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Background  Thick blood films are routinely used to diagnose  Plasmodium falciparum  malaria. Here, they were used to diagnose volunteers exposed to experimental malaria challenge.    Methods  The frequency with which blood films were positive at given parasite densities measured by PCR were analysed. The poisson distribution was used to calculate the theoretical likelihood of diagnosis. Further  in vitro  studies used serial dilutions to prepare thick films from malaria cultures at known parasitaemia.    Results  Even in expert hands, thick blood films were considerably less sensitive than might have been expected from the parasite numbers measured by quantitative PCR.  In vitro  work showed that thick films prepared from malaria cultures at known parasitaemia consistently underestimated parasite densities.    Conclusion  It appears large numbers of parasites are lost during staining. This limits their sensitivity, and leads to erroneous estimates of parasite density.

Thick blood film examination for Plasmodium falciparum malaria has reduced sensitivity and underestimates parasite density