Interpretation of results

Interpreting
laboratory tests results

May 2007

Laboratory Training for Field Epidemiologists

Learning objectives

At the end of the presentation, participants should

Be able to think critically for interpreting positive and negative
test results
Interpret the laboratory result in the context of the situation

Laboratory Training for Field Epidemiologists

Objectives of the lecture

Understand what can be said about the results of laboratory

tests
Interpretation

Understand what can not be said about the results of

laboratory tests
Limitations

Laboratory Training for Field Epidemiologists

A real life clinical example:

High amylases in a febrile patient

Traveller returning from South Asia develops

Headaches
Progressive fever, 40oC after a week
Diarrhea

Examination indicates dissociated pulse, splenomegaly

Laboratory investigation show:

Leuco-neutropenia
High level of amylases

What do you make of the high level of amylases?

Laboratory Training for Field Epidemiologists

A real life clinical example:

Can you interpret the amylases?

Why was a test requested for amylases?

Nothing would have led the clinician to suspect pancreatitis

Subsequent isolation of Salmonella Typhi in the stools

Working diagnosis: Typhoid

Concerns over the amylases prompts more investigations:

No abnormality of the pancreas in the ultrasound

You cannot interpret a test (i.e. the amylases) that was not
requested according to a properly framed hypothesis

The same applies to laboratory-epidemiology investigations

Laboratory Training for Field Epidemiologists

Planning a collaborative epidemiologylaboratory investigation

Formulating the
objectives

Drawing conclusions

Planning

Analysing

Data analysis

Lab analysis

Data

Preparing
Instruments

Specimens

Collecting
Sampling
strategy

Data

Specimens

When faced with the need to interpret laboratory results,

bear in mind why they were done
Laboratory Training for Field Epidemiologists

Use of sensitive tests

A sensitive test is able to pick up affected persons

Used to rule out diagnoses

Used when there is a penalty in missing a case
Diagnosis a dangerous but treatable condition
(e.g., Tuberculosis)
Blood screening for HIV

Used at an early stage of a diagnosis work-up

A sensitive test is most useful when negative

Interpretation according to the prevalence
Use of the predictive value negative

Laboratory Training for Field Epidemiologists

Use of specific tests

A sensitive test is able to pick up non-affected persons

Used to rule in diagnoses

Used when a false positive can harm a patient
HIV test for individual counselling
Cancer diagnosis before chemotherapy

Used to confirm a diagnosis suspected because of other data

A sensitive test is most useful when positive

Interpretation according to the prevalence
Use of the predictive value positive

Laboratory Training for Field Epidemiologists

Possible objectives of joint laboratory

epidemiology investigations

Test a hypothesis (Qualitative outcome)

Test a hypothesis
About an etiologic agent
(e.g., Is West Nile virus the cause of the outbreak?)
About the relatedness of isolates
(e.g., Are the cases caused by an identical pathogen?)

Measure a quantity (Quantitative outcome)

Estimate a quantity
Prevalence
Incidence

Laboratory Training for Field Epidemiologists

Using laboratory evidence to confirm a

diagnosis during an outbreak

Short list potential etiologic agents (hypothesis generating)

according to:
Epidemiological characteristics
Clinical characteristics
Setting

Test for agents short listed (hypothesis testing)

Positive test
Negative test

Use predictive values positive and negatives

Laboratory Training for Field Epidemiologists

Interpreting positive tests results

during an outbreak

Use the predictive value positive that depends upon:

The frequency of the disease
The specificity of the test +++

Elements that will support the hypothesis of a true positive

The disease is frequent
The test is specific

Elements that will support the hypothesis of a false positive

The disease is rare
The test is not sufficiently specific

Laboratory Training for Field Epidemiologists

If you are trying to rule in a diagnosis

Short list possible agents well

Increases the probability that you are dealing with the agent
Increases the predictive value of a positive test

Use a specific test

Be careful before concluding when:

The disease is unlikely
The test is not specific

Laboratory Training for Field Epidemiologists

Interpreting negative tests results

during an outbreak

Use the predictive value negative that depends upon:

The frequency of the disease
The sensitivity of the test +++

Elements that will support the hypothesis of a true negative

The disease is rare
The test is sensitive

Elements that will support the hypothesis of a false negative

The disease is common
The test is not sufficiently sensitive

Laboratory Training for Field Epidemiologists

A test was negative only for the

pathogens that were looked for

If the culture on a specific medium was not done, the test

cannot be interpreted as negative for the specific pathogen

If you did not ask for Campylobacter culture, the negative

stool culture is not really negative for Campylobacter

Laboratory Training for Field Epidemiologists

If you are trying to rule out a diagnosis

Use a sensitive test

Be careful before concluding when:

The disease is common
The test is not sensitive

Laboratory Training for Field Epidemiologists

The specific case of emergent pathogens

Epidemiological and clinical evidence are of limited

usefulness to generate hypotheses regarding the agent

A progressive inductive process from the laboratory

generate hypotheses about potential pathogens involved

Additional investigations, including epidemiological

investigations, will test the hypothesis that the candidate
agent isolated in the laboratory causes the disease
Usefulness of Koch criteria

Laboratory Training for Field Epidemiologists

Koch criteria modified by River

for viral diseases

Isolation of the pathogen from the diseased host

Cultivation in host cells

Proof of filterability

Production of comparable disease in the original host

species or a related one

Re-isolation of the virus

Detection of a specific immune response to the virus

Laboratory Training for Field Epidemiologists

In some cases, the agent isolated in the

laboratory is not the cause of the disease

Hepatitis G virus identified in various patients

Epidemiological studies did not confirm the hypothesis that

the agent is associated with chronic viral hepatitis

Laboratory Training for Field Epidemiologists

Host-pathogen relationship

Presence of an organism may have different interpretation

according to the context

Immune system
Immunocompetent patient
Opportunistic pathogens may be innocent by-standers

Immunocompromised patient
Opportunistic pathogens may be the cause of the infection

Age

Physiological status (e.g. urinary infection in pregnancy)

Laboratory Training for Field Epidemiologists

Using laboratory evidence to confirm the

relatedness of isolates

Generate hypotheses using epidemiological evidence

Studies allowing the use of statistical tests
Studies not allowing the use of statistical tests

Test hypotheses using laboratory evidence

Use typing technique adapted to:
Hypothesis
Pathogen

Laboratory Training for Field Epidemiologists

Generating hypotheses in an investigation

not allowing the use of statistics (1)

Investigation of a case of HCV seroconversion in a child with

clotting factor disorders in New Jersey, USA, 1996
The child only received recombinant clotting factors
Two other household members had HCV infection
The older brother (Clotting factor disorder)
The mother (Former injection drug use)

In-depth interview gathered that:

There was no exposure to the blood of the older brother
The mother pricked herself with a needle before injecting him
with factors

Laboratory Training for Field Epidemiologists

Testing hypotheses of relatedness using

laboratory evidence (2)

HCV sequencing indicates that:

The sequence of the virus of the child is different from the virus of
the older brother
The sequence of the virus is close from the virus of the mother

Sequencing data supports the epidemiological hypothesis

that the child acquired HCV from his mother through a
percutaneous exposure

Laboratory Training for Field Epidemiologists

Generating hypotheses in an investigation

allowing the use of statistics (1)

A multi-state outbreak of hepatitis A among school children,

USA, 1997

Cases in three states

Michigan (more than 200)
Maine (few dozens)
Arizona (handful)

Laboratory Training for Field Epidemiologists

Epidemiological and
laboratory results (2)
State

Epidemiological results

Laboratory results

Michigan

Two clusters in two cities

Indistinguishable hepatitis A

Hepatitis associated with

virus

consumption of frozen
strawberries in two
epidemiological studies
Maine

Cases scattered in the state

Hepatitis A virus

Borderline association

indistinguishable from the

Michigan virus

between hepatitis and

consumption of frozen
strawberries
Arizona

Handful of cases having

Hepatitis A virus

eaten frozen strawberries

indistinguishable from the

Michigan and Maine virus

Laboratory Training for Field Epidemiologists

Interpretation (3)

The multi-state outbreak was caused by the consumption of

the same frozen strawberries among school children
In Michigan, the epidemiological information is sufficient to
conclude
In Maine, the laboratory evidence supports the unclear
epidemiological evidence
In Arizona where cases are to few, only the laboratory evidence
allows to conclude

The smaller number of cases in Maine and Arizona may

reflect a lower level of contamination of the product
distributed in these two states

Laboratory Training for Field Epidemiologists

Interpreting prevalence and incidence

A quantitative epidemiological study estimating the

frequency of a disease on the basis of a laboratory test (e.g.,
serological survey) must be interpreted according to:
Predictive value positive
Predictive value negative

These will depend upon:

The test used (sensitivity and specificity)
The frequency of the disease

Laboratory Training for Field Epidemiologists

Be careful about what the manufacturer

may say about the predictive values

The manufacturer may report values of

Sensitivity
Specificity

These probably come from panel testing

Be careful with values of predictive values positive and

negative reported by manufacturers
These values depends upon specific prevalence settings
They may come from a combination of a positive and negative
panels that generate an artificial prevalence of 50%

Laboratory Training for Field Epidemiologists

Take home message:

Interpret epidemiological and laboratory
evidence as a team

Positive tests are likely to rule in the diagnosis if the test is

specific and the disease common

Negative tests are likely to rule out the diagnosis if the test is
sensitive and the disease uncommon

Emergent pathogens are discovered in the laboratory and

assessed according to additional studies

Laboratory investigations of relatedness must be based on

hypotheses developed on the basis of the epidemiology

Interpret incidence and prevalence indicators according to

predictive values positive and negative

Laboratory Training for Field Epidemiologists

Interpretation of results

Developed by:
The Department of Epidemic and Pandemic Alert
and Response of the World Health Organization
with the assistance of:
European Program for Field Epidemiology
Training
Canadian Field Epidemiology Programme
Thailand Ministry of Health
Pasteur
Laboratory Training Institut
for Field Epidemiologists