1. CDI Module 16: RDT Training
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on Community-Directed Intervention (CDI) to Improve Access to Essential Health Services

2. Module 16 Objectives By the end of this module, learners will:
Explain why the malaria control program has elected to use RDTs in the country/district
Describe a rapid diagnostic test (RDT)
Name appropriate actions for RDT positive, negative and invalid results
Describe the steps in performing a malaria RDT

3. In Addition, Learners Will …
Demonstrate the correct and appropriate skills for drawing blood safely and effectively with a finger prick
State the universal precautions
Correctly interpret different RDT outcomes
Demonstrate the skills for performing RDT safely and effectively, using the job aid as a guide
State appropriate treatment based on RDT results

4. Why Use RDTs?
Most of the febrile illnesses share common signs and symptoms:
Fever
Headache
Weakness
Positive RDT results help to confirm malaria and thereby differentiate it from other febrile illness
Giving anti-malarial drugs/artemisinin-based combination therapy (ACT) presumptively is expensive and might lead to drug resistance

5. Many Different RDT Products
The World Health Organization and its partners have tested over 400 different types and brands of RDT
RDTs are chosen by each country’s National Malaria Control Program (NMCP) based on factors like …
Malaria prevalence
Stable endemic, year-round
Unstable, epidemic, seasonal
Malaria type
Plasmodium falciparum
Plasmodium vivax

6. Key Similarities among RDTs
Most all RDTs have:
A lancet to draw blood
A tube, pipette or straw to transfer blood
A cassette to deposit blood and display results
A buffer solution to add to the blood

7. Overall Steps for CHWs/CDDs
When training community health workers (CHWs)/
community-directed distributors (CDDs), explain each step and provide an opportunity for them to:
Determine if signs and symptoms suggest malaria
Do RDT
Interpret the test
Take appropriate action
(If RDT result is positive) treat appropriately, according to national standards
(If RDT result is negative) seek further information, and either:
Treat for other conditions like pneumonia or diarrhea
Refer to the nearest health center, if severe
(If RDT result is invalid) repeat test with a new cassette from a different batch

8. Prepare for Demonstration and Return Demonstration for CHWs/CDDs
Assemble all needed materials
Ensure that the RDTs used for the demonstration match those approved by your NMCP
Make sure supportive materials like gloves, sharps box, etc. are available

9. Gather Materials Needed

10. Gather Additional Materials Needed
Biohazard safety box

11. Check Product Expiry Date
Show CDDs where to look for expiry (expiration) date
Explain that expired RDTs will not give correct result
Pass around packets for CHWs to examine and find dates
Discuss importance of planning ahead so RDT stocks do not expire or expired ones are replaced quickly

12. Wear Gloves Why is it important to wear gloves when doing the test?
To protect:
CHWs from possible infection with blood-borne diseases, including HIV/AIDS
Patients from possible infection with blood-borne diseases, including HIV/AIDS

13. Open the Test Packet and Remove the Contents
As you remove each item, hold it up so that everyone can see it
Explain how it is used

14. Review Blood Transfer Devices
Once the packet is opened, the desiccant sachet serves no purpose and should be discarded
It may be harmful if swallowed, so it should be kept away from children

15. Examine the Test Cassette
The square hole, labeled “A,” is where you add the blood
The round hole, labeled “B,” is where you add the buffer
The rectangular hole is the results window where you read the test results
The results window is divided into two sections

16. How to Determine the Diagnosis
The longer section near the letter “T” is where you determine the diagnosis
If a line appears in this section, it means the patient has malaria
If no line appears here, it means malaria was not detected in the patient
Remember that the lines may be different for different brands/types of RDT—so be sure to explain what is currently approved by the NMCP

17. Look for Lines to Appear
The smaller section near the letter “C” tells you whether the test is working correctly
A line must appear in this section for the test to be valid
If no line appears here, the test is not working properly and the results are invalid
If no line appears here, you must discard the cassette and test the patient again using a new test packet that has not been previously opened

18. Label the Test Cassette for Proper Identification
Every patient’s test cassette must be clearly labeled for proper identification

19. Clean to Prevent Infection
Clean the chosen finger with an alcohol swab
This will help to prevent infection of the finger that could be caused by dirt

20. How to Draw Blood
Prick the patient’s finger, preferably toward the side of the pulp (ball) of the finger
Pricking the midline or tip is more painful
Check to be sure the finger prick will produce enough blood
Then discard the lancet in the sharps container

21. Never set the lancet down before discarding it
Follow Universal Precautions to Ensure Blood Safety When Using a Lancet
Remind learners that every time they use a lancet, they must take all of the following steps to ensure blood safety:
Discard the lancet in an appropriate sharps container immediately after using it
Never set the lancet down before discarding it
Never discard the lancet in a non-sharps container
Never use a lancet on more than one person

22. Dispose of Used Materials Safely
Ensure that used sharp objects like lancets and capillary tubes/test tubes are properly discarded immediately after use
Even though it is called “sharps container,” we should dispose of all medical waste in it

23. How to Collect the Patient’s Blood
On the next two slides, we show four blood collection devices
You may show these devices to the CHWs, but give special attention to the device in the current RDT packet or kit

24. Examples of Blood-Collection Devices for RDT: Capillary Tube, Straw

25. Examples of Two More Blood-Collection Devices for RDT: Loop, Pipette

26. Deposit Blood from Collection Device on Cassette and Then Dispose of Blood-Collection Device Safely

27. Dispense the Buffer Reagent Appropriately
Dispense the appropriate number of drops of the buffer reagent to the appropriate hole (round hole) of the cassette
Read out from packet insert the number of drops recommended for the type of RDT being used

28. Time the Test Properly
Make sure the test stands for 15 minutes after adding the buffer, before reading the result
Be sure to read the RDT packet insert because some types call for longer times

29. Dispose of Used Materials Safely
Take care to remove and discard your gloves safely
Plan a system for safe disposal of all RDT waste materials
Decide whether CHWs will dispose of items in the village or bring these items to the health center for disposal

30. How to Interpret the RDT Results
Square hole
(for blood)
The square hole labeled “A” is where you add the blood
The round hole labeled “B” is where you add the buffer
The rectangular hole is the results window where you read the test results
The smaller section near the letter “C” tells you whether the test is working correctly (it is also known as the control)
Round hole
(for buffer)
Test window
“C” control line
“T2” test line
“T1” test line

31. How to Interpret Results of RDTs Designed for More than One Type of Malaria
Lines in “T1” and “T2” and a line in “C” means:
The patient DOES have falciparum malaria monoinfection or a mixed infection
NO LINE in “T1” or “T2” but a line in ‘C’ means: C T1 T2
Negative T1 T2 C
Pf or Mixed +
In the graphic above, Pf = P. falciparum.
The patient DOES NOT have either falciparum malaria or non-falciparum malaria

32. How to Interpret the RDT Results (continued)
Line in “T1” or “T2” and NO LINE in “C” means:
No line in “T1” or “T2” and NO LINE in “C” means: T2 T1 T2
Invalid T1
Invalid
The test is damaged.
Results are INVALID.
The test is damaged.
Results are INVALID.

33. Review Different Possible Results
A line in “T2” and a line in “C” means: T2 T1
Non-Pf +
In the graphic above, Non-Pf = non-falciparum.
The patient DOES have non-falciparum
malaria (P. vivax, P. ovale, P. malariae
or a mixed infection of these).

34. Review Different Possible Results (continued)
A line in “T1” and a line in “C”
means:
The test is POSITIVE even if the line in “T1” is very faint. T1 T2 T2 T1
Pf +
The patient DOES have falciparum malaria.
Pf +

35. RDT Interpretation Chart
Control line
Test lines
P. falciparum line
Pan-specific line
P. falciparum/pan-specific RDT
e.g., detects P. falciparum-specific and other species (P. vivax, P. malariae, P. ovale)
NEGATIVE /
POSITIVE (P. falciparum only)
POSITIVE (P. falciparum and other species)
POSITIVE non-P. falciparum (i.e., other species)
INVALID

36. Can You Interpret These Tests?

37. Interpretations for Test Results 1‒10
P. falciparum
Negative
Invalid (no control)
Non-falciparum (P. vivax, P. ovale, P. malariae, or a mixed infection of these)
Non-falciparum (P. vivax, P. ovale, P. malariae, or a mixed infection of these)
Negative
P. falciparum
P. falciparum or a mixed infection

38. How to Record Results 1‒10 on a Chart
Positive ( + )
Negative (-)
Invalid Pf
Pf or Mixed
Non-Pf 1 ↔ 2 3 4 5 6 7 8 9 10
In the chart above, Pf = P. falciparum.

39. Demonstrate the RDT for Learners
The facilitator will demonstrate the steps in performing an RDT for all to see
He/she will ask questions of the learners as he/she performs the demonstration

40. Review and Questions Which RDT is currently used in your country?
What are the main components of the test?
How do we distinguish between a positive and negative test?
How do we know if a result is invalid or unclear?
What should we do with such results?
How do we know what treatment is appropriate after conducting the RDT?

41. Learners Practice Performing an RDT
Learners will form small groups
Each learner will have a chance to practice the RDT
Group members will give feedback after each person attempts the test
Make copies of the checklist that follows for learners to observe each other

42. RDT Performance Checklist—Procedure 1
Task
1. RDT preparation (four tasks)
Assemble all materials required for the RDT test
Read expiration date
Use test with earliest expiration date
Allow RDT to come to room temperature (if kept in cool storage)

43. RDT Performance Checklist—Procedure 2
Task
2. Patient preparation (four tasks)
Wash hands
Identify patient’s details and record patient’s name on the RDT cassette
Explain procedure to patient. Provide reassurance, as needed
Wear gloves

44. RDT Performance Checklist—Procedure 3
Task
3. Blood collection + dispensing (five tasks)
Select site for blood collection. Clean site with alcohol swab and allow it to dry
Prick site firmly with sterile lancet
DO NOT squeeze finger excessively
Collect an adequate volume of blood
Dispense blood in correct well

45. RDT Performance Checklist—Procedure 4
Task
4. RDT procedure + reading results (four tasks)
Dispense correct volume of buffer
Wait for correct time (according to manufacturer’s instructions)
Verify internal test control
Read results correctly

46. RDT Checklist—Procedures 5, 6, 7
Task
5. Recording results (two tasks)
Record results correctly (including mixed infections if a combo test is used)
Record date and time of reporting results
6. Disposal of infectious material (two tasks)
Dispose of used tests, and transfer devices and other contaminated material to plastic-lined bin
Dispose of used lancet in a sharps container
7. Deliver the results (one task)
Explain to the patient the results and what they mean

47. RDT Performance Checklist
After the small group practice sessions, bring the whole group back together
Ask learners to talk about their experience
Using the checklist findings, ask learners what steps were easy or difficult—and why

48. Summary: RDT Results
If RDT result is positive, treat according to national guidelines
If RDT result is negative, seek further information and either:
Treat for other conditions like pneumonia or diarrhea as seen in our modules, or
Refer to the nearest health center, if severe (i.e., lethargic or unconscious)
If RDT result is invalid, repeat test with a new cassette from a different batch

49. Summary: Safety and Precautions
Employ universal precautions to ensure safety when handling blood:
Always put on gloves before handling blood
Avoid contacting any wound with blood (Wounds must be appropriately covered before conducting the RDT test)
Wash hands appropriately with soap before and after conducting the RDT test
Clean the finger to be pricked with an alcohol swab to prevent infection
Never use a lancet or any blood collection device (loop, capillary tube, straw or pipette) on more than one person
Dispose of all sharp objects appropriately (use a sharps box)
Take care to remove and discard your gloves safely

50. Storing and Using RDTs in the Village
In closing the session, ask CHWs/CDDs to discuss and plan the following:
How can we store RDTs in a safe and cool place in the village?
How can we safely dispose of sharps and medical waste from the RDTs in the village?
How can we explain to patients who believe they have malaria, but their RDT is negative?
What other concerns do you have?