Diagnostic performance of four hepatitis-B surface antigen conformité Européenne (CE) marked and one WHO prequalified rapid diagnostic tests in Uganda

Leah Naluwagga Baliruno; Charles Drago Kato; Harriet Nakigozi; Huzaima Mujuzi; Emmanuel Seremba

doi:10.1371/journal.pone.0346259

. 2026 Apr 8;21(4):e0346259. doi: 10.1371/journal.pone.0346259

Diagnostic performance of four hepatitis-B surface antigen conformité Européenne (CE) marked and one WHO prequalified rapid diagnostic tests in Uganda

Leah Naluwagga Baliruno ^1,^*, Charles Drago Kato ², Harriet Nakigozi ¹, Huzaima Mujuzi ³, Emmanuel Seremba ⁴

Editor: Seth Agyei Domfeh⁵

PMCID: PMC13061167 PMID: 41950204

Abstract

Background

Globally, over 254 million people are infected with chronic Hepatitis B (HBV). Eighty million of these reside in sub-Saharan Africa (SSA). HBV claims an estimated one million lives annually. Efforts to eradicate it from SSA have been slow, partly due to a lack of affordable, accurate screening tools. The diagnostic accuracy of the commonly used rapid diagnostic tests (RDTs) in SSA is poorly understood; hence a need to characterize the validity of five RDTs being used for HBV diagnosis using the Hepatitis B surface antigen (HBsAg) serologic marker.

Methods

In this case-control study with 1:1 case: control matching, and a prevalence of 50%, 200 samples of residual donor blood were tested using RDTs against the reference test Fortress Diagnostic, 2016 Enzyme-Linked Immunosorbent Assay (ELISA). They were subsequently subjected to five RDT kits: the SD Bioline (Abbott Diagnostics Korea Inc.), a World Health Organization (WHO) pre-qualified test kit, and four Conformité Européenne (CE) Marked RDTs: One-Step, NOVA (Atlas Link Technology), Astracare (Astra Biotech GmbH), and Accurate (Pharmagen Uganda Ltd). Sensitivity and specificity were computed using ELISA as the reference test. The Statistical Program for Social Sciences (SPSS) was used for statistical analysis.

Results

All five RDT brands demonstrated a sensitivity of 93% (95% CI 93%− 93%). Their specificity, however, ranged from 95% (95% CI 94.9%− 97.8%) for Astracare to 98% (95% CI 94.9%− 98.0%) for SD Bioline.

Conclusion

All the RDTs demonstrated good specificity and good performance characteristics. CE-marked RDTs thus present an opportunity for massive screening of the at-risk populations in the WHO-led campaign to eliminate HBV as a public health threat in Uganda and other low-resource settings by 2030.

1. Introduction

Hepatitis B virus (HBV) is a common cause of viral hepatitis infection with possible complications of liver failure, cirrhosis, and hepatocellular carcinoma that are responsible for an estimated mortality of 500,000–1.2 million worldwide every year [1]. Currently, the global mortality from viral hepatitis exceeds that of HIV, TB, or malaria, and is likely to exceed the toll from those three diseases combined by 2040 [2]. An estimated 1.3 million people died from viral hepatitis in 2022, from data obtained from 187 countries, and viral hepatitis is one of the communicable diseases for which mortality is increasing. Out of the 1.3 million deaths caused by hepatitis, hepatitis B caused 1.1 million deaths. The WHO African Region accounts for 63% of new hepatitis B infections. Additionally, the diagnosis coverage and end treatment coverage among all people with hepatitis B was 4% and 0.2% by the end of 2022 [3].

In its bid to eliminate HBV as a public health threat by 2030, the WHO has identified the shortage of screening tools as one of the key challenges that must be addressed for the success of the campaign [4]. This challenge is undoubtedly huge in low-resource settings, including sub-Saharan Africa. Screening and diagnosis of HBV infections is usually achieved through testing for the hepatitis B surface antigen (HBsAg). This is the first serological marker to appear in blood following infection and it becomes detectable during the incubation period [5]. Its presence signifies current infection. Several serological methods are available to detect HBsAg, including Enzyme Immuno Assays (EIA), and lateral flow or rapid diagnostic tests [6].

The EIA methods are generally used by reference laboratories and blood banks. Routine clinical testing in low-resource settings employs Rapid Diagnostic tests (RDTs) that are based on immunochromatographic principles. These tests are relatively less expensive, require minimal infrastructure and training, and provide an easy-to-interpret result within 30 minutes [7]. Various brands of RDTs demonstrated varied performance in different settings.

Varied performance characteristics were, however, recorded in East and West African populations. In Gabon, the sensitivity of the Biosynex Immunoquicks HBsAg kit was 78.0% and specificity 100% [8], and in Togo, the sensitivity of the RDT kits was 70.0% for Acon HBsAg and 95.6% for OnSite HBsAg Rapid Test-Cassette. Both kits demonstrated a specificity value of 100.0% [9]. Furthermore, in a meta study conducted, thirty studies assessed the diagnostic accuracy of 33 brands of RDTs in 23,716 individuals from 23 countries using EIA as the reference standard. The pooled sensitivity and specificity were 90.0% (95% CI: 89.1, 90.8) and 99.5% (95% CI: 99.4, 99.5), respectively, but accuracy varied widely among brands [10]. In Uganda, data from a hospitalized population demonstrated that the Cortez rapid brand had a poor sensitivity of 43.5% and specificity of 95.8% [11].

Since 2017, the WHO has recommended one-step testing for HBV using rapid diagnostic tests in high-prevalence settings [12]. We therefore aimed to calculate the sensitivity and specificity of 4 brands of RDTs in Uganda.

2. Materials and methods

2.1. Study design

The study was carried out at the Uganda Blood Transfusion Service (UBTS), a regional branch in Kampala, Uganda, between April and May 2021. In this case-control study, five brands of hepatitis B rapid diagnostic test kits (RDTs) were evaluated for their diagnostic accuracy for viral hepatitis B. These included a WHO-prequalified SD Bioline and four CE-marked brands: One Step, NOVA, Astra care and Accurate.

2.2. Sample size determination and sample collection

A sensitivity of 98.9% and specificity 96.7% got from a meta-analysis study [13] was rounded up to a conservative sensitivity and specificity of 95% which was used in Buderer’s formula for sample size calculation in diagnostic accuracy studies. The case control prevalence of 50%, a confidence interval of 95%, and a width of 5% was used in the Buderers’ formula. Thereafter, a sample size of 99 and 34 for specificity and sensitivity, respectively, was obtained. For Buderer’s formula, it states that where sensitivity and specificity are equally important to the study, the sample size for both sensitivity and specificity is determined separately, and the final sample size of the study would be the larger of these two. Given the case–control design with an assumed prevalence of 50%, the sample included 73 cases and 73 controls, making a total sample size of 146. To account for potential data loss, invalid test results, or incomplete records, an additional 10% was considered, yielding a final target sample size of approximately 160. Therefore our minimum sample size was 160 samples.

Two hundred previously collected donor blood samples available at UBTS regional branch in Kampala were purposively selected based on their HBsAg status (positive or negative for HBsAg). These were used to evaluate the diagnostic performance of five HBsAg RDTs which were particularly selected and evaluated due to their availability for routine use for HBV testing in many clinical settings in the country.

Enzyme-Linked Immunosorbent Assay (ELISA) was used as the reference standard, following the national blood bank testing algorithm. It was the only available reference standard at the time, hence this choice of reference standard. Only viable serum donor blood samples were evaluated. We included all serum samples that were sufficient in volume, < 0.75µl, and non-haemolysed. Multiple operators were available for laboratory testing.

2.3. Data collection and laboratory procedures

Data on socio-demographic and clinical characteristics including age, sex, area of residence, blood type, and co-infection was retrieved from archived data stored on the regional blood bank database in Kampala.

2.3.1. Laboratory procedures.

All laboratory procedures were carried out at the UBTS laboratory in Kampala, Uganda.

2.3.1.2 ELISA laboratory procedure. Reference testing was done using the Fortress Diagnostic, 2016 Enzyme-Linked Immunosorbent Assay (ELISA) done according to manufacturer’s instructions. It has a specificity of 99.97% and sensitivity 99.99% [14].

2.3.1.3 Rapid diagnostic testing. Following World Health Organization guidelines [15], HBsAg testing using rapid diagnostic tests was done on previously collected blood samples from the blood bank and tested in parallel using brands One Step Hepatitis B surface antigen Test^® Strip (Accurate, China), NOVA test^® China, Astracare^® China, Accurate^® China and SD BIOLINE HBsAg WB, Abbott, Standard Diagnostic Inc, Korea Abbott Diagnostics Korea Inc. Samples were added to each of the test kits in accordance with the manufacturer’s instructions that were clearly stated in the package inserts of each brand. Average read time for the four test kits was 10–20 minutes. The presence of HBsAg triggered the chemical reaction leading to a pink/red color observed in the test region and a similar pink/red colored band in the control region. In the absence of HBsAg, only one colored band appears in the control region and none in the test region. The total absence of color in both regions constituted an invalid test result [16]. The results were then recorded in a record form, dated and initialed by the reader. After test performance, a picture was taken of the RDT within the time period that test interpretation could be done. In case of RDT failure, the assay was repeated. When the results were discordant between the RDT test and the reference assay, those specimens with results discrepancies from the reference result were retested in duplicate using the same lot number by the same operator. The results that occurred two out of three times were recorded as the final result. When the result was discrepant again, the specimen was retested on a second lot number, if it was available. If the result on the second lot was concordant with the reference result, no further testing was performed. If the result was still discrepant from the reference results, the result was recorded as is [17].

2.4. Data analysis

The results generated were recorded onto worksheets and entered in excel, the collected data was then coded. The data was cleaned and checked for accuracy. The Statistical Program for Social Sciences (SPSS 20.0 for windows; SPSS Inc. Chicago, IL) was used for statistical analysis. The sensitivity and specificity of the HBsAg tests in detecting HBV infection were calculated. Pearson Chi-square test was applied for categorical variables as appropriate. P values of less than 0.05 were used to indicate statistical significance.

2.5. Ethical considerations

The Mulago Hospital Research and Ethics Committee (MHREC) approved the study and granted a waiver of informed consent for Protocol MHREC 2048. All methods were performed per the relevant guidelines and regulations. Administrative clearance was obtained from UBTS before the study. The research type did not require individual informed consent.

3. Results

3.1. Socio-demographic and clinical characteristics

We included 200 samples in this study. The study population consisted of young blood donors with a mean age of 26 years. The majority of participants 119 (59.5%) were male. Most of the participants were of blood group O + 83 (49.1%) followed by A + 48 (28.7%) and B + 27 (16.2%) respectively. Infection with HIV, viral hepatitis C and syphilis were uncommon in this population each at 3 (1.5%) (Table 1).

Table 1. Socio-demographic characteristics of blood donors.

Characteristics	Total N = 200
Sex
Male	119 (67.2%)
Female	58 (32.8%)
Age group (years)
≤ 20	62 (35%)
21-30	66 (37.3%)
31-40	35 (19.8%)
41-50	12 (6.8%)
51-60	2 (1.1%)
Region
Central region	118 (67.8%)
Northern region	12 (6.9%)
West/South-Western region	21 (12.1%)
Eastern region	23 (13.2%)
Blood group
A+	48 (28.7%)
B+	27 (16.2%)
O+	82 (49.1%)
AB+	8 (4.8%)
B-	1 (0.6%)
O-	1 (0.6%)
Co-infection
None	193 (96%)
Syphilis	3 (1.5%)
HCV	3 (1.5%)
HIV	3 (1.5%)
HbsAg status
Positive	100 (50%)
Negative	100 (50%)

Open in a new tab

* indicates statistical significance of a variable.

3.2. Sensitivity and specificity

All the study RDTs (SD Bioline, Astracare, Accurate, One Step and NOVA) demonstrated a sensitivity 93% (95% CI 93%−93%) against the ELISA platform. There was however a difference in specificity, with the SD Bioline having the highest specificity of 98% (95 CI 94.9%− 97.8%), followed by One Step at 97% (95 CI 94.9%− 97.8%). Astracare had the lowest specificity of 95% (95 CI 94.9%− 97.8%). Both Accurate and NOVA had the same specificity of 96% (95 CI 94.9%− 97.8%) (Table 2).

Table 2. Sensitivity and specificity of the five brands of RDTs in the detection of HBsAg.

RDT brands	True positive rate	Sensitivity (Se) (95% CI)	True negative rate	Specificity (Sp) (95% CI)
SD BIOLINE	93/100	93.0% (93.0% − 93.0%)	98/100	98.0% (94.9%− 98.0%)
ASTRACARE	93/100	93.0% (93.0% − 93.0%)	95/100	95.0% (94.9%− 97.8%)
ACCURATE	93/100	93.0% (93.0% − 93.0%)	96/100	96.0% (94.9%− 97.8%)
ONE STEP	93/100	93.0% (93.0% − 93.0%)	97/100	97.0% (94.9%− 97.8%)
NOVA	93/100	93.0% (93.0% − 93.0%)	96/100	96.0% (94.9%− 97.8%)

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4. Discussion

Our study is among the first in Uganda to evaluate the diagnostic performance of multiple brands of RDT kits for HBsAg detection. All five brands – SD Bioline, Accurate, Astracare, One Step, and NOVA tested. All RDTs fell short of the WHO prequalification criteria of sensitivity set at >99%. All the kits demonstrated the same sensitivity and the specificity findings were comparable across the various kits. However the sensitivity of 93% (95% CI 93%− 93%) in this study is lower than of 100% (95% CI 98.3%− 100%) recorded by the manufacturers [18]. In earlier studies in the Ivory Coast [19], Mongolia [13], and the Democratic Republic of Congo (DRC) [20], this kit showed a better performance with a sensitivity ranging from 98.84−100%. Unlike our study, in these populations; it met the WHO prequalification criteria of a sensitivity of ≥99% [21]. Lower sensitivities can lead to missing out on HBV cases [9]. The other brands, Astracare, Accurate, One Step and NOVA also had sensitivities of 93% (95% CI 93%− 93%) in this study, which is below the manufacturers claim of a sensitivity of >99.0%. Our findings are also lower than the 100% sensitivity recorded in the Democratic Republic of Congo [20] and in Mongolia [13]. Comparison of the performance of the Astracare and NOVA elsewhere was hindered by paucity of data in other settings. It is not clear why the diagnostic accuracy of the above kits was lower in Uganda as compared to other African countries and elsewhere. However, previous disparities in sensitivity results of rapid tests have been attributed to the existence of mutant viruses which have modified surface antigens (HBsAg) that are not readily detectable by routine immunological techniques impossible, lower HBsAg concentration and viral load that could lead to a false-negative reaction [19].

With regard to specificity, SD Bioline had a specificity of 98% (95% CI 94.9%−98.0%), the highest among the RDTs tested. This is closer to the specificity of 100% (95% CI 99.5%−100%) that was recorded by the manufacturers and comparable with the 97.1% (95% CI 96.4%–100.0%) and the 99.82% (95% CI 98.88%−100%) recorded in earlier studies in Ivory Coast [19] and DRC [20]. Similarly, the other four study kits had specificity values ranging from 95–97%, comparable to the 97.0% listed by their manufacturers. Thus, all the study RDTs met the WHO recommendation of a specificity of ≥95% [21]. For the purposes of screening and diagnosis, the sensitivity and specificity profiles of the rather inexpensive RDTs: Astracare, Accurate, One Step, and NOVA would qualify them as reasonably accurate and affordable testing platforms in resource-limited settings whose populations are highly under-tested for HBV. They would indeed be an invaluable tool to reducing the screening gap, particularly in Uganda where the population has an estimated 52% lifetime exposure to HBV, and yet 9 out of every 10 people have never tested for the disease [22]. In Uganda and some other settings where confirmatory nucleic acid testing is offered by the government or other stakeholders, false-positive results are preferable to false-negative results as positive serology often triggers repeat testing with alternative methods for case confirmation [23]. False-negative results are a potential vehicle of silent transmission and spread of the disease infection among people [19].

Generally, RDT tests with high sensitivity and negative predictive values would be more beneficial than those with high specificity and positive predictive values for routine use in poor resource settings, since negative samples from patients referred for HBV screening are rarely re-tested due to financial constraints [6]. Positive and negative predictive values are influenced by the prevalence of the disease in the population, affecting how we interpret positive and negative test results. This necessitates different approaches to follow-up testing and diagnosis confirmation depending on the epidemiological context [24].

In this study, the prevalence of HBsAg is higher in males than in females. This finding is consistent with the other African studies in South Africa [22] and Rwanda and could be attributed to males being more prone to high-risk behaviors like sexual contact, promiscuity, violence, and conflicts in which blood contact may occur [25]. The age group 21–30 years had the highest prevalence of HBsAg in this study. This is consistent with previous findings [26] and could be a reflection of the sexual transmission, as this is the most sexually active age group [27]. HBV infection being higher in younger people may also be due to their greater exposures and interaction in society as compared to children and aged persons [28]. This calls for strengthening of measures for the prevention of childhood transmission of HBV.

This study has some limitations: It was performed among blood donors who are generally healthy individuals thus results may not be generalizable to less-healthy populations such as persons living with co-infections such as HIV. Also, nucleic acid testing and sequencing were not performed, hence it is possible that occult HBV was missed.

We are also unable to add anti-Hbc core testing for the samples due to the unavailability of the testing platform. This was a limitation of the study because chronic hepatitis B was not ruled out for HbsAg-negative samples. False negatives can be reduced by adding other tests such as HBV viral load, anti-HBc testing and anti-HBs testing where possible. Repeat testing can also be carried out after a few weeks when clinical suspicion is high, to account for the window period when HBsAg levels might be below detectable limits.

In addition, we were unable to relate a specific viral genotype or HBsAg mutant to the false-negative result. Further, we could not correlate the HBsAg quantities with RDT performance. Likewise, the study used purposive sampling of the samples thus, there was a limitation of generalizability of the results. The sample size was relatively small, and smaller sample sizes typically result in higher variability among these estimates, leading to lower precision. Additionally, the study design used 1:1 matching, meaning that the predictive values were not interpretable for this population.

Also, the biggest challenge with RDTs is that their sensitivity might not be sufficient to reliably detect low levels of infection that can occur during the window period, thus making them unsuitable for blood donor screening. Another limitation was that ELISA test results were available to the operator doing the RDT assessments it was therefore an unblinded assessment which may weaken the study quality.

5. Conclusions

We demonstrated that among the studied RDTs, the WHO-prequalified SD Bioline had the highest specificity among all the RDTs tested. Nevertheless, the less expensive CE-marked RDTs performed well, showing sensitivity and specificity characteristics comparable to the more expensive SD Bioline RDT. Hence, CE-marked RDTs offer affordable point-of-care tools for massive screening of at-risk populations for HBV. Their wide application can potentially contribute greatly to achieving the WHO-led goal to eliminate HBV as a public health threat by 2030.

Supporting information

S1 Fig. This is the S1 Fig Used rapid diagnostic tests (RDTs) showing both positive and negative strips.

(PDF)

pone.0346259.s001.pdf^{(116.3KB, pdf)}

S1 Appendix. This is the S1 Appendix ELISA laboratory procedure.

(DOCX)

pone.0346259.s002.docx^{(13.3KB, docx)}

S1 Dataset. This is the S1 Dataset for blood bank donor samples.

(XLSX)

pone.0346259.s003.xlsx^{(21.3KB, xlsx)}

Acknowledgments

The authors wish to thank the staff of the Uganda Blood Transfusion Services, Uganda National Laboratory Services and the College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University for their contribution to the current study. We are also grateful to the study staff and participants.

Abbreviations

ART: Anti-retroviral therapy
CDC: US Centers for Disease Control and Prevention
CE: Conformité Européenne
DNA: Deoxyribonucleic Acid
EIA: Enzyme Immuno Assays
HAA: Haemo Agglutination Assays
HBsAg: Hepatitis B surface antigen
HBV: Hepatitis B Virus
HCC: Hepatocellular carcinoma
ICA: Immuno Chromatographic Assays
MOH: Ministry of Health
PCR: Polymerase Chain Reaction
POC: Point of care
PVST: Post Vaccination Serologic Testing
RDTs: Rapid Diagnostic Tests
RNA: Ribonucleic acid
UPHIA: Uganda Population-based HIV Impact Assessment

Data Availability

The data underlying the results is presented in the study and is available within the paper.

Funding Statement

The author(s) received no specific funding for this work.

References

1.World Health Organization WHO. Factsheets: Hepatitis B. 2021.
2.Organization WH. Financing prevention, testing and treatment of hepatitis in the context of Universal Health Coverage: report from a satellite meeting at the Replenishment Conference of the Global Fund to Fight AIDS, Tuberculosis and Malaria, March 2020. Financing prevention, testing and treatment of hepatitis in the context of Universal Health Coverage: report from a satellite meeting at the Replenishment Conference of the Global Fund to Fight AIDS, Tuberculosis and Malaria, March 2020. 2020.
3.WHO. Global hepatitis report 2024: action for access in low-and middle-income countries. World Health Organization. 2024. [Google Scholar]
4.Spearman CW, Afihene M, Ally R, Apica B, Awuku Y, Cunha L, et al. Hepatitis B in sub-Saharan Africa: Strategies to achieve the 2030 elimination targets. Lancet Gastroenterol Hepatol. 2017;2(12):900–9. doi: 10.1016/S2468-1253(17)30295-9 [DOI] [PubMed] [Google Scholar]
5.Kao J-H. Diagnosis of hepatitis B virus infection through serological and virological markers. Expert Rev Gastroenterol Hepatol. 2008;2(4):553–62. doi: 10.1586/17474124.2.4.553 [DOI] [PubMed] [Google Scholar]
6.Chameera EWS, Noordeen F, Pandithasundara H, Abeykoon A. Diagnostic efficacy of rapid assays used for the detection of hepatitis B virus surface antigen. 2013;:21–7.
7.Xiao Y, Thompson AJ, Howell J. Point-of-Care Tests for Hepatitis B: An Overview. 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Marie J, Mba E, Bisseye C, Mombo LE, Mireille J, Ndong N, et al. Assessment of rapid diagnostic tests and fourth ‐ generation Enzyme ‐ Linked Immunosorbent Assays in the screening of Human Immunodeficiency and Hepatitis B virus infections among first ‐ time blood donors in Libreville (Gabon). 2019;1–6. doi: 10.1002/jcla.22824 [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Salou M, Ehlan A, Dossim S, Ali-Edje K, Ouro-Medeli A, Douffan M. Assessment of the performance of six in vitro diagnostic kits for qualitative detection of hepatitis B virus surface antigen (HBsAg) in human serum or plasma in Lomé, Togo. Afr J Clin Exp Microbiol. 2020;21:211–6. [Google Scholar]
10.Amini A, Varsaneux O, Kelly H, Tang W, Chen W, Boeras DI, et al. Diagnostic accuracy of tests to detect hepatitis B surface antigen: A systematic review of the literature and meta-analysis. BMC Infect Dis. 2017;17(Suppl 1):698. doi: 10.1186/s12879-017-2772-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Seremba E, Ocama P, Opio CK, Kagimu M, Yuan HJ, Attar N. Validity of the rapid strip assay test for detecting HBsAg in patients admitted to hospital in Uganda. J Med Virol. 2010;1340:1334–40. doi: 10.1002/jmv [DOI] [PubMed] [Google Scholar]
12.World Health Organization WHO. Guidelines on hepatitis B and C testing. 2017.
13.Jargalsaikhan G, Eichner M, Boldbaatar D, Bat-Ulzii P, Lkhagva-Ochir O, Oidovsambuu O, et al. Sensitivity and specificity of commercially available rapid diagnostic tests for viral hepatitis B and C screening in serum samples. PLoS One. 2020;15(7):e0235036. doi: 10.1371/journal.pone.0235036 [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Fortress Diagnostic Product Catalogue. https://www.fortressdiagnostics.com/media/2072/br001for-jun24-product-catalogue.pdf. Accessed 2023 October 1.
15.Hellard ME, Chou R, Easterbrook P. WHO guidelines on testing for hepatitis B and C - meeting targets for testing. BMC Infect Dis. 2017;17(Suppl 1):703. doi: 10.1186/s12879-017-2765-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Wondfo. A rapid, one step test for the qualitative detection of antibody to hepatitis B surface antigen (HBsAb or anti-HBs) in serum or plasma. 2019.
17.Central Public Health Laboratories, Ministry of Health. Performance Verification of the Standard Q HCV Test using SD Bioline HCV TEST as a Reference.
18.Diagnostics S. SD Bioline HBsAg WB (01FK10W). 2018.
19.Dembele B, Affi-aboli R, Kabran M, Sevede D, Goha V, Adiko AC. Evaluation of four rapid tests for detection of hepatitis B surface antigen in Ivory Coast. 2020;2020:2020. [DOI] [PMC free article] [PubMed]
20.Kabamba AT, Mwamba CM, Dessilly G, Dufrasne F, Kabamba BM, Longanga AO. Evaluation of the analytical performance of six rapid diagnostic tests for the detection of viral hepatitis B and C in Lubumbashi, Democratic Republic of Congo. J Virol Methods. 2020;285:113961. doi: 10.1016/j.jviromet.2020.113961 [DOI] [PubMed] [Google Scholar]
21.Djimadoum M, Bessimbaye N, Moussa AM, Tidjani A, Narassem M, Narbe MD, et al. Évaluation de la performance de cinq tests de diagnostic rapide pour le dépistage du virus de l’Immunodéficience Humaine (VIH 1 & 2) au Tchad. Int J Bio Chem Sci. 2019;12(5):2162. doi: 10.4314/ijbcs.v12i5.18 [DOI] [Google Scholar]
22.Msomi N, Naidoo K, Yende-Zuma N, Padayatchi N, Govender K, Singh JA, et al. High incidence and persistence of hepatitis B virus infection in individuals receiving HIV care in KwaZulu-Natal, South Africa. BMC Infect Dis. 2020;20(1):847. doi: 10.1186/s12879-020-05575-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
23. Ansari MHK, Mir-DDavood O, Movahedi V. Comparative Evaluation of Immunochromatographic Rapid Diagnostic Tests (Strip and Device) and PCR Methods for Detection of Human Hepatitis B Surface Antigens Article. Hepatitis Monthly. 2007 [Google Scholar]
24.Brief P. Guidelines for the prevention, care and treatment of persons with chronic hepatitis b infection. 2015. [PubMed]
25.Makuza JD, Rwema JOT, Ntihabose CK, Dushimiyimana D, Umutesi J, Nisingizwe MP, et al. Prevalence of hepatitis B surface antigen (HBsAg) positivity and its associated factors in Rwanda. BMC Infect Dis. 2019;19(1):381. doi: 10.1186/s12879-019-4013-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
26.Kolou M, Katawa G, Salou M, Gozo-Akakpo KS, Dossim S, Kwarteng A. High prevalence of hepatitis B virus infection in the age range of 20-39 years old individuals in lome. The Open Virology Journal. 2017;11:1–7. doi: 10.2174/1874357901710011001 [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Omatola CA, Onoja BA, Agama J. Detection of Hepatitis B Surface Antigen among Febrile Patients in Ankpa, Kogi State, Nigeria. J Trop Med. 2020;2020:5136785. doi: 10.1155/2020/5136785 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Khan F, Shams S, Qureshi ID, Israr M, Khan H, Sarwar MT, et al. Hepatitis B virus infection among different sex and age groups in Pakistani Punjab. Virol J. 2011;8:225. doi: 10.1186/1743-422X-8-225 [DOI] [PMC free article] [PubMed] [Google Scholar]

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Thank you for the effort on this well written paper addressing a very important concern on limited screening tests for hepatitis in a population which has substantive exposure. I have no concern with regards to dual publication, research ethics, or publication ethics.

Please see below for few comments which you can take into consideration as you work towards a final version:

In the abstract result section and the whole of the paper there is a result on sensitivity of 93% with a CI of 93 - 93%. Please confirm this reporting version.

The cheaper RDTs here written as 'CE marked' compared with 'CE Marked' elsewhere in the document. Please consider for consistency

Introduction

Line 40 please consider deleting the word 'above'

Line 51 - 53 is this referring to only the Iranian study? Why is this part separated from the paragraph below which is addressing results from other studies?

Line 60 please consider a new paragraph

Line 68 - 70 please clarify if this is to detect acute infection

Methods and Materials

Is 200 calculation for both positives and negatives? or for each?

Is there any concern with multiple operators in the testing?

Results

In the flow chart how many participants were not included due to heamolysis for example or the flow chart starts at the ones selected for the main batch of samples?

The flow chart itself may require redoing so that it is clearer and without any overlaps

In the tables it is noted that one decimal place and 2 decimals places are used

Appendix

consider pictures of one each of the tests for clarity and submit as supplement. Add a description of the attachments

Reviewer #2: This diagnostic performance evaluation tested four HBsAg CE marked and one WHO PQ RDTs in a blood transfusion service in Uganda.

The authors evaluated 200 residual blood donor samples, with a 1:1 ratio of known positive to negative samples.

Major comments:

1. Abstract. Please state the reference ELISA and RDT manufacturers. If additional space is required, the reference to the stats program could be removed.

2. Mention in the abstract the prevalence in population (eg. 50% 1:1 case:control matching)

Introduction

3. The authors should provide a reference for this statement:

"Currently, the global mortality from viral 31 hepatitis exceeds that of HIV, TB or malaria, and is likely to exceed the toll from those three 32 diseases combined by 2040."

4. The epidemiological estimates should be updated using the WHO global hepatitis report 2024.

5. "Several immunological methods are available to detect HBsAg, including Enzyme Immuno Assays (EIA), Radio Immuno Assays (RIA), Immuno Chromatographic Assays (ICA), and Haemo Agglutination Assays (HAA)."

Both RIA and HAA are archaic methods and should not be refered to. Chemiluminescent immunoassays and EIAs are the leading methods. Immuno Chromatographic assays are commonly referred to as lateral flow or rapid diagnostic tests.

6. "In Iran, Acon, Atlas, Intec, Blue Cross, Dima and Cortez had sensitivities ranging from 97.5% -99.0 % and specificities of 97.5%- 99.2% (8). Varied performance characteristics were however recorded in East and West African populations."

This study in Iran should not be referred to in the introduction and is not clearly relevant to the current study. There are more relevant data from Africa. The statement about data from East and West African populations is more relevant but belongs as an introduction to the following paragraph. I would recommend referring to a meta-analysis or review of HBsAg RDT performance.

7. When mentioning test kits, please refer to the manufacturer and city/country of origin, not just the brand name (there are many similar brands of kits).

8. "The WHO

62 prequalified diagnostic kits are recommended internationally, however, standards for rapid

63 diagnostic test prequalification by this organization are quite stringent, making them expensive.

64 In Sub-Saharan Africa, developing countries such as Uganda, use standards for validating

65 diagnostic tools set by international regulatory bodies. These bodies include: the United States

66 Food and Drug Administration and the Conformité Européenne (CE) that are less costly as a

67 precondition for considering a diagnostic test"

I am not aware of any evidence that FDA or CE evaluation is less rigorous than the WHO PQ (or less costly). The reference provided is "ASLM. Lab culture, The ASLM Magazine. 2015;", which does not refer to a specific article (no URL or page number) or provide evidence for this assertion.

8. "However, for acute hepatitis B, RDTs may not be suitable since they can provide a false sense of security in case of negativity (14)."

This is not the case, HBsAg is positive during acute hepatitis, the reference 14 refers to national testing guidelines and not any empirical evidence to back this assertion.

9. "We therefore, aimed to calculate the sensitivity, specificity, positive and negative predictive values of 4 brands of RDTs in Uganda."

I believe you tested 5 brands?

10. The sample size formula refers to a national prevalence of 4.1% but this has not been used to calculate the sample size, instead a prevalence of 50% has been used in keeping with the study design.

11. For the Fortress diagnostic ELISA reference test, please state any available data on diagnostic/analytical sensitivity, validation data, and stringent regulatory approvals for this assay.

12. The details on methods for ELISA are not necessary, they can be moved to an appendix and just state according to manufacturers instructions.

13. Was the result of the ELISA test available to the operator doing the RDT assessments? If so, state this and list as a limitation (unblinded and not independent assessment weakens the study quality).

14. The method to retest multiple times in case of discordance with the ELISA result has resulted in an artificially (improved) assessment of test performance in relation to real conditions. This is a concern, this renders the resulting performance characteristics essentially invalid.

"Retesting was done where results were discordant, this was done to improve the accuracy of the study results"

This is inappropriate. If available, present the results before retesting multiple times ie. the first test result.

15. The flow chart is not interpretable, the lines are crossed and do not flow properly. Since the flowchart does not show any study exclusions, it is better summarised in a table (as shown in table 3).

16. Stratify table 1 by HBsAg test result, as well as showing overall characteristics.

17. A major consideration is that by taking a 1:1 case:control ratio, the sample prevalnece is 50% vs 4% nationally. Therefore all predictive values presented (PPV and NPV) are invalid, they are wildly different from a scenario when the prevalence is 4%. I would not present any predictive values. If these are to be shown, it should be shown as simulation data, weighting for a hypothetical scenario with sample prevalence of 4% (and where test performance in positive and negative samples is applied to the hypothetical scenario).

**********

what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2026 Apr 8;21(4):e0346259. doi: 10.1371/journal.pone.0346259.r002

Author response to Decision Letter 1

23 Sep 2025

PONE-D-25-07381

Diagnostic Performance of Four Hepatitis-B Surface Antigen Conformité Européenne (CE) Marked and One WHO Prequalified Rapid Diagnostic Tests in Uganda

PLOS ONE

Dear Dr. Baliruno,

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Seth Agyei Domfeh, PhD

Academic Editor

PLOS ONE

Journal requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. In the online submission form, you indicated that [The data underlying the results presented in the study are available from the corresponding author].

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Please see below for few comments which you can take into consideration as you work towards a final version:

Comment: In the abstract result section and the whole of the paper there is a result on sensitivity of 93% with a CI of 93 - 93%. Please confirm this reporting version.

Response: Thank you for this comment. Yes, this is the reporting version.

Comment: The cheaper RDTs here written as 'CE marked' compared with 'CE Marked' elsewhere in the document. Please consider for consistency

Response: Thank you for this comment. This has been revised in the manuscript.

Introduction

Comment: Line 40 please consider deleting the word 'above'

Response: Thank you for this comment. This has been revised in the manuscript.

Comment: Line 51 - 53 is this referring to only the Iranian study? Why is this part separated from the paragraph below which is addressing results from other studies?

Response: Thank you for this comment. The Iranian study has been replaced with references to a meta-analysis, “Diagnostic accuracy of tests to detect hepatitis B surface antigen: a systematic review of the literature and meta-analysis”

Comment: Line 60 please consider a new paragraph

Response: Thank you for this comment. This has been revised in the manuscript.

Comment: Line 68 – 70 please clarify if this is to detect acute infection

Response: Thank you for the comment. The statement has been removed because RDTs can detect both acute and chronic hepatitis B surface antigen (HbsAg).

Methods and Materials

Comment: Is 200 calculation for both positives and negatives? or for each?

Response: Thank you for this comment. The 200 calculation is for both positive and negative samples.

Comment: Is there any concern with multiple operators in the testing?

Response: Thank you for this comment. Multiple operators were employed to reduce the risk of bias.

Results

Comment: In the flow chart how many participants were not included due to heamolysis for example or the flow chart starts at the ones selected for the main batch of samples?

The flow chart itself may require redoing so that it is clearer and without any overlaps

Response: Thank you for this comment. The flow chart has been removed, as it did not add any substantial value.

Comments: In the tables it is noted that one decimal place and 2 decimals places are used

Response: Thank you for this comment. This has been revised in the manuscript to one decimal place to ensure uniformity.

Appendix

Comment: consider pictures of one each of the tests for clarity and submit as supplement. Add a description of the attachments

Response: Thank you for the comment. However, not all the pictures for each one of the tests is available. For the available picture, I have added a description.

Reviewer #2: This diagnostic performance evaluation tested four HBsAg CE marked and one WHO PQ RDTs in a blood transfusion service in Uganda.

The authors evaluated 200 residual blood donor samples, with a 1:1 ratio of known positive to negative samples.

Major comments:

1. Comment: Abstract. Please state the reference ELISA and RDT manufacturers. If additional space is required, the reference to the stats program could be removed.

Response: Thank you for this comment. This has been revised in the abstract and the manuscript.

2. Comment: Mention in the abstract the prevalence in population (e.g. 50% 1:1 case: control matching)

Response: Thank you for this comment. This has been revised accordingly in the abstract.

Introduction

3. Comment: The authors should provide a reference for this statement:

"Currently, the global mortality from viral 31 hepatitis exceeds that of HIV, TB or malaria, and is likely to exceed the toll from those three 32 diseases combined by 2040."

Response: Thank you for this comment. The reference for the above statement has been added to the manuscript.

4. Comment: The epidemiological estimates should be updated using the WHO global hepatitis report 2024.

Response: Thank you for this comment. This is kindly updated and revised using the WHO global hepatitis report 2024.

5. Comment: "Several immunological methods are available to detect HBsAg, including Enzyme Immuno Assays (EIA), Radio Immuno Assays (RIA), Immuno Chromatographic Assays (ICA), and Haemo Agglutination Assays (HAA)."

Response: Thank you, this is kindly noted and revised in the manuscript.

6. Comment: "In Iran, Acon, Atlas, Intec, Blue Cross, Dima and Cortez had sensitivities ranging from 97.5% -99.0 % and specificities of 97.5%- 99.2% (8). Varied performance characteristics were however, recorded in East and West African populations."

Response: Thank you for this comment. The Iranian study has been replaced with references to a meta-analysis “Diagnostic accuracy of tests to detect hepatitis B surface antigen: a systematic review of the literature and meta-analysis”

7. Comment: When mentioning test kits, please refer to the manufacturer and city/country of origin, not just the brand name (there are many similar brands of kits).

Response: Thank you for the comment, this is kindly noted and revised.

8. Comment: "The WHO

62 prequalified diagnostic kits are recommended internationally, however, standards for rapid

63 diagnostic test prequalification by this organization are quite stringent, making them expensive.

64 In Sub-Saharan Africa, developing countries such as Uganda, use standards for validating

65 diagnostic tools set by international regulatory bodies. These bodies include: the United States

66 Food and Drug Administration and the Conformité Européenne (CE) that are less costly as a

67 precondition for considering a diagnostic test"

Response: Thank you for your comment. I have updated the reference (12) alluding to the statement above, because the earlier reference was removed from the website.

8. Comment: "However, for acute hepatitis B, RDTs may not be suitable since they can provide a false sense of security in case of negativity (14)."

This is not the case, HBsAg is positive during acute hepatitis, the reference 14 refers to national testing guidelines and not any empirical evidence to back this assertion.

Response: Thank you for the comment. The statement has been removed from the manuscript following the guidance provided.

9. Comment: "We therefore, aimed to calculate the sensitivity, specificity, positive and negative predictive values of 4 brands of RDTs in Uganda."

I believe you tested 5 brands?

Response: Thank you for this comment. Yes, we tested 5 brands, and this has been corrected in the manuscript.

10. Comment: The sample size formula refers to a national prevalence of 4.1% but this has not been used to calculate the sample size, instead a prevalence of 50% has been used in keeping with the study design.

Response: Thank you for this comment. This has been kindly noted.

11. Comment: For the Fortress diagnostic ELISA reference test, please state any available data on diagnostic/analytical sensitivity, validation data, and stringent regulatory approvals for this assay.

Response: Thank you for this comment. I have added to the available details for the Fortress diagnostic ELISA reference test in the manuscript.

12. Comment: The details on methods for ELISA are not necessary, they can be moved to an appendix and just state according to manufacturer’s instructions.

Response: Thank you for comment. The details on methods for ELISA have been moved to the appendix.

13. Comment: Was the result of the ELISA test available to the operator doing the RDT assessments? If so, state this and list as a limitation (unblinded and not independent assessment weakens the study quality).

Response: The ELISA result was available to the operator doing the RDT and I have stated this as a limitation in the limitations section.

14. Comments: The method to retest multiple times in case of discordance with the ELISA result has resulted in an artificially (improved) assessment of test performance in relation to real conditions. This is a concern, this renders the resulting performance characteristics essentially invalid.

"Retesting was done where results were discordant, this was done to improve the accuracy of the study results"

This is inappropriate. If available, present the results before retesting multiple times ie. the first test result.

Response: Thank you for the comment. The wording may have implied the manipulation of the result. However, this was not the case an internal rapid diagnostic validation protocol was followed.

15. Comments: The flow chart is not interpretable, the lines are crossed and do not flow properly. Since the flowchart does not show any study exclusions, it is better summarised in a table (as shown in table 3).

Response: Thank you for the comment. The flow chart was removed as it did not add any substantial value to the study.

16. Comments: Stratify table 1 by HBsAg test result, as well as showing overall characteristics.

Response: Thank you for the comment. Overall characteristics are shown in the table. Initially the table was stratified by gender, but this

Attachment

Submitted filename: Response to Reviewers.docx

pone.0346259.s005.docx^{(26.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0346259.r003

Decision Letter 1

Seth Domfeh

9 Oct 2025

Dear Dr. Baliruno,

Please submit your revised manuscript by Nov 23 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Seth Agyei Domfeh, PhD

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: No

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

**********

Reviewer #2: There are some unresolved issues that require revision:

1. The abstract continues to refer to 296 million people with HBV, while the introduction has been updated with Global Hepatitis report data from WHO (254 million). Please be consistent.

2. The abstract refers to SD bioline as having superior specificity relative to the other assays but the confidence intervals are entirely overlapping. I would recommend recharacterizing this as all assays having good specificity, as the finding for SD bioline may be a chance finding.

3. Introduction:

"An estimated 254 million people are living with hepatitis B. Only 13%

35 of people living with chronic hepatitis B infection had been diagnosed, presenting a big gap in

36 testing for HBV, and close to 3% had received antiviral therapy at the end of 2022. The WHO

37 African Region accounts for 63% of new hepatitis B infections (3)."

I would recommend to report the statistics for Africa from this report (4% diagnosed and 0.2% treated).

4. "Several immunological methods are available"

This isn't strictly an immunological method since we are detecting viral antigens, not antibodies. I would recharacterize as "serological methods" instead.

Here I would also mention chemiluminescent immunoassays (CLIA) as this is the most commonly used method globally.

5. "The WHO prequalified diagnostic kits are recommended

63 internationally, however, standards for rapid diagnostic test prequalification by this organization

64 are quite stringent, making them expensive."

Again, I am making the same point here: I do not think that the WHO PQ is more stringent than CE marking or FDA approval. I believe it is the opposite, fees for FDA or CE marking can exceed 200k USD whereas fees for WHO PQ are substantially lower and may be abridged if the product already has stringent regulatory approval. The WHO PQ process may be slower and requires an independent performance evaluation but to my knowledge there is no evidence it is more stringent. The cited article does not provide any evidence in support of the assertion made here.

6. Again I am making the same point here: The sample size calculation again makes reference to the Uganda local prevalence, which is not relevant, since a 50% prevalence was used in the study design. The authors used a study which showed a prevalence of 45% as the source estimate- surely this cannot be considered as the expected sensitivity. I would recalculate the sample size using a more realistic sensitivity estimate (eg. from the cited meta-analyiss) and include the prevalence of 50% as per the study design, as the current sample size calculation is not credible.

7. Again I am making the same point here: again, the study design refers to retesting if there was discrepancy, and then taking only the final result from 3 tests to evaluate at the final result in the event of discrepancy.

At the risk of repeating myself, this is not an appropriate study design since it artificially inflates the diagnostic performance. Instead, take the result from the first RDT result only (disregard the outcome of repeated testing) and use this to evaluate performance. You may later specify the result of retesting in a separate section, but do not include this in the diagnostic test evaluation.

8. Is there any room to state what is the HBsAg prevalence in blood donors locally?

9. For the 7 samples which were negative with all 5 RDTs, was there a systematic difference observed in S/CO in the ELISA result eg. close to 1? Were ELISA results checked in duplicate?

10. Discussion:

"SD Bioline, the WHO prequalified kit, had the best diagnostic performance" Again see point above about the lack of statistical difference in specificity for this test vs the others.

11. "False-negative results are a potential vehicle of silent transmit

186 ssion and spread of disease infection among people (21)."

Check spelling of "transmission" and grammar of "disease infection"

12. Add to the limitations that the study design used 1:1 matching meaning that the predictive values were not interpretable for this population.

13. I would add to the interpretation that the RDTs were found not to be suitable for a blood donor screening population as the sensitivity was insufficient.

**********

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Reviewer #2: No

**********

PLoS One. 2026 Apr 8;21(4):e0346259. doi: 10.1371/journal.pone.0346259.r004

Author response to Decision Letter 2

23 Jan 2026

PONE-D-25-07381R1

Diagnostic Performance of Four Hepatitis-B Surface Antigen Conformité Européenne (CE) Marked and One WHO Prequalified Rapid Diagnostic Tests in Uganda

PLOS ONE

Dear Dr. Baliruno,

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Seth Agyei Domfeh, PhD

Academic Editor

PLOS ONE

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

________________________________________

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: No

________________________________________

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: No

________________________________________

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

________________________________________

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

________________________________________

6. Review Comments to the Author

Reviewer #2: There are some unresolved issues that require revision:

1. The abstract continues to refer to 296 million people with HBV, while the introduction has been updated with Global Hepatitis report data from WHO (254 million). Please be consistent.

Thank you for the comment. I have adjusted this accordingly.

Thank you, this is well noted. I have rectified this.

3. Introduction:

"An estimated 254 million people are living with hepatitis B. Only 13%

35 of people living with chronic hepatitis B infection had been diagnosed, presenting a big gap in

36 testing for HBV, and close to 3% had received antiviral therapy at the end of 2022. The WHO

37 African Region accounts for 63% of new hepatitis B infections (3)."

I would recommend to report the statistics for Africa from this report (4% diagnosed and 0.2% treated).

Thank you for this comment. The statistics have been adjusted to reflect the current HBV status.

4. "Several immunological methods are available."

This isn't strictly an immunological method since we are detecting viral antigens, not antibodies. I would recharacterize as "serological methods" instead.

Here I would also mention chemiluminescent immunoassays (CLIA) as this is the most commonly used method globally.

5. "The WHO prequalified diagnostic kits are recommended

63 internationally, however, standards for rapid diagnostic test prequalification by this organization

64 are quite stringent, making them expensive."

Thank you for this comment. This statement has been removed.

Thank you for your comment. I have used the average sensitivity 98.9% and average specificity of 96.7% from a recent meta-analysis conducted and the local prevalence of hepatitis among local blood donors in Uganda. Using 50% the sample size was too low for diagnostic accuracy.

Thank you for this comment. I have considered the first RDT test result and have removed the statement from the diagnostic test evaluation.

8. Is there any room to state what is the HBsAg prevalence in blood donors locally?

Thank you for the comment. I have added the HBsAg prevalence of blood donors locally, which ranges from 2.8% to 4.1% among blood donors in Uganda, under “sample size determination and sample collection”.

9. For the 7 samples which were negative with all 5 RDTs, was there a systematic difference observed in S/CO in the ELISA result eg, close to 1? Were ELISA results checked in duplicate?

Thank you for the comment. The ELISA results were checked in duplicate, and the S/CO was consistently below 1.0.

10. Discussion:

"SD Bioline, the WHO prequalified kit, had the best diagnostic performance." Again see point above about the lack of statistical difference in specificity for this test vs the others.

Thank you for your comment. I have removed this statement from the discussion.

11. "False-negative results are a potential vehicle of silent transmit

186 ssion and spread of disease infection among people (21)."

Check spelling of "transmission" and grammar of "disease infection"

Thank you for this comment. This has been noted and corrected accordingly.

12. Add to the limitations that the study design used 1:1 matching meaning that the predictive values were not interpretable for this population.

Thank you for this comment. I have added this to the limitations.

13. I would add to the interpretation that the RDTs were found not to be suitable for a blood donor screening population, as the sensitivity was insufficient.

Thank you for this comment. I have also as part of the limitations.

________________________________________

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Reviewer #2: No

________________________________________

Attachment

Submitted filename: Response to reviewers_PLOS One manuscript_10-12-25_LN.docx

pone.0346259.s006.docx^{(22.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0346259.r005

Decision Letter 2

Seth Domfeh

10 Feb 2026

Dear Dr. Baliruno,

Please submit your revised manuscript by Mar 27 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

Reviewer #2: Yes

**********

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Reviewer #2: Yes

**********

Reviewer #2: The authors have addressed most of my comments from the previous revision. However, there are two outstanding issues:

1. In section 2.2 it continues to reference a prevalence of between 2.8 to 4.1% for calculating the sample size.

This is the third time I am making the same point. The study is a case:control design, the design prevalence is 50%, you cannot use the expected population prevalence (3-4%) to estimate your sample size, when the study prevalence is 50%.

The rationale given in the comments is effectively that the result was unwanted, which is unacceptable:

"Thank you for your comment. I have used the average sensitivity 98.9% and average specificity of 96.7% from a recent meta-analysis conducted and the local prevalence of hepatitis among local blood donors in Uganda. Using 50% the sample size was too low for diagnostic accuracy."

If I apply a sample size calculation in R:

library(SampleSizeDiagnostics)

# Example assumptions

Se0 <- 0.95 # Round to more conservatives estimates

Sp0 <- 0.95

p <- 0.50 # Case control prevalence= 50%

CI <- 0.95

w <- 0.05 # Half-width of 5%

SampleSizeDiagnostics(sn = Se0, sp = Sp0, p = p, w=w, CI=CI)

Result: Sample size = 146

2. From the previous review:

"13. I would add to the interpretation that the RDTs were found not to be suitable for a blood

donor screening population, as the sensitivity was insufficient."

"Thank you for this comment. I have also as part of the limitations."

I cannot see this point added in the limitations. You mention the "window period" but the discussion does not specifically mention this important point that the observed sensitivity would be insufficient for blood donor screening according to WHO criteria, and low level HBsAg may been seen most commonly in people approaching spontaneous seroclearance/ functional cure.

**********

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Reviewer #2: No

**********

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PLoS One. 2026 Apr 8;21(4):e0346259. doi: 10.1371/journal.pone.0346259.r006

Author response to Decision Letter 3

12 Mar 2026

Review Comments to the Author

Reviewer #2: The authors have addressed most of my comments from the previous revision. However, there are two outstanding issues:

1. In section 2.2 it continues to reference a prevalence of between 2.8 to 4.1% for calculating the sample size.

The rationale given in the comments is effectively that the result was unwanted, which is unacceptable:

If I apply a sample size calculation in R:

library(SampleSizeDiagnostics)

# Example assumptions

Se0 <- 0.95 # Round to more conservatives estimates

Sp0 <- 0.95

p <- 0.50 # Case control prevalence= 50%

CI <- 0.95

w <- 0.05 # Half-width of 5%

SampleSizeDiagnostics(sn = Se0, sp = Sp0, p = p, w=w, CI=CI)

Result: Sample size = 146

Response

Thank you for the comment. I have taken into consideration the fact that this is a case-control study, and I have revised section 2.2 Sample size determination and sample collection accordingly.

2. From the previous review:

"13. I would add to the interpretation that the RDTs were found not to be suitable for a blood

donor screening population, as the sensitivity was insufficient."

"Thank you for this comment. I have also as part of the limitations."

Response

Thank you for this comment. I have added this limitation in the write-up as advised.

Attachment

Submitted filename: Response to Reviewers_11-03-2026_LN.docx

pone.0346259.s007.docx^{(19.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0346259.r007

Decision Letter 3

Seth Domfeh

17 Mar 2026

<p>Diagnostic Performance of Four Hepatitis-B Surface Antigen Conformité Européenne (CE) Marked and One WHO Prequalified Rapid Diagnostic Tests in Uganda

PONE-D-25-07381R3

Dear Dr. Baliruno,

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Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0346259.r008

Acceptance letter

Seth Domfeh

PONE-D-25-07381R3

PLOS One

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Fig. This is the S1 Fig Used rapid diagnostic tests (RDTs) showing both positive and negative strips.

(PDF)

pone.0346259.s001.pdf^{(116.3KB, pdf)}

S1 Appendix. This is the S1 Appendix ELISA laboratory procedure.

(DOCX)

pone.0346259.s002.docx^{(13.3KB, docx)}

S1 Dataset. This is the S1 Dataset for blood bank donor samples.

(XLSX)

pone.0346259.s003.xlsx^{(21.3KB, xlsx)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0346259.s005.docx^{(26.5KB, docx)}

Attachment

Submitted filename: Response to reviewers_PLOS One manuscript_10-12-25_LN.docx

pone.0346259.s006.docx^{(22.2KB, docx)}

Attachment

Submitted filename: Response to Reviewers_11-03-2026_LN.docx

pone.0346259.s007.docx^{(19.3KB, docx)}

Data Availability Statement

The data underlying the results is presented in the study and is available within the paper.

[pone.0346259.ref001] 1.World Health Organization WHO. Factsheets: Hepatitis B. 2021.

[pone.0346259.ref002] 2.Organization WH. Financing prevention, testing and treatment of hepatitis in the context of Universal Health Coverage: report from a satellite meeting at the Replenishment Conference of the Global Fund to Fight AIDS, Tuberculosis and Malaria, March 2020. Financing prevention, testing and treatment of hepatitis in the context of Universal Health Coverage: report from a satellite meeting at the Replenishment Conference of the Global Fund to Fight AIDS, Tuberculosis and Malaria, March 2020. 2020.

[pone.0346259.ref003] 3.WHO. Global hepatitis report 2024: action for access in low-and middle-income countries. World Health Organization. 2024. [Google Scholar]

[pone.0346259.ref004] 4.Spearman CW, Afihene M, Ally R, Apica B, Awuku Y, Cunha L, et al. Hepatitis B in sub-Saharan Africa: Strategies to achieve the 2030 elimination targets. Lancet Gastroenterol Hepatol. 2017;2(12):900–9. doi: 10.1016/S2468-1253(17)30295-9 [DOI] [PubMed] [Google Scholar]

[pone.0346259.ref005] 5.Kao J-H. Diagnosis of hepatitis B virus infection through serological and virological markers. Expert Rev Gastroenterol Hepatol. 2008;2(4):553–62. doi: 10.1586/17474124.2.4.553 [DOI] [PubMed] [Google Scholar]

[pone.0346259.ref006] 6.Chameera EWS, Noordeen F, Pandithasundara H, Abeykoon A. Diagnostic efficacy of rapid assays used for the detection of hepatitis B virus surface antigen. 2013;:21–7.

[pone.0346259.ref007] 7.Xiao Y, Thompson AJ, Howell J. Point-of-Care Tests for Hepatitis B: An Overview. 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref008] 8.Marie J, Mba E, Bisseye C, Mombo LE, Mireille J, Ndong N, et al. Assessment of rapid diagnostic tests and fourth ‐ generation Enzyme ‐ Linked Immunosorbent Assays in the screening of Human Immunodeficiency and Hepatitis B virus infections among first ‐ time blood donors in Libreville (Gabon). 2019;1–6. doi: 10.1002/jcla.22824 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref009] 9.Salou M, Ehlan A, Dossim S, Ali-Edje K, Ouro-Medeli A, Douffan M. Assessment of the performance of six in vitro diagnostic kits for qualitative detection of hepatitis B virus surface antigen (HBsAg) in human serum or plasma in Lomé, Togo. Afr J Clin Exp Microbiol. 2020;21:211–6. [Google Scholar]

[pone.0346259.ref010] 10.Amini A, Varsaneux O, Kelly H, Tang W, Chen W, Boeras DI, et al. Diagnostic accuracy of tests to detect hepatitis B surface antigen: A systematic review of the literature and meta-analysis. BMC Infect Dis. 2017;17(Suppl 1):698. doi: 10.1186/s12879-017-2772-3 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref011] 11.Seremba E, Ocama P, Opio CK, Kagimu M, Yuan HJ, Attar N. Validity of the rapid strip assay test for detecting HBsAg in patients admitted to hospital in Uganda. J Med Virol. 2010;1340:1334–40. doi: 10.1002/jmv [DOI] [PubMed] [Google Scholar]

[pone.0346259.ref012] 12.World Health Organization WHO. Guidelines on hepatitis B and C testing. 2017.

[pone.0346259.ref013] 13.Jargalsaikhan G, Eichner M, Boldbaatar D, Bat-Ulzii P, Lkhagva-Ochir O, Oidovsambuu O, et al. Sensitivity and specificity of commercially available rapid diagnostic tests for viral hepatitis B and C screening in serum samples. PLoS One. 2020;15(7):e0235036. doi: 10.1371/journal.pone.0235036 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref014] 14.Fortress Diagnostic Product Catalogue. https://www.fortressdiagnostics.com/media/2072/br001for-jun24-product-catalogue.pdf. Accessed 2023 October 1.

[pone.0346259.ref015] 15.Hellard ME, Chou R, Easterbrook P. WHO guidelines on testing for hepatitis B and C - meeting targets for testing. BMC Infect Dis. 2017;17(Suppl 1):703. doi: 10.1186/s12879-017-2765-2 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref016] 16.Wondfo. A rapid, one step test for the qualitative detection of antibody to hepatitis B surface antigen (HBsAb or anti-HBs) in serum or plasma. 2019.

[pone.0346259.ref017] 17.Central Public Health Laboratories, Ministry of Health. Performance Verification of the Standard Q HCV Test using SD Bioline HCV TEST as a Reference.

[pone.0346259.ref018] 18.Diagnostics S. SD Bioline HBsAg WB (01FK10W). 2018.

[pone.0346259.ref019] 19.Dembele B, Affi-aboli R, Kabran M, Sevede D, Goha V, Adiko AC. Evaluation of four rapid tests for detection of hepatitis B surface antigen in Ivory Coast. 2020;2020:2020. [DOI] [PMC free article] [PubMed]

[pone.0346259.ref020] 20.Kabamba AT, Mwamba CM, Dessilly G, Dufrasne F, Kabamba BM, Longanga AO. Evaluation of the analytical performance of six rapid diagnostic tests for the detection of viral hepatitis B and C in Lubumbashi, Democratic Republic of Congo. J Virol Methods. 2020;285:113961. doi: 10.1016/j.jviromet.2020.113961 [DOI] [PubMed] [Google Scholar]

[pone.0346259.ref021] 21.Djimadoum M, Bessimbaye N, Moussa AM, Tidjani A, Narassem M, Narbe MD, et al. Évaluation de la performance de cinq tests de diagnostic rapide pour le dépistage du virus de l’Immunodéficience Humaine (VIH 1 & 2) au Tchad. Int J Bio Chem Sci. 2019;12(5):2162. doi: 10.4314/ijbcs.v12i5.18 [DOI] [Google Scholar]

[pone.0346259.ref022] 22.Msomi N, Naidoo K, Yende-Zuma N, Padayatchi N, Govender K, Singh JA, et al. High incidence and persistence of hepatitis B virus infection in individuals receiving HIV care in KwaZulu-Natal, South Africa. BMC Infect Dis. 2020;20(1):847. doi: 10.1186/s12879-020-05575-6 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref023] 23. Ansari MHK, Mir-DDavood O, Movahedi V. Comparative Evaluation of Immunochromatographic Rapid Diagnostic Tests (Strip and Device) and PCR Methods for Detection of Human Hepatitis B Surface Antigens Article. Hepatitis Monthly. 2007 [Google Scholar]

[pone.0346259.ref024] 24.Brief P. Guidelines for the prevention, care and treatment of persons with chronic hepatitis b infection. 2015. [PubMed]

[pone.0346259.ref025] 25.Makuza JD, Rwema JOT, Ntihabose CK, Dushimiyimana D, Umutesi J, Nisingizwe MP, et al. Prevalence of hepatitis B surface antigen (HBsAg) positivity and its associated factors in Rwanda. BMC Infect Dis. 2019;19(1):381. doi: 10.1186/s12879-019-4013-4 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref026] 26.Kolou M, Katawa G, Salou M, Gozo-Akakpo KS, Dossim S, Kwarteng A. High prevalence of hepatitis B virus infection in the age range of 20-39 years old individuals in lome. The Open Virology Journal. 2017;11:1–7. doi: 10.2174/1874357901710011001 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref027] 27.Omatola CA, Onoja BA, Agama J. Detection of Hepatitis B Surface Antigen among Febrile Patients in Ankpa, Kogi State, Nigeria. J Trop Med. 2020;2020:5136785. doi: 10.1155/2020/5136785 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0346259.ref028] 28.Khan F, Shams S, Qureshi ID, Israr M, Khan H, Sarwar MT, et al. Hepatitis B virus infection among different sex and age groups in Pakistani Punjab. Virol J. 2011;8:225. doi: 10.1186/1743-422X-8-225 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Diagnostic performance of four hepatitis-B surface antigen conformité Européenne (CE) marked and one WHO prequalified rapid diagnostic tests in Uganda

Leah Naluwagga Baliruno

Charles Drago Kato

Harriet Nakigozi

Huzaima Mujuzi

Emmanuel Seremba

Roles

Abstract

Background

Methods

Results

Conclusion

1. Introduction

2. Materials and methods

2.1. Study design

2.2. Sample size determination and sample collection

2.3. Data collection and laboratory procedures

2.3.1. Laboratory procedures.

2.4. Data analysis

2.5. Ethical considerations

3. Results

3.1. Socio-demographic and clinical characteristics

Table 1. Socio-demographic characteristics of blood donors.

3.2. Sensitivity and specificity

Table 2. Sensitivity and specificity of the five brands of RDTs in the detection of HBsAg.

4. Discussion

5. Conclusions

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Seth Domfeh

Roles

Author response to Decision Letter 1

Decision Letter 1

Seth Domfeh

Roles

Author response to Decision Letter 2

Decision Letter 2

Seth Domfeh

Roles

Author response to Decision Letter 3

Decision Letter 3

Seth Domfeh

Roles

Acceptance letter

Seth Domfeh

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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