Pe spec i e
Sel -collec ed
nasal
swabs
o
de ec
in ec ion
and
coloniza ion:
a
use ul
ool
o
popula ion-based
epidemiological
s udies?
M.K.
Akma o
a,
*,
F.
Pessle
a,b
a
Depa men
o
In ec ion
Gene ics,
P ojec
G oup
Epidemiology,
Helmhol z
Cen e
o
In ec ion
Resea ch,
Inho ens aße
7,
D-38124
B aunschweig,
Ge many
b
Uni e si y
Child en’s
Hospi al,
Di ision
o
Rheuma ology
and
Immunology,
Technical
Uni e si y
D esden,
D esden,
Ge many
1.
In oduc ion
Why
a e
he e
so
ew
la ge
popula ion-based
epidemiological
s udies
on
isk
ac o s
o
in ec ious
diseases?
Indeed,
in ec ious
diseases
ha e
been
all
bu
excluded
om
he
la ge
popula ion-
based
coho
s udies
ha
a e
cu en ly
in
a ious
s ages
o
e olu ion
wo ldwide.
This
is
he
mo e
su p ising
since
en i on-
men al,
li es yle,
and
hos
gene ic
ac o s
clea ly
con ibu e
o
acquisi ion,
ansmission,
clinical
cou se,
and
ou come
o
essen-
ially
all
in ec ious
diseases
known
o
da e.
Hos
gene ic
ac o s
in
pa icula
may
play
impo an
oles
in
many
acu e
in ec ious
diseases,
as
exemplified
by
influenza
1,2
and
no o i us
in ec ion.
3
This
pauci y
o
popula ion-based
app oaches
o
in ec ious
diseases/in ec ions
may
be
explained,
a
leas
in
pa ,
by
me hodological
limi a ions.
In
con as
o
he
common
ch onic
diseases
ha
a e
usually
ea u ed
in
popula ion-based
s udies
(e.g.,
ca dio ascula ,
me abolic,
neoplas ic,
o
neu odegene a i e
dis-
eases),
in ec ious
diseases
o en
ollow
an
acu e
cou se
and
he
pa hogen
may
only
be
de ec able
du ing
a
na ow
ime-window.
Fo
ins ance,
maximal
shedding
o
influenza
i us
occu s
in
he
fi s
3
days
o
in ec ion
in
humans,
and
he
a e
o
i al
de ec ion
by
PCR
declines
apidly
a e
5
days.
4
Mo eo e ,
in ec ious
diseases
may
ollow
a
mild
o
e en
asymp oma ic
cou se,
and
some
indi iduals
may
be
colonized
wi h
mic obial
pa hogens
(e.g.,
S aphylococcus
au eus)
wi hou
displaying
any
symp oms.
Thus,
heal hca e
u iliza ion
by
hese
indi iduals
is
low
and
hei
iden ifica ion
in
he
con ex
o
popula ion-based
s udies
is
di ficul .
Consequen ly,
esea ch
on
in ec ious
diseases
is
o en
hospi al-based,
esul ing
in
an
o e sampling
o
diseases
cha ac-
e ized
by
compa a i ely
high
mo bidi y
and
heal hca e
u iliza-
ion.
The e o e,
di e en
me hods
o
sample
collec ion
a e
needed
o
iden i y
asymp oma ic
ca ie s
o
indi iduals
wi h
acu e
in ec ions
no
se e e
enough
o
necessi a e
a
isi
o
a
medical
ca e
p o ide .
As
exemplified
by
s udies
on
influenza
in ec ion,
a
ained
membe
o
he
field
eam
may
collec
he
diagnos ic
specimen
by
pe o ming
a
nasal
swab
on
he
s udy
pa icipan
du ing
a
house
call.
5
Howe e ,
o
his
app oach
o
unc ion,
he
subjec s
need
o
no i y
he
s udy
cen e
p omp ly
and
eliably
a
he
onse
o
symp oms.
An
addi ional
d awback
is
ha
he
cos
o
his
app oach
sky ocke s
when
la ge
numbe s
o
inciden
cases
need
o
be
iden ified,
e.g.,
o
a
genome-wide
associa ion
s udy
(GWAS).
An
a ac i e
al e na i e
app oach
would
be
o
ask
he
pa icipan s
o
pe o m
he
swabs
hemsel es
(‘sel -swabbing’).
The e
is
ample
e idence
om
a ious
clinical
scena ios
demon-
s a ing
he
easibili y
o
sel -swabbing
among
specific
isk
g oups
and
pa ien
popula ions.
6–10
Sel -swabbing
has
se e al
ad an ages
o e
he
collec ion
o
samples
by
s udy
pe sonnel.
Fi s ,
inciden
cases
o
acu e
in ec ions
ha
ea u e
a
sho
du a ion
o
mild
symp oms
can
be
iden ified
mo e
easily.
Thus,
his
me hod
may
imp o e
iden ifica ion
o
inciden
cases
and
he eby
educe
disease
misclassifica ion.
Second,
a
la ge
numbe
o
s udy
subjec s
can
be
included
in
a
gi en
s udy
due
o
he
lowe
cos
and
simple
logis ics.
Fo
In e na ional
Jou nal
o
In ec ious
Diseases
15
(2011)
e589–e593
A
R
T
I
C
L
E
I
N
F
O
A icle
his o y:
Recei ed
17
No embe
2010
Recei ed
in
e ised
o m
1
Ma ch
2011
Accep ed
22
Ap il
2011
Co esponding
Edi o :
J.
Pe e
Donnelly,
Nijmegen,
he
Ne he lands.
Keywo ds:
Sel -collec ed
nasal
swabs
Bac e ial
and
i al
in ec ions
Epidemiological
s udies
S
U
M
M
A
R
Y
Popula ion-based
epidemiological
s udies
on
in ec ious
diseases
a e
limi ed
by
me hodological
p oblems
ha
may
no
be
encoun e ed
in
o he
fields
o
epidemiology.
The
acu e
o
asymp oma ic
na u e
o
many
in ec ions
hinde s
a
imely
diagnosis
by
ained
pe sonnel
in
a
s udy
cen e,
indica ing
he
need
o
new
collec ion
me hods
o
biological
specimens.
One
al e na i e
app oach
is
o
ha e
he
pa icipan s
collec
he
specimens
hemsel es,
o
ins ance
nasal
swabs
o
he
de ec ion
o
bac e ial
o
i al
pa hogens.
Al hough
sel -collec ion
is
widely
accep ed
in
clinical
s udies
o
specific
popula ions
(e.g.,
sel -collec ion
o
aginal
swabs
by
young
women
o
diagnose
sexually
ansmi ed
in ec ions),
i
has
no
been
employed
much
in
popula ion-based
s udies.
He e,
we
e iew
ecen
expe ience
wi h
sel -
collec ion
o
nasal
swabs
o
he
de ec ion
o
mic oo ganisms
and
discuss
u u e
p ospec s
and
applica ions
o
his
echnique.
ß
2011
In e na ional
Socie y
o
In ec ious
Diseases.
Published
by
Else ie
L d.
All
igh s
ese ed.
*
Co esponding
au ho .
Tel.:
+49
0
531
6181
1112;
ax:
+49
0
531
6181
1199.
E-mail
add ess:
[email p o ec ed]
(M.K.
Akma o ).
Con en s
lis s
a ailable
a
ScienceDi ec
In e na ional
Jou nal
o
In ec ious
Diseases
jou
nal
h
o
mep
ag
e:
w
ww
.else ie
.co
m
/loc
a e/ijid
1201-9712/$36.00
–
see
on
ma e
ß
2011
In e na ional
Socie y
o
In ec ious
Diseases.
Published
by
Else ie
L d.
All
igh s
ese ed.
doi:10.1016/j.ijid.2011.04.009
example,
o
a
planned
GWAS
on
gene ic
ac o s
o
influenza
in ec ion
(de ec ed
in
nasal
swabs)
in
an
u ban/subu ban
popula ion,
we
compa ed
he
cos
o
swabbing
by
s udy
pe sonnel
o
he
cos
o
sel -swabbing.
In
o de
o
de ec
an
odds
a io
o
1.5
(assuming
10%
clinical
a ack
a e,
80%
powe ,
and
5

10
8
ype
1
e o
accoun ing
o
mul iple
hypo hesis
es ing),
1000
cases
would
be
needed.
Expec ing
an
in ec ion
a e
o
app ox.
25%,
a
disco e y
sample
o
n
=
4000
pa icipan s
would
be
needed
o
yield
1000
cases.
Assuming
an
a e age
o
wo
acu e
espi a o y
in ec ions
(ARI)
pe
indi idual
pe
yea ,
11
app ox.
8000
home
isi s
a
a
cos
o
a
leas
20
eu os/ isi
(pe sonal
communica ion,
Thomas
Beh ens,
B emen
Ins i u e
o
P e en ion
Resea ch
and
Social
Medicine;
based
on
cu en
cos
o
pe sonnel
ime
and
a el
in
Ge many)
would
be
equi ed,
cos ing
upwa d
o
160
000
eu os.
Including
pa icipan s
om
u al
o
emo e
a eas
would
esul
in
e en
highe
cos s
due
o
highe
a el
expenses.
On
he
o he
hand,
he
cos
o
sel -collec ion
o
swabs
would
be
app ox.
32
000
eu os,
mos ly
o
packaging
and
pos age.
He e,
we
e iew
he
li e a u e
on
sel -collec ion
o
nasal
swabs
o
he
de ec ion
o
mic oo ganisms
and
discuss
u u e
p ospec s
and
applica ions
o
his
p omising
new
ool
o
in ec ious
disease
field
esea ch.
2.
S a e
o
he
a
2.1.
Sample
collec ion
in
an
unsupe ised
se ing
A
summa y
o
all
s udies
ha
ha e
used
sel -collec ed
nasal
swabs
is
p esen ed
in
Table
1.
4,12–20
Only
wo
s udies
we e
uly
popula ion-based
and
ea u ed
sel -collec ion
ou side
o
a
s udy
cen e.
4,19
an
Clee
e
al.
examined
he
p e alence
o
li es ock-
associa ed
me hicillin- esis an
S aphylococcus
au eus
(MRSA)
in
he
Ne he lands.
19
In
his
s udy,
swabbing
supplies
we e
sen
by
mail
o
indi iduals
who
had
ag eed
o
pa icipa e
in
he
s udy
(n
=
644).
App oxima ely
90%
e u ned
he
swabs,
indica ing
ha
sel -collec ion
may
be
highly
easible
in
he
gene al
popula ion.
In
ano he
popula ion-based
s udy
o
espi a o y
in ec ions,
pa en s
we e
asked
o
collec
nasal
and
pha yngeal
swabs
om
hei
child en.
4
The
main
ou come
in
his
s udy
was
he
p opo ion
o
swabs
ha
we e
posi i e
o
any
one
o
se en
espi a o y
pa hogens.
By
compa ing
esul s
o
(1)
nasal
and
h oa
swabs
and
(2)
swabs
collec ed
by
pa en s
who
wo ked
in
heal hca e
s.
pa en s
who
did
no ,
i
was
ound
ha
nasal
swabs
we e
mo e
o en
posi i e
han
pha yngeal
swabs,
bu
ha
he e
was
no
di e ence
in
he
p opo ion
o
posi i e
swabs
when
compa ing
Table
1
Summa y
o
published
s udies
using
sel -collec ed
nasal
swabs
Au ho /yea
S udy
design
S udy
popula ion
To al
sample
size
Ou come
Sel -swabbing
Mos
ele an
esul s
Gilbe
e
al.
2007
18
C oss-sec ional
(pa ien -based)
Adul s
(ma ginalized
u ban
popula ion,
e.g.,
d ug
use s)
271
MRSA
coloniza ion
Sel -collec ed
nasal
swabs
MSSA
was
de ec ed
in
95
o
271
(36%)
swabs,
any
MRSA
s ain
in
13
(4.8%),
and
MRSA
USA300
in
10
(3.7%)
Coope
e
al.
2008
16
C oss-sec ional
(pa ien -based)
Adul s
296
Influenza
i us
de ec ion
Sel -collec ed
nasal
swabs
142
o
296
(48%)
swabs
we e
e u ned
by
mail
No
di ficul ies
in
sel -swabbing
epo ed
Mean
ime
be ween
he
phone
call
and
sel -swabbing
7.4
days
No
di e ences
in
mean
imes
be ween
posi i e
and
nega i e
samples
Lambe
e
al.
2008
4
Coho
s udy
(communi y-based)
Child en
234
De ec ion
o
espi a o y
i uses
Pa en -collec ed
nasal
swabs
Highe
posi i i y
a es
o
nasal
samples
o
any
i us
(78%)
compa ed
o
samples
om
h oa
(71%)
No
di e ences
in
he
posi i i y
a es
be ween
pa en s
who
did
and
did
no
wo k
in
heal hca e
Time
om
symp om
onse
o
sel -
swabbing
o
less
han
5
days
i espec i e
o
ime
om
sel -
swabbing
o
labo a o y
analysis
did
no
influence
he
posi i i y
a e
Time
om
symp om
onse
o
sel -
swabbing
o
mo e
han
6
days
combined
wi h
ime
om
sel -
swabbing
o
labo a o y
analysis
o
2
and
mo e
days
dec eased
he
posi i i y
a e
High
accep ance
(e.g.,
87%
o
pa icipan s
ag eed
o
pa icipa e
in
u he
s udies)
Di ficul ies
wi h
h oa
swab
(58%)
Lu
e
al.
2008
15
Con enience
sample
o
labo a o y
s a
Adul s
4
Rhino i us
Se ial
sel -collec ed
nasal
swabs
Samples
we e
used
o
de elop
a
eal- ime
PCR
assay
o
de ec ion
o
human
hino i uses
Ellio
e
al.
2009
13
C oss-sec ional
(pa ien -based)
Adul s
3129
Influenza
su eillance
Sel -collec ed
nasal
swabs
1783
swabs
o
3129
(57%)
we e
e u ned
by
mail
1076
swabs
o
1346
(80%)
we e
ecei ed
wi hin
7
days
o
symp om
onse
M.K.
Akma o ,
F.
Pessle
/
In e na ional
Jou nal
o
In ec ious
Diseases
15
(2011)
e589–e593
e590
pa en al
p o ession
(heal hca e
s.
non-heal hca e
wo ke s).
These
esul s
a e
a
fi s
indica ion
ha
–
a
leas
in
his
se ing
o
pa en al
swabbing
–
lay
pe sons
can
collec
swabs
as
e ficien ly
as
heal hca e
wo ke s.
The
i al
de ec ion
a e
emained
cons an
as
long
as
he
ime
ha
elapsed
be ween
he
onse
o
illness
and
collec ion
o
he
specimen
was
5
days
o
less.
Howe e ,
i
dec eased
when
he
ime
om
illness
onse
o
labo a o y
analysis
exceeded
8
days,
unde sco ing
he
impo ance
o
imely
e u n
o
sel -collec ed
swabs
o
he
s udy
cen e.
Sel -sampling
has
also
been
ound
o
imp o e
symp oma ic
su eillance
by
p o iding
addi ional
labo a o y-based
in o ma-
ion.
13,16
Fo
example,
du ing
he
2004–2005
influenza
seasons,
he
UK
Na ional
Heal h
Se ice
es ablished
a
elephone
ho line
(‘NHS
Di ec ’).
16
Calle s
who
oiced
a
conce n
o
su e ing
om
an
influenza-like
illness
we e
sen
swabbing
supplies
by
mail
and
we e
asked
o
sel -collec
a
nasal
swab
and
mail
i
o
a
cen al
e e ence
labo a o y.
Mos
s udy
pa icipan s
pe o med
he
swab
and
e u ned
i
wi hin
he
eques ed
ime:
he
ime
in e als
be ween
he
phone
call
and
sel -swabbing
and
be ween
he
phone
call
and
labo a o y
analysis
we e
4.1
and
7.4
days,
espec i ely.
The
majo i y
o
pa icipan s
epo ed
no
di ficul ies
wi h
sel -
sampling.
2.2.
Sample
collec ion
in
a
supe ised
se ing
In
a
ecen
pa ien -based
s udy
o
influenza
in ec ion
in
child en,
esea che s
compa ed
he
e ficiency
o
nasal
swabs
collec ed
by
pedia icians
and
pa en s.
14
Sensi i i y
(89%)
and
specifici y
(98%)
o
pa en -collec ed
swabs
(compa ed
o
pedia i-
cian-collec ed
swabs)
o
he
de ec ion
o
influenza
i us
by
eal-
ime
PCR
we e
high,
and
he
mean
i al
copy
numbe
pe
posi i e
swab
did
no
di e
be ween
pa en -
and
pedia ician-collec ed
samples.
The
pa en s
epo ed
ha
he
child en
we e
mo e
sa isfied
when
nasal
swabs
we e
aken
by
he
pa en s
han
by
he
pedia icians.
14
In
a
e y
ecen
s udy,
a
newly
de eloped
flocked
nasal
swab
was
e alua ed
o
he
de ec ion
o
espi a o y
in ec ions.
17
Ini ially,
symp om- ee
pa icipan s
we e
asked
o
collec
swabs
om
one
nos il.
A
he
same
ime,
swabs
we e
collec ed
by
s udy
pe sonnel
wi h
a
ayon
nasopha yngeal
swab
(gold
s anda d)
om
he
o he
nos il.
The
sel -collec ed
nasal
swabs
yielded
be e
esul s
han
he
gold
s anda d
(based
on
a
highe
epi helial
cell
coun
and
de ec ion
o
highe
le els
o
human
b
-ac in
gene
coding
sequences,
which
we e
used
as
p oxy
endpoin s).
Fu he mo e,
espi a o y
i al
in ec ions
we e
de ec ed
in
symp oma ic
sub-
jec s;
among
he
108
symp oma ic
subjec s
any
one
o
se e al
ARI
was
de ec ed
in
42
sel -collec ed
swabs
(39%).
Howe e ,
his
endpoin
was
no
compa ed
wi h
he
gold
s anda d
me hod.
The
majo i y
o
subjec s
(87%
o
55)
had
no
o
mino
di ficul ies
wi h
sel -swabbing.
Six y-fi e
pe cen
o
subjec s
epo ed
no
o
only
mino
discom o
om
sel -swabbing,
31%
epo ed
mode a e
discom o ,
and
4%
se e e
discom o .
A
fi s
glance,
nasal
swabbing
does
no
appea
o
be
a
echnically
demanding
p ocedu e,
bu
specific
aspec s
such
as
he
applied
p essu e
and
he
numbe
o
e olu ions
du ing
swabbing,
he
dep h
o
inse ion
owa d
he
u bina es,
o
e en
which
nos il
o
p obe,
a e
all
pa ame e s
ha
could
po en ially
a ec
he
e ficiency
o
de ec ion.
Hence,
i
mus
be
no ed
ha
he
s udy
on
pa en -collec ed
swabs
is
he
only
one
whe e
he
de ec ion
a e
o
sel -collec ed
nasal
swabs
was
compa ed
di ec ly
o
samples
ob ained
by
ained
pe sonnel.
14
Howe e ,
pa en s
collec ed
he
swabs
in
he
p esence
o
s udy
pe sonnel
and
may
ha e
el
mo e
confiden ,
esul ing
in
be e
swabbing.
In
he
abo e-men ioned
s udy
by
Smieja
e
al.,
17
he
numbe
o
nasal
epi helial
cells
and
he
Table
1
(Con inued
)
Au ho /yea
S udy
design
S udy
popula ion
To al
sample
size
Ou come
Sel -swabbing
Mos
ele an
esul s
Loeb
e
al.
2009
12
Randomized
ial
(con enience
sample
o
hospi al
s a )
Adul s
446
Influenza
i us
ansmission
Sel -collec ed
nasal
swabs
Compa ison
o
a
su gical
mask
(g oup
1)
and
an
N95
espi a o
(g oup
2)
o
p e en
ansmission
o
influenza
A
o
B
i us
Influenza
i us
was
de ec ed
in
2.8%
o
he
212
swabs
om
g oup
1
s.
1.9%
o
he
210
swabs
om
g oup
2
O he
espi a o y
i uses
we e
de ec ed
in
9.4%
(g oup
1)
and
10.5%
(g oup
2)
o
he
swabs
Esposi o
e
al.
2010
14
Coho
s udy
(pa ien -based)
Child en
203
Influenza
i us
de ec ion
Pa en -collec ed
nasal
swabs
High
sensi i i y
(89%)
and
specifici y
(98%)
o
he
sel -
collec ed
swabs
(gold
s anda d:
pedia ician-collec ed
swabs)
Highe
sa is ac ion
o
child en
wi h
pa en -
han
pedia ician-collec ed
swabs
No
di e ence
in
i us
de ec ion
a e
be ween
pa en -
and
pedia ician-
collec ed
swabs
Smieja
e
al.
2010
17
C oss-sec ional
s udy
(con enience
sample
o
hospi al
s a
and
isi o s)
Adul s
250
Respi a o y
i al
in ec ions
Sel -collec ed
nasal
swabs
108
pa icipan s
o
250
(44%)
sel -
swabbed
wi hin
4
days
o
symp om
onse
and
e u ned
he
swabs
wi hin
5
days
Van
Clee
e
al.
2010
19
C oss-sec ional
s udy
(communi y-based)
Adul s
644
MRSA
coloniza ion
Sel -collec ed
nasal
swabs
583
swabs
o
644
(91%)
we e
e u ned
by
mail
Ammons
e
al.
2010
20
C oss-sec ional
s udy
(con enience
sample
o
s uden
popula ion)
Young
adul s
375
a
MRSA
coloniza ion
Sel -collec ed
nasal
swabs
S aphylococcus
au eus
was
de ec ed
in
7
o
375
swabs
(1.9%);
6
o
which
we e
MRSA
MRSA,
me hicillin- esis an
S aphylococcus
au eus;
MSSA,
me hicillin-sensi i e
S aphylococcus
au eus.
a
Numbe
o
swabs.
M.K.
Akma o ,
F.
Pessle
/
In e na ional
Jou nal
o
In ec ious
Diseases
15
(2011)
e589–e593
e591
p esence
o
DNA
sequences
encoding
he
human
b
-ac in
gene
we e
used
o
quan i y
hos
issue
in
which
i uses
o
o he
pa hogens
migh
be
de ec ed.
Howe e ,
he
i al
de ec ion
a e
was
no
compa ed
be ween
sel -collec ed
and
pe sonnel-collec ed
swabs.
Thus,
he
diagnos ic
equi alence
o
sel -collec ed
swabs
by
adul s
has
no
been
es ablished
o mally.
We
a e
cu en ly
conduc ing
such
a
s udy,
in
which
sel -collec ed
and
ained
pe sonnel-collec ed
nasal
swabs
a e
being
compa ed
in
e ms
o
hei
accu acy
in
he
de ec ion
o
i al
espi a o y
pa hogens.
In
wo
s udies,
nasal
swabs
we e
sel -collec ed
by
labo a o y
15
and
hospi al
s a .
12
In
hese
selec ed
popula ions,
sel -swabbing
should
be
easible
since
unde s anding
o
he
swabbing
p ocedu e
and
compliance
wi h
i s
echnical
aspec s
should
be
good.
The
abo e-men ioned
s udies
indica e
ha
sel -swabbing
was
highly
accep able
among
he
s udied
popula ions.
I
also
appea s
o
be
a
easible
me hod
o
he
diagnosis
o
a ious
mic oo ganisms,
as
long
as
he
ime
in e als
om
onse
o
symp oms
o
sample
collec ion
and
hen
o
a i al
in
he
labo a o y,
a e
moni o ed
ca e ully.
Fu he
alida ion
s udies
a e
needed
o
in es iga e
he
e ficacy
o
sel -collec ed
nasal
swabs
o
de ec
espi a o y
pa hogens,
pa icula ly
by
compa ing
sel -swabbing
wi h
he
espec i e
gold
s anda d
me hod,
e.g.
s a -collec ed
nasal
swabs.
3.
Challenges
The
abo e-men ioned
s udies
show
ha
sel -swabbing
may
be
a
iable
and
cos -e ec i e
al e na i e
me hod
o
he
pu pose
o
collec ing
nasal
swabs
o
epidemiological
s udies.
Howe e ,
he e
a e
some
challenges
ha
ha e
o
be
conside ed
p io
o
using
his
me hod.
Fi s ,
an
inadequa e
sampling
echnique
will
undoub edly
comp omise
he
alue
o
any
labo a o y
analysis.
E en
hough
i
appea s
ob ious
ha
s udy
pa icipan s
should
be
in i ed
once
o
a
s udy
cen e
whe e
s udy
pe sonnel
can
explain
and
demons a e
he
co ec
sel -swabbing
echnique,
i
has
no
ye
been
de e -
mined
whe he
his
is
eally
necessa y.
In
coun ies
wi h
well-
unc ioning
mail
deli e y
sys ems,
swabbing
supplies
ha e
also
been
p o ided
by
mail.
13,16,19
I
his
app oach
is
o
be
used,
pa icipan s
should
be
p o ided
wi h
de ailed
p in ed
ins uc ions
on
how
o
ob ain
he
sample,
including
simple
isual
ma e ial.
Second,
o
achie e
imely
and
eliable
sample
collec ion
(which
is
pa icula ly
impo an
in
he
de ec ion
o
ARI),
pa icipan s
should
ecei e
eminde s
on
a
egula
basis.
Va ious
eminde
sys ems
can
be
used,
such
as
elephone
calls,
e-mail,
o
SMS
(sho
message
se ice;
ex ).
Thi d,
logis ic
p oblems
can
a ise
i
sel -swabbing
is
o
ake
place
ou side
o
a
s udy
cen e
(e.g.,
a
home)
and
he
swabs
a e
o
be
e u ned
by
he
pa icipan s
in
pe son
o
by
mail.
In
he
abo e-
men ioned
s udies,
he
swabs
we e
e u ned
by
mail,
wi h
e u n
a es
a ying
be ween
48%
16
and
91%.
19
The
esul s
o
labo a o y
analyses
will
depend
on
he
ime
elapsed
be ween
sel -swabbing
and
labo a o y
analysis;
an
ea ly
deli e y
o
swabs
may
inc ease
he
sensi i i y
and
specifici y,
bu
his
will
a y
wi h
he
o ganism
o
be
de ec ed.
As
men ioned
abo e,
when
a
panel
o
pa hogenic
i uses,
mos ly
consis ing
o
RNA
i uses,
was
used,
he
de ec ion
a e
o
any
i us
dec eased
i
mo e
han
8
days
elapsed
be ween
symp om
onse
and
labo a o y
analysis.
4
Concei ably,
his
was
due
o
nucleic
acid
deg ada ion
du ing
anspo .
In e es ingly,
in
a
s udy
o
sel -collec ed
aginal
swabs
(in
which
e-mail
was
used
success ully
as
a
eminde
ool),
no
e ec
o
anspo
ime
on
DNA
quan i y
was
de ec ed,
pe haps
due
o
he
inhe en
highe
s abili y
o
DNA
compa ed
wi h
RNA.
I
he e o e
appea s
impo an
o
e alua e
nucleic
acid
p ese a i es
(e.g.,
RNAla e
1
,
RNAp o ec
1
,
and
o he s)
as
al e na e
collec ion
and
anspo
media
o
scena ios
in
which
RNA
s abili y
would
be
a
conce n,
and
cul u e
( equi ing
iable
o ganisms)
is
no
planned.
Use
o
such
media
would
be
pa icula ly
impo an
in
s udies
in
which
gene
exp ession
pa e ns
o
en i e
mic obial
popula ions
(mic obiomes)
a e
o
be
de e mined.
4.
Conclusions
and
p ospec s
o
he
u u e
Sel -collec ion
o
nasal
swabs
may
be
a
cos -e ficien
me hod
o
he
de ec ion
o
mic oo ganisms
in
popula ion-based
epide-
miological
s udies.
By
using
his
me hod
one
may
inc ease
he
size
o
he
s udy
popula ion,
hus
acili a ing
in es iga ions
on
complex
associa ions
be ween
in ec ious
diseases/in ec ions
and
a ious
isk
ac o s.
In
he
small
numbe
o
s udies
in
which
sel -swabbing
was
employed,
i
was
ound
o
be
sa e
and
was
me
wi h
a
high
deg ee
o
accep ance
and
sa is ac ion
on
he
pa
o
he
pa icipan s.
Howe e ,
i
has
no
been
es ablished
whe he
he
de ec ion
a es
o
a ious
mic oo ganisms
om
sel -collec ed
swabs
and
om
swabs
ob ained
by
ained
pe sonnel
a e
compa able.
Thus,
u he
alida ion
s udies
a e
needed
be o e
he
use
o
sel -swabbing
can
be
ad oca ed
wi hou
ese a ions.
Acknowledgemen s
We
hank
D .
Thomas
Ja
¨nisch
(Heidelbe g
Uni e si y
Hospi al),
P o .
Lo ha
K eienb ock
(Uni e si y
o
Ve e ina y
Medicine
Hanno e )
and
P o .
Klaus
Schugha
(Helmhol z
Cen e
o
In ec ion
Resea ch,
B aunschweig)
o
c i ical
eadings
o
he
manusc ip
and
help ul
discussions.
This
wo k
was
suppo ed
by
in amu al
unding
om
he
Helmhol z
Associa ion
(P og am
In ec ion
and
Immuni y).
Conflic
o
in e es :
No
conflic
o
in e es .
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