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Open Access Highly Accessed Case study

Misclassification of Plasmodium infections by conventional microscopy and the impact of remedial training on the proficiency of laboratory technicians in species identification

Peter Obare1*, Bernhards Ogutu14, Mohammed Adams2, James Sande Odera1, Ken Lilley3, David Dosoo2, Christine Adhiambo1, Seth Owusu-Agyei2, Fred Binka4, Elizabeth Wanja1 and Jacob Johnson1

Author Affiliations

1 Kenya Medical Research Institute/United States Army Medical Research Unit, Kenya, Malaria Diagnostics Centre, Box 54 - 40100, Kisumu, Kenya

2 Kintampo Health Research Center, Box 200, Kintampo, Brong Ahafo Region, Ghana

3 Australian Army Malaria Institute, Weary Dunlop Drive, Enoggera, QLD 4051, Australia

4 Malaria Clinical Trials Alliance, INDEPTH-Network, Box 213, Kanda, Accra, Ghana

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Malaria Journal 2013, 12:113  doi:10.1186/1475-2875-12-113

Published: 27 March 2013

Abstract

Background

Malaria diagnosis is largely dependent on the demonstration of parasites in stained blood films by conventional microscopy. Accurate identification of the infecting Plasmodium species relies on detailed examination of parasite morphological characteristics, such as size, shape, pigment granules, besides the size and shape of the parasitized red blood cells and presence of cell inclusions. This work explores misclassifications of four Plasmodium species by conventional microscopy relative to the proficiency of microscopists and morphological characteristics of the parasites on Giemsa-stained blood films.

Case description

Ten-day malaria microscopy remedial courses on parasite detection, species identification and parasite counting were conducted for public health and research laboratory personnel. Proficiency in species identification was assessed at the start (pre) and the end (post) of each course using known blood films of Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale and Plasmodium vivax infections with densities ranging from 1,000 to 30,000 parasites/μL. Outcomes were categorized as false negative, positive without speciation, P. falciparum, P. malariae, P. ovale, P. vivax and mixed infections.

Discussion and evaluation

Reported findings are based on 1,878 P. falciparum, 483 P. malariae, 581 P. ovale and 438 P. vivax cumulative results collated from 2008 to 2010 remedial courses. Pre-training false negative and positive misclassifications without speciation were significantly lower on P. falciparum infections compared to non-falciparum infections (p < 0.0001). Post-training misclassifications decreased significantly compared to pre- training misclassifications which in turn led to significant improvements in the identification of the four species. However, P. falciparum infections were highly misclassified as mixed infections, P. ovale misclassified as P. vivax and P. vivax similarly misclassified as P. ovale (p < 0.05).

Conclusion

These findings suggest that the misclassification of malaria species could be a common occurrence especially where non-falciparum infections are involved due to lack of requisite skills in microscopic diagnosis and variations in morphological characteristics within and between Plasmodium species. Remedial training might improve reliability of conventional light microscopy with respect to differentiation of Plasmodium infections.

Keywords:
Microscopy; Species; Morphology; Misclassification; Training