Accuracy of the direct agglutination test for diagnosis of visceral leishmaniasis: a systematic review and meta-analysis

Abstract

Background: Parasitological investigation of bone marrow, splenic or lymph node aspirations is the gold standard for the diagnosis of visceral leishmaniasis (VL). However, this invasive test requires skilled clinical and laboratory staff and adequate facilities, and sensitivity varies depending on the tissue used. The direct agglutination test (DAT) is a serological test that does not need specialised staff, with just minimal training required. While previous meta-analysis has shown DAT to have high sensitivity and specificity when using parasitology as the reference test for diagnosis, meta-analysis of DAT compared to other diagnostic techniques, such as PCR and ELISA, that are increasingly used in clinical and research settings, has not been done.

Methods: We conducted a systematic review to determine the diagnostic performance of DAT compared to all available tests for the laboratory diagnosis of human VL. We searched electronic databases including Medline, Embase, Global Health, Scopus, WoS Science Citation Index, Wiley Cochrane Central Register of Controlled Trials, Africa-Wide Information, LILACS and WHO Global Index. Three independent reviewers screened reports and extracted data from eligible studies. A meta-analysis estimated the diagnostic sensitivity and specificity of DAT.

Results: Of 987 titles screened, 358 were selected for full data extraction and 78 were included in the analysis, reporting on 32,822 participants from 19 countries. Studies included were conducted between 1987-2020. Meta-analysis of studies using serum and DAT compared to any other test showed pooled sensitivity of 95% (95%CrI 90-98%) and pooled specificity of 95% (95%CrI 88-98%). Results were similar for freeze-dried DAT and liquid DAT when analysed separately. Sensitivity was lower for HIV-positive patients (90%, CrI 59-98%) and specificity was lower for symptomatic patients (70%, CrI 43-89%). When comparing different geographical regions, the lowest median sensitivity (89%, CrI 67-97%) was in Western Asia (five studies).

Conclusions: This systematic review and meta-analysis demonstrates high estimated pooled sensitivity and specificity of DAT for diagnosis of VL, although sensitivity and specificity were lower for different patient groups and geographical locations. This review highlights the lack of standardisation of DAT methods and preparations, and the lack of data from some important geographical locations. Future well-reported studies could provide better evidence to inform test implementation for different patient populations and use cases.

Prospero registration: CRD42021240830.

Keywords: Diagnosis; Direct agglutination test; Leishmania; Meta-analysis; Visceral leishmaniasis.

Fig. 1

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram of publications screened in a systematic review of the direct agglutination test for the diagnosis of visceral leishmaniasis. DAT = Direct agglutination test; VL = Visceral leishmaniasis; PKDL = Post-kalazar dermal leishmaniasis; TP = True positive; TN = True negative; FP = False positive; FN = False negative

Fig. 2

Forest plot of the sensitivity and specificity of DAT for the 63 studies that included serum sample type

Fig. 3

Summary receiver operating characteristic curves for pooled (shaded) and predicted (dashed) estimates of DAT for the 63 studies including serum sample type

Fig. 4

Forest plot of the pooled estimates of sensitivity and specificity grouped for all the data, studies from symptomatic patients, studies grouped by geographic region, and specific analysis for studies that include FD-DAT or LQ-DAT

Fig. 5

Forest plot of the predicted estimates of sensitivity and specificity grouped for all the data, studies from symptomatic patients, studies grouped by geographic region, and specific analysis for studies that include FD-DAT or LQ-DAT