ELISA, ELISpot and Alternative Assays

These new reporters can have various advantages, including higher sensitivities and multiplexing (2, 3). In technical terms, these newer variants of assays are not strictly ELISA, as they are not "enzymelinked", but are instead linked to some non-enzymatic reporter. However, given that the general principles in these assays are largely similar, they are often referred to as ELISA.

Occurrence in literature

This study has looked at the last 17 years of publications (2000-2017) as reported by Google Scholar, by recording the number of articles returned using the following key words: “ELISA” plus “Enzymelinked ImmunoSorbent”, “sandwich ELISA”, “competition ELISA” plus “competitive ELISA”, and “ELISPOT”.

Certain papers may have used both keywords when meaning the same (such as “ELISA” and “Enzyme-linked ImmunoSorbent”), in which case such papers are counted double. In this analysis we made sure not to miss the papers where either one without the other is being used. The graph (figure 1) summarizes this study. It appears that the more generic “ELISA” and Enzyme-linked Immunosorbent” has far out the highest frequency of occurrence, but its frequency peaked in the period 2006-2011 and is dramatically decreased since 2015.

Although the frequency of “sandwich ELISA” is an order of magnitude lower than of “ELISA”/”enzyme-linked immunosorbent”, we see the down trend much earlier. Since Google Scholar returns research papers and patents, these frequencies need to be interpreted as a prelude of practical use. In other words, the practical use of such assays in a clinical routine only happens AFTER the research has been settled.

Hence, while the research on such assays decline, their clinical applications may in fact rise, until the market saturates. The keywords “competition ELISA”/”competitive ELISA” and “ELISPOT” show a two-orders of magnitude lower frequency compared to “ELISA”/”Enzyme-linked Immunosorbent”.

Although we see no significant decline, the much lower frequency of occurrence in the literature suggests that a lot of other assays are being used as alternative to these standard ELISA methods.

Alternative assays in literature

Next to research, ELISA is used in both preclinical and clinical applications for the quantitative analysis of analytes at large scale. However, alternatives are also being used. Many analytes, particularly smallweight molecules and non-protein molecules are better detected through other means as antibodies are not always available or fit for detection in ELISA.

Other immune assays that serve as an alternative to ELISA are RIA (radioimmunoassay), Lateral Flow, and Multiplex Assay (Luminex beads). The latter is used for simultaneous detection of a set of different molecules in one go. In addition to such alternative immunoassays, aptamers are increasingly used as a replacement for antibodies (5). The Surface Plasmon Resonance (Biacore instrument) is a method to detect interactions between known molecules.

The most versatile and non-immunological method of detection and identification (and with extreme high sensitivity) is the mass spectrometry. The frequency of articles featuring these alternatives have been scored through Google Scholar, in the same way as above for the various ELISA assay approaches (See figure 2).

The results show strong growth for multiplex, aptamer and lateral flow, while research papers using mass spectrometry has been in decline in recent years, although still an order of magnitude higher than the others.

Evaluation of different assays

Reviews on immunoassays for heparin-induced thrombocytopenia reveal Important differences between classes of immunoassays, type of antibody specificity, thresholds, and manufacturers (6,7). Such variables apply to any analyte, thus there is a tendency to identify or develop more robust alternatives to the traditional immunoassays when possible.

When not possible, the traditional methods (mainly ELISA) are adjusted, for example through a different way of detection (such as (electro-)chemiluminescence, fluorescence, Polymerase Chain Reaction, Surface Plasmon Resonance, ElectroHydroDynamics, or micro-Nuclear Magnetic Resonance), or through scaling down the sample size to address long processing time, high costs, poor user-friendliness, technical complexity, poor sensitivity and specificity associated with the traditional platforms (8).

Over the last decade, various microfluidic-based Point-Of-Care platforms are developed for detecting nucleic acids, proteins, pathogens and cells (9). However, despite the advantages of reduced consumption of reagents and samples, operational automation, cheap unit cost, low power consumption, and compact size, success is still limited by fabrication materials, packaging method, purification/concentration, and reagent storage (9).

But based on the literature (see above), the most cited method is Mass Spectrometry (figure 2). This method is the most powerful one for its versatility (it can be combined with a pre-step of a chromatography method or an immunoassay method), for its high sensitivity, and for the extreme low quantities of biological material that is required for analysis. This makes this instrument fit for the detection and identification of all types of molecules, varying from protein fragments to small steroids, lipids, carbohydrates, etc.

However, the high costs and slow speed is a great limitation, especially for Point-of-Care applications. The other very popular alternative with the strongest growth (figure 2) is the multiplex immunoassay, as it enables high throughput identification of protein biomarkers which is sought after both for diagnostics and companion diagnostics. There is a fundamental distinction to be made between bead-based multiplexing, also known as Suspension Array Technology (in this context using capture antibodies linked to microbeads, for example Luminex) and homogenous sandwich-type multiplexing (using all reagents in solution, thus preventing washing steps).

However, despite its increased popularity, there remain issues around high-throughput validation, matrix interference and cross-reactivity (10). Conclusions Immunoassays are being used based on scientific research, based on preclinical assessments, and based on routine clinical tests. In addition, immunoassays are used in human medical and veterinary context, and in forensic and environmental sciences. Only the results of scientific research will end up in scientific papers, so the assessments of frequency of the different assays in the scientific literature does not reflect accurately the demand in the market. All the use in clinical and pre-clinical applications would represent the major market without any reflection in scientific publications.

That said, the rise and decline of certain assays in the literature do reflect the attention to these technologies in scientific research and the observed decline in mass spectrometry might indicate that most science are to be completed using such instrumentation. This could mean that the mass spectrometry still has an increased role to play in the day-to-day routines. The strong growth of multiplex, lateral flow and aptamer-based assays implies that the increased attention in scientific research is inevitably followed by increased demand when the resulting products are introduced in the day-to-day routine practice.

It is worth noting that all the different types of ELISA have been accompanied with so many different alternatives, that the observed decline in sales of ELISA kits should be seen in this light. It is likely that certain analytes who were originally monitored by sandwich ELISA, are currently being monitored by lateral flow, by aptamer-based assays or by mass spectrometry. One another can be verified by looking at specific products that showed declined sales and to see if alternatives specific to the same marker have emerged in the market. Any comparison between ELISA platforms and ELISPOT is not very helpful as both serve completely different purposes.