Optimal decision theory for diagnostic testing: Minimizing indeterminate classes with applications to saliva-based SARS-CoV-2 antibody assays

Prevalence estimation and optimal classification methods to account for time dependence in antibody levels

Serology testing can identify past infection by quantifying the immune response of an infected individual providing important public health guidance. Individual immune responses are time-dependent, which is reflected in antibody measurements. Moreover, the probability of obtaining a particular measurement from a random sample changes due to changing prevalence (i.e., seroprevalence, or fraction of individuals exhibiting an immune response) of the disease in the population. Taking into account these personal and population-level effects, we develop a mathematical model that suggests a natural adaptive scheme for estimating prevalence as a function of time. We then combine the estimated prevalence with optimal decision theory to develop a time-dependent probabilistic classification scheme that minimizes the error associated with classifying a value as positive (history of infection) or negative (no such history) on a given day since the start of the pandemic. We validate this analysis by using a combination of real-world and synthetic SARS-CoV-2 data and discuss the type of longitudinal studies needed to execute this scheme in real-world settings.

Optimal classification and generalized prevalence estimates for diagnostic settings with more than two classes

An accurate multiclass classification strategy is crucial to interpreting antibody tests. However, traditional methods based on confidence intervals or receiver operating characteristics lack clear extensions to settings with more than two classes. We address this problem by developing a multiclass classification based on probabilistic modeling and optimal decision theory that minimizes the convex combination of false classification rates. The classification process is challenging when the relative fraction of the population in each class, or generalized prevalence, is unknown. Thus, we also develop a method for estimating the generalized prevalence of test data that is independent of classification of the test data. We validate our approach on serological data with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) naïve, previously infected, and vaccinated classes. Synthetic data are used to demonstrate that (i) prevalence estimates are unbiased and converge to true values and (ii) our procedure applies to arbitrary measurement dimensions. In contrast to the binary problem, the multiclass setting offers wide-reaching utility as the most general framework and provides new insight into prevalence estimation best practices.

Modeling in higher dimensions to improve diagnostic testing accuracy: Theory and examples for multiplex saliva-based SARS-CoV-2 antibody assays

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has emphasized the importance and challenges of correctly interpreting antibody test results. Identification of positive and negative samples requires a classification strategy with low error rates, which is hard to achieve when the corresponding measurement values overlap. Additional uncertainty arises when classification schemes fail to account for complicated structure in data. We address these problems through a mathematical framework that combines high dimensional data modeling and optimal decision theory. Specifically, we show that appropriately increasing the dimension of data better separates positive and negative populations and reveals nuanced structure that can be described in terms of mathematical models. We combine these models with optimal decision theory to yield a classification scheme that better separates positive and negative samples relative to traditional methods such as confidence intervals (CIs) and receiver operating characteristics. We validate the usefulness of this approach in the context of a multiplex salivary SARS-CoV-2 immunoglobulin G assay dataset. This example illustrates how our analysis: (i) improves the assay accuracy, (e.g. lowers classification errors by up to 42% compared to CI methods); (ii) reduces the number of indeterminate samples when an inconclusive class is permissible, (e.g. by 40% compared to the original analysis of the example multiplex dataset) and (iii) decreases the number of antigens needed to classify samples. Our work showcases the power of mathematical modeling in diagnostic classification and highlights a method that can be adopted broadly in public health and clinical settings.

Modeling in higher dimensions to improve diagnostic testing accuracy: theory and examples for multiplex saliva-based SARS-CoV-2 antibody assays

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has emphasized the importance and challenges of correctly interpreting antibody test results. Identification of positive and negative samples requires a classification strategy with low error rates, which is hard to achieve when the corresponding measurement values overlap. Additional uncertainty arises when classification schemes fail to account for complicated structure in data. We address these problems through a mathematical framework that combines high dimensional data modeling and optimal decision theory. Specifically, we show that appropriately increasing the dimension of data better separates positive and negative populations and reveals nuanced structure that can be described in terms of mathematical models. We combine these models with optimal decision theory to yield a classification scheme that better separates positive and negative samples relative to traditional methods such as confidence intervals (CIs) and receiver operating characteristics. We validate the usefulness of this approach in the context of a multiplex salivary SARS-CoV-2 immunoglobulin G assay dataset. This example illustrates how our analysis: (i) improves the assay accuracy (e.g. lowers classification errors by up to 42 % compared to CI methods); (ii) reduces the number of indeterminate samples when an inconclusive class is permissible (e.g. by 40 % compared to the original analysis of the example multiplex dataset); and (iii) decreases the number of antigens needed to classify samples. Our work showcases the power of mathematical modeling in diagnostic classification and highlights a method that can be adopted broadly in public health and clinical settings.