Original article

Ann Biol Clin 2018; 76 (4): 416-20

Sickle SCANTM (BioMedomics) fulfills

analytical conditions for neonatal
screening of sickle cell disease
Intérêt du Sickle SCANTM (BioMedomics)
pour le dépistage néonatal de la drépanocytose
Copyright © 2019 John Libbey Eurotext. Téléchargé par BIB INTER DE SANTE POLE le 10/01/2019.

Thao Nguyen-Khoa1 Abstract. Sickle SCANTM is a rapid, qualitative, point-of-care lateral flow
Louis Mine1 immunoassay for the identification of AS, AC, SS/S␤0 thal, SC and CC/C␤0 thal
Bichr Allaf2 phenotype. We evaluated this test under the conditions encountered in the French
newborn screening (NBS) program for sickle cell disease: a total of 104 dried
Jean-Antoine Ribeil3
blood spots (DBSs) were tested with an HPLC reference method and then with
Christelle Remus3,4 the Sickle SCANTM device. Sickle SCANTM identified the hemoglobin (Hb)
Aurélie Stanislas3,4 phenotype correctly on 96% of cases. In the four non-concordant cases, the
Valérie Gauthereau5 antibody anti-HbS cross-reacted with HbE (n=2), HbD (n=1) or HbX (n=1).
Sarah Enouz3,4 There were no false negative. In order to test Sickle SCANTM ’s sensitivity to
Jason S. Kim6 low levels of HbA and HbS in the presence of high HbF levels, we selected
another 21 DBS cards with low percentages of HbA (0.6-4.2%) and HbS (2.0-
Xiaoxi Yang6
6.9%). HbA and HbS were always detected when present at levels of more than
Eliane Gluckman7 1% and 2%, respectively. Sickle SCANTM appears to be an accurate point-of-
Jean-Louis Beaudeux1 care method for the identification of newborns with SCD trait. The device meets
Arnold Munnich8 the criteria for sickle cell disease NBS programs in endemic countries with poor
Robert Girot8 access to laboratory equipment.
Marina Cavazzana3,4 Key words: sickle cell disease, hemoglobin S, newborn screening, point-of-care
1Service de biochimie générale, Hôpital
universitaire Necker-Enfants malades, Résumé. Le dispositif Sickle SCANTM est un test de diagnostic rapide
AP-HP, Paris, France
<thao.nguyen-khoa@aphp.fr>
(TDR) basé sur le principe de détection par immuno-chromatographie des
2 Unité de dépistage néonatal de la hémoglobines (Hb) HbA, HbS et HbC pour l’identification des phénotypes
drépanocytose et des hémoglobino- AS, AC, SS/S␤0 thal, SC et CC/C␤0 thal. Nous avons évalué ce TDR dans les
pathies, Laboratoire de biochimie conditions du programme français de dépistage néonatal de la drépanocytose :
hormonologie, Hôpital Robert Debré, 104 papiers buvards à partir desquels les taches de sang séché ont été testées
AP-HP, Paris, France
3 Département de biothérapie, Hôpital
avec la méthode chromatographique de référence du programme de dépistage,
universitaire Necker-Enfants malades,
puis avec le TDR Sickle SCANTM . Dans 96 % des cas, les phénotypes de l’Hb
AP-HP, Paris, France ont été correctement identifiés. Pour les quatre cas discordants, l’anticorps anti-
4 Centre d’investigation clinique, HbS a réagi de manière croisée avec l’HbE (n = 2), l’HbD (n = 1) et avec une
Hôpitaux universitaires Paris-Ouest, HbX (n = 1). Il n’y a pas eu de faux négatif. D’autre part, 21 autres papiers
AP-HP, Inserm, Paris, France buvards ont servi à tester la sensibilité du Sickle SCANTM avec des faibles
5 Fédération parisienne pour le
taux d’HbA et HbS (0,6 à 4,2 % d’HbA et 2,0 à 6,9 % d’HbS). Les HbA et
dépistage et la prévention des
handicaps de l’enfant, Hôpital
HbS ont toujours été détectées lorsqu’elles étaient présentes à plus de 1 %
universitaire Necker-Enfants malades, et 2 %, respectivement. Le TDR Sickle SCANTM est sensible et spécifique
AP-HP, Paris, France pour l’identification des nouveau-nés présentant un phénotype drépanocytaire.
doi:10.1684/abc.2018.1354

Reprints: T. Nguyen-Khoa

To cite this article: Nguyen-Khoa T, Mine L, Allaf B, Ribeil JA, Remus C, Stanislas A, Gauthereau V, Enouz S, Kim JS, Yang X, Gluckman E, Beaudeux JL, Munnich
416 A, Girot R, Cavazzana M. Sickle SCANTM (BioMedomics) fulfills analytical conditions for neonatal screening of sickle cell disease. Ann Biol Clin 2018; 76(4): 416-20
doi:10.1684/abc.2018.1354
 Sickle SCANTM for neonatal screening of SCD

6 BioMedomics Inc., Durham, North
Carolina, USA
7 Eurocord/Monacord, Hôpital
Saint-Louis, AP-HP, Paris et Centre
scientifique de Monaco, Monaco, France
8 Département de génétique, Institute
Imagine, Paris, France
Il répond aux critères de qualité des TDR pour l’orientation diagnostique de la
drépanocytose et sera particulièrement utile dans les pays d’endémie où l’accès
aux équipements de laboratoire est très limité.
Mots clés : drépanocytose, hémoglobine S, dépistage néonatal, test de dia-
gnostic rapide

Article received May 04, 2018,

accepted May 26, 2018
Copyright © 2019 John Libbey Eurotext. Téléchargé par BIB INTER DE SANTE POLE le 10/01/2019.

Sickle SCANTM is a new point-of-care test Materials and methods

(POCT) commercialized by BioMedomics, Inc.
(www.biomedomics.com, USA) for the diagnosis of
sickle cell disease (SCD) via the specific identification of
patients with AS or AC trait, SS/S␤0 thal, SC or CC/C␤0 thal
phenotype. Hereafter, the term “HbX” is used to refer to
unknown Hb. In newborns, fetal Hb (HbF) stays at a high
level for several months after birth, and then falls to the
adult level by 12 months. The newborn’s HbF phenotype
is expressed as FA for normal Hb and FAS, FAC, FAD,
FAE, FS, FC, and so on for newborns with sickle cell trait
Hb.
As a POCT, the device must be practical and rapid to
use, and capable of identifying the SCD phenotype with
high levels of sensitivity and specificity. Kanter et al. [1]
validated the Sickle SCANTM device using 71 capillary
blood samples from 21 children (mean age of 13.5 years)
and 50 adults. Furthermore, McGann et al. [2] tested 139
venous and capillary blood samples from pediatric and
adult patients and also 7 dried blot spot (DBS) samples (by
transferring venous blood onto newborn screening (NBS)
cards).
The Necker pediatric hospital (Paris, France) specializes in
the treatment of SCD. In 2016, the Ile-de-France regional
NBS service (Fédération parisienne pour le dépistage et
la prévention des handicaps de l’enfant, Paris, France)
tested 132115 DBS cards for SCD (representing 40% of
the national cohort); the regional incidence of the disease
was 1 in 541 [3].
The objective of the present study was to evaluate the qual-
ity of the Sickle SCANTM procedure with reference to
the high-performance procedures used in our laboratories.
Under the conditions used in the regional NBS program,
we tested 104 DBS cards with an unknown phenotype
and 21 DBS for which the phenotype was known (with
a high level of HbF and low levels - between 1 and 10%
- of either HbA and sickle cell Hb (HbS), as observed in
newborns).
Samples
The NBS laboratory supplied our study with 104 DBS cards
with sufficient dried blood to allow retesting for the Hb
trait with the Sickle SCANTM device. The Sickle SCANTM
operators were blinded to the phenotype determined with
the reference technique. To test the Sickle SCANTM ’s sen-
sitivity, a separate set of 21 DBS cards with a known, low
proportion of HbA and HbS were selected. A 3 mm disc
was punched out of the DBS card and tested with the Sickle
SCANTM device.
High-performance liquid chromatography (HPLC)
The regional NBS laboratory analyzes Hb from DBS cards
with an HPLC-based VARIANT nbsTM system (BioRad
Laboratories, Marnes-La-Coquette, France); this served as
the reference method in our study.
The Sickle SCANTM procedure
Sickle SCANTM is a chromatographic sandwich
immunoassay for the qualitative detection of human
HbA, HbS and HbC in a blood sample [1, 2]. The kit
includes tubes prefilled with 1.0 mL of hemolysis buffer
and a testing cartridge. The disc punched out of a DBS is
introduced into a prefilled tube. After 5 minutes, 5 drops
of hemolysate are placed in the cartridge inlet. The latter
contains mouse monoclonal antibody (Ab) conjugated
to blue-colored nanoparticles and directed against the
C-terminus of the human Hb ␣-chain. The conjugated Ab
thus forms a complex with any Hb present in the sample.
Next, the complex diffuses through an absorbent strip
containing three test lines (containing rabbit monoclonal
capture Abs against the N-terminal amino acid sequence
of human sickle cell Hb (HbS or HbC) and normal Hb
(HbA), respectively) and a control line (containing a goat

Ann Biol Clin, vol. 76, n◦ 4, juillet-août 2018 417

 Original article
anti-mouse IgG Ab). Each specific Hb-Ab complex is
captured at the corresponding test line, where it produces
a blue-colored band. Excess conjugate flows past the test
lines and is captured on the control line. The test result is
read after 5 minutes of migration.
Phenotyping
DBS cards were tested first with the HPLC method and then
with the Sickle SCANTM device. All the Sickle SCANTM
tests were performed by the same operator. The presence or
absence of Sickle SCANTM bands was observed by two dif-
Copyright © 2019 John Libbey Eurotext. Téléchargé par BIB INTER DE SANTE POLE le 10/01/2019.
ferent readers, on a double-blind basis. The Sickle SCANTM
phenotype was classified as a function of the Hb band
intensity.
Results
Diagnostic accuracy in SCD
The Sickle SCANTM results were the same for the two read-
ers, who found the Hb bands easy to read (table 1). The
operator found the procedure easy to perform, with few
handling steps.
Sickle SCANTM identified the Hb phenotype correctly on
100 of the 104 (96%) DBS cards (table 1). In the four
non-concordant cases, Sickle SCANTM detected two FAE
phenotypes as FAS, one FAD phenotype as FAS, and a FAX
phenotype as FAS (table 1). Interestingly, Sickle SCANTM
detected a sickle cell trait hemoglobin in all four cases; the
exact phenotypes could be determined later using the HPLC
reference method.
Sensitivity for the detection of low levels of HbA
and HbS in the presence of high HbF levels
We selected 21 samples with low levels of HbA and HbS,
as determined by HPLC (ranges of 0.6-4.2% and 2.0-6.9%,
respectively; table 2). When the percentage of HbA was
lower than that of HbS, the phenotype was supposedly
FS␤+ thal. When the percentage of HbA was higher than
that of HbS, the phenotype was supposedly FAS. When the
percentages of HbA and HbS were respectively higher than
1% and 2%, these Hb were always detected by the Sickle
SCANTM test - even in the presence of high HbF levels
(table 2). Sickle ScanTM thus met the sensitivity criteria for
SCD NBS programs.
Discussion
Sickle SCANTM is a rapid, qualitative, point-of-care lat-
eral flow immunoassay for the identification of AS, AC,
418
SS/S␤0 thal, SC and CC/C␤0 thal phenotype. We evaluated
this test under the conditions encountered in the French
NBS program for SCD: a total of 104 DBSs were tested
with an HPLC reference method and then with the Sickle
SCANTM device. Sickle SCANTM identified the Hb phe-
notype correctly in the presence of high HbF levels, on
96% of the DBS cards. In the four non-concordant cases,
the antibody anti-HbS cross-reacted with HbE (FAE phe-
notype, n=2), HbD (FAD phenotype, n=1) or HbX (FAX
phenotype, n=1). However, this would not have had an
impact on the newborn’s medical care; when an HbX
result is obtained, the exact Hb phenotype is determined
later using the HPLC reference method. There were no
false negatives. Hence, Sickle SCANTM appears to be an
accurate point-of-care method for the identification of AS,
AC, SS/S␤0 thal, SC and CC/C␤0 thal phenotypes on DBS
cards.
The Sickle SCANTM device’s analytical qualities have been
extensively documented by Kanter et al. [1] and McGann et
al. [2] with capillary and/or venous blood samples present-
ing a broad panel of abnormal Hb phenotypes. Sensibility
and specificity were above 98% for the diagnosis of SS and
SC [1, 2]. Our results attest to Sickle SCANTM ’s analyti-
cal reliability - even in newborns with high levels of HbF,
and for HbA and HbS percentages as low as 1% and 2.3%,
respectively. Our present results demonstrate that the Sickle
SCANTM test is able to discriminate between normal and
SCD phenotypes under neonatal screening conditions.
In developed countries, Hb phenotype analysis in NBS
programs is based on HPLC, capillary electrophoresis,
isoelectric focusing, tandem mass spectrometry (MS/MS)
[4]. Other new methods are also currently emerging, e.g.
MALDI-TOF (matrix assisted laser desorption ionisation
- time of flight)-MS, DNA-based methods. However, these
methods are costly and require a specialist operator - condi-
tions that are not always met in SCD-endemic countries.
This is why POCTs might be of great value for NBS pro-
grams in these countries. A number of POCTs for SCD have
been developed, on the basis of the particular characteristics
of red blood cells (RBCs) in SCD:
– density measurements [5, 6]. The polymerization of HbS
increases the RBCs’ density. However, this approach does
not discriminate between AS and AA phenotypes, and cen-
trifugation is required for a rapid result (12 min, versus
hours with gravity flow in the absence of centrifugation);
– measurements of the dynamic deformability and adhe-
sion of sickled RBCs under flow conditions mimicking the
post-capillary venule [7]. This approach is limited by inter-
ference from high levels of HbF, and the complexity of the
microfluidic technology;
– a paper-based sickle cell anemia test, based on the fact
that HbS is less soluble than HbA, HbF, and HbC [8-10].
This approach has two disadvantages (i) AS and SC pheno-
Ann Biol Clin, vol. 76, n◦ 4, juillet-août 2018
 Sickle SCANTM for neonatal screening of SCD

Table 1. Comparison of hemoglobin phenotyping results using the HPLC Variant nbsTM reference method (BioRad) and the Sickle SCANTM
chromatographic immunoassay (BioMedomics Inc).

Hemoglobin phenotype HPLC Variant nbsTM Sickle ScanTM Number of

non-concordant
results
FA 15 15 0
FAS 33 33 0
FAC 7 7 0
FS (SS/S␤◦ ) 19 19 0
FSC 5 5 0
FAX 8 7 1 A+S
Copyright © 2019 John Libbey Eurotext. Téléchargé par BIB INTER DE SANTE POLE le 10/01/2019.

FAE 5 3 2 A+S
FAD 6 5 1 A+S
FC (CC/C␤◦ ) 3 3 0
FA Bart’s 2 2 0
FA O-Arab 1 1 0
Total 104 4

Table 2. Sensitivity of hemoglobin (Hb) phenotype detection using the Sickle SCANTM chromatographic immunoassay with low percentages
of HbA or HbS determined by HPLC Variant nbsTM reference method.

Hb phenotype HPLC HbA% HPLC HbS% Sickle ScanTM test

FS 0.0 2.7 S
FS␤+ 0.6 3.6 S
FS␤+ 0.8 3.3 S
FS␤+ 1.0 4.4 S+A low
FS␤+ 1.0 3.5 S+A low
FS␤+ 1.0 3.5 S+A low
FS␤+ 1.3 5.3 S+A low
FS␤+ 1.4 4.7 S+A low
FS␤+ 1.4 4.7 S+A low
FS␤+ 1.5 5.5 S A low
FS␤+ 1.5 3.3 S+A low
FS␤+ 1.6 4.4 S+A low
FS␤+ 1.6 4.4 S+A low
FS␤+ 1.6 3.4 S+A low
FS␤+ 1.7 6.9 S+A low
FS␤+ 1.7 6.9 S+A low
FAS 2.6 2.0 AS
FAS 3.5 2.9 AS
FAS 3.6 3.3 AS
FAS 3.8 2.3 AS
FAS 4.2 3.8 AS

types give the same result, and (ii) low levels of HbS cannot
be detected in the presence of high levels of HbF;
– lateral-flow immunochromatographic assays [11] such
as HemoTypeSCTM (Silver Lake Research Corporation,
CA, USA) [12] and Sickle SCANTM [1, 2, 13]. The
two tests are based on the same principle, both using
monoclonal Abs. The Sickle SCANTM test is easier to
operate than the HemoTypeSCTM which requires more
handling steps and more reagents. Furthermore, Sickle
SCANTM ’s optical detection procedure is enhanced by
the complex formation with blue colored beads. This
means that Sickle SCANTM has a relative high level
of sensitivity when the sample contains low levels of
SCD Hb.

Ann Biol Clin, vol. 76, n◦ 4, juillet-août 2018 419

 Original article
The Sickle SCANTM test may be of value in SCD-endemic
countries, where laboratories are not always equipped with
HPLC systems. Sickle SCANTM does not require a labora-
tory environment or the use of electronic equipment. It was
very easy to use, and the detection of SCD Hb (enhanced by
blue dye) was easily read by an operator with no training in
laboratory techniques. A study in Nigeria has demonstrated
the practicality of the Sickle SCANTM device when used
by non-expert operators [12].
Sickle SCANTM might also be useful in emergency situa-
tions, when the laboratory is too far away for rapid, adequate
Copyright © 2019 John Libbey Eurotext. Téléchargé par BIB INTER DE SANTE POLE le 10/01/2019.
diagnostic processing.
Conclusion
When tested on a series of DBS cards from newborns, the
Sickle SCANTM test appears to be an accurate method
for the identification of patients with AS or AC trait,
SS/S␤0 thal, SC or CC/C␤0 thal phenotype - even in the
presence of high level of HbF and low levels of HbA and
HbS (>1% and >2.3%, respectively). Although false posi-
tive tests were observed for some samples containing HbE
or HbD, these would not have had an impact on medical
care. More importantly, no false negatives were found with
regard to the identification of HbS and HbC. The Sickle
SCANTM test meets the analytical criteria for NBS for
SCD in endemic countries with poor access to laboratory
equipment.
Conflict of interest: J. S. Kim: employee of BioMe-
domics. None of the other authors has any conflict of interest
to disclosure.
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