Rapid Single-Round Pool Testing of Infectious Disease Enabled by Multicolor Digital Melting PCR.

Pooled nucleic acid amplification test is a promising strategy to reduce cost and resources for screening large populations for infectious disease. However, the benefit of pooled testing is reversed when disease prevalence is high, because of the need to retest each sample to identify infected individual when a pool is positive. Split, Amplify, and Melt analysis of Pooled Assay (SAMPA) is presented, a multicolor digital melting PCR assay in nanoliter chambers that simultaneously identify infected individuals and quantify their viral loads in a single round of pooled testing. This is achieved by early sample tagging with unique barcodes and pooling, followed by single molecule barcode identification in a digital PCR platform using a highly multiplexed melt curve analysis strategy. The feasibility is demonstrated of SAMPA for quantitative unmixing and variant identification from pools of eight synthetic DNA and RNA samples corresponding to the N1 gene, as well as from heat-inactivated SARS-CoV-2 virus. Single round pooled testing of barcoded samples with SAMPA can be a valuable tool for rapid and scalable population testing of infectious disease.

Implementing the Lolli-Method and pooled RT-qPCR testing for SARS-CoV-2 surveillance in schools: a pilot project.

PURPOSE: School closures have been used as part of lockdown strategies to contain the spread of SARS-CoV-2, adversely affecting children's health and education. To ensure the accessibility of educational institutions without exposing society to the risk of increased transmissions, it is essential to establish SARS-CoV-2 testing strategies that are child-friendly, scalable and implementable in a daily school routine. Self-sampling using non-invasive saliva swabs combined with pooled RT-qPCR testing (Lolli-Method) has been proven to be a sensitive method for the detection of SARS-CoV-2. METHODS: We conducted a pilot project in Cologne, Germany, designed to determine the feasibility of a large-scale rollout of the Lolli-Method for testing without any additional on-site medical staff in schools. Over a period of three weeks, students from 22 schools were sampled using the Lolli-Method. At the end of the project, teachers were asked to evaluate the overall acceptance of the project. RESULTS: We analyzed a total of 757 pooled RT-qPCRs obtained from 8,287 individual swabs and detected 7 SARS-CoV-2 infected individuals. The Lolli-Method was shown to be a feasible and accepted testing strategy whose application is only slightly disruptive to the daily school routine. CONCLUSION: Our observations suggest that the Lolli-Method in combination with pooled RT-qPCR can be implemented for SARS-CoV-2 surveillance in daily school routine, applicable on a large scale.

Accelerating COVID-19 testing: An experimental approach.

The COVID-19 pandemic, ever since its global outbreak in 2020, has continued to wreak havoc. Governments across the world were compelled to enforce strict nation-wide lockdowns, while emphasising on social distancing and quarantining suspected people in order to slow down the spread of the virus. During this time, there was a massive increase in demand for COVID-19 test kits. However, given the limited supply, countries were finding it hard to test enough people. This study proposes an approach called Encoded Blending (EB) to increase the number of tests drastically, without increasing the number of test kits. EB modifies the pooled testing method; this has been followed by countries like Germany, Israel and South Korea for mass testing their citizens. EB has the potential to reduce test kits requirement by up to 85% and 80% in a population with 5% and 10% affected cases, respectively.

Saliva-Based, COVID-19 RT-PCR Pooled Screening Strategy to Keep Schools Open.

BACKGROUND: As of March 2020, governments throughout the world implemented business closures, work from home policies, and school closures due to exponential increase of coronavirus disease 2019 (COVID-19) cases, leaving only essential workers being able to work on site. For most of the children and adolescent school closures during the first lockdown had significant physical and psychosocial consequences. Here, we describe a comprehensive Return to School program based on a behavior safety protocol combined with the use of saliva-based reverse transcriptase-polymerase chain reaction (RT-PCR) pooled screening technique to keep schools opened. METHODS: The program had 2 phases: before school (safety and preparation protocols) and once at school (disease control program: saliva-based RT-PCR pooled screening protocol and contact tracing). Pooling: Aliquots of saliva from 24 individuals were pooled and 1 RT-PCR test was performed. If positive, the initial 24-pool was then retested (12 pools of 2). Individual RT-PCR tests from saliva samples from positive pools of 2 were performed to get an individual diagnosis. RESULTS: From August 31 until December 20, 2020 (16-wk period) a total of 3 pools, and subsequent 3 individual diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease were reported (2 teachers and 1 staff). CONCLUSION: Until COVID-19 vaccine can be administered broadly to all-age children, saliva-based RT-PCR pooling testing is the missing piece we were searching for to keep schools opened.

Optimizing SARS-CoV-2 Pooled Testing Strategies Through Differentiated Pooling for Distinct Groups.

Pooled testing has been successfully used to expand SARS-CoV-2 testing, especially in settings requiring high volumes of screening of lower-risk individuals, but efficiency of pooling declines as prevalence rises. We propose a differentiated pooling strategy that independently optimizes pool sizes for distinct groups with different probabilities of infection to further improve the efficiency of pooled testing. We compare the efficiency (results obtained per test kit used) of the differentiated strategy to a traditional pooling strategy in which all samples are processed using uniform pool sizes under a range of scenarios. For most scenarios, differentiated pooling is more efficient than traditional pooling. In scenarios examined here, an improvement in efficiency of up to 3.94 results per test kit could be obtained through differentiated versus traditional pooling, with more likely scenarios resulting in 0.12 to 0.61 additional results per kit. Under circumstances similar to those observed in a university setting, implementation of our strategy could result in an improvement in efficiency between 0.03 to 3.21 results per test kit. Our results can help identify settings, such as universities and workplaces, where differentiated pooling can conserve critical testing resources.

Modeling the optimization of COVID-19 pooled testing: How many samples can be included in a single test?

Objectives: This study tries to answer the crucial question of how many biological samples can be optimally included in a single test for COVID-19 pooled testing. Methods: It builds a novel theoretical model which links the local population to be tested in a region, the number of biological samples included in a single test, the "attitude" toward resource cost saving and time taken in a single test, as well as the corresponding resource cost function and time function, together. The numerical simulation results are then used to formulate the resource cost function as well as the time function. Finally, a loss function to be minimized is constructed and the optimal number of samples included is calculated. Results: In a numerical example, we consider a region of 1 million population which needs to be tested for the infection of COVID-19. The solution calculates the optimal number of biological samples included in a single test as 4.254 when the time taken is given the weight of 50% under the infection probability of 10%. Other combinations of numerical results are also presented. Conclusions: As we can see in our simulation results, given the infection probability at 10%, setting the number of biological samples included in a single test (in the integer level) at [4,6] is reasonable for a wide range of the subjective attitude between time and resource costs. Therefore, in the current practice, 5-mixed samples would sound better than the commonly used 10-mixed samples.

Pooled surveillance testing for asymptomatic SARS-CoV-2 infections at a Veterinary Teaching Hospital College, University of Minnesota, December 2020-April 2021.

To evaluate the use of asymptomatic surveillance, we implemented a surveillance program for asymptomatic SARS-CoV-2 infection in a voluntary sample of individuals at the College of Veterinary Medicine at the University of Minnesota. Self-collected anterior nasal samples were tested using real time reverse transcription-polymerase chain reaction (RT-PCR), in a 5:1 pooled testing strategy, twice weekly for 18 weeks. Positive pools were deconvoluted into individual tests, revealing an observed prevalence of 0.07% (3/4,525). Pooled testing allowed for large scale testing with an estimated cost savings of 79.3% and modeling demonstrated this testing strategy prevented up to 2 workplace transmission events, averting up to 4 clinical cases. At the study endpoint, antibody testing revealed 80.7% of participants had detectable vaccine antibody levels while 9.6% of participants had detectable antibodies to natural infection.

Online Heuristic Approach for Efficient Allocation of Limited COVID-19 Testing Kits

Testing kit scarcity plays an important role in aggravating any epidemiological response against pandemics such as COVID-19, especially for resource-constrained countries. Better decision-making tools are essential to assist policymakers in containing the disease from spreading to a large extent despite limited resource availability. We propose a testing kit allocation framework that comprises three components: estimation of time-varying prevalence rates using empirical Bayes model, testing kit allocation using multi-armed bandit algorithms, and pooled testing technique to extract the maximum utility from the available testing kits. We conduct simulation experiments based on real-world data and obtain results to demonstrate the enhanced efficiency in detecting COVID-19 cases. We conclude that Bayesian estimation of prevalence coupled with bandit-based allocation performs significantly well. We also identify scenarios under which pooled testing offers a strong advantage.

Application of pooled testing in estimating the prevalence of COVID-19.

Testing at a mass scale has been widely accepted as an effective way to contain the spread of the SARS-CoV-2 Virus. In the initial stages, the shortage of test kits severely restricted mass-scale testing. Pooled testing was offered as a partial solution to this problem. However, it is a relatively lesser-known fact that pooled testing can also result in significant gains, both in terms of cost savings as well as measurement accuracy, in prevalence estimation surveys. We review here the statistical theory of pooled testing for screening as well as for prevalence estimation. We study the impact of the diagnostic errors, and misspecification of the sensitivity and the specificity on the performances of the pooled as well as individual testing procedures. Our investigation clarifies some of the issues hotly debated in the context of COVID-19 and shows the potential gains for the Indian Council for Medical Research (ICMR) in using a pooled sampling for their upcoming COVID-19 prevalence surveys.

Evaluation of conventional and point-of-care real-time RT-PCR tests for the detection of SARS-CoV-2 through a pooled testing strategy.

BACKGROUND: The rapid identification and isolation of individuals infected with SARS-CoV-2 are fundamental countermeasures for the efficient control of the COVID-19 pandemic, which has affected millions of people around the world. Real-time RT-PCR is one of the most commonly applied reference methods for virus detection, and the use of pooled testing has been proposed as an effective way to increase the throughput of routine diagnostic tests. However, the clinical applicability of different types of real-time RT-PCR tests in a given group size remains inconclusive due to inconsistent regional disease prevalence and test demands. METHODS: In this study, the performance of one dual-target conventional and two point-of-care real-time RT-PCR tests in a 5-specimen pooled testing strategy for the detection of SARS-COV-2 was evaluated. RESULTS: We demonstrated the proof of concept that all of these real-time RT-PCR tests could feasibly detect SARS-CoV-2 from nasopharyngeal and oropharyngeal specimens that contain viral RNA loads in the range of 3.48 × 105 to 3.42 × 102 copies/ml through pooled testing in a group size of 5 with overall positive percent agreement (pooling vs. individual testing) ranging from 100% to 93.75%. Furthermore, the two POC real-time RT-PCR tests exhibited comparable sensitivity to that of the dual-target conventional one when clinical specimens were tested individually. CONCLUSION: Our findings support the feasibility of using real-time RT-PCR tests developed as a variety of platforms in routine laboratory detection of suspected COVID-19 cases through a pooled testing strategy that is beneficial to increasing the daily diagnostic capacity.

Triple-Probe DNA Framework-Based Transistor for SARS-CoV-2 10-in-1 Pooled Testing.

Accurate and population-scale screening technology is crucial in the control and prevention of COVID-19, such as pooled testing with high overall testing efficiency. Nevertheless, pooled testing faces challenges in sensitivity and specificity due to diluted targets and increased contaminations. Here, we develop a graphene field-effect transistor sensor modified with triple-probe tetrahedral DNA framework (TDF) dimers for 10-in-1 pooled testing of SARS-CoV-2 RNA. The synergy effect of triple probes as well as the special nanostructure achieve a higher binding affinity, faster response, and better specificity. The detectable concentration reaches 0.025-0.05 copy µL-1 in unamplified samples, lower than that of the reverse transcript-polymerase chain reaction. Without a requirement of nucleic-acid amplification, the sensors identify all of the 14 positive cases in 30 nasopharyngeal swabs within an average diagnosis time of 74 s. Unamplified 10-in-1 pooled testing enabled by the triple-probe TDF dimer sensor has great potential in the screening of COVID-19 and other epidemic diseases.

COVID-19 TESTING STRATEGIES IN POST-SECONDARY EDUCATION INSTITUTIONS: CASE STUDY OF CLARKSON UNIVERSITY

During the pandemic, post-secondary education institutions specially universities which have not gone fully online had to develop strict and reliable strategies to minimize the probability of an outbreak. The major efforts include COVID-19 testing, contact tracing, and social distancing. This study has focused on COVID-19 testing which is the costliest, but the most essential operation and it is exclusively the responsibility of the universities. As such, it is worthwhile to look at ways to improve the testing procedure used at campuses. For instance, analyzing how to decrease the cost associated without compromising the reliability of the testing procedure;or increasing the number of the testing with the same budget, etc. As a case study, we analyzed the COVID-19 testing procedure at Clarkson University currently testing 300 students a week to sample the prevalence on campus and attempt to stop COVID-19 at its source. While it is a good start, the question rises whether Clarkson is leveraging its resources in an optimal way. Throughout this analysis, pooled testing is looked at as a viable option to reduce cost or be able to test more students at the same cost. © American Society for Engineering Management, 2021

Pooled testing of sputum with Xpert MTB/RIF and Xpert Ultra during tuberculosis active case finding campaigns in Lao People's Democratic Republic.

INTRODUCTION: Active case finding (ACF) of individuals with tuberculosis (TB) is a key intervention to find the 30% of people missed every year. However, ACF requires screening large numbers of individuals who have a low probability of positive results, typically <5%, which makes using the recommended molecular tests expensive. METHODS: We conducted two ACF surveys (in 2020 and 2021) in high TB burden areas of Lao PDR. Participants were screened for TB symptoms and received a chest X-ray. Sputum samples of four consecutive individuals were pooled and tested with Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF) (Xpert-MTB/RIF) (2020) or Xpert-Ultra (2021). The agreement of the individual and pooled samples was compared and the reasons for discrepant results and potential cartridge savings were assessed. RESULTS: Each survey included 436 participants, which were tested in 109 pools. In the Xpert-MTB/RIF survey, 25 (sensitivity 89%, 95% CI 72.8% to 96.3%) of 28 pools containing MTB-positive samples tested positive and 81 pools containing only MTB-negative samples tested negative (specificity 100%, 95% CI 95.5% to 100%). In the Xpert-Ultra survey, all 32 (sensitivity 100%, 95% CI 89.3% to 100%) pools containing MTB-positive samples tested positive and all 77 (specificity 100%, 95% CI 95.3% to 100%) containing only MTB-negative samples tested negative. Pooling with Xpert-MTB/RIF and Xpert-Ultra saved 52% and 46% (227/436 and 199/436, respectively) of cartridge costs alone. CONCLUSION: Testing single and pooled specimens had a high level of agreement, with complete concordance when using Xpert-Ultra. Pooling samples could generate significant cartridge savings during ACF campaigns.

Pooling for SARS-CoV2 Surveillance: Validation and Strategy for Implementation in K-12 Schools.

Repeated testing of a population is critical for limiting the spread of the SARS-CoV-2 virus and for the safe reopening of educational institutions such as kindergarten-grade 12 (K-12) schools and colleges. Many screening efforts utilize the CDC RT-PCR based assay which targets two regions of the novel Coronavirus nucleocapsid gene. The standard approach of testing each person individually, however, poses a financial burden to these institutions and is therefore a barrier to using testing for re-opening. Pooling samples from multiple individuals into a single test is an attractive alternate approach that promises significant cost savings-however the specificity and sensitivity of such approaches needs to be assessed prior to deployment. To this end, we conducted a pilot study to evaluate the feasibility of analyzing samples in pools of eight by the established RT-PCR assay. Participants (1,576) were recruited from amongst the Tufts University community undergoing regular screening. Each volunteer provided two swabs, one analyzed separately and the other in a pool of eight. Because the positivity rate was very low, we spiked approximately half of the pools with laboratory-generated swabs produced from known positive cases outside the Tufts testing program. The results of pooled tests had 100% correspondence with those of their respective individual tests. We conclude that pooling eight samples does not negatively impact the specificity or sensitivity of the RT-PCR assay and suggest that this approach can be utilized by institutions seeking to reduce surveillance costs.

Pooled testing efficiency increases with test frequency.

Pooled testing increases efficiency by grouping individual samples and testing the combined sample, such that many individuals can be cleared with one negative test. This short paper demonstrates that pooled testing is particularly advantageous in the setting of pandemics, given repeated testing, rapid spread, and uncertain risk. Repeated testing mechanically lowers the infection probability at the time of the next test by removing positives from the population. This effect alone means that increasing frequency by x times only increases expected tests by around [Formula: see text] However, this calculation omits a further benefit of frequent testing: Removing infections from the population lowers intragroup transmission, which lowers infection probability and generates further efficiency. For this reason, increasing testing frequency can paradoxically reduce total testing cost. Our calculations are based on the assumption that infection rates are known, but predicting these rates is challenging in a fast-moving pandemic. However, given that frequent testing naturally suppresses the mean and variance of infection rates, we show that our results are very robust to uncertainty and misprediction. Finally, we note that efficiency further increases given natural sampling pools (e.g., workplaces, classrooms) that induce correlated risk via local transmission. We conclude that frequent pooled testing using natural groupings is a cost-effective way to provide consistent testing of a population to suppress infection risk in a pandemic.

Pooling of Samples for SARS-CoV-2 Detection Using a Rapid Antigen Test.

While molecular assays, such as reverse-transcription polymerase chain reaction (RT-PCR), have been widely used throughout the coronavirus disease 2019 (COVID-19) pandemic, the technique is costly and resource intensive. As a means to reduce costs and increase diagnostic efficiency, pooled testing using RT-PCR has been implemented. However, pooling samples for antigen testing has not been evaluated. Here, we propose a proof-of-concept pooling strategy for antigen testing that would significantly expand SARS-CoV-2 surveillance, especially for low-to-middle income countries, schools, and workplaces. Our laboratory-based testing demonstrates that combining of up to 20 nasal swab specimens per pool can expand surveillance with antigen tests, even if a pool contains only one positive sample.

Performance and cost-effectiveness of a pooled testing strategy for SARS-CoV-2 using real-time polymerase chain reaction in Uganda.

Real-time polymerase chain reaction (RT-PCR) remains the gold standard for detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This study tested the performance of a pooled testing strategy for RT-PCR and its cost-effectiveness. In total, 1280 leftover respiratory samples collected between 19 April and 6 May 2021 were tested in 128 pools of 10 samples each, out of which 16 pools were positive. The positivity rate of the unpooled samples was 1.9% (24/1280). After parallel testing using the individual and pooled testing strategies, positive agreement was 100% and negative agreement was 99.8%. The overall median cycle threshold (Ct) value of the unpooled samples was 29.8 (interquartile range 22.3-34.3). Pools that remained positive when compared with the results of individual samples had lower median Ct values compared with those that turned out to be negative (28.8 versus 34.8; P=0.0.035). Pooled testing reduced the cost >4-fold. Pooled testing may be a more cost-effective approach to diagnose SARS-CoV-2 in resource-limited settings without compromising diagnostic performance.

Rapid SARS-CoV-2 Nucleic Acid Testing and Pooled Assay by Tetrahedral DNA Nanostructure Transistor.

Direct SARS-CoV-2 nucleic acid testing with fast speed and high frequency is crucial for controlling the COVID-19 pandemic. Here, direct testing of SARS-CoV-2 nucleic acid is realized by field-effect transistors (FETs) with an electro-enrichable liquid gate (LG) anchored by tetrahedral DNA nanostructures (TDNs). The applied gate bias electrostatically preconcentrates nucleic acids, while the liquid gate with TDNs provides efficient analyte recognition and signal transduction. The average diagnosis time is ∼80 s, and the limit of detection approaches 1-2 copies in 100 µL of clinical samples without nucleic acid extraction and amplification. As such, TDN-LG FETs solve the dilemma of COVID-19 testing on mass scale that diagnosis accuracy and speed undergo trade-off. In addition, TDN-LG FETs achieve unamplified 10-in-1 pooled nucleic acid testing for the first time, and the results are consistent with PCR. Thus, this technology promises on-site and wide population COVID-19 screening and ensures safe world-reopening.

Pooled RT-qPCR testing for SARS-CoV-2 surveillance in schools - a cluster randomised trial.

BACKGROUND: The extent to which children and adolescents contribute to SARS-CoV-2 transmission remains not fully understood. Novel high-capacity testing methods may provide real-time epidemiological data in educational settings helping to establish a rational approach to prevent and minimize SARS-CoV-2 transmission. We investigated whether pooling of samples for SARS-CoV-2 detection by RT-qPCR is a sensitive and feasible high-capacity diagnostic strategy for surveillance of SARS-CoV-2 infections in schools. METHODS: In this study, students and school staff of 14 educational facilities in Germany were tested sequentially between November 9 and December 23, 2020, two or three times per week for at least three consecutive weeks. Participants were randomized for evaluation of two different age adjusted swab sampling methods (oropharyngeal swabs or buccal swabs compared to saliva swabs using a 'lolli method'). Swabs were collected and pooled for SARS-CoV-2 RT-qPCR. Individuals of positive pooled tests were retested by RT-qPCR the same or the following day. Positive individuals were quarantined while the SARS-CoV-2 negative individuals remained in class with continued pooled RT-qPCR surveillance. The study is registered with the German Clinical Trials register (registration number: DRKS00023911). FINDINGS: 5,537 individuals were eligible and 3970 participants were enroled and included in the analysis. In students, a total of 21,978 swabs were taken and combined in 2218 pooled RT-qPCR tests. We detected 41 positive pooled tests (1·8%) leading to 36 SARS-CoV-2 cases among students which could be identified by individual re-testing. The cumulative 3-week incidence for primary schools was 564/100,000 (6/1064, additionally 1 infection detected in week 4) and 1249/100,000 (29/2322) for secondary schools. In secondary schools, there was no difference in the number of SARS-CoV-2 positive students identified from pooled oropharyngeal swabs compared to those identified from pooled saliva samples (lolli method) (14 vs. 15 cases; 1·3% vs. 1·3%; OR 1.1; 95%-CI 0·5-2·5). A single secondary school accounted for 17 of 36 cases (47%) indicating a high burden of asymptomatic prevalent SARS-CoV-2 cases in the respective school and community. INTERPRETATION: In educational settings, SARS-CoV-2 screening by RT-qPCR-based pooled testing with easily obtainable saliva samples is a feasible method to detect incident cases and observe transmission dynamics. FUNDING: Federal Ministry of education and research (BMBF; Project B-FAST in "NaFoUniMedCovid19"; registration number: 01KX2021).