title: Of gastro and the gold standard: evaluation and policy implications of norovirus test performance for outbreak detection.
abstract: BACKGROUND
  The norovirus group (NVG) of caliciviruses are the etiological agents of most institutional outbreaks of gastroenteritis in North America and Europe. Identification of NVG is complicated by the non-culturable nature of this virus, and the absence of a diagnostic gold standard makes traditional evaluation of test characteristics problematic.
  
  
  METHODS
  We evaluated 189 specimens derived from 440 acute gastroenteritis outbreaks investigated in Ontario in 2006-07. Parallel testing for NVG was performed with real-time reverse-transcriptase polymerase chain reaction (RT2-PCR), enzyme immunoassay (EIA) and electron microscopy (EM). Test characteristics (sensitivity and specificity) were estimated using latent class models and composite reference standard methods. The practical implications of test characteristics were evaluated using binomial probability models.
  
  
  RESULTS
  Latent class modelling estimated sensitivities of RT2-PCR, EIA, and EM as 100%, 86%, and 17% respectively; specificities were 84%, 92%, and 100%; estimates obtained using a composite reference standard were similar. If all specimens contained norovirus, RT2-PCR or EIA would be associated with > 99.9% likelihood of at least one test being positive after three specimens tested. Testing of more than 5 true negative specimens with RT2-PCR would be associated with a greater than 50% likelihood of a false positive test.
  
  
  CONCLUSIONS
  Our findings support the characterization of EM as lacking sensitivity for NVG outbreaks. The high sensitivity of RT2-PCR and EIA permit identification of NVG outbreaks with testing of limited numbers of clinical specimens. Given risks of false positive test results, it is reasonable to limit the number of specimens tested when RT2-PCR or EIA are available.
authors.affiliation: Division of Epidemiology and Surveillance, Ontario Agency for Health Protection and Promotion, Toronto, Canada. david.fisman@gmail.com
authors.forename: David N
authors.initials: DN
authors.lastname: Fisman
authors.forename: Amy L
authors.initials: AL
authors.lastname: Greer
authors.forename: George
authors.initials: G
authors.lastname: Brouhanski
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Drews