Evidence brief: “It doesn’t require blood!”: Perceptions around non-invasive malaria testing tools in Indonesia, Peru, and Rwanda

Abstract

Malaria remains a major global health challenge. Prompt, accurate diagnosis is crucial for effective case management. Current diagnostic approaches rely on invasive or minimally invasive sampling via venous or fingerpick blood draw, posing a risk to healthcare workers via the handling of potentially infectious body fluids. They may also be a barrier to recipients, particularly in malaria-endemic areas where there is routine testing of non-symptomatic individuals. Non-invasive tests based on saliva, exhaled volatile organic compounds (VOCs), and transdermal detection have the potential to increase case detection and linkage to care while reducing biosafety risks. Knowledge gaps exist regarding the feasibility and acceptability of these tools. This qualitative study, conducted in Indonesia, Peru, and Rwanda, aimed to generate evidence from end-users around the potential adoption of non-invasive diagnostic technologies, to determine whether these technologies are fit for purpose. Between October and November 2023, 24 semi-structured interviews were conducted with stakeholders and professionals working at borders, and 16 focus group discussions were conducted with caregivers of children under 5 years, pregnant women, healthcare workers, teachers and other community members (139 participants in total). The comfort non-invasive approaches offer to recipients of care was widely noted, especially compared with blood draw, which is considered painful for children. Ease of use and rapid diagnostic capabilities enabling real-time disease diagnosis were perceived as particularly beneficial in remote areas with limited healthcare infrastructure. Device portability was seen as a game-changer. Major concerns were the lack of information regarding the accuracy of non-invasive tools compared with established methods, the lack of trust in tests targeting specimens other than blood products, and their inability to differentiate between malaria species. Early engagement with stakeholders in the development of novel interventions is essential to ensure that end products meet the needs of communities.

Introduction

Malaria remains a major global health issue, with an estimated 249 million cases across 85 countries and causing 608,000 deaths in 2022 alone [1]. Rapid diagnosis of malaria is crucial to facilitating prompt care, reducing the risk of complications, and protecting patient health. The most common methods of diagnosing malaria involve the use of microscopy to detect whole parasites in peripheral blood or lateral flow assay (LFA)-based rapid diagnostic tests (RDTs) that detect specific parasite proteins [2]. While these methods have proven effective [3], they can be invasive and uncomfortable for recipients due to blood collection via finger prick or venous blood draw [4]. Microscopy remains the gold standard for laboratory diagnosis but requires experienced microscopists to ensure accuracy. Although automated and digital microscopes are being developed, these are not yet widely accessible [5]. In addition, there are limitations to current LFA-based RDTs. Some strains of Plasmodium falciparum, the deadliest malaria parasite species, have deletions in the gene that produces histidine-rich protein 2 (HRP2), the protein detected by commonly used RDTs, leading to false-negative results [6,7]. Newer technologies are being developed to overcome these challenges and improve malaria diagnosis. This includes RDTs based on the combined detection of parasite lactate dehydrogenase (pLDH) and HRP2.