Are rapid diagnostic tests reliable for the detection of malaria in the emergency department?
Date First Published:
January 5, 2026
Last Updated:
January 5, 2026
Report by:
Chloé Moran (1) and Saoirse Coyne (2), Foundation Year 2 Doctors ((1) Manchester Royal Infirmary, (2) North Manchester General Hospital)
Search checked by:
Dr Gregory Yates, Emergency Medicine Registrar, Manchester University Foundation Trust
Three-Part Question:
In (patients who have been exposed to malaria) are (malaria rapid diagnostic tests acceptable) for (the detection of malaria in the emergency department)?
Clinical Scenario:
An adult patient presents to the emergency department with fever and myalgia 5 days after returning from a malaria-endemic region of Nigeria. They have no past medical history. A rapid diagnostic test for malaria is performed at triage and is negative. You wonder whether malaria can be excluded on this basis, or whether expert microscopy is still required.
Search Strategy:
EMBASE and MEDLINE were searched using the OVID interface. The results were limited to adult participants only and papers in English.
Duplicates were removed using the ‘Remove Duplicates’ function. Additional searches using the Cochrane library and Google Scholar were undertaken. Any relevant and recent papers were included. These papers were then reviewed using the ‘Cited by’ feature on Google Scholar to identify additional studies that referenced our selected papers. The final selection of papers was subsequently created.
Duplicates were removed using the ‘Remove Duplicates’ function. Additional searches using the Cochrane library and Google Scholar were undertaken. Any relevant and recent papers were included. These papers were then reviewed using the ‘Cited by’ feature on Google Scholar to identify additional studies that referenced our selected papers. The final selection of papers was subsequently created.
Search Details:
(exp Malaria/ OR exp Plasmodium/ OR malari$.mp. OR (malaria* or plasmodium or falciparum or vivax).mp.) AND (exp Rapid Diagnostic Test$/ OR exp Point of Care Test$/ OR (rapid diagnostic test* or RDT* or antigen test or immunochromatographic test* or point of care).mp.) AND (exp Emergency Department/OR (emergency hospital or emergency room or ED or emergency service).mp.) AND (exp Adult$/)
Outcome:
114 papers were identified using our search strategy. 103 were excluded on abstract review as they were irrelevant to our three-part question. Case reports, narrative reviews and conference abstracts were excluded. 11 papers underwent full-text review. Five were further excluded- four did not address our question, and one was a pre-print. Six papers were used in the final analysis, which included three retrospective cohort studies and three cross-sectional studies. The results are summarised in Table 1.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Performance of the Now Malaria rapid diagnostic test with returned travellers: a 2-year retrospective study in a French teaching hospital F. Durand, B. Crassous, H. Fricker-Hidalgo, F. Carpentier, J.-P. Brion, R. Grillot, H. Pelloux 14 September 2005 France | Patients presenting to the Grenoble teaching hospital between April 2002 and April 2004 with a clinical history compatible with a diagnosis of malaria. | Retrospective cohort study N=413 Mean age: 32.2 Ratio of male to female: 1.6 |
RDT vs. quantitative buffy coat test and thin blood film for P. falciparum malaria: | RDT vs. quantitative buffy coat test and thin blood film for P. falciparum malaria. RDT vs. quantitative buffy coat test and thin blood film for non-falciparum malaria. | Non-endemic setting, therefore might not be as generalisable to endemic settings. Limited reporting of uncertainty (confidence intervals, p-values) in the abstract. Operator/blinding and inter-reader variability not reported. |
| Sensitivity: 96.4 % | |||||
| Specificity: 97% | |||||
| RDT vs. quantitative buffy coat test and thin blood film for non-falciparum malaria: | |||||
| Sensitivity: 66.7% | |||||
| Specificity: 100% | |||||
| Evaluation of rapid diagnostic tests for malaria in Swedish travellers Bronner U, Karlsson L, Evengård B. 17 november 2010 Sweden | Blood specimens obtained from travellers at an emergency department, at wards and at out-patient clinics in Sweden. | Retrospective cohort study N= 635 Mean age: 33.4 40.3% of the positive samples were from female travellers |
Malaria detection on RDT compared with microscopy for P. Falciparum. Malaria detection on RDT compared with microscopy for non-falciparum malaria. | Malaria detection on RDT compared with microscopy for P. Falciparum: | Non-endemic setting, therefore might not be as generalisable to endemic settings. The setting is a university hospital laboratory of parasitology, so makes the study less generalisable to less expertise-settings. Retrospective study therefore may have limitations such as selection bias and missing data. |
| Sensitivity : 97.7% | |||||
| Specificity : 97.3% | |||||
| Malaria detection on RDT compared with microscopy for non-falciparum malaria: | |||||
| Sensitivity : 58.3% | |||||
| Specificity: 99.7% | |||||
| Safety of falciparum malaria diagnostic strategy based on rapid diagnostic tests in returning travellers and migrants: a retrospective study Rossi IA, D'Acremont V, Prod'Hom G, Genton B 16 November 2012 Switzerland | All adults suspected of having malaria to an outpatient clinic and emergency ward of a University Hospital over a period of 8 years (1999-2007) | Retrospective cohort study N= 2,139 Mean age: 38.9 |
RDTs median time to get a first malaria test reduction | RDTs median time to get a first malaria test reduction: 2.1 | The findings come from a single centre outpatient/emergency setting in a developed country with a non-immune population. This limits generalisability to more endemic settings. |
| Number of patients with negative RDT who developed severe malaria or died | Number of patients with negative RDT who developed severe malaria or died: 0 | ||||
| Comparative Performance Evaluation of Routine Malaria Diagnosis at Ho Municipal Hospital James Osei-Yeboah, Gameli Kwame Norgbe, Sylvester Yao Lokpo, Mohammed Khadijah Kinansua, Loverage Nettey, Emmanuel Alote Allotey 25 September 2016 Ghana | Outpatients between January 2016 and April 2016 at the Ho Municipal Hospital in Ghana. The patients included those who presented with signs and symptoms of malaria. | Purposive convenient cross-sectional study carried out between January 2016 and April 2016 N= 299 |
Malaria detection on RDT compared with microscopy as a standard | Malaria detection on RDT compared with microscopy: | The focus was on “routine malaria diagnosis” rather than a controlled research laboratory setting. There may have been variability in how diagnostics that were implemented (microscopy quality, staff training, slide reading), which may introduce heterogeneity and bias. |
| Clinical diagnosis compared with microscopy as a standard | |||||
| Sensitivity: 62.5% | |||||
| Specificity: 92.73% | |||||
| Clinical diagnosis: | |||||
| Sensitivity: 70.83% | |||||
| Specificity: 25.82% | |||||
| A diagnostic performance evaluation of rapid diagnostic tests and microscopy for malaria diagnosis using nested polymerase chain reaction as reference standard in a tertiary hospital in Jos, Nigeria Okokon I Ita , Akaninyene A Otu , Kenneth Onyedibe , Anthony A Iwuafor , Edmund Banwat , Daniel Z Egah 25 July 2018 Nigeria | Patients presenting to Jos University Teaching Hospital with a history of fever or temperature >37.5. | Prospective cross-sectional, hospital-based study N= 200 |
Malaria detection on RDT compared with expert microscopy with polymerase chain reaction. | RDT Sensitivity: 75% (95% CI: 56.60–88.54) | Relatively small sample for robust estimates of sensitivity and specificity. Patient population is from a single centre tertiary hospital, so findings may not be generalisable to community settings, primary care clinics, or rural health posts. |
| PCR Sensitivity: 88.24% (95% CI: 72.55–96.70) | |||||
| RDT Specificity: 98.80% (95% CI: 95.72–99.85) | |||||
| PCR Specificity: 100.0% (95% CI: 97.80–100.0) | |||||
| Assessment of malaria diagnostic methods and treatments at a Ghanaian health facility James Kojo Prah, Samuel Amoah, Andrew Nicholas Yartey, Adelaide Ampofo-Asiama, Elvis Ofori Ameyaw 19 August 2021 Ghana | Patients with symptoms suggestive of malaria who presented to the outpatient department of the University of Cape Coast Hospital | Cross sectional study N=799 55.9% were female Average age: 23.9 |
RDT (Carestart and Wondofo) reliability for the detection of malaria compared with expert microscopy. | Carestart sensitivity: 91.38% (81.02-97.14) | Focuses on RDT and microscopy together compared with expert microscopy for the diagnosis of malaria, rather than only RDT. |
| Carestart specificity: 94.87% (93.03-96.35) | |||||
| Wondofo sensitivity: 94.83% (85.62-98.2) | |||||
| Wondofo specificity : 94.60% (92.72-96.12) | |||||
| Microscopy sensitivity: 68.79% (55.46-80.46) | |||||
| Microscopy specificity: 98.92% (97.88-99.53). | |||||
| Clinical diagnosis sensitivity: 17.2% (8.59-29.43) | |||||
| Clinical diagnosis specificity: 86.50% (83.88-88.88) |
Author Commentary:
Our search returned six studies relevant to our three-part question. (1-6) These studies demonstrate that rapid diagnostic tests (RDTs) provide a timely bedside identification of malaria and are therefore recommended as point-of-care testing in the emergency department to initiate timely isolation, admission and treatment. (1-3) Their clinical utility is greatest in settings where microscopy is unavailable or where access may be delayed. (2-4,6)
RDTs show high sensitivity for the detection of P. Falciparum. (1,2) However, they are still not as sensitive as expert microscopy. (5,6) This is important to consider, given P. Falciparum’s high mortality rate; RDTs lack the sufficient rule-out value for a potentially lethal disease, especially in malaria-endemic areas. (1,2,4,5) One study did show a sensitivity of detecting P. falciparum of only 62.5%. (4) However, the authors state that this could be due to the composite reference; they state that RDTs achieve an adequate comparison with the gold standard for use. (4)
RDTs have a significantly lower sensitivity in detecting non-falciparum malaria, which limits their usefulness excluding mixed infections. (1,2,5) In areas where non-falciparum malaria is endemic, a negative RDT should therefore be treated with more suspicion and confirmed with microscopy. (1,2,5) RDTs are markedly more reliable than clinical assessment alone and should be used when available, rather than presumptive diagnosis. (6)
RDTs show high sensitivity for the detection of P. Falciparum. (1,2) However, they are still not as sensitive as expert microscopy. (5,6) This is important to consider, given P. Falciparum’s high mortality rate; RDTs lack the sufficient rule-out value for a potentially lethal disease, especially in malaria-endemic areas. (1,2,4,5) One study did show a sensitivity of detecting P. falciparum of only 62.5%. (4) However, the authors state that this could be due to the composite reference; they state that RDTs achieve an adequate comparison with the gold standard for use. (4)
RDTs have a significantly lower sensitivity in detecting non-falciparum malaria, which limits their usefulness excluding mixed infections. (1,2,5) In areas where non-falciparum malaria is endemic, a negative RDT should therefore be treated with more suspicion and confirmed with microscopy. (1,2,5) RDTs are markedly more reliable than clinical assessment alone and should be used when available, rather than presumptive diagnosis. (6)
Bottom Line:
Emergency medicine clinicians should use RDTs alone when expert microscopy is not available or when delays to accessing expert microscopy are anticipated. When available, gold-standard expert microscopy should be used to confirm infection, identify the species, quantify parasitaemia and confirm negative RDTs, particularly in malaria-endemic settings.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- F. Durand, B. Crassous, H. Fricker-Hidalgo, F. Carpentier, J.-P. Brion, R. Grillot, H. Pelloux. Performance of the Now Malaria rapid diagnostic test with returned travellers: a 2-year retrospective study in a French teaching hospital
- Bronner U, Karlsson L, Evengård B.. Evaluation of rapid diagnostic tests for malaria in Swedish travellers
- Rossi IA, D'Acremont V, Prod'Hom G, Genton B. Safety of falciparum malaria diagnostic strategy based on rapid diagnostic tests in returning travellers and migrants: a retrospective study
- James Osei-Yeboah, Gameli Kwame Norgbe, Sylvester Yao Lokpo, Mohammed Khadijah Kinansua, Loverage Nettey, Emmanuel Alote Allotey. Comparative Performance Evaluation of Routine Malaria Diagnosis at Ho Municipal Hospital
- Okokon I Ita , Akaninyene A Otu , Kenneth Onyedibe , Anthony A Iwuafor , Edmund Banwat , Daniel Z Egah. A diagnostic performance evaluation of rapid diagnostic tests and microscopy for malaria diagnosis using nested polymerase chain reaction as reference standard in a tertiary hospital in Jos, Nigeria
- James Kojo Prah, Samuel Amoah, Andrew Nicholas Yartey, Adelaide Ampofo-Asiama, Elvis Ofori Ameyaw. Assessment of malaria diagnostic methods and treatments at a Ghanaian health facility