Pooling blood donor samples to reduce the cost of HIV-1 antibody testing

Serum pooling for rapid expansion of anti-SARS-CoV-2 antibody testing capacity

Objectives

Examine possible pooling strategies designed to expand SARS-CoV-2 serological testing capacity.

Methods

Negative pools were assessed to determine optimal optical density (OD) cutoffs, followed by spiking weak or strong positive samples to assess initial assay performance. Samples were then randomly subjected to pool and individual testing approaches.

Results

Single positive specimens consistently converted pools of 5, 10, or 20 into positive outcomes. However, weaker IgG-positive samples failed to similarly convert pools of 50 to a positive result. In contrast, a stronger individual positive sample converted all pools tested into positive outcomes. Finally, examination of 150 samples configured into pools of 5, 10, 20 or 50 accurately predicted the presence of positive or negative specimens within each pool.

Conclusions

These results suggest that pooling strategies may allow expansion of serological testing capacity. While limitations exist, such strategies may aid in large-scale epidemiological screening or identification of optimal convalescent plasma donors.

Serological and Molecular Methods to Study Epidemiological Aspects of Human T-Cell Lymphotropic Virus Type 1 Infection

We estimated that at least 5-10 million individuals are infected with HTLV-1. Importantly, this number is based on the study of nearly 1.5 billion people living in known human T-cell lymphotropic virus type 1 (HTLV-1) endemic areas, for which reliable epidemiological data are available. However, for some highly populated regions including India, the Maghreb, East Africa, and some regions of China, no consistent data are yet available which prevents a more accurate estimation. Thus, the number of HTLV-1 infected people in the world is probably much higher. The prevalence of HTLV-1 prevalence varies depending on age, sex, and economic level in most HTLV-1 endemic areas. HTLV-1 seroprevalence gradually increases with age, especially in women. HTLV-1 has a simian origin and was originally acquired by humans through interspecies transmission from STLV-1 infected monkeys in the Old World. Three main modes of HTLV-1 transmission have been described; (1) from mother-to-child after prolonged breast-feeding lasting more than six months, (2) through sexual intercourse, which mainly, but not exclusively, occurs from male to female and lastly, (3) from contaminated blood products, which contain HTLV-1 infected lymphocytes. In specific areas, such as Central Africa, zoonotic transmission from STLV-1 infected monkeys to humans is still ongoing.The diagnostic methods used to study the epidemiological aspects of HTLV-1 infection mainly consist of serological assays for the detection of antibodies specifically directed against different HTLV-1 antigens. Screening tests are usually based on enzyme-linked immunoabsorbent assay (ELISA), chemiluminescence enzyme-linked immunoassay (CLEIA) or particle agglutination (PA). Confirmatory tests include mostly Western blots (WB)s or innogenetics line immunoassay (INNO-LIA™) and to a lesser extent immunofluorescence assay (IFA). The search for integrated provirus in the DNA from peripheral blood cells can be performed by qualitative and/or quantitative polymerase chain reaction (qPCR). qPCR is widely used in most diagnostic laboratories and quantification of proviral DNA is useful for the diagnosis and follow-up of HTLV-1 associated diseases such as adult T-cell leukemia (ATL) and tropical spastic paraparesis/HTLV-1 associated myelopathy (TSP/HAM). PCR also provides amplicons for further sequence analysis to determine the HTLV-1 genotype present in the infected person. The use of new generation sequencing methodologies to molecularly characterize full and/or partial HTLV-1 genomic regions is increasing. HTLV-1 genotyping generates valuable molecular epidemiological data to better understand the evolutionary history of this virus.

Evaluation of pooled screening for anti-HCV in two blood services set-ups

OBJECTIVE

Screening blood donations for anti-HCV is only partially performed in many developing countries due to the relatively high costs of testing. The screening expenditures can be reduced by testing donations in pools. This study evaluates the accuracy and feasibility of pooled screening procedure for anti-HCV in blood banks in Israel and the Palestinian Authority.

METHODS

The sensitivity and specificity of tests performed on pool sizes of 6-24 samples were compared to singleton immunoassay testing. All negative samples and those positive for anti-HCV were obtained from the routine work of Magen David Adom Blood Services in Israel and Shifa Hospital blood bank in Palestinian Authority. The experiments were run in parallel with different technologies.

RESULTS

The sensitivity of pooled-testing for anti-HCV by Magen David Adom was 94-97% for verified samples. In the Shifa Hospital, the sensitivity was estimated as 96-97% for non-verified samples. Cost-analysis showed benefits up to $2 per donation screened for anti-HCV in Shifa Hospital.

CONCLUSIONS

We recommend using manually created pools of up to 6 samples when testing for anti-HCV, but at the cost of 3% loss in sensitivity. Pooling can be considered, in countries which do not perform routine screening, due to their limited economic resources.

Pooling Experiments for Blood Screening and Drug Discovery

Pooling experiments date as far back as 1915 and were initially used in dilution studies for estimating the density of organisms in some medium. These early uses of pooling were necessitated by scientific and technical limitations. Today, pooling experiments are driven by the potential cost savings and precision gains that can result, and they are making a substantial impact on blood screening and drug discovery. A general review of pooling experiments is given here, with additional details and discussion of issues and methods for two important application areas, namely, blood testing and drug discovery. The blood testing application is very old, from 1943, yet is still used today, especially for HIV antibody screening. In contrast, the drug discovery application is relatively new, with early uses occurring in the period from the late 1980s to early 1990s. Statistical methods for this latter application are still actively being investigated and developed through both the pharmaceutical industries and academic research. The ability of pooling to investigate synergism offers exciting prospects for the discovery of combination therapies.

Pooling of samples for seroepidemiological surveillance of human T-cell lymphotropic virus types I and II

We evaluated a straight forward pooling strategy for antibody screening of HTLV-I/II, using panels of sera from various parts of the world including a total of 43 HTLV-I and 54 HTLV-II positive specimens. Four antibody screening assays were included in the evaluation: the HTLV-I/II GE 80/81 (Murex Diagnostics), the HTLV-I/HTLV-II Ab Capture ELISA (Ortho Diagnostics), the HTLV-I/II ELISA 3.0 (Genelabs Diagnostics) and the Serodia HTLV-I (Fujirebio). The Murex and Ortho assays represent a new generation of HTLV screening tests with a sandwich format incorporating both HTLV-I and HTLV-II synthetic and/or recombinant peptide antigens. The Genelabs assay is an indirect ELISA with recombinant HTLV-I and -II antigens and Serodia is a particle agglutination assay with HTLV-I whole viral lysate. Each HTLV-positive sample was included in pools of 1/1 up to 1/16, in two-fold steps made in normal HTLV-negative blood donor serum from one up to nine donors. For HTLV-I, with the exception of one false negative sample in dilution 1/16 with Genelabs ELISA, all assays were positive at all dilutions. The Murex assay had absorbance values at maximum levels for all samples at all dilutions. The other assays had gradually decreasing absorbance values although clearly above cut-off. For HTLV-II, the Murex assay correctly detected all samples to dilution 1/16 despite gradually decreasing signals. The Serodia assay had 100% sensitivity to dilution 1/4 while at 1/8 and 1/16 it decreased 82 and 80%, respectively. The Genelabs ELISA had gradually decreasing sensitivity for HTLV-II from 98 (1/1) to 33% (1/16) while the Ortho assay detected all specimens at all dilutions in a limited set of samples tested. Taken together, this evaluation has shown that pooling of samples may be an appropriate strategy for serosurveillance of HTLV. It is, however, crucial to limit the number of samples and to choose assays that allow the dilution caused by the pooling. Using the best performing assays in this evaluation for pools of e.g. five samples would leave a reasonable safety margin.

Estimating the prevalence of infectious agents using pooled samples: biometrical considerations

Pooled testing of units is a common approach in the prevalence estimation of infectious agents, which leads to a reduction of total costs of diagnostic testing. We examine how the pool size affects the statistical properties of the prevalence estimator r. Exact formulae are used to determine bias and precision of r. It is shown that with moderate pool sizes the (upward) bias of r is negligible. If there is no diagnostic error, the random error of r increases slightly with higher pool sizes, whereas if sensitivity and specificity are lower than 1, pooling may markedly decrease the random error of r. Another reason why pooling may be beneficial (and even indispensable) is that it greatly reduces the huge bias that can result if the assumed values of the sensitivity and specificity of the diagnostic test are not equal to the true values. The numerical calculations show that, in case of prevalence rates of up to 5% and total sample sizes of n > or = 500, pool sizes of about 10 to 20 are generally satisfactory from a statistical view-point. The methodological advantages and disadvantages of more complicated pooling strategies involving repeated testing of units are discussed.

Group testing in presence of classification errors

We modify Dorfman's and Sterrett's group testing protocols to make them suitable for testing blood samples for the presence of HIV antibodies, as well as for many industrial applications, when false negatives cannot be tolerated. We first propose that test kit sensitivity be increased to nearly 100 per cent by altering the reactive versus non-reactive threshold. Subsequently, group and repeat testing are used with a careful selection of group size and the number of times a test is repeated, in order to maximize efficiency while keeping the false positive predictive value (FPPV) within a specified limit. Numerical calculations show that our testing protocol is efficient, has low procedural complexity and keeps both types of classification errors below specified tolerance limits.

Detection of human immunodeficiency virus type 1 (HIV-1) RNA in pools of sera negative for antibodies to HIV-1 and HIV-2

A total of 234 pools were prepared from 10,692 consecutive serum samples negative for antibodies to human immunodeficiency virus type 1 (HIV-1) and HIV-2 collected at five virological laboratories (average pool size, 45 serum samples). Pools were screened for the presence of HIV-1 RNA by a modified commercial assay (Amplicor HIV-1 Monitor test) which included an additional polyethylene glycol (PEG) precipitation step prior to purification of viral RNA (PEG Amplicor assay). The sensitivity of this assay for HIV-1 RNA detection in individual serum samples within pools matches that of standard commercial assays for individual serum samples, i.e., 500 HIV-1 RNA copies per ml. Five pools were identified as positive, and each one contained one antibody-negative, HIV-1 RNA-positive serum sample, corresponding to an average of 1 infected sample per 2,138 serum samples. Retrospective analysis revealed that the five HIV-1 RNA-positive specimens originated from individuals who had symptomatic primary HIV-1 infection at the time of sample collection and who were also positive for p24 antigenemia. We next assessed the possibility of performing the prepurification step by high-speed centrifugation (50,000 x g for 80 min) of 1.5-ml pools containing 25 microl of 60 individual serum samples, of which only 1 contained HIV-1 RNA (centrifugation Amplicor assay). The sensitivity of this assay also matches the sensitivities of standard commercial assays for HIV-1 RNA detection in individual serum samples. The results demonstrate that both assays with pooled sera can be applied to the screening of large numbers of serum samples in a time- and cost-efficient manner.