotech, Inc.2Onsite Pf Ag Rapid Test R0114C3OnSite Pf Ag Rapid TestR0114C 2Onsite Pf/Pan Ag Rapid TestR0113C3OnSite Pf/Pan Malaria Ag Rapid TestR0113C 2Onsite Pf/Pv Ag Rapid Test R0112C3OnSite Malaria Pf/Pv Ag Rapid TestR0112C DiaMed - A Division of Bio-Rad1OptiMAL-IT 7100243OptiMAL-IT710024 Guangzhou Wondfo Biotech Co. Ltd.1Wondfo One Step Malaria Pf/Pan Whole Blood Test W56-C (4.0mm)3One Step Malaria P.f./Pan Whole Blood TestW56-C 2One Step Malaria P.f TestbW37-C (4.0mm)3One Step Malaria P.f Test W37-C ICT Diagnostics1ICT Malaria Combo Cassette Test ML023ICT Diagnostics Malaria ComboML02 1ICT Malaria Pf Cassette Test ML013ICT Diagnostics Malaria P.fML01 InTec Products, Inc.1ADVANCED QUALITY™ One Step Malaria (p.f.) Test (whole blood) ITP11002TC403Advanced Quality™ One Step Malaria P.f TestITP11002 TC40 Orchid Biomedical Systems1Paracheck Pf Rapid test for P.falciparum Malaria (Device) 303010253Paracheck® Pf Device - Rapid test for P. falciparum Malaria (Ver. 3)30301025 1Paracheck Pf Rapid test for P.falciparum Malaria (Dipstick) 303020253Paracheck® Pf Dipstick - Rapid test for P. falciparum Malaria (Ver.3)30302025 Premier Medical Corporation Ltd. 1First Response Malaria Ag Combo (pLDH/HRP2)II6FRC302First Response® Malaria Ag Combo (pLDH/HRP2)I16FRC30 Span Diagnotics Ltd.1Parahit-f TEST DEVICE FOR FALCIPARUM MALARIA 259753ParaHIT® - f (Device)55IC102-10 1Parahit-f DIPSTICK FOR FALCIPARUM MALARIA 259773ParaHIT® - f (Dipstick)55IC101-10 Standard Diagnostics Inc. (now Alere Healthcare (Pty) Ltd)1SD BIOLINE Malaria Ag 05FK40-02-5d3SD BIOLINE Malaria Ag05FK40 1SD BIOLINE Malaria Ag Pf/Pan 05FK60-02-3d3SD BIOLINE Malaria Ag P.f/Pan05FK60 Vision Biotech (Pty) Ltd (now Alere Healthcare (Pty) Ltd)

1Malaria Rapid Combo VB0113Clearview® Malaria ComboVB11e 1Malaria Rapid Pf VB013Clearview ®Malaria PfVB01 1Malaria Rapid Dual VB0203Clearview® Malaria Dual Test DeviceVB20e Zephyr Biomedical Systems1Malascan Rapid Test for Malaria Pf/Pan (Device) 504020253Malascan™ Device - Rapid test for Malaria Pf/Pan 50402025 1Parabank Rapid Test for Malaria Pan (Device) 503010253Parabank™ Device - Rapid test for Malaria Pan 50301025 1Parascreen Rapid Test for Malaria Pan/Pf (Device) 503100253Parascreen™ Device -Rapid test for Malaria Pan/Pf50310025 a 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. b In Round 2, product did not pass Phase 1, therefore results do not feature in Summary tables. c Error in WHO Malaria RDT Product Testing: Round 1 report: product code (II6FRC30) should have been ( I16FRC30 ), as in Round 2 d 02-05/02-03 suffix refers to version of the package inserts e New company acquisition (Alere™) -hence name changes/product codes. Manufacturer confirmed compliance with product definition.

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