Combining Analytical Approaches and Multiple Sources of Information to Improve Interpretation of Diagnostic Test Results for Tuberculosis in Wild Meerkats

SIMPLE SUMMARY: Diagnostic tests used in animals are ideally extensively trialled to ensure that practitioners have confidence in the results; the ideal target should be 100% of infected animals testing positive (sensitivity), and 100% of uninfected animals testing negative (specificity). In these trials, a gold standard is necessary, against which the diagnostic tests may be compared. Commonly, tests of wild animals are not extensively trialled due to shortages of samples and the rarity of gold standard tests. This study uses samples collected for the purpose of diagnosing Mycobacterium suricattae infection in meerkats and estimates the sensitivity and specificity of available tests, both individually, and in combination. A small number of post-mortems (gold standard) were carried out, providing definitive evidence of infected animals against which to compare the tests. In addition, test results were unconventionally compared to survival times and clinical characteristics, aiming to quantify the prognostic capabilities of the tests. The study therefore not only estimates the required parameters against which to assess these tests, but also provides a model for future assessment of diagnostic tests in imperfect field scenarios. Wildlife diseases are increasingly recognised as important to society, and so methods to better quantify these are increasingly important. ABSTRACT: Diagnostic tests are used to classify individual animals’ infection statuses. However, validating test performance in wild animals without gold standard tests is extremely challenging, and the issue is further complicated in chronic conditions where measured immune parameters vary over time. Here, we demonstrate the value of combining evidence from different diagnostic approaches to aid interpretation in the absence of gold standards, large sample sizes, and controlled environments. Over a two-year period, we sampled 268 free-living meerkats (Suricata suricatta) longitudinally for Mycobacterium suricattae (a causative agent of tuberculosis), using three ante-mortem diagnostic tests based on mycobacterial culture, and antigen-specific humoral and cell-mediated immune responses, interpreting results both independently and in combination. Post-mortem cultures confirmed M. suricattae infection in 22 animals, which had prior ante-mortem information, 59% (13/22) of which were test-positive on a parallel test interpretation (PTI) of the three ante-mortem diagnostic assays (95% confidence interval: 37–79%). A similar ability to detect infection, 65.7% (95% credible interval: 42.7–84.7%), was estimated using a Bayesian approach to examine PTI. Strong evidence was found for a near doubling of the hazard of death (Hazard Ratio 1.75, CI: 1.14–2.67, p = 0.01), associated with a positive PTI result, thus demonstrating that these test results are related to disease outcomes. For individual tests, small sample sizes led to wide confidence intervals, but replication of conclusions, using different methods, increased our confidence in these results. This study demonstrates that combining multiple methodologies to evaluate diagnostic tests in free-ranging wildlife populations can be a useful approach for exploiting such valuable datasets.