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Clinical and Vaccine Immunology, January 2008, p. 106-114, Vol. 15, No. 1
1071-412X/08/$08.00+0     doi:10.1128/CVI.00223-07
Copyright © 2008, American Society for Microbiology. All Rights Reserved.

Utility of Composite Reference Standards and Latent Class Analysis in Evaluating the Clinical Accuracy of Diagnostic Tests for Pertussis{triangledown}

Andrew L. Baughman,1* Kristine M. Bisgard,2 Margaret M. Cortese,1 William W. Thompson,3 Gary N. Sanden,1,{dagger} and Peter M. Strebel1

National Center for Immunization and Respiratory Diseases,1 Office of Workforce and Career Development,2 Office of the Director, Centers for Disease Control and Prevention, Atlanta, Georgia3

Received 31 May 2007/ Returned for modification 28 August 2007/ Accepted 25 October 2007

Numerous evaluations of the clinical sensitivity and specificity of PCR and serologic assays for Bordetella pertussis have been hampered by the low sensitivity of culture, the gold standard test, which leads to biased accuracy estimates. The bias can be reduced by using statistical approaches such as the composite reference standard (CRS) (e.g., positive if culture or serology positive; negative otherwise) or latent class analysis (LCA), an internal reference standard based on a statistical model. We illustrated the benefits of the CRS and LCA approaches by reanalyzing data from a 1995 to 1996 study of cough illness among 212 patients. The accuracy of PCR in this study was evaluated using three reference standards: culture, CRS, and LCA. Using specimens obtained 0 to 34 days after cough onset, estimates of the sensitivity of PCR obtained using CRS (47%) and LCA (34%) were lower than the culture-based estimate (62%). The CRS and LCA approaches, which utilized more than one diagnostic marker of pertussis, likely produced more accurate reference standards than culture alone. In general, the CRS approach is simple, with a well-defined disease status. LCA requires statistical modeling but incorporates more indicators of disease than CRS. When three or more indicators of pertussis are available, these approaches should be used in evaluations of pertussis diagnostic tests.

* Corresponding author. Mailing address: Centers for Disease Control and Prevention, 1600 Clifton Road, NE, Mailstop C-25, Atlanta, GA 30329. Phone: (404) 639-8198. Fax: (404) 639-2483. E-mail: ALB1{at}cdc.gov

{triangledown} Published ahead of print on 7 November 2007.

{dagger} Present address: 1830 Mountain Valley Rd., La Veta, CO 81055.

Clinical and Vaccine Immunology, January 2008, p. 106-114, Vol. 15, No. 1
1071-412X/08/$08.00+0     doi:10.1128/CVI.00223-07
Copyright © 2008, American Society for Microbiology. All Rights Reserved.





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