A nanobody-based test for highly sensitive detection of hemoglobin in fecal samples

Colon cancer has a high prevalence worldwide and is a serious public health problem. Early diagnosis greatly improves its prognosis and, among the existing methods, the detection of fecal occult blood is the only noninvasive test recommended for screening of the disease. To promote its massive application as a screening tool for asymptomatic populations in low-resource settings, the availability of a reliable and cost-effective method is imperative. Here, we describe the development and validation of a sensitive nanobody-based immunoassay for the detection of hemoglobin in human fecal samples. The nanobodies were selected from a library generated from a llama immunized with human hemoglobin, using a high-throughput platform that enabled the identification of the best nanobody pair. The assay allowed a sub-ng/mL limit of detection to be reached in phosphate-buffered saline, and was validated with stool samples, showing excellent reproducibility (CV% < 15 inter-day precision) and accuracy at 2 and 4 μg of hemoglobin per gram of feces, which are well below the recommended cutoff for this test (10-20 μg/g). Moreover, no cross-reactivity was observed with a panel of dietary non-human hemoglobins removing the need for pre-test dietary restrictions. Considering that the monodomain nature of nanobodies facilitates their straightforward and low-cost production by bacterial fermentation, with their provided sequences and using synthetic genes, the assay reported here could be replicated in any laboratory to perform thousands of tests for early detection of colorectal cancer at almost no cost. Graphical abstract.