Improved assessment of accuracy and performance indicators in paper-based ELISA

Abstract

Paper-based devices are an excellent match for low-cost point-of-care testing (POCT) tools. Their user-friendliness, portability, and short time of analysis, coupled with ease of local manufacture make these devices the best option for inexpensive diagnostic testing tools. However, despite all their positive features, these low-cost diagnostic devices must present good performance indicators, such as sensitivity, specificity, and accuracy. We developed and validated a paper-based ELISA for toxoplasmosis diagnosis through the detection of Toxoplasma gondii immunoglobulin G (IgG) antibodies in 100 human serum samples. From among the different ways to define the cut-off value, we chose Youden's J index (cut-off = 21.73 A.U.), which presented a higher sensitivity value. Our paper-based assay presented a sensitivity of 0.96, a specificity of 0.87, and a gray zone comprising 16 samples (±15% of the cut-off value, with 3 false positive outputs). The accuracy of the test was estimated by using ROC curves (AUC = 0.97). We also created a macro in Microsoft Excel® to estimate the accuracy of the test (m-Accuracy) based on a non-parametric method, which evidenced a value = 0.88, which classifies our test as moderately to highly accurate. We also provide the m-Accuracy macro for download and the paper-based microplate designs for printing, in order to collaborate with the scientific community and facilitate further studies using this platform. The improvement of these diagnostic tools can bring this technology for those who need it, contributing to population health and well-being.