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Original article
Comparative study on Saliva and Nasopharyngeal swabs and the outcome of RT-PCR test in patients with mild symptoms of SARS-CoV-2
Estudio comparativo de muestras de saliva y nasofaríngeas y el resultado de la prueba RT-PCR en pacientes con síntomas leves de SARS-CoV-2
Satvinder Singh Bakshia,
Corresponding author
saty.bakshi@gmail.com

Corresponding author.
, V. Mangayarkarasib, Debabrata Dashb, Soumyajit Dasa, Seepana Ramesha, Cheeranjeevi Jayamc, Vinoth Kumar Kalidossd
a Department of ENT and Head & Neck Surgery, All India Institute of Medical Sciences Mangalagiri, Guntur, Andhra Pradesh, India
b Department of Microbiology, AIIMS Mangalagiri, Guntur, Andhra Pradesh, India
c Department of Dentistry, AIIMS Mangalagiri, Guntur, Andhra Pradesh, India
d Department of Community and Family Medicine, AIIMS Mangalagiri, Guntur, Andhra Pradesh, India
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronavirus 2019 &#40;COVID-19&#41; infection due to the SARS-CoV-2 virus has proven to be a serious and deadly disease causing a great deal of mortality and morbidity globally&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A key to preventing the spread of the virus is early diagnosis and isolation of infected individuals&#46; Nasopharyngeal swabbing&#44; followed by reverse transcription of the extracted RNA &#40;RT-PCR&#41;&#44; is the gold standard for detecting SARS-CoV-2 infection&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This swab collection requires trained medical personnel<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and may not always be successful in the first attempt&#46; In addition to exposing the healthcare personnel to a high risk of infection&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> they increase the consumption of personal protective equipment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The nasopharyngeal swab &#40;NPS&#41; collection method also causes discomfort to the patient<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and is difficult to perform in patients with nasal pathology like gross deviated nasal septum&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore there is a need for a simpler and less invasive method that reduces the risk to healthcare personnel and the economic and logistic burden on healthcare systems&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">One potential candidate in this regard is saliva&#46; Saliva collected from the mouth is a mixture of glandular secretions&#44; gingival crevicular fluid&#44; expectorated airway surface liquid and mucus&#44; epithelial and immune cells from the oral mucosa and upper airways&#44; and oral microbes and viruses&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Saliva has proven useful in many oral and systemic conditions&#44; including viral infections like dengue&#44; West Nile&#44; chikungunya&#44; Ebola&#44; Zika&#44; and Yellow Fever&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> In addition&#44; saliva has also been used for diagnosing coronaviruses responsible for severe acute respiratory syndrome &#40;SARS&#41; and the Middle East respiratory syndrome &#40;MERS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Potential advantages of saliva specimens are that they can be easily be self-collected by adults and even children eliminating the need for health care professionals and reducing nosocomial infection&#46; This will reduce the time and cost associated with the specimen collection&#46; Easier sample collection will also help in increasing the compliance of patients and in mass screening&#46; Considering these advantages&#44; we planned a study to compare the efficacy of standard nasopharyngeal swabs and saliva in detecting the SARS CoV-2 infection&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Method</span><p id="par0020" class="elsevierStylePara elsevierViewall">Sample Size&#58; Previous studies showed the saliva sample has a sensitivity of 85&#46;19&#37; compared with the oro-nasopharyngeal swab sample&#46; Using this sensitivity and 95&#37; confidential interval and 5&#37; Precision&#44; the sample size was calculated to be 194 using n-master 2&#46;0 software&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study was carried out in a tertiary care center in India from April to June 2021&#46; The study was approved by the institute ethics committee &#40;AIIMS&#47;MG&#47;IEC&#47;2020-21&#47;&#41;&#46; After obtaining informed written consent&#44; patients with symptoms of SARS-CoV-2 infection attending the sampling area of the hospital were taken for the study&#46; Very sick or unstable patients with all forms of ARDS&#44; sepsis&#44; terminally ill&#44; and patients using mouthwash regularly were excluded&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Saliva was collected by asking the patient to cough saliva from their throat into a sterile container&#44; and 2&#8239;mL of viral transport medium was then added&#46; They were asked not to eat&#44; drink&#44; smoke or use oral hygiene products for at least 10&#8239;min before the collection process&#46; The nasopharyngeal swab was taken with flocculated swabs inserted into the nostril parallel to the palate just above the floor of the nasal cavity&#46; The swab was inserted till resistance was felt and was left for a few seconds inside the nasal cavity&#46; It was then gently removed by rotating it&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Saliva and Nasopharyngeal swab were collected from patients to detect SARS-CoV-2 by real-time reverse transcriptase RT-PCR&#46; RNA was extracted from clinical samples with a QIAamp viral RNA mini kit &#40;QIAGEN&#44; Hilden&#44; Germany&#41; following the manufacturer&#8217;s instructions&#46; A final volume of 50&#8239;&#181;l of RNA was eluted and kept at &#8722;80&#8239;&#176;C till further processing&#46; All specimens were handled with biosafety guidelines per the Indian Council of Medical Research &#40;ICMR&#41;&#47;WHO&#47;Center for Disease Control and Prevention for COVID-19&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">After RNA extraction&#44; one-step RT-qPCR &#40;the reverse transcriptase reaction automatically precedes the PCR phase in the same tube&#41; was performed using ICMR approved RT-PCR kitin Quantstudio 5 real-time PCR instrument &#40;Thermo Fisher Scientific Inc&#46;&#41; based on the instruction for use &#40;IFU&#41; provided&#46; Briefly&#44; the master mix &#40;a pre-mixed concentrated solution consisting of buffer&#44; Reverse transcriptase enzyme&#44; nucleotide&#44; forward primer&#44; reverse primer&#44; TaqMan probe&#44; DNA polymerase&#41; was prepared dispensed into PCR tubes&#44; and finally&#44; RNA elutes were added&#46; To check the validity of the test&#44; negative control&#44; positive control&#44; and no template control were also added in each run&#46; The basic cycling conditions were as follows&#58; reverse transcription at 55&#8239;&#176;C for 5&#8239;min&#44; denaturation at 95&#8239;&#176;C for 5&#8239;min&#44; and then 45 cycles of amplification at 95&#8239;&#176;C for 5&#8239;s and at60&#8239;&#176;C for 15&#8239;s&#46; Results were seen on the Quant studio 5&#8239;software&#46; Each reaction was read for the screening and confirmatory genes after confirming the performance of positive control and negative control results&#46; As suggested in the manufacturer&#39;s instruction&#44; a proper sigmoid curve with a Ct value is taken as positive&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">The agreement between both the tests was summarized as percent agreement and positive percent agreement&#59; Kappa statistics were used to measure the association between types of sample collection&#46; The Ct value of RT-PCR was compared using spearman correlation&#46; A P-value of &#60;0&#46;05 was considered statistically significant&#46; Analysis was done using R software&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Result</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 405&#8239;samples were collected&#44; of which 250 males and 155 females&#46; The detailed age group distribution is presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Both nasopharyngeal swab &#40;NPS&#41; and saliva were processed&#46; The sample is reported positive if either showed a positive sigmoid curve in the real-time reverse transcriptase PCR&#46; Out of 405&#8239;samples&#44; 159 NPS and 148 salivary samples were positive&#46; The analysis did not include six NPS and eight salivary samples as they failed to show any fluorescence in the internal control&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Out of 391 samples included in the analysis&#44; 370 &#40;94&#46;63&#37;&#41; samples were found to have concordant results&#44; and 21 &#40;5&#46;37&#37;&#41; samples had discordant results&#46; Taking the nasopharyngeal swab as the gold standard sample&#44; the saliva was compared with a 2&#8239;&#215;&#8239;2 chi-square table &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; with the online software epitools &#40;<a href="https://epitools.ausvet.com.au/">https&#58;&#47;&#47;epitools&#46;ausvet&#46;com&#46;au&#47;</a>&#41;&#46; The sensitivity of the saliva sample was found to be 89&#46;94&#37; with a 95&#37; confidence interval &#40;84&#46;17&#8211;94&#46;14&#41; and specificity 97&#46;84&#37; with a 95&#37; confidence interval &#40;95&#46;04&#8211;99&#46;3&#41; with a p-value of 0&#46;02&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Taking a prevalence of 20&#37; in the state of Andhra Pradesh&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> the positive and negative predictive values were calculated and found to be 91&#46;25&#37; and 97&#46;49&#37;&#44; respectively&#44; with an accuracy of 96&#46;26&#37;&#46; The likelihood ratio &#40;LR&#41; was calculated and found to be 41&#46;73 and 0&#46;10&#44; respectively&#44; for positive likelihood ratio &#40;LR&#43;&#41; and negative likelihood ratio &#40;LR &#8722;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The threshold cycle value &#40;Ct value&#41; for both the samples in case of a positive result was also compared for various target genes like internal control&#44; E gene&#44; N gene&#44; RdRp gene&#44; and orf one ab2 genes &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; All the parameters showed positive correlation with the rho &#40;&#961;&#41; value ranging from 0&#46;141 to 0&#46;585&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The use of saliva in diagnosing COVID 19 infections presents an exciting opportunity since it is easy to collect&#44; non-invasive&#44; and reduces the exposure and risk for healthcare workers involved in collecting the specimens&#46; The use of saliva as a diagnostic modality has been reported in previous studies&#44; with most of the studies supporting its role<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> and some casting doubt on its usefulness&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In our study&#44; the sensitivity of saliva was 89&#46;94&#37;&#44; which is higher than the previously reported sensitivity of saliva samples ranging from 83&#37; to 86&#37;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#59; however&#44; these studies had a limited number of samples&#46; A sensitivity of 100&#37; has also been reported in a study<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; however&#44; only hospitalized COVID 19 were enrolled in this study&#46; Rao M et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> found that the sensitivity and specificity of random saliva were higher than Nasopharyngeal&#8239;&#43;&#8239;Oropharyngeal swabs &#40;95&#46;0&#59; 99&#46;9 vs&#46; 72&#46;2&#59; 99&#46;4&#41;&#46; The variation in disease severity&#44; the procedure of saliva collection&#44; and the use of different target genes for detection may cause the variation in sensitivities reported in these studies&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In their study&#44; Johnson AJ<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> et al&#46; found that saliva retained high clinical sensitivity even in the early pre-symptomatic stage of the disease&#46; Other studies have also highlighted the efficacy of saliva in detecting the virus in the early stages of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> In addition&#44; previous studies that evaluated the performance of saliva compared to nasopharyngeal swabs in children have also shown favorable results&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The method of collection of saliva has also been reported in previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> and various techniques like early morning self-collection&#44; coughing or deep throat saliva&#44; and avoiding food&#44; drink&#44; or tooth brushing resulted in &#62;5&#37; increased positive saliva detection rates&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Our study also obtained self-collected deep throat samples&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The majority of the studies have been performed in patients with severe COVID 19 infections or hospitalized patients&#59; the advantage of our study is that the population studied was primarily mildly symptomatic or asymptomatic &#40;contacts of confirmed COVID 19 cases&#41;&#46; This shows the feasibility of using saliva on a larger scale for mass screening in the community&#46; The self-collected non-invasive sample collection technique may make the population more permissible for testing and enhance community surveillance&#46; Another advantage of our study is that we collected both the nasopharyngeal and saliva samples simultaneously from each participant&#59; this will reduce the chance of variation in viral load among the specimens&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">There are certain limitations of our study&#46; Firstly our sample size is limited&#44; and the setting is hospital-based&#46; Further studies on community collected samples can be planned to assess the actual feasibility of collecting&#44; transporting&#44; and processing saliva samples&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Saliva can be considered a reliable and efficacious alternative for nasopharyngeal swab specimens to detect COVID 19 infection&#46; It is postulated that the use of saliva will reduce the risk of transmission of infection to healthcare workers&#44; which will reduce the healthcare worker burnout seen during the pandemic&#46; In addition&#44; the demand for personal protective equipment and swabs will also reduce&#44; thereby decreasing the cost of testing&#46; The feasibility of using saliva in community settings should be explored further&#46; In addition various aspects like asymptomatic presentation&#44; severity of disease&#44; positive history of contact&#44; paediatric vs&#46; adult&#44; late vs&#46; early course of disease should be evaluated in further studies as they may influence the results&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A simple and reliable method for diagnosing COVID 19 infections is the needed&#46; The role of saliva in the transmission of the infection has already been established&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Saliva and nasopharyngeal swabs from patients suspected to have COVID 19 infections were taken simultaneously&#44; and the results of the RT-PCR were compared&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Result</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Total 405&#8239;samples were collected&#44; of which 250 males and 155 females&#46; In the 391 samples included for analysis&#44; 370 &#40;94&#46;63&#37;&#41; samples were found to have concordance results&#44; and 21 &#40;5&#46;37&#37;&#41; samples had discordant results&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The use of saliva to diagnose COVID 19 infection is reliable&#44; and its use can be recommended&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Un m&#233;todo simple y confiable para diagnosticar infecciones por COVID 19 es necesario&#46; Ya se ha establecido el papel de la saliva en la transmisi&#243;n de la infecci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se tomaron simult&#225;neamente hisopos de saliva y nasofar&#237;ngeos de pacientes con sospecha de infecci&#243;n por COVID 19 y se compararon los resultados de la RT-PCR&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultado</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se recogieron 405 muestras&#44; de las cuales 250 hombres y 155 mujeres&#46; En las 391 muestras incluidas para el an&#225;lisis&#44; se encontr&#243; que 370 &#40;94&#44;63&#37;&#41; muestras ten&#237;an resultados de concordancia y 21 &#40;5&#44;37&#37;&#41; muestras ten&#237;an resultados discordantes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El uso de la saliva para diagnosticar la infecci&#243;n por COVID 19 es confiable y se puede recomendar su uso&#46;</p></span>"
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                  \t\t\t\t">17 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;8&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#8211;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;16&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#40;9&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">106 &#40;26&#46;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#8211;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&#40;15&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;8&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98 &#40;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#8211;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;11&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;5&#46;93&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70 &#40;17&#46;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#8211;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#40;7&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;5&#46;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;12&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#8211;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;5&#46;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;3&#46;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;9&#46;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#8211;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;1&#46;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;1&#46;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">250 &#40;61&#46;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">155 &#40;38&#46;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">405 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3371218.png"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Age wise distribution of the samples &#40;n&#8239;&#61;&#8239;405&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
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        "etiqueta" => "Table 2"
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          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" colspan="2" style="border-bottom: 2px solid black"></th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nasopharyngeal Swab</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Saliva</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">227&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">243&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">232&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">391&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 3"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Name of the gene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Avg&#46; Ct value &#40;NPS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Avg&#46; Ct value &#40;Saliva&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spearman correlation&#40;rho-&#961;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Internal Control &#40;IC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;141&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E gene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;585&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N gene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos