Evaluation of a Urine Pooling Strategy for the Rapid and Cost-Efficient Prevalence Classification of Schistosomiasis

Background: A key epidemiologic feature of schistosomiasis is its focal distribution, which has important implications for the spatial targeting of preventive chemotherapy programs. We evaluated the diagnostic accuracy of a urine pooling strategy using a point-of-care circulating cathodic antigen (POC-CCA) cassette test for detection of Schistosoma mansoni, and employed simulation modeling to test the classification accuracy and efficiency of this strategy in determining where preventive chemotherapy is needed in low-endemicity settings. Methodology: We performed a cross-sectional study involving 114 children aged 6–15 years in six neighborhoods in Azaguié Ahoua, south Côte d’Ivoire to characterize the sensitivity and specificity of the POC-CCA cassette test with urine samples that were tested individually and in pools of 4, 8, and 12. We used a Bayesian latent class model to estimate test characteristics for individual POC-CCA and quadruplicate Kato-Katz thick smears on stool samples. We then developed a microsimulation model and used lot quality assurance sampling to test the performance, number of tests, and total cost per school for each pooled testing strategy to predict the binary need for school-based preventive chemotherapy using a 10% prevalence threshold for treatment. Principal Findings: The sensitivity of the urine pooling strategy for S. mansoni diagnosis using pool sizes of 4, 8, and 12 was 85.9%, 79.5%, and 65.4%, respectively, when POC-CCA trace results were considered positive, and 61.5%, 47.4%, and 30.8% when POC-CCA trace results were considered negative. The modeled specificity ranged from 94.0–97.7% for the urine pooling strategies (when POC-CCA trace results were considered negative). The urine pooling strategy, regardless of the pool size, gave comparable and often superior classification performance to stool microscopy for the same number of tests. The urine pooling strategy with a pool size of 4 reduced the number of tests and total cost compared to classical stool microscopy. Conclusions/Significance: This study introduces a method for rapid and efficient S. mansoni prevalence estimation through examining pooled urine samples with POC-CCA as an alternative to widely used stool microscopy. Author Summary: Schistosomiasis is a disease caused by parasitic worms that affects over 250 million people. The global control strategy is regular deworming of school-aged children. Before deworming campaigns can be conducted, one must know where the disease is present. The current method requires collection of individual stool and urine samples that are examined under a microscope by trained laboratory technicians. We present an alternative method that can inform where schistosomiasis is present in above 10% of the population, which is the threshold at which school-based deworming is recommended. The proposed strategy involves pooling multiple urine samples and using a rapid diagnostic test. The goal is to reduce the number of tests, cost, time, and laboratory infrastructure to guide decision-making. We collected data in Côte d’Ivoire to evaluate this new diagnostic procedure of pooling urine, and used computer simulation to predict its performance in classification of communities above or below the 10% threshold. We found that the urine pooling strategy with a pool size of 4 reduced the number of tests and cost compared to the current standard method, while maintaining the same accuracy. Our findings suggest that this strategy may be an effective and cost-saving method compared to traditional microscopy.