2.1.2. Nucleic Acid Amplification and Detection Methods
Among the biomarkers that testify to the presence of a viral micro-organism, RNA and DNA are among those most relevant for detecting infectious diseases. Although both carry genetic information, their functions are quite different. DNA constitutes the genetic heritage of a micro-organism, be it a virus, prokaryote or eukaryote. Most of it is contained in the nucleus and is highly stable due to its double-helix structure, making it a kind of genetic trace of the presence of a virus. So, in the event of a viral infection, DNA detection is tantamount to knowing whether the host has been infected by the virus. It does not give precise temporal information on the stage of the disease or its evolution; the DNA will always be present, even once the infection is over. Viral RNA, on the other hand, exists as messenger RNA to code viral proteins, thanks to ribosomes. Its lifespan is very short, from a few minutes to a few days at most, due to the RNA enzymes present in the cytoplasm, which degrade it. Thus, the presence of viral RNA indicates an ongoing infection. Quantifying and monitoring RNA concentration can also help track the evolution of a disease. This is why the detection of nucleic acids, and more specifically of RNAs, is widely used to detect and monitor the evolution of viral infections [
10].
Detection methods based on nucleic acids, either DNA or RNA, are generally specific and highly sensitive, and can be used for all categories of infectious micro-organisms. To perform nucleic acid detection, it is first necessary to know the specific sequence of the micro-organism to be detected. This process is called sequencing and involves determining the nucleotide sequence of the DNA or RNA present in a given micro-organism, in order to isolate a unique nucleic acid sequence specific to it. The first species to be sequenced were viruses, as they have small genomes, mostly less than 10 kilobases (or base pairs). The SARS-CoV-2 virus has a genome of 30 kilobases, making it one of the larger viruses. By way of comparison, the genome size of bacteria is of the order of a few million base pairs, and of a few billion in eukaryotic cells. Once sequencing has been completed, it is possible to use the infectious micro-organism's gene sequences to create specific primers, which are then used to amplify the target DNA or RNA. Most nucleic acid detection techniques rely on prior amplification, as DNA and RNA concentrations are very low in biological samples [
11].
PCR (Polymerase Chain Reaction) is the most widely used method for amplifying nucleic acids, whether DNA or RNA (in the case of RNA, it's called RT-PCR for Transcription Reverse-PCR). It was the method most widely used during the SAR-CoV-2 pandemic to detect viral RNAs in biological samples and is described in detail in
Figure 1.
The PCR process involves several dozen cycles, each divided into 3 steps: denaturation of DNA strands, primer hybridization and polymerase elongation. If the target to be detected is RNA, a preliminary step of transcribing RNA into DNA by a reverse transcriptase enzyme is necessary. DNA denaturation involves heating the sample to around 95°C to separate the two complementary strands. Primers specific to the target DNA are then hybridized to the separated DNA strands. This step is called primer hybridization and takes place between 40 and 65°C, depending on primer size and sequence. These primers serve as a starting point for DNA polymerase enzymes, which synthesize a complementary copy of the DNA strands in a third step taking place at around 70°C. Each PCR cycle doubles the number of starting DNA strands, in less than 10 minutes. These PCR cycles are repeated between 20 and 50 times to obtain sufficient copies of the target sequence. PCR is an amplification method, but not a detection method so that it is not possible to determine the presence or concentration of nucleic acids in a biological sample. To obtain a quantification of the nucleic acid sequence sought, it is necessary to use qPCR (quantitative PCR), also known as real-time PCR.
qPCR is a variant of PCR in which a fluorescent DNA probe is added to the reaction mixture, enabling real-time monitoring of the number of DNA copies produced. These fluorescent probes are of various types and can bind specifically to double-stranded DNA (SYBR technology) or to a precise sequence of replicated DNA (Taqman and Beacon technology) [
12]. These probes only fluoresce when they are bound to DNA chains; when they are free in solution, they are extinguished by proximity to a fluorescence quencher. Analysis of fluorescence as a function of the number of PCR cycles enables the initial RNA concentration to be determined, and the evolution of viral infection to be assessed. Although qPCR is a specific and highly sensitive method, the use of a thermocycler and high temperatures (in the range 40-95°C) does not always make it easy to use, and trained laboratory staff are required. These constraints are not compatible with the WHO's ASSURED guideline for sensitive, specific, portable and easy-to-use diagnostic devices. For this reason, isothermal temperature gene amplification methods have been developed, requiring much less instrumentation. Some of these methods use temperatures close to room temperature, such as RPA (Recombinase Polymerase Amplification, between 37 and 42°C) [
13], while others require heating devices: LAMP (Loop Mediated Isothermal Amplification, between 60 and 65°C) [
14], NASBA (Nucleic Acid Sequence Amplification, between 40 and 55°C) [
3,
15], or lesser-used ones such as SDA (Strand Displacement Amplification, 60°C) [
16], HDA (Helicase-Dependent Amplification, 65°C) [
17] and EXPAR (EXponential Amplification Reaction, 55°C) [
18]. Like PCR, these isothermal nucleic acid amplification methods use primers, DNA polymerases and other proteins to successfully amplify DNA sequences without the denaturation step. Some of their characteristics are described in
Table 1 and will not be detailed here. Although these methods are much less cumbersome from an instrumental point of view, and more suitable for field measurement, their main drawback is their lack of sensitivity. Quantification of viral nucleic acids is therefore not always possible at low concentrations. Specificity isn't always ideal either, with some methods unable to recognize differences of a single base pair in the targeted sequences.
To sum up, nucleic acids, and RNA in particular, are specific biomarkers of infectious diseases, and their quantification makes it possible to monitor the evolution of a viral infection over time. On one hand, PCR is the standard method for detecting nucleic acids, but its limitations make it difficult to use in a POC device. On the other hand, isothermal amplification methods do not yet offer sufficient sensitivity and selectivity to meet POCs needs [
19]. Efforts must therefore be concentrated on developing new systems for the quantifiable and sensitive detection of viral RNAs, in diagnostic platforms that are as simple as possible, portable and easy to use. To this end, CRISPR-Cas systems are promising; they are detailed in the remainder of this sub-section.