Evaluation of OneStep Dengue NS1 RapiDip TM InstaTest and OneStep
Dengue Fever IgG/IgM RapiCard TM InstaTest during the course of a dengue
type 1 epidemic

Ivan Vickers, Kevin Harvey, Kereann Nelson, Michelle Brown, Marion

Bullock-DuCasse, John Lindo

PII: S0732-8893(17)30271-7
DOI: doi: 10.1016/j.diagmicrobio.2017.08.019
Reference: DMB 14417

To appear in: Diagnostic Microbiology and Infectious Disease

Received date: 24 March 2017

Revised date: 26 July 2017
Accepted date: 22 August 2017

Please cite this article as: Vickers Ivan, Harvey Kevin, Nelson Kereann, Brown Michelle,
Bullock-DuCasse Marion, Lindo John, Evaluation of OneStep Dengue NS1 RapiDipTM
InstaTest and OneStep Dengue Fever IgG/IgM RapiCardTM InstaTest during the course
of a dengue type 1 epidemic, Diagnostic Microbiology and Infectious Disease (2017), doi:
10.1016/j.diagmicrobio.2017.08.019

This is a PDF file of an unedited manuscript that has been accepted for publication.
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 ACCEPTED MANUSCRIPT

Evaluation of OneStep Dengue NS1 RapiDip™ InstaTest and OneStep Dengue Fever
IgG/IgM RapiCard™ InstaTest during the course of a dengue type 1 epidemic
Ivan Vickersa*, Kevin Harveyb, Kereann Nelsona, Michelle Browna, Marion Bullock-DuCasseb,
John Lindoa

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a
Department of Microbiology, The University of the West Indies, Mona, Kingston 7, Jamaica
b
Ministry of Health, Kingston, Jamaica.
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*Corresponding author.

Dr Ivan Vickers
Department of Microbiology,
The University of the West Indies,
Mona, Kingston 7, Jamaica
Email: ilvee2@yahoo.com
Tel.: 1-876-977-2206
Facsimile: 1-876-977-9553

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ABSTRACT

We determined the diagnostic performance of the OneStep NS1 and the OneStep IgG/IgM RDT

kits against a panel of samples which comprised of 174 dengue positive and 165 dengue

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negative sera characterized by three reference enzyme-linked immunosorbent assays (ELISAs).

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The diagnostic sensitivities of the OneStep kits for the detection of individual biomarkers of

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NS1, IgM and IgG were 90% (95% CI: 82.1-94.7), 32.4% (95% CI: 24.8-40.8) and 44.4%

(95% CI: 38.2-50.7), respectively. The combination of the OneStep IgG/IgM kit with the

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OneStep NS1 kit demonstrated significantly higher sensitivities for the combined NS1/IgM
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(96.8%; 95% CI: 90.9-99.3) and NS1/IgM/IgG (99.5%; 95% CI: 97.1-99.9)(p < 0.001). In

conclusion, the OneStep NS1 kit has high sensitivity and specificity and is highly recommended
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for use. The low sensitivities for IgG (44.4%) and for IgM (32.4%) of the OneStep IgG/IgM kit

when used alone suggest it is best used in combination with the OneStep NS1 kit to enhance its
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overall diagnostic performance.

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Keywords: Dengue, NS1, IgM, IgG, sensitivity, Jamaica

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1. Introduction

Dengue virus (DENV) is a positive-sense RNA virus of the genus Flavivirus and the family

Flaviviridae (Gupta et al., 2012). Four antigenically distinct serotypes of dengue virus (DENV-

1, DENV-2, DENV-3 and DENV-4) exist and they are important etiologic agents of dengue

(Henchal et al., 1990). Dengue is transmitted primarily by the bite of female Aedes aegypti and

less commonly Ae. albopictus mosquitoes (McBride et al., 2002; Senanayake, 2006). Patients

with dengue may be asymptomatic or present with a range of symptoms and signs such as fever,

myalgia, arthralgia, retro-orbital pains, skin rash, bleeding episodes, and shock (WHO, 2009;

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Kalayanaroo, 2011; WHO, 2017). First infection with dengue virus is called primary dengue

infection and the patient develops serotype specific protection against later infection (FRY,

2011; WHO, 2017). Subsequent exposure to another serotype results in secondary infection

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which is a risk factor for the development of severe dengue such as dengue hemorrhagic fever

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(DHF) (Halstead, 1998; Guzman, 2002; WHO, 2017). Dengue is endemic in many tropical and

subtropical countries and may give rise to cyclic epidemics (Halstead, 2007; Dick 2012; WHO,

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2017). In 2012 Jamaica experienced a dengue epidemic caused by DENV-1 (Moncayo et al.,

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2015; PAHO, 2012). There were no other arboviruses found to be circulating in Jamaica during

that epidemic based on results obtained from the then Caribbean Epidemiology Centre
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(CAREC)(Personal communication).
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Serologic tests using enzyme-linked immunosorbent assays (ELISAs) have been the mainstay of

dengue diagnostics in many countries since results are available on the same day and they are
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more affordable than molecular detection or viral isolation methods (Dussart, 2006; Hermann,
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2014). However, these ELISAs may be unavailable in some settings in developing countries and

are not ideal to be used at the point of care or for field diagnosis (Gan et al, 2014; Hunsperger et
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al, 2014; Naz et al, 2014). There are several point of care rapid diagnostic tests (RDTs) which

are now widely available (Blacksell, 2012; Hunsperger et al. 2014). These include ones that

detect the non-structural protein 1(NS1) antigen and/or immunoglobulin (Ig)-M and IgG

antibodies (Blacksell, 2012). NS1 is a highly conserved glycoprotein of flaviviruses which recent

studies now implicate as a viral toxin that contributes to vascular leak via activation of

inflammatory cytokines (Beatty, 2015; Modhiran, 2015). NS1 can be detected in serum or

plasma most often from day 1 and up to day 9 after the onset of symptoms, thus making it very

convenient for early dengue diagnosis (Dussart et al., 2006). Anti-dengue IgM antibodies are

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usually not detectable until 3 to 5 days after the onset of symptoms while it takes on average 5-

14 days for anti-dengue IgG detection (Schilling et al., 2004). The OneStep Dengue NS1

RapiDip™ InstaTest (OneStep NS1 RDT) and the OneStep Dengue Fever IgG/IgM RapiCard™

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InstaTest (OneStep IgG/IgM RDT) are marketed in Jamaica and other countries. However, at

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the time of writing, there is no independently published evaluation report on their use for the

detection of dengue biomarkers. We have assessed the diagnostic performance features of these

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two OneStep dengue test kits to determine their suitability for detection of dengue antigen and

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antibodies in a developing country setting as ours.
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2. Material and Methods

2.1 Study site and Design

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Archived single time-point serum samples stored at -70oC in the virology laboratory (Department

of Microbiology, UWI, Kingston, Jamaica) were screened for selection retrospectively. These
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samples were obtained from patients with febrile illnesses and for whom testing of dengue
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biomarkers were requested between October and December 2012. The samples were received

from private and public health facilities across Jamaica inclusive of the University Hospital of
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the West Indies (UHWI), Bustamante Hospital for Children (BHC), Cornwall Regional Hospital

(CRH), St Ann’s Bay Hospital (SABH), Kingston Public Hospital (KPH) and Health Centers of

the Ministry of Health, Jamaica. The inclusion criteria for the sample selection were availability

of information on day(s) after the onset of symptom (DAOS) and sufficient sample volume to do

all tests. Sociodemographic (age, sex, address) and clinical (symptoms, signs, diagnoses)

information about the patients were abstracted from the hospital records. The minimum sample

size for a 95% confidence level and 5% precision level assuming a sensitivity of 70% and a

prevalence of 15% of dengue IgM in the population was determined to be 332 using the method

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of Malhotra and Indrayan (Malhotra and Indrayan, 2010). A total of 339 stored serum samples

met the inclusion criteria and were selected consecutively. Ethical approval (ECP 181, 12/13)

was granted by the ethics committee of the University of the West Indies (UWI)/University

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Hospital of the West Indies (UHWI).

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2.2 Test methods and classification of samples

The SD Dengue NS1 antigen ELISA (Standard Diagnostics Inc., Seoul, Korea) with reported

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sensitivity and specificity of 93.3% and 98.9%, respectively, was used as the reference NS1

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assay (Standard Diagnostics, 2016). The samples were also characterized using the Dengue IgM

ELISA (Focus Diagnostics, Cypress, PA, USA), overall sensitivity 96% and specificity 97%
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(Focus Diagnostics, 2016) and the Dengue IgG antibody capture ELISA (Focus Diagnostics,

Cypress, PA, USA), overall sensitivity 96% and specificity 93% (Focus Diagnostics, 2016b).
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The manufacturers’ instructions were followed for all testing procedures.

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The OneStep Dengue NS1 RapiDip InstaTest (Diagnostic Automation/Cortez Diagnostics,

Inc., CA, USA)(OneStep, 2013) was conducted according to the manufacturer’s instructions.
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Briefly, three drops of chase buffer Type A were added to the sample reservoir well. This was
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followed by placing 50 μl of the test serum sample onto the Sample Pad which was immediately

placed in the reservoir well. The results were read after 30 minutes. The test was interpreted as

positive for NS1 antigen when the control line (C) and the Test line (T) appeared in the test area.

It was read as negative when only the control line appeared.

The procedure of the OneStep Dengue Fever IgG/IgM RapiCard™ InstaTest (Diagnostic

Automation/Cortez Diagnostics, Inc., CA, USA)(OneStep, 2015) was in keeping with the

manufacturer’s guidelines. Briefly, 5 µl of serum was applied to the “SI” area of the card

indicated by the arrow mark. Two drops of sample buffer were next added to the well marked as

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“S”. The results were read after 20 minutes. The test was interpreted as IgM positive if both the

control line and the higher test line appeared. If both the control line and the lower test line

appeared it was read as IgG positive. A negative reading occurred when only the control line

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appeared and if there was no control line it was deemed invalid. Both rapid assays were

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conducted by an operator who was blinded to the dengue reference ELISA results of the samples.

A sample was determined to be positive for dengue based on a positive reaction for dengue

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NS1 antigen and/or dengue IgM using reference ELISAs. A non-dengue sample was defined

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when negative for all three biomarkers (NS1, IgM, IgG) or positive for IgG alone which is an

indicator of previous infection. The IgM/IgG optical density (OD) ratio of ≥1.2 or <1.2 was used
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to designate samples as primary or secondary infections, respectively (WHO, 2009). Blood

samples collected ≤ 5 or  5 DAOS were deemed acute or convalescent samples, respectively.

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Day 0 was defined as the same day of onset of symptom. Infection with dengue was classified as
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dengue fever (DF) or dengue hemorrhagic fever (DHF) based on the suspected clinical diagnoses

reported by the physicians on the request forms received with the blood samples.
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2.3 Data analysis

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Data were tabulated in Microsoft Excel (Microsoft Inc., Redmond, WA, USA) and were

analyzed using Epi info 7 (Centers for Disease Control and Prevention, Atlanta, USA). The chi-

square test and the Fisher’s exact test (two sided) were used to compare categorical variables. A

probability (p) value of ≤0.05 was taken as the level of significant association.

The sensitivity, specificity, kappa coefficient, positive predictive value (PPV), negative

predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-) and

efficiency were calculated using the following formulae in which TP is the number of true

positives, FP the number of false positives, FN the number of false negatives and TN the number

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of true negatives: Sensitivity = TP/[TP + FN]; Specificity = TN/ [TN + FP]; Accuracy = [TP +

TN]/ [TP + TN +FP + FN]; PPV = TP/[TP + FP]; NPV = TN/[TN + FN]; LR+= sensitivity/ [100

- specificity] and LR- = [100 - sensitivity]/specificity. The Landis and Koch criteria for the

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interpretation of kappa were used in which scores of 0.01-0.20, 0.21-0.40, 0.41-0.60, 0.61-0.80

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and 0.81-0.99 indicate slight, fair, moderate, substantial and almost perfect agreement,

respectively (Landis and Koch, 1977).

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3. RESULTS

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3.1 Characteristics of the study population MA
One hundred and seventy four (51%) of the 339 patients were serologically confirmed with
dengue infection as they were positive for NS1 and/or IgM using reference ELISAs. Thirty of
the 165
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Table 1 Demographic characteristics of the patients whose samples were tested.

Characteristics Total Dengue Non-dengue
No of patients 339 174 (51 %) 165 (49 %)
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Sex (male/female) 178/161 88/86 90/75

Median age (range) 13yr. (10d-95yr.) 12yr. (10d-65yr.) 13yr. (14d-95yr.)
Time of specimen collection
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(DAOS)
≤5 days (acute) 281 (83%) 144 (83%) 137 (83%)
>5 days (convalescent) 58 (17%) 30 (17%) 28 (17%)
Median (range) 4 (1-22) days 4 (1-22) days 3.5 (1-14) days
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Clinical symptoms a
Fever 146 (91%) 93 (95%) 53 (85%)
Headache 37 (23%) 25 (26%) 12 (19%)
Eye pain 29 (18%) 19 (19%) 10 (16%)
Rash 11 (7%) 6 (6%) 5 (8%)
Bleeding 25 (16%) 17 (17%) 8 (13%)
Joint pain 16 (10%) 10 (10%) 6 (10%)
Classification of dengue
Suspected DF 155 (46%) 155 (89%) 0
Suspected DHF 19 (6%) 19 (11%) 0
Primaryb 77 (23%) 77 (44%) 0
Secondaryc 97 (29%) 97 (56%) 0
DAOS = day(s) after the onset of symptom; DF = dengue fever; DHF = dengue hemorrhagic fever; a = complete
information was available for 160 patients (98 dengue and 62 non-dengue); b = based on an IgM/IgG optical density
ratio of ≥1.2; c = based on an IgM/IgG optical density ratio of <1.2; d = days; yr. = years. + = ELISA positive

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non-dengue patients were negative for all 3 dengue biomarkers (NS1, IgM and IgG) while 135

were positive for IgG alone.

3.2 Test Performance of the OneStep NS1 RDT

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The performance of the OneStep NS1 RDT was compared to the reference SD NS1 ELISA

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(Table 2). The OneStep NS1 RDT correctly identified 81 of the 90 SD NS1 ELISA positive

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dengue

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Table 2 Overall Performance characteristics of the OneStep dengue kits compared to reference ELISAs
OneStep
Sensitivity% Specificity% PPV % NPV % Accuracy Kappa
dengue
(95% CI) (95% CI)
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parameter

NS1 90 96.8 91 96.4 95 0.87

(82.1-94.7) (93.8-98.4) (83.3-95.4) (93.3-98.1) (92.1-96.9) (0.77-0.98)
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32.4 94.9 82.1 66.1 68.7 0.3

IgM
(24.8-40.8) (90.9-97.5) (69.6-91.1) (60.2-71.6) (63.6-73.4) (0.21-0.39)
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44.4 95.1 96.6 35.3 56.6 0.25

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IgGa
(38.2-50.7) (88.0-98.7) (91.6-99.1) (29.0-42.0) (51.3-61.8 (0.18-0.33)

NS1/IgM 96.8 100 100 98 98.8 0.97

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(90.9-99.3) (97.6-100) (96.0-100) (94.4-99.6) (96.5-99.6) (0.85-1.1)

79.6 100 100 53.1 83.4 0.59

IgM/IgG
(73.1-85.1) (91.8-100) (97.5-100) (41.7-64.3) (78.0-87.7) (0.48-0.71)

99.5 100 100 96.4 99.5 0.98

NS1/IgM/IgG (97.1-99.9) (87.5-100) (98.0-100) (82.3-99.4) (97.4-99.9) (0.85-1.1)
a The detection of IgG is not definitive for a diagnosis of dengue and results are included for comparative purposes
only. PPV = positive predictive value; NPV = negative predictive value; IgM/IgG = IgM and/or IgG; NS1/IgM = NS1
and/or IgM; NS1/IgM/IgG = NS1 and/or IgM and/or IgG

samples giving a sensitivity of 90%. Of the 249 SD NS1 ELISA negative samples, the OneStep

NS1 RDT result was negative in 241 samples with a specificity of 96.8%.

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The positive predictive value (PPV) was calculated as 91% while the negative predictive value

(NPV) was 96.4%. The likelihood ratio of a positive OneStep NS1 RDT was 28 (95% CI: 21.9-

35.9) and the likelihood ratio of a negative test was 0.1 (95% CI: 0.08-0.13). The overall

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diagnostic accuracy of the test kit was assessed as 95% (95% CI: 92.1-96.9) and the kappa value

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was 0.87 (95% CI: 0.77-0.98).

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The sensitivity of the OneStep NS1 in acute and convalescent samples were 89.4% and 90.5%,

respectively (Table 3). The assay was able to detect NS1 antigen from day 0 to 13 days after the

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onset of symptom. In general, the sensitivity of the OneStep NS1 RDT in primary infection was
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89.8% and was not significantly different from that of 90.3% in secondary infection (Table 3).

Table 3 Effect of variables on the sensitivities of OneStep kits for NS1 and IgM detection.
NS1 sensitivity IgM sensitivity
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Variables p value p value

% (95% CI) % (95% CI)
Time of specimen collection
Acute 89.4 (79.7-94.8) 1.00 a 25.8 (17.3-35.9) 0.148a
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Convalescent 90.5 (71.1-97.4) 44.9 (30.7-59.8)

Immune status
Primary 89.8 (79.5-95.3) 1.00 b 62.7 (49.2-75.0) <0.001b
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Secondary 90.3 (75.1-96.7) 10.8 (5.1-19.6)

Clinical diagnosis
Suspected DF 91.0 (82.6-95.6) 0.34 c 32.8 (24.7-41.8) 0.95c
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Suspected DHF 83.3 (55.2-95.3) 29.4 (10.3-56.0)

Dengue biomarkers
NS1 positive - 58.6 (44.9-71.4) <0.001d
NS1 negative - 14.3 (7.6-23.6)
IgG positive 86.8 (72.7-94.3) 0.737 e 19.4 (12.5-28.2) <0.001e
IgG negative 90.4 (79.4-95.8) 73.5 (55.6-87.1)
IgM positive 86.7 (70.3-94.7) 0.725 f -
IgM negative 86.8 (72.7-94.3) -
DF = dengue fever; DHF = dengue hemorrhagic fever; a = comparing acute and convalescent; b = comparing
primary and secondary; c = comparing DF and DHF; d = comparing NS1 positive and NS1 negative;
e = comparing IgG positive and IgG negative; f = comparing IgM positive and IgM negative.

The OneStep NS1 RDT sensitivity among those with suspected DHF of 83.3 % was not

significantly different from the 91% for those with suspected DF (Table 3). The NS1 detection

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rate in the presence of IgM and IgG was 86.7% and 86.8%, respectively (Table 3). The presence

or absence of IgM and/or IgG in sera did not significantly influence the sensitivity of the

OneStep NS1 RDT.

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3.3 Test performance of the OneStep IgG/IgM RDT

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The OneStep IgG/IgM RDT detected 46 of the 142 reference IgM-positive and 114 of the 257

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reference IgG-positive samples. The sensitivity, specificity, positive and negative predictive

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values of the OneStep IgM parameter compared to the reference IgM ELISA were 32.4% (95%

CI: 24.8-40.8), 94.9% (95% CI: 90.9-97.5), 82.1% (95% CI: 69.6-91.1) and 66.1% (95% CI:
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60.2-71.6), respectively (Table 2). The sensitivity and specificity of the OneStep IgG parameter

were 44.4% (95% CI: 38.2-50.7) and 95.1% (95% CI: 88.0-98.7), respectively. The sensitivity
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of the OneStep IgM was significantly lower (p < 0.001) in secondary (10.8%; 95% CI: 5.1-19.6)
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compared to primary (62.7%; 95% CI: 49.2-75.0) infection status (Table 2). The sensitivity was

also lower in acute (25.8%) than in convalescent (44.9%) samples although this was not of
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statistical significance (p = 0.148). The IgM sensitivity was significantly higher (p < 0.001) in
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NS1 positive samples (58.6%; 95% CI: 44.9-71.4) than in NS1 negative samples (14.3%; 95%

CI: 7.6-23.6). Similarly, there was significantly (p < 0.001) higher IgM sensitivity in samples

that were IgG negative (73.5%; 95% CI: 55.6- 87.1) than in those that were IgG positive (19.4%;

95% CI: 12.5-28.2).

Combining the OneStep IgG/IgM kit with the OneStep NS1 kit resulted in significantly

higher sensitivities for the detection of NS1/IgM (positive for NS1 and/or IgM biomarkers) and

NS1/IgM/IgG (positive for NS1 and/or IgM and/or IgG biomarkers) (p < 0.001). The

sensitivities for the deteciton of NS1/IgM and NS1/IgM/IgG were 96.8% (95% CI: 90.9-99.9)

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and 99.5% (95% CI: 97.1-99.9), respectively, both with 100% specificities and positive

predictive values (Table 2).

4. Discussion

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This is the first published independent evaluation of either OneStep kits. Tests to detect dengue

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NS1 antigen are considered as useful in expanding the diagnostic window of opportunity for

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dengue when compared to the gold standards of virus isolation and molecular detection methods

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(Hirayama et al., 2012; Poloni et al., 2010). This is because NS1 antigen is usually detected

before the emergence of antibodies and circulate in serum for longer periods than viral RNA.
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Most studies have demonstrated that NS1 antigen is detected from day 1 to day 8 or 9 (Alcon et

al., 2002; Dussart et al., 2006). In this study we were able to detect NS1 antigen for a longer
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period from day 0 to day 13. Our findings were supported by others who have found NS1

antigen in patients’ sera up to day 14 and even up to day 18 (Wang and Sekaran, 2010; Xu et al.,
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2006).
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There was no significant difference found between the sensitivities of OneStep NS1 RDT

when using acute or convalescent samples. Our results are in agreement with those of Gan et al.
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(Gan et al., 2014) and Sanchez-Vargas et al. (Sanchez-Vargas et al., 2014) who have evaluated

some other NS1-based kits. Gan et al. (Gan et al., 2014) reported sensitivities of 86% and 79.4%

for early (≤5 days) and late (> 5 days) presentations from fever onset, respectively, while using a

composite reference standard of PCR, virus isolation and serology. Sanchez-Vargas et al.

(Sanchez-Vargas et al., 2014) used an ELISA reference standard in their study and described

sensitivities of 87.3% and 90% for acute and convalescent dengue, respectively.

Most studies reported higher NS1 sensitivities in primary versus secondary infections and

these have been explained by the presence of anti-NS1 IgG antibodies which form complexes

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with NS1 antigens (Andries et al., 2012; Osorio et al., 2010). In the present study the sensitivity

in primary and secondary infections were comparable and the presence or absence of dengue

IgM and/or IgG antibodies did not significantly affect the NS1 detection rates. Others have also

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reported similar findings to ours (Andries et al., 2012; Osorio et al., 2010). The differences

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amongst the reported studies may be, in part, a result of using different comparators and dengue

serotypes (Hermann et al., 2014; Pal et al., 2014).

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The sensitivities of the OneStep IgG/IgM kit for the detection of dengue IgG and IgM were

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low (44.4% and 34.2%, respectively) despite having high specificities. The manufacturer

reported a 100% agreement with the Dengue DUO cassette (Panbio, Australia) in a study of 60
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positive and 40 negative sera (OneStep Dengue Fever IgG/IgM RapiCard™ InstaTest, 2013).

The Dengue DUO cassette itself was evaluated to have moderate sensitivities of 67.3% and
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81.8% for the detection of IgM by Nga et al. (Nga et al., 2007) and Moorthy et al. (Moorthy et
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al., 2009, respectively. The OneStep IgM sensitivity was observed to be significantly higher in

primary infection than in secondary infection. It was also found to be significantly higher in
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NS1 positive and IgG negative samples compared to NS1 negative and IgG positive samples.
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All these findings are in agreement with primary infection status where IgM antibodies are the

first to appear followed by IgG antibodies in low titers.

Despite the low sensitivities of the individual IgM and IgG parameters of the OneStep

IgG/IgM RDT kit there were remarkable improvements in sensitivities when this kit was

combined with the OneStep NS1 kit. This suggests that the OneStep IgG/IgM RDT kit should

not be used alone but in conjunction with an antigen detection kit. While we support the

usefulness of the OneStep NS1 RDT to aid in the detection of NS1 biomarkers during dengue

serotype 1 infections, we would recommend that the OneStep IgG/IgM kit be used in

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combination with assays that detect dengue NS1 antigens. These OneStep kits should also be

evaluated using samples of other dengue serotypes in our setting since some authors have

reported significant decreases in test sensitivities with dengue serotypes 2 and 4 (Blacksell et al.,

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2006; Osorio et al., 2010).

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In the present study the OneStep dengue RDTs were compared to three reference dengue

ELISAs. Many studies have shown the superior diagnostic performance characteristics of

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ELISAs over RDTs (Hang et al., 2009; Pal et al., 2014; Solanke et al., 2015). Discrepant results

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between the OneStep dengue rapid tests and our reference ELISAs may be due to the different

design of these kits. Design features such as the methods of preparing and coating of
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antigens/antibodies may affect kit performance.

One weakness of this study was the use of only serological methods to define dengue
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positive and dengue negative cases which could have been improved by the use of molecular
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and/or virus isolation methods but these were not available at our laboratory. Also, we used

single serum samples and not paired samples which would be better able to identify dengue
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seroconversion. However, the overall results of this study are consistent with the growing body
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of evidence which shows enhanced diagnostic sensitivities when dengue antigen and antibody

detections are combined (Gan et al., 2014; Hermann et al., 2014).

The current evaluation of the OneStep NS1 RDT shows it has high sensitivity and specificity

whereas the OneStep IgG/IgM RDT was of low sensitivity despite exhibiting high specificity.

The OneStep IgG/IgM kit when used together with the OneStep NS1 kit demonstrated

significantly higher sensitivities which support the combined testing strategy of antigen and

antibody detection in dengue diagnostics.

Conflict of interests: None

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Funding

The study was financially supported by the Government of Jamaica and the USAID PEPFAR

Project. The funding body had no role in the design of the study, data collection, data analysis,

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results interpretation and in the writing of the manuscript.

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Acknowledgements

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The authors would like to thank the members of staff of the Department of Microbiology (UWI)

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for their invaluable input.

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Evaluation of OneStep Dengue NS1 RapiDip™ InstaTest and OneStep Dengue Fever IgG/IgM
RapiCard™ InstaTest during the course of a dengue type 1 epidemic

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Highlights

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 The OneStep dengue NS1 antigen test is highly sensitive for the diagnosis of dengue.

 The OneStep dengue IgG/IgM test has low sensitivity despite high specificity.
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 Combining the OneStep dengue NS1 test with the OneStep dengue IgG/IgM test significantly improves
the overall sensitivity versus the IgG/IgM test alone.
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