title: Leishmaniasis direct agglutination test: using pictorials as training materials to reduce inter-reader variability and improve accuracy.
abstract: BACKGROUND
  The Direct Agglutination Test (DAT) has a high diagnostic accuracy and remains, in some geographical areas, part of the diagnostic algorithm for Visceral Leishmaniasis (VL). However, subjective interpretation of results introduces potential for inter-reader variation. We report an assessment of inter-laboratory agreement and propose a pictorial-based approach to standardize reading of the DAT.
  
  
  METHODS
  In preparation for a comparative evaluation of immunochromatographic diagnostics for VL, a proficiency panel of 15 well-characterized sera, DAT-antigen from a single batch and common protocol was sent to nine laboratories in Latin-America, East-Africa and Asia. Agreement (i.e., equal titre or within 1 titer) with the reading by the reference laboratory was computed. Due to significant inter-laboratory disagreement on-site refresher training was provided to all technicians performing DAT. Photos of training plates were made, and end-titres agreed upon by experienced users of DAT within the Visceral-Leishmaniasis Laboratory-Network (VL-LN).
  
  
  RESULTS
  Pre-training, concordance in DAT results with reference laboratories was only 50%, although agreement on negative sera was high (94%). After refresher training concordance increased to 84%; agreement on negative controls increased to 98%. Variance in readings significantly decreased after training from 3.3 titres to an average of 1.0 titre (two-sample Wilcoxon rank-sum (Mann-Whitney) test (z = -3,624 and p = 0.0003)).
  
  
  CONCLUSIONS
  The most probable explanation for disagreement was subjective endpoint reading. Using pictorials as training materials may be a useful tool to reduce disparity in results and promote more standardized reading of DAT, without compromising diagnostic sensitivity.
authors.affiliation: Royal Tropical Institute Koninklijk Instituut voor de Tropen, Amsterdam, The Netherlands. e.adams@kit.nl
authors.forename: Emily R
authors.initials: ER
authors.lastname: Adams
authors.forename: Diane
authors.initials: D
authors.lastname: Jacquet
authors.forename: Gerard
authors.initials: G
authors.lastname: Schoone
authors.forename: Kamlesh
authors.initials: K
authors.lastname: Gidwani
authors.forename: Marleen
authors.initials: M
authors.lastname: Boelaert
authors.forename: Jane
authors.initials: J
authors.lastname: Cunningham
mesh_terms: D000351:Africa, Eastern; D000372:Agglutination Tests / Q000379:methods* / Q000592:standards*; D001208:Asia; D006302:Health Services Research; D006801:Humans; D059021:Laboratory Proficiency Testing; D007843:Latin America; D007898:Leishmaniasis, Visceral / Q000175:diagnosis*; D015588:Observer Variation; D010274:Parasitology / Q000193:education* / Q000379:methods*; D012680:Sensitivity and Specificity