Indication - Neglected tropical diseases
Dengue virus antigen (NS1)
First added in 2019
Changed in 2020
Aid to diagnosis, Surveillance
To aid in the diagnosis of dengue fever (always in combination with IgM) and for population surveys
WHO prequalified or recommended products
WHO supporting documents
Dengue: guidelines for diagnosis, treatment, prevention and control (2009) https://apps.who.int/iris/handle/10665/44188
ICD11 code: 1D2Z
Summary of evidence evaluation
A systematic review and meta-analysis of 30 studies showed low sensitivity and high specificity for two different assays: sensitivity 66% (95% CI 61 ; 71) and 74% (95% CI 63 ; 82); specificity 99% (95% CI 96 ; 100) and 99% (95% CI 97 ; 100).
Summary of SAGE IVD deliberations
Dengue fever is the most rapidly spreading mosquito-borne viral disease in the world. Antibody and antigen tests are essential for case management, surveillance and confirmation of outbreaks. There is substantial evidence that NS1 ELISA and RDT tests have poor sensitivity when used alone, although their specificity is consistently high. Several studies have evaluated the combination of NS1 and IgM, as separate tests or in a purpose-made dual RDT, which appears to increase sensitivity without compromising specificity, but no systematic review of studies of this test combination has been reported.
SAGE IVD recommendation
The SAGE IVD recommended inclusion on the EDL of the EIA or RDT for dengue NS1 antigen only if used in combination with the EIA or RDT for DENV IgM (see above) in a specified algorithm. The Group noted that guidelines for DENV testing would become available shortly and recommended that the test be prequalified to ensure that the most appropriate tests are available.
Details of submission from 2020
leakage with or without haemorrhage. Intravenous rehydration is the therapy of choice, as it can reduce the fatality rate of severe cases to < 1%. Progression from non-severe to severe disease is difficult to define; however, appropriate treatment can prevent more severe clinical conditions. Does this test meet a medical need? Efficient, accurate diagnosis of dengue is of primary importance for clinical care (for early detection of severe cases, case confirmation and differential diagnosis from other infectious diseases), surveillance, outbreak control, pathogenesis, academic research, vaccine development and clinical trials. In relation to the EDL, antibody and antigen tests are essential for case management and surveillance. During the early stages of the disease, detection of antigens can be used to diagnose an infection, while, at the end of the acute phase of infection, serology is the method of choice. The choice of the assay for diagnosis depends on the time of sample collection and the purpose of testing (1). As for other Aedes-borne arboviruses, viraemia is present during the acute phase, and 90% of cases of primary and secondary dengue fever can be identified accurately from a single serum specimen collected during the first 10 days of illness, with DENV-1-4 real-time RT-PCR plus IgM ELISA or NS1 antigen ELISA (2, 3). Purposes of testing: In surveillance, the test is used to alert health authorities to possible emergence of an outbreak. Tests to identify the cause of an outbreak must be highly sensitive and specific in detecting DENV directly by isolation of the virus, its nucleic acid or its antigen in the acute phase of infection. Infection can also be diagnosed retrospectively from seroconversion of IgM or a four-times increase in IgG between the acute and convalescent values in serum samples collected > 14 days apart. A combination of IgM and either NAATs or antigen detection tests extends the window of detection of acute infection. The tests can also be used to assess the extent of an outbreak, inform control strategies and identify hotspots. High-throughput, ideally highly specific tests that can be used in various populations are required. In research, they are used to assess the impact of control interventions and improve understanding of the pathogen and its pathogenesis. DENV NS1 testing by ELISA or RDT is essential to confirm DENV infection directly, during onset of the disease. Both tests are straightforward EIA and RDT assays, and no significant difficulties have been reported by users. Disposal of the kits is routine and does not require special precautions. How the test is used: Depending on the set-up, the assay can be used at three levels of health systems: primary care centres, district centres and reference centres. A single test is sufficient if the sample is taken within the predefined time. As dengue fever is easily confused with non-dengue illnesses, particularly in non-epidemic situations, the DENV IVD can also be used as a differential test. The NS1 glycoprotein is produced by all flaviviruses and is secreted from mammalian cells. NS1 produces a very strong humoral response. Many studies have shown that detection of NS1 can be used to make an early diagnosis of DENV infection. Commercial kits for the detection of NS1 antigen are available, although they do not differentiate between DENV serotypes.
Public health relevance
Prevalence: Dengue fever is the most rapidly spreading mosquito-borne viral disease in the world. Its incidence has increased 30 times over the past 50 years, with increasing geographical spread to new countries and, in the current decade, from urban to rural settings. An estimated 50 million cases of DENV infection occur annually, and approximately 2.5 billion people live in dengue- endemic countries. World Health Assembly resolution WHA55.17 in 2002 urged greater commitment to dengue by WHO and its Member States. Of particular significance is World Health Assembly resolution WHA58.3 on revision of the IHR in 2005, which included dengue fever as an example of a disease that may constitute a PHEIC, with implications for health security due to disruption and rapid epidemic spread beyond national borders. Socioeconomic impact: The global cost of dengue fever is estimated to be almost US$ 9 billion per year for prevention and control (4), and WHO estimated that more than 3 billion DALYs are lost annually from dengue illness.
WHO or other clinical guidelines relevant to the test
Guidelines for patient care in the Region of the Americas (5).
Evidence for clinical usefulness and impact
In a review of the performance of commercially available NS1 RDTs, Blacksell et al. (6) summarized the results of evaluations of each of the SD Bioline Dengue Duo (Alere, USA) (four studies), the Panbio® Early Rapid NS1 (Alere, USA) (three studies) and the Dengue NS1 Strip (Bio-Rad, France) (12 studies) in various countries. The sensitivity of the RDTs varied from 48.5% to 98.9%, but their specificity was reasonably consistent, all being > 92%. Blacksell et al. (6), however, noted that the comparator used in the studies, RT-PCR or NS1-ELISA, was “skewed”, and the authors did not investigate the possibility of false-negative results by testing paired sera to determine a dynamic rise in serological assays such as IgM- or IgG-capture ELISAs. In studies of the diagnostic accuracy of NS1 assays in primary and secondary infections, the RDTs were generally more sensitive in primary than in secondary infections (7–10).
Evidence for economic impact and/or cost–effectiveness
If only a subset of patients is tested during outbreaks or endemic periods for confirmation, the impact on overall budgets will be small.
Ethical issues, equity and human rights issues
Consent is required to obtain a serum sample. Dengue predominantly affects populations living in poverty, and access to high-quality diagnostics can reduce the burden and improve equity.
1. Peeling R, Murtagh M, Olliaro P. Epidemic preparedness: why is there a need to accelerate the development of diagnostics? Lancet Infect Dis. 2019;19(5):e172–8. 2. Hunsperger EA, Muñoz-Jordán J, Beltran M, Colón C, Carrión J, Vazquez J, et al. Performance of dengue diagnostic tests in a single-specimen diagnostic algorithm. J Infect Dis. 2016;214(6): 836–44. 3. Peeling RW, Olliaro P. Reimagining the future of the diagnosis of viral infections. J Infect Dis. 2016;214(6):828–9. 4. Shepard DS, Undurraga EA, Halasa YA, Stanaway JD. The global economic burden of dengue: a systematic analysis. Lancet Infect Dis. 2016;16(8):935–41. 5. Dengue: Guidelines for patient care in the Region of the Americas. Second edition. Washington DC: Pan American Health Organization; 2016. 6. Blacksell SD. Commercial dengue rapid diagnostic tests for point-of-care application: recent evaluations and future needs? J Biomed Biotechnol. 2012:151967. 7. Guzman MG, Jaenisch T, Gaczkowski R, Ty Hang VT, Sekaran SD, Kroeger A, et al. Multi-country evaluation of sensitivity and specificity of two commercially-available NS1 ELISA assays for dengue diagnosis. PLoS Negl Trop Dis. 2010;4(8):e811. 8. Shu PY, Yang CF, Kao JF, Su CL, Chang SF, Lin CC, et al. Application of the dengue virus NS1 antigen rapid test for on-site detection of imported dengue cases at airports. Clin Vac Immunol. 2009;16:589–91. 9. Hang VT, Nguyet NM, Trung DT, Tricou V, Yoksan S, Dung NM, et al. Diagnostic accuracy of NS1 ELISA and lateral flow rapid tests for dengue sensitivity, specificity and relationship to viraemia and antibody responses. PLoS Negl Trop Dis. 2009;1:e360. 10. Chaiyaratana W, Chuansumrit A, Pongthanapisith V, Tangnararatchakit K, Lertwongrath S, Yoksan S. Evaluation of dengue nonstructural protein 1 antigen strip for the rapid diagnosis of patients with dengue infection. Diagn Microbiol Infect Dis. 2009;64:83–4.