Two-Component Cluster Analysis of a Large Serodiagnostic Database for Specificity of Increases of IgG Antibodies against Pertussis Toxin in Paired Serum Samples and of Absolute Values in Single Serum Samples

ABSTRACT Measuring IgG antibodies against pertussis toxin (IgG-Ptx) with an enzyme-linked immunosorbent assay (ELISA) can be used to diagnose pertussis infection; however, the cutoff points are not unanimously defined. To determine the diagnostic specificity of increases of IgG-Ptx in paired sera and of absolute values in single serum samples, we applied a two-component cluster analysis to serum samples of patients suspected for pertussis, whose sera had been submitted to a routine diagnostic laboratory between 2003 and 2009, and had been assayed with an in-house IgG-Ptx ELISA calibrated with the international FDA lot 3 IgG-Ptx reference serum. Children eligible for the acellular pertussis vaccination were excluded to avoid interference from a vaccine-induced IgG-Ptx rise. Binary distribution mixtures were fitted to the data. Receiver operating characteristic (ROC) curves were calculated for absolute values in single samples (n = 14,452) and increases in paired samples (n = 2,455). For both parameters, two subpopulations could be identified: a population with high reactivity (persons with pertussis infection) and a population with low reactivity (persons without pertussis infection). For absolute values in single samples, the area under the curve (AUC) of the ROC curve was 0.993 and the optimum cutoff (with the highest cumulative value of specificity plus sensitivity) was 67.7 IU/ml (95% confidence interval, 63.9 to 74.1; sensitivity, 96.4%; specificity, 95.7%). A previously determined diagnostic cutoff of 125 IU/ml was associated with a sensitivity of 88.1% and a specificity of 98.8%. For increases in paired sera, the AUC was 0.999 and the optimum cutoff was 3.1-fold (95% CI, 2.8 to 3.4; sensitivity, 99.6%; specificity, 99.2%). Given the methodology of this study, estimates of sensitivity probably are overrated (because pertussis patients without IgG-Ptx response are not detected), but estimates of specificities can be considered very accurate.