Vector biology of the cat flea Ctenocephalides felis.

Ctenocephalides felis, the cat flea, is among the most prevalent and widely dispersed vectors worldwide. Unfortunately, research on C. felis and associated pathogens (Bartonella and Rickettsia spp.) lags behind that of other vectors and vector-borne pathogens. Therefore, we aimed to review fundamental aspects of C. felis as a vector (behavior, epidemiology, phylogenetics, immunology, and microbiome composition) with an emphasis on key techniques and research avenues employed in other vector species. Future laboratory C. felis experimental infections with Bartonella, Rickettsia, and Wolbachia species/strains should examine the vector-pathogen interface utilizing contemporary visualization, transcriptomic, and gene-editing techniques. Further environmental sampling will inform the range and prevalence of C. felis and associated pathogens, improving the accuracy of vector and pathogen modeling to improve infection/infestation risk assessment and diagnostic recommendations.

New records of pathogenic bacteria in different species of fleas collected from domestic and peridomestic animals in Spain. A potential zoonotic threat?

Climate change is causing many vectors of infectious diseases to expand their geographic distribution as well as the pathogens they transmit are also conditioned by temperature for their multiplication. Within this context, it is worth highlighting the significant role that fleas can play as vectors of important pathogenic bacteria. For this purpose, our efforts focused on detecting and identifying a total of 9 bacterial genera (Rickettsia sp.; Bartonella sp.; Yersinia sp.; Wolbachia sp., Mycobacterium sp., Leishmania sp., Borrelia sp., Francisella sp. and Coxiella sp.) within fleas isolated from domestic and peridomestic animals in the southwestern region of Spain (Andalusia). Over a 19-months period, we obtained flea samples from dogs, cats and hedgehogs. A total of 812 fleas was collected for this study. Five different species were morphologically identified, including C. felis, C. canis, S. cuniculi, P. irritans, and A. erinacei. Wolbachia sp. was detected in all five species identified in our study which a total prevalence of 86%. Within Rickettsia genus, two different species, R. felis and R. asembonensis were mainly identified in C. felis and A. erinacei, respectively. On the other hand, our results revealed a total of 131 fleas testing positive for the presence of Bartonella sp., representing a prevalence rate of 16% for this genus identifying two species B. henselae and B. clarridgeiae. Lastly, both Y. pestis and L. infantum were detected in DNA of P. irritans and C. felis, respectively isolated from dogs. With these data we update the list of bacterial zoonotic agents found in fleas in Spain, emphasizing the need to continue conducting future experimental studies to assess and confirm the potential vectorial role of certain synanthropic fleas.

The presence of Rickettsia felis in communities in the central highlands of Vietnam.

Rickettsia felis is an emerging flea-borne spotted fever pathogen that causes febrile illness in humans. In Vietnam, R. felis was detected in hospitalized patients, but there is no information on its presence in the Vietnamese community. This cross-sectional study aimed to determine the presence of R. felis in humans of the Central Highlands of Vietnam. A total of 158 blood and 213 serum samples were subjected to PCR and IFAT, respectively, to detect the presence of R. felis DNA and antibodies against R. felis. PCR assays detected R. felis DNA in four out of 158 blood samples, accounting for a prevalence of 2.53 % (95 % CI: 0.81 %-6.76 %). Phylogenetic analysis indicated the presence of R. felis and R. felis genotype RF2125 in the communities in the Central Highlands of Vietnam. The result of IFAT identified seven out of 213 serum samples (3.29 %, 95 % CI: 1.45 %-6.93 %) positive for antibodies against R. felis. This study was the first to demonstrate the presence of active R. felis infections in the communities in the Central Highlands of Vietnam utilizing both molecular and serological methods.

A novel Rickettsia species closely related to Rickettsia felis in Anopheles mosquitoes from Yingkou City, Northeast China.

Mosquitoes are generally recognized as the most important vector of many zoonotic pathogens. In this study, seven mosquitoes species were identified (Anopheles pullus, Anopheles sinensis, Anopheles lesteri, Anopheles kleini, Ochlerotatus dorsalis, Aedes koreicus and Culex inatomii) in samples collected from Yingkou City, Liaoning Province, Northeastern China. A novel Rickettsia species was detected in Anopheles sinensis (two of 71, 2.82%) and Anopheles pullus (one of 106, 0.94%) mosquitoes. Genetic analysis indicated that the rrs and ompB genes have highest 99.60% and 97.88%-98.14% identities to Rickettsia felis, an emerging human pathogen of global concern mainly harboured by fleas, mosquitoes and booklice. The gltA sequences of these strains have 99.72% of nucleotide similarity with Rickettsia endosymbiont of Medetera jacula. The groEL sequences have 98.37% similarity to both Rickettsia tillamookensis and Rickettsia australis. The htrA sequences have 98.77% similarity to Rickettsia lusitaniae. In the phylogenetic tree based on concatenated nucleotide sequences of rrs, gltA, groEL, ompB and htrA genes, these strains are closely related to R. felis. Herein, we name it 'Candidatus Rickettsia yingkouensis'. Its human pathogenicity to humans and animals is still to be determined.

Molecular identification of Bartonella spp. and Rickettsia felis in fox fleas, Chile.

Seventy-five flea pools (one to ten fleas per pool) from 51 Andean foxes (Lycalopex culpaeus) and five South American grey foxes or chillas (Lycalopex griseus) from the Mediterranean region of Chile were analyzed for the presence of DNA of Bartonella spp. and Rickettsia spp. through quantitative real-time PCR for the nouG and gltA genes, respectively. Positive samples were further characterized by conventional PCR protocols, targeting gltA and ITS genes for Bartonella, and gltA, ompA, and ompB genes for Rickettsia. Bartonella was detected in 48 % of the Pulex irritans pools (B. rochalimae in three pools, B. berkhoffii in two pools, B. henselae in one pool), and 8 % of the Ctenocephalides felis felis pools (B. rochalimae, one pool). Rickettsia was confirmed in 11 % of P. irritans pools and 92 % of the Ct. felis pools. Characterization confirmed R. felis in all sequenced Rickettsia-positive pools. All Ct. canis pools were negative. A Ct. felis pool from a wild-found domestic ferret (Mustela putorius furo) also resulted positive for R. felis. Although opportunistic, this survey provides the first description of zoonotic pathogens naturally circulating in fleas parasitizing Chilean free-living carnivores.

Complete bacterial profile and potential pathogens of cat fleas Ctenocephalides felis.

Fleas are important ectoparasites and vectors associated with a wide range of pathogenic diseases, posing threats to public health concerns, especially cat fleas that spread worldwide. Understanding the microbial components is essential due to cat fleas are capable of transmitting pathogens to humans, causing diseases like plague and murine typhus. In the present study, metagenomic next-generation sequencing was applied to obtain the complete microbiota and related functions in the gut of Ctenocephalides felis. A total of 1,870 species was taxonomically recognized including 1,407 bacteria, 365 eukaryotes, 69 viruses, and 29 archaea. Proteobacteria was the dominant phylum among the six samples. Pathogens Rickettsia felis, Acinetobacter baumannii, Coxiella burnetii, and Anaplasma phagocytophilum were taxonomically identified and had high abundances in all samples. The resistance gene MexD was predominant in microbial communities of all cat fleas. We also performed epidemiological surveys of pathogens R. felis, A. baumannii, C. burnetii, and A. phagocytophilum among 165 cat fleas collected from seven provinces in China, while only the DNAs of R. felis (38/165, 23.03%) and C. burnetii (2/165, 1.21%) were obtained. The data provide new insight and understanding of flea intestinal microbiota and support novel information for preventing and controlling fleas and their transmitted diseases.

Molecular detection of Rickettsia felis in fleas and ticks collected from dogs and cats of Puebla, Mexico.

Fleas and ticks represent the two main groups of ectoparasites that infest companion animals. In particular, the flea Ctenocephalides felis felis and several members of the Rhipicephalus sanguineus complex are the main vectors of a wide range of pathogens on the American continent. They are competent vectors for several members of the genus Rickettsia, which encompass at least 15 pathogenic obligate intracellular bacteria that colonize the endothelial cells of vertebrates. In Mexico, 10 species of Rickettsia belonging to three groups have been detected in six species of ectoparasites from dogs in 9 of the 32 states of the country. However, in some larger regions of the country, active epidemiological surveillance has not been carried out. For this reason, the aim of this study was to identify the presence of members of the genus Rickettsia in fleas and ticks of dogs and cats in the state of Puebla, Mexico. A cross-sectional study was carried out to collect ectoparasites of dogs and cats during August to November 2019. Samples were fixed in 70% ethanol and examined to identify the presence of Rickettsia DNA by the amplification and sequencing of specific fragments of the gltA and ompB genes using conventional PCR. The recovered sequences were compared with those deposited in GenBank, and phylogenetic analyses were carried out to identify the position of the pathogens detected with respect to the valid species previously reported worldwide. Additionally, ecological parameters of the ectoparasite infestations were also calculated. We recovered 196 ectoparasites belonging to two species, 33 C. felis felis and 163 R. sanguineus s.l. (Rhipicephalus linnaei), parasitizing 46 hosts (42 dogs and 4 cats) in 11 localities of the state of Puebla. We detected the presence of Rickettsia felis in three pools of C. felis felis, and five from R. sanguineus s.l. Our work provides the first record of R. felis in hard ticks of Mexico and Central America, with new collection localities for this pathogen in central Mexico.

Rickettsia felis and species of fleas parasitizing on household dogs in the Central Highlands of Vietnam.

Rickettsia felis is an obligate intracellular gra m-negative bacterium that belongs to the family of Rickettsiaceae. Ctenocephalides felis, cat flea, is the primary vector of the bacteria. The flea is the most common ectoparasite in dogs and associated with flea-borne spotted fever in humans. Information on R. felis and flea species parasitizing on dogs in Vietnam is limited. This study aimed to identify the species of fleas collected from dogs in the Central Highlands of Vietnam and detected the existence of R. felis in these fleas utilizing molecular tools. Morphological identification of 1618 fleas and molecular confirmation revealed the predominance of C. felis orientis parasitizing on dogs in the Central Highlands of Vietnam. Sixty-eight out of 100 fleas collected from household dogs were positive for spotted fever group rickettsiae; whilst R. felis was detected in 97.06 % (66/68) of C. felis orientis and C. felis felis. The results of this study indicate the potentially high risk of R. felis infection to humans and animals.

Rickettsia felis is an emerging human pathogen associated with cat fleas: A review of findings in Taiwan.

Rickettsia felis is an emerging rickettsial agent principally associated with cat fleas (Ctenocephalides felis), formerly discovered in 1990. Since then, clinical cases of R. felis infection have been identified globally by specific DNA sequences in patients with undifferentiated febrile illness, including in Taiwan, but such evidence is limited. R. felis rickettsiosis is self-limiting and easily treated with doxycycline, but its diagnosis remains a challenge. Environmental risk factors for R. felis rickettsiosis have yet to be clearly demonstrated, and its transmission biology is incompletely understood. Cat fleas are naturally infected with R. felis at varying rates, and vector competence in the transmission of R. felis has been demonstrated in animal models, including dogs, which may serve as reservoir hosts. In northern Taiwan, despite ∼20% of cat fleas infesting companion animals consistently found to be infected with R. felis, only a few cases of potential R. felis infection have been identified through a retrospective serological investigation, though without molecular confirmation. Ecological studies have identified divergent R. felis-like organisms in different arthropod hosts, but these strains appear to serve as nonpathogenic endosymbionts. Although its association with disease is limited, we believe cat flea-borne R. felis warrants increased recognition in an aging population due to immunosenescence and the proximity of companion animals to the elderly. Adopting a One Health approach involving collaboration and communication between clinicians, veterinarians, public health practitioners, and environmental scientists will improve our knowledge about this neglected pathogen and promote the prevention and control of vector-borne diseases.

Transposon mutagenesis of Rickettsia felis sca1 confers a distinct phenotype during flea infection.

Since its recognition in 1994 as the causative agent of human flea-borne spotted fever, Rickettsia felis, has been detected worldwide in over 40 different arthropod species. The cat flea, Ctenocephalides felis, is a well-described biological vector of R. felis. Unique to insect-borne rickettsiae, R. felis can employ multiple routes of infection including inoculation via salivary secretions and potentially infectious flea feces into the skin of vertebrate hosts. Yet, little is known of the molecular interactions governing flea infection and subsequent transmission of R. felis. While the obligate intracellular nature of rickettsiae has hampered the function of large-scale mutagenesis strategies, studies have shown the efficiency of mariner-based transposon systems in Rickettsiales. Thus, this study aimed to assess R. felis genetic mutants in a flea transmission model to elucidate genes involved in vector infection. A Himar1 transposase was used to generate R. felis transformants, in which subsequent genome sequencing revealed a transposon insertion near the 3' end of sca1. Alterations in sca1 expression resulted in unique infection phenotypes. While the R. felis sca1::tn mutant portrayed enhanced growth kinetics compared to R. felis wild-type during in vitro culture, rickettsial loads were significantly reduced during flea infection. As a consequence of decreased rickettsial loads within infected donor fleas, R. felis sca1::tn exhibited limited transmission potential. Thus, the use of a biologically relevant model provides evidence of a defective phenotype associated with R. felis sca1::tn during flea infection.

Prevalence of selected pathogens in ectoparasites from free-roaming domestic cats in the southern Great Plains of the United States.

Rickettsia sp. and Bartonella sp. were detected in ectoparasites of free-roaming domestic cats (Felis catus) from a trap-neuter-release program in central Oklahoma during January and February 2020. We used polymerase chain reaction and sequencing to identify fleas containing DNA of five different pathogens: Rickettsia felis (84%), 'Candidatus R. andeanae' (8%), Bartonella henselae (32%), Bartonella clarridgeiae (36%), and Bartonella sp. (8%). Co-infections with R. felis with three Bartonella species were identified. One tick was positive for R. felis, one flea was positive for 'Candidatus R. andeanae' and one ear mite was positive for a Bartonella species. These results highlight the need for more focus on free-roaming domestic cats and their ectoparasites in the Great Plains region.

Molecular Detection of Rickettsia felis in Fleas of Companion Animals in East Texas.

Flea-borne spotted fever is an emerging insect-borne rickettsial infection caused by Rickettsia felis and has been identified worldwide. This study sought to explore the prevalence of rickettsiae associated with fleas on companion dogs and cats from Walker and Montgomery Counties in East Texas. Fleas were collected from animals entering local veterinary clinics for routine checkups. Collected fleas were identified as Ctenocephalides felis or Pulex irritans and analyzed by polymerase chain reaction for the presence of rickettsiae and subsequent sequencing. An estimation of the bcMLE (bias-corrected maximum likelihood estimation) of pooled samples was calculated. Four hundred eighty-eight fleas (comprising C. felis and P. irritans) were collected from 16 cats and 77 dogs. Our results demonstrate R. felis in 21 pools of fleas from dogs (bcMLE 15.28%) and a bcMLE of 7.25% from flea samples collected from cats. Sequence analysis revealed R. felis as the only Rickettsia that could be amplified in our samples using the rickettsial citrate synthase gene and subsequent sequencing. In this study, the presence of R. felis in fleas from companion cats and dogs suggests a potential risk of flea-borne spotted fever in humans who encounter flea-infested animals.

Is vertical transmission the only pathway for Rickettsia felis?

The genus Rickettsia encompasses several species grouped into two main clusters, Typhus and the Transitional groups. The latter group contains Rickettsia felis, an endosymbiont of several arthropods with an uncertain human pathogenicity and whose most efficient transmission mechanism described thus far is transovarial. The aim of this study was to evaluate whether this pathway exists using phylogenetic analysis and partial sequences of the 17kDa and gltA genes and comparing them with host phylogeny using the cytb region. This is the first study that evaluates the vertical transmission of R. felis. In general, both phylogenies of R. felis showed no polytomies, as suspected if this pathway was the only pathway occurring. When phylogenies of the invertebrates and the gltA of R. felis were compared for strong coevolutionary insight, intricate relationships were observed, suggesting that other transmission pathways must occur, such as horizontal transmission. Further studies are needed to determine which other transmission routes occur in hematophagous arthropods.

Culture Isolate of Rickettsia felis from a Tick.

Although the cat flea, Ctenocephalides felis, has been identified as the primary vector of Rickettsia felis, additional flea, tick, mite, and louse species have also been associated with this bacterium by molecular means; however, the role of these arthropods in the transmission of R. felis has not been clarified. Here, we succeeded in culture isolation of R. felis from a host-seeking castor bean tick, Ixodes ricinus, the most common tick in Slovakia. The bacterial isolation was performed on XTC-2 cells at 28 °C using the shell-vial technique. An evaluation of the growth properties was performed for both the XTC-2 and Vero cell lines. We observed R. felis in the infected host cells microscopically by Gimenez staining and immunofluorescence assay. The R. felis isolate was purified by gradient ultracentrifugation and visualized by electron microscopy. Fragments of the genes gltA, ompA, ompB, htrA, rpoB, sca4, rffE, and rrs were amplified and compared with the corresponding sequences of the type strain URRWXCal2 and other R. felis culture -isolated strains. We did not detect any nucleotide polymorphisms; however, plasmid pRFδ, characteristic of the standard strain, was absent in our isolate. Herein, we describe the first successful isolation and characterization of a tick-derived R. felis strain "Danube", obtained from an I. ricinus nymph.

Rickettsiae in fleas infesting domestic pets of eastern Himalayan terrains of India.

BACKGROUND: Flea-borne rickettsioses have been limitedly explored in the Indian sub-Himalayan belt, including the North Eastern Region (NER) of India. This study investigates the presence of rickettsiae hosts and their probable pathogens in the disease-endemic hilly state of the NER of India. METHODS: Entomological surveys were carried out in disease-reporting localities in a hilly state in India. Fleas collected from domesticated animals were processed for detection of a Rickettsia-specific 17-kDa gene. RESULTS: Sequence analysis revealed Rickettsia felis in six flea pools (40%), Candidatus Rickettsia senegalensis in two pools (13.3%) and Rickettsia asembonensis in one pool (6.6%). CONCLUSIONS: Our findings suggest Ctenocephalides felis, Ctenocephalides canis and Pulex irritans as potential carriers of R. felis and R. felis-like organisms in India.

Ecology of fleas and their hosts in the trifinio of north-east Argentina: first detection of Rickettsia asembonensis in Ctenocephalides felis felis in Argentina.

Fleas are important in public health due to their role as parasites and vectors of pathogens, including Rickettsia. The aim of this study was to evaluate the diversity, abundance and prevalence of fleas and the presence of Rickettsia in the trifinio of north-east Argentina. Fleas from household and synanthropic animals were obtained from urban and periurban areas. They were taxonomically identified and samples of 227 fleas in 86 pools were analysed by polymerase chain reaction targeting the gltA and ompB genes of Rickettsia spp. The study revealed that Ctenocephalides felis felis was dominant on dogs, cats and opossums, with higher prevalence in the periurban area. The Shannon-Wiener and Morisita-Horn indices expressed differences in the diversity and similarity values of the absolute abundances of the species between the areas compared. DNA amplifications revealed 30.8% C. f. felis pools positive for Rickettsia spp. Phylogenetic analysis showed that the haplotype obtained was identical to Rickettsia asembonensis from Peru and Brazil. This is the first detection in Argentina of R. asembonensis that infects C. f. felis, and we emphasize the importance of conducting research from a 'One Health' perspective on the role of opossums and rodents in the integration of the transmission cycles of rickettsial bacteria.

Molecular Evidence of Rickettsia felis in Phereoeca sp.

Rickettsia felis is an obligate intracellular bacterium capable of infecting ticks, fleas, lice, and other arthropods. This bacterium is classified as a member of the Transitional Group (TRG) Rickettsia. It is known the evidence of R. felis mutualistic and obligatory relationship with some eukaryote organisms. However, there aren't scientific accounts of R. felis and moths of the order Lepidoptera association. The current work reports the first identification of the bacteria R. felis in Phereoeca sp. For that, a polymerase chain reaction (PCR) assay using gltA, ompA, and ompB genes was used. The nucleotide sequences showed 100% of identity with other Rickettsia felis sequences. The genus-level identification of the moth larvae was performed by morphological taxonomic keys and PCR analysis of the cytochrome oxidase I (COI) gene. The nucleotide sequenced showed 94.94% similarity with the species Phereoeca praecox. However, with the low number of sequences deposited in the databases, the species was classified as Phereoeca sp. The results suggest that R. felis may develop in an organism without blood-feeding behavior (Lepidoptera), as it has been demonstrated for booklice (Psocoptera). Further investigation is necessary in order to confirm pathogenic or mutualistic association with moths.

Dynamic gene expression in salivary glands of the cat flea during Rickettsia felis infection.

The cat flea, Ctenocephalides felis, is an arthropod vector capable of transmitting several human pathogens including Rickettsia species. Earlier studies identified Rickettsia felis in the salivary glands of the cat flea and transmission of rickettsiae during arthropod feeding. The saliva of hematophagous insects contains multiple biomolecules with anticlotting, vasodilatory and immunomodulatory activities. Notably, the exact role of salivary factors in the molecular interaction between flea-borne rickettsiae and their insect host is still largely unknown. To determine if R. felis modulates gene expression in the cat flea salivary glands, cat fleas were infected with R. felis and transcription patterns of selected salivary gland-derived factors, including antimicrobial peptides and flea-specific antigens, were assessed. Salivary glands were microdissected from infected and control cat fleas at different time points after exposure and total RNA was extracted and subjected to reverse-transcriptase quantitative PCR for gene expression analysis. During the experimental 10-day feeding period, a dynamic change in gene expression of immunity-related transcripts and salivary antigens between the two experimental groups was detected. The data indicated that defensin-2 (Cf-726), glycine-rich antimicrobial peptide (Cf-83), salivary antigens (Cf-169 and Cf-65) and deorphanized peptide (Cf-75) are flea-derived factors responsive to rickettsial infection.

Small Indian Mongooses (Herpestes auropunctatus) Serve As Reservoirs of Bartonella henselae and Rickettsia felis Vectored by Ctenocephalides felis.

Small Indian mongooses (SIMs, Herpestes auropunctatus) have invasively inhabited over 60 islands worldwide. They have been confirmed as a reservoir of rabies, leptospirosis, and salmonellosis; however, their role in the epidemiology of other zoonoses is little known. On St. Kitts, as well as other islands, SIMs harbor Ctenocephalides felis, which can vector several zoonotic diseases. In this study, SIMs were examined for fleas, and the collected fleas analyzed by PCR and DNA sequencing for Bartonella henselae, Rickettsia felis, Yersinia pestis, and Dipylidium caninum. Of the 87 SIMs, 75 (86.2%) harbored C. felis. C. felis recovered from nine (10.3%), one (1.1%), and one (1.1%) of the SIMs was positive for B. henselae, R. felis, and D. caninum, respectively. These data indicate that SIMs serve as an additional reservoir of B. henselae and R. felis, which should be taken into consideration in control and prevention of these rapidly emerging zoonoses.

Molecular detection of Rickettsia felis in common fleas in Greece and comparative evaluation of genotypic methods.

INTRODUCTION: Rickettsia felis is the causative agent of flea-borne spotted fever (FBSF), an emerging zoonosis. Although there is evidence of FBSF in Greece, fleas, the classic vectors of R. felis, have not been adequately studied. Thus, the aim of this study was to detect and characterize bacteria of genus Rickettsia and especially R. felis from common fleas parasitizing domestic cats and dogs in Greece and evaluate the efficiency of established molecular techniques. MATERIALS AND METHODS: DNA of flea-pools (samples) by animal-host was investigated by quantitative real-time PCRs (qPCR), and 16S metagenomics (16S). Determination of Rickettsia spp., Rickettsia felis-like organisms (RFLOs), and R. felis was based on a combination of qPCRs targeting gltA and ompB genes, 16S automated metagenomics and manual comparison of 16S sequences for >99% similarity with the publicly available 16S R. felis GenBank sequences using the Basic Local Alignment Search Tool (BLAST>99). Information for the animal-hosts was available and statistically analyzed. RESULTS: Among 100 flea-pools, R. felis was detected in 14 samples with a combination of six, five and three assays in 10, two and two samples, respectively. The sensitivity of the assays for Rickettsia genus (16S, and genus specific qPCRs) ranged from 62.5% to 93.8% and the specificity from 65.0% to 100%. R. felis-targeting qPCRs for gltA and ompB demonstrated sensitivity and specificity of 92.9% and 100%, and 100.0% and 87.5%, respectively. 16S metagenomics using the assay software was not able to identify R. felis positive specimens, although manual BLAST>99 did identify the species, but demonstrated sensitivity of 92.9% and specificity of 65.0%. No association of the detection rate of Rickettsia genus or R. felis, with the epidemiological data collected, was identified. CONCLUSIONS: These observations suggest the occurrence of R. felis in fleas from pets in Attica, Greece, but PCR and sequencing assays varied considerably in sensitivity and specificity and a consensus methodology for assigning the positivity status is required to be established.