Comparison of sensitivity and faecal egg counts of Mini-FLOTAC using fixed stool samples and Kato-Katz technique for the diagnosis of Schistosoma mansoni and soil-transmitted helminths

Accurate diagnostic tools for human helminthiasis are crucial for improved patient management and evaluation of community-based intervention studies. However, the diagnosis of intestinal schistosomiasis and soil-transmitted helminthiasis heavily relies on stool microscopy using the Kato-Katz technique, which has a low sensitivity. The Mini-FLOTAC method is an alternative microscopy-based technique, but its diagnostic performance using sodium acetate-acetic acid-formalin (SAF) fixed stool specimens has not been validated. The fixation of stool samples for later examination in a laboratory may reduce logistical and financial barriers of prevalence surveys by not requiring field laboratories. We compared the diagnostic accuracy of the Kato-Katz technique using fresh stool samples with the Mini-FLOTAC technique employing matched stool samples that were fixed in SAF. Three consecutive stool samples from 149 school-aged children in Côte d'Ivoire were subjected to quintuplicate Kato-Katz thick smears examined on the same day. From the remaining stool, approximately 2g were fixed in 10ml of SAF for about 3 months, and then subjected to the Mini-FLOTAC method using two flotation solutions (FS2 and FS7). The combined results of multiple Kato-Katz and Mini-FLOTAC readings revealed prevalences of Schistosoma mansoni, Trichuris trichiura and hookworm of 99.3%, 72.5% and 7.4%, respectively. Employing a Bayesian latent class analysis to estimate the true sensitivity of the diagnostic approaches, the sensitivity of Mini-FLOTAC using FS2 was 50.1% (95% Bayesian credible interval (BCI): 30.9-70.2%) for hookworm and 68.0% (95% BCI: 34.9-93.5%) for T. trichiura. When applying Mini-FLOTAC using FS7, the sensitivity was 89.9% (95% BCI: 86.9-97.4%) for S. mansoni, 37.2% (95% BCI: 17.2-60.6%) for hookworm and 67.7% (95% BCI: 33.0-93.0%) for T. trichiura. The specificity ranged from 80.1-95.0% in all Mini-FLOTAC tests. Of note, Mini-FLOTAC revealed higher arithmetic mean faecal egg counts (FECs) than the Kato-Katz technique. We found a significant correlation in FECs between Kato-Katz and Mini-FLOTAC for S. mansoni and T. trichiura. We conclude that Mini-FLOTAC shows reasonable diagnostic accuracy when using stool samples fixed in SAF for 3 months, and may be an alternative to multiple Kato-Katz thick smears.