DIAGNOSTIC TEST FOR MALARIA

OLEH:
ANNA YUSRIA
13/356967/PKU/14051

PROGRAM STUDI ILMU KEDOKTERAN TROPIS

FAKULTAS KEDOKTERAN
UNIVERSITAS GADJAH MADA
YOGYAKARTA
2014
SKENARIO KASUS

 Seorang laki-laki berusia 35 tahun datang ke IGD

RSU XX pada jam 01.00 WIB dengan keluhan
panas tinggi, menggigil, penurunan kesadaran
dan kejang-kejang. Dari alloanamnesa diketahui
os baru pulang dari daerah endemis malaria
(Flores) dan sebelumnya tidak mendapat terapi
profilaksis. Dibutuhkan pemeriksaan cepat untuk
menegakkan diagnosa pada pasien ini yang
dicurigai terinfeksi malaria cerebral. Karena itu
digunakan pemeriksaan rapid diagnostic test
malaria
The clinical question: PICO

Patient or Intervention Comparison Outcome

Problem
Laki-laki RDT malaria Gold Diagnosis
dewasa (Parachek-Pf) standard: malaria
dengan suspek Blood slide
Malaria microscopy
Cerebral
The clinical question

 Pada laki-laki dewasa ini, apakah pemeriksaan

RDT malaria seperti Paracheck-Pf se-akurat
dengan pemeriksaan apusan darah secara
mikroskopis dalam menegakkan diagnosa
malaria pada keadaan gawat darurat?
The Evidence

 Hussein Mohammed, Moges Kassa, Amha Kebede,

Tekola Endeshaw: Paracheck-Pf Test versus microscopy
in the diagnosis of falciparum malaria in Arbaminch Zuria
Woreda of South Ethiopia. Ethiop J Health Sci. Vol. 22,
No.2 July 2012
Appraising the Evidence

1. Is this evidence about the accuracy of a

diagnostic test valid?
2. Does this (valid) evidence demonstrate an
important ability of this test to accurately
distinguish patients who do and do not have
a specific disorder?
3. Can I apply this valid, important diagnostic
test to a specific patient?
Is this evidence about the
accuracy of a diagnostic test
valid?
 Is this evidence about the
accuracy of a diagnostic
test valid?
1. Measurement
 Was the reference (“gold”) standard measured
independently, i.e. blind to our target test?
 Yes. RDT and microscopy results were read by
different individuals at the health centre, each
blinded to the results of the other diagnostic
technique. All blood films were re-read and checked
for the second time by an experienced microscopist
blinded to the initial microscopy and RDT results. The
discrepant readings were resolved by a third reader
that was considered as a final result.
 Is this evidence about the
accuracy of a diagnostic
test valid?
2. Representative
 Was the diagnostic test evaluated in an
appropriate spectrum of patients (those in
whom we would use it in practice)?
 Yes. The research was conducted at Health Center in Arbaminch
Zuria woreda South Ethiopia, with a catchment population of about
47,044 inhabitants. Of this population, a total of 1293 patients
suspected for malaria infection were selected for microscopic
diagnosis regardless of their age.
 Is this evidence about the
accuracy of a diagnostic
test valid?
3. Ascertainment
 Was the reference standard ascertained
regardless of the diagnostic test result?
 Yes, blood specimens were collected for preparation of
blood smear and Paracheck-Pf test from finger prick
using sterile lancet. All RDT devices were labelled with
similar patient ID numbers to that of the blood film.
 Are the results of this
study valid?
 This is a well designed study according to ACP
Journal Club.
Does this (valid) evidence
demonstrate an important
ability of this test to
accurately distinguish
patients who do and do not
have a specific disorder?
2 x 2 Table
Disease Totals
Present Absent
Diagnostic Positive a b a+b
Test Negative c d c+d
Totals a+c b+d a+b+c+d

Sensitvity = a/(a+c).
Specificity = d/(b+d).
Positive Predictive Value = a/(a+b).
Negative Predictive Value = d/(c+d).
What are the results?
Pl. Falciparum Blood Totals
slide microscopy
Positive Negative
Paracheck-Pf Positive 111 8 119
Paracheck-Pf Negative 7 32 39
Totals 118 40 158
Technical precision
Pl. Falciparum Blood Totals
slide microscopy
Positive Negative
Paracheck-Pf Positive 111 8 119
Paracheck-Pf Negative 7 32 39
Totals 118 40 158

Sensitivity = true positive / all disease positives =

111/118 = 94.1% ► 94.1% of the patient who had
plasmodium falciparum infection, tested positive for
the disease
Technical precision
Pl. Falciparum Blood Totals
slide microscopy
Positive Negative
Paracheck-Pf Positive 111 8 119
Paracheck-Pf Negative 7 32 39
Totals 118 40 158

Specificity: measures the proportion of patients without

the disease who also test negative for the disease in
this study.
Specificity = true negative / all disease negatives =
32/40= 80% ► 80% of the patients who did not have
plasmodium falciparum, tested negative for the disease.
Clinical precision
Pl. Falciparum Blood Totals
slide microscopy
Positive Negative
Paracheck-Pf Positive 111 8 119
Paracheck-Pf Negative 7 32 39
Totals 118 40 158

Positive Predictive Value: measures the proportion of

patients tested positive for the disease who have
Plasmodium falciparum.
Positive Predictive Value = true positive / all tested
positive = 111/119 = 93.3% ► 93.3% of the patients who
tested positive for the disease have Plasmodium
falciparum.
 Clinical precision
Pl.falciparum Blood Totals
slide microscopy
Positive Negative
Paracheck-Pf Positive 111 8 119
Paracheck-Pf Negative 7 32 39
Totals 118 40 158

Negative Predictive Value: measures the proportion of

patients test negative for the disease who do not have the
disease.
Negative Predictive Value = true negative / all tested
negatives = 32/39= 82.1% ► 82.1% of the patients tested
negative for the disease who did not have Plasmodium
falciparum.
Technical Precision

 Specificity: Remember SpPin

When a test has a high Specificity, a
Positive test rules IN the disorder.
 Sensitivity: Remember SnNout
When a test has a high Sensitivity, a
Negative result rules OUT the disorder.
Can I apply this valid,
important diagnostic test
to a specific patient?
 Are the results of this
diagnostic study applicable
1.
to my patient?
Is the diagnostic test available, affordable,
accurate, and precise in our setting?
• Yes
 Are the results of this
diagnostic study applicable
to my patient?
2. Can we generate a clinically sensible estimate of
our patient’s pre-test probability?
a. From personal experience, prevalence statistics,
practice databases, or primary studies.
 Yes
b. Are the study patients similar to our own?
 Yes
c. Is it unlikely that the disease possibilities have changed
since this evidence was gathered?
 Yes
 Likelihood Ratio
Pl.falciparum Blood Totals
slide microscopy
Positive Negative
Paracheck-Pf Positive 111 8 119
Paracheck-Pf Negative 7 32 39
Totals 118 40 158
Likelihood Ratio+ = sens/(1-spec) = 94.1/(100-80) = 94.1/20 = 4.71
Likelihood Ratio- = (1-sens)/spec = (100-94.1)/80 = 5.9/80 = 0.07
Prevalence = (a+c)/(a+b+c+d) = 118/158 = 0.75 = 75%
Study pre-test odds = prevalence/(1-prevalence) = 75/25 = 3
Post-test odds = pre-test odds x likelihood ratio = 3 x 4.71 = 14.13
Post-test probability = post-test odds/(post-test odds +1) = 14.13/15.13 = 0.93
 Are the results of this
diagnostic study applicable
to my patient?
3. Will the resulting post-test probabilities affect
our management and help our patient?
1. Could it move us across a test-treatment threshold?
 Yes, from pre-test probability of 75% to post-test
probability of 93%
 Are the results of this
diagnostic study applicable
to my patient?
3. Will the resulting post-test probabilities affect our
management and help our patient? (cont.)
2. Would our patient be a willing partner in carrying it out?
 Probably yes
3. Would the consequences of the test help our patient
reach his or her goals in all this?
 Yes, reassurance when negative, labeling and possibly
generating awful diagnostic and prognostic news if positive,
leading to further diagnostic tests and treatments, etc.