Boonyong et al.

Parasites & Vectors (2024) 17:13 Parasites & Vectors

https://doi.org/10.1186/s13071-023-06108-1

RESEARCH Open Access

High‑throughput detection of parasites

and ova in stool using the fully automatic digital
feces analyzer, orienter model fa280
Sudarat Boonyong1, Saowalak Hunnangkul2, Sirirat Vijit1, Suphaluck Wattano1, Parwin Tantayapirak1,
Sumas Loymek3 and Sirichit Wongkamchai1*

Abstract
Background Intestinal parasitic infections can harm health by causing malnutrition, anemia, impaired growth
and cognitive development, and alterations in microbiota composition and immune responses. Therefore, it is cru-
cial to examine stool samples to diagnose parasitic infections. However, the traditional microscopic detection
method is time-consuming, labor-intensive, and dependent on the expertise and training of microscopists. Hence,
there is a need for a low-complexity, high-throughput, and cost-effective alternative to labor-intensive microscopic
examinations.
Methods This study aimed to compare the performance of a fully automatic digital feces analyzer, Orienter Model
FA280 (People’s Republic of China) with that of the formalin-ethyl acetate concentration technique (FECT). We
assessed and compared the agreement between the FA280 and the FECT for parasite detection and species iden-
tification in stool samples. The first part of the study analyzed 200 fresh stool samples for parasite detection using
the FECT and FA280. With the FA280, the automatic feces analyzer performed the testing, and the digital micro-
scope images were uploaded and automatically evaluated using an artificial intelligence (AI) program. Additionally,
a skilled medical technologist conducted a user audit of the FA280 findings. The second set of samples comprised
800 preserved stool samples (preserved in 10% formalin). These samples were examined for parasites using the FECT
and FA280 with a user audit.
Results For the first set of stool samples, there was no statistically significant difference in the pairwise agreements
between the FECT and the FA280 with a user audit (exact binomial test, P = 1). However, there were statistically
significant differences between the pairwise agreements for the FECT and the FA280 with the AI report (McNe-
mar’s test, P < 0.001). The agreement for the species identification of parasites between the FA280 with AI report
and FECT showed fair agreement (overall agreement = 75.5%, kappa [κ] = 0.367, 95% CI 0.248–0.486). On the other
hand, the user audit for the FA280 and FECT showed perfect agreement (overall agreement = 100%, κ = 1.00, 95%
CI 1.00–1.00). For the second set of samples, the FECT detected significantly more positive samples for parasites
than the FA280 with a user audit (McNemar’s test, P < 0.001). The disparity in results may be attributed to the FECT
using significantly larger stool samples than those used by the FA280. The larger sample size used by the FECT
potentially contributed to the higher parasite detection rate. Regarding species identification, there was strong agree-
ment between the FECT and the FA280 with a user audit for helminths (κ = 0.857, 95% CI 0.82–0.894). Similarly, there

*Correspondence:
Sirichit Wongkamchai
[email protected]
Full list of author information is available at the end of the article

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 2 of 10

was perfect agreement for the species identification of protozoa between the FECT and the FA280 with user audit
(κ = 1.00, 95% CI 1.00–1.00).
Conclusions Although the FA280 has advantages in terms of simplicity, shorter performance time, and reduced con-
tamination in the laboratory, there are some limitations to consider. These include a higher cost per sample testing
and a lower sensitivity compared to the FECT. However, the FA280 enables rapid, convenient, and safe stool examina-
tion of parasitic infections.
Keywords FA280 autoanalyzer, FECT, Formalin-ethyl acetate, Helminth, Parasitic detection, Protozoa

Background need for low-complexity, high-throughput, and cost-

Parasitic infections pose significant health challenges, effective tools to replace labor-intensive microscopic
particularly in tropical regions. Approximately 3.5 billion examinations.
people worldwide are affected by intestinal parasites [1, Several digital imaging-based automated stool exami-
2]. Intestinal helminth infections can have detrimental nation systems have been developed to diagnose parasitic
effects on health, including malnutrition, anemia, and infections [21–23]. Yang and colleagues were the first to
impaired growth and cognitive development [3–6]. In validate an automated stool examination system. They
pregnant women, intestinal helminth infections can lead recommended the development of an adjusted algorithm
to inadequate weight gain, intrauterine growth retarda- to accurately classify helminth eggs [21]. Subsequently,
tion, and low birth weight in newborns [7]. Furthermore, an automated urine sediment microscopy analyzer, the
these infections can significantly compromise the mental sediMAX I, was introduced for identification and count-
and educational development of children [3–5, 8]. Pro- ing of particles of urine sediment [24]. The sediMAX I
tozoa infections are a major contributor to malnutrition, microscope has an attachment for a digital camera, with
and they may contribute to changes in the microbiota image magnification approximating to 400 × enlarge-
composition and activation of immune responses [2, 9, ment. All images are analyzed by a high-quality image
10]. processing software that is able to detect and classify the
Consequently, stool examination is a fundamental tool particles in urine as blood cells, epithelial cells, crystals,
for diagnosing parasitic infections in clinical laboratories. bacteria, yeasts, sperm, and mucus and can be accessed
Macroscopic examination assesses general character- from remote locations [24, 25]. Although the sediMAX
istics such as color, consistency, form, and odor of stool I had not yet been approved for detection of intestinal
samples, while microscopic examination is used for para- parasites, Indra and colleagues has modified sediMAX-I
site detection [11]. Various manual methods are available in detecting intestinal parasites, helminths, and proto-
for the detection of intestinal parasites in stool samples, zoa. They concluded that sediMAX-1 exhibited excellent
including direct wet smear, Kato’s thick smear, and con- performance in detecting eggs of Dibothriocephalus
centration methods such as simple sedimentation, flota- nihonkaiensis, Taenia species, Hymenolepis nana, Tri-
tion, and formalin-ethyl acetate [12–14]. Each method churis trichiura, Ascaris lumbricoides, and Paragonimus
has advantages and limitations in terms of sensitivity, westermani [22, 23]. Additionally, FECPAKG2 (Techion,
stool preparation procedure, and processing time. The Mosgiel, New Zealand), an image-based diagnostic plat-
spectrum of parasites detected by each method also var- form for quantitatively detecting parasite eggs in fecal
ies depending on the testing principles and other factors, samples, has also been validated [26–28].
such as the amount of stool used. The objective of this study was to compare the effi-
The direct wet smear method is widely used in most ciency of a fully automatic digital feces analyzer (Model
clinical laboratories owing to its ease, rapidity, and cost- FA280, Orienter, Chengdu, Sichuan, People’s Republic
effectiveness. However, it has been reported to have of China) with that of the FECT. The FA280 employs a
low sensitivity because of the small stool sample used digital imaging-based method to diagnose parasitic infec-
(0.2 g) [15–18]. Both Kato’s thick smear method and tions in human stool samples. The comparison was based
the formalin-ethyl acetate concentration technique on the following criteria: (1) sensitivity of parasite detec-
(FECT) have demonstrated higher sensitivities than tion in stool samples, (2) agreement in detecting parasite
the direct wet smear method [19]. Despite being con- species in the stool samples, (3) simplicity of the method,
sidered the gold standard for detecting intestinal para- (4) practicability of the method for routine diagnosis,
sites, microscopic detection is time-consuming, tedious, and (5) total and hands-on times required to perform the
labor-intensive, and heavily reliant on the expertise analyses. Through this comparison, we aimed to evalu-
and training of microscopists [20]. Therefore, there is a ate the performance and practicality of the digital feces

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 3 of 10

analyzer, thereby assessing its potential as an alternative The tube was tightly closed and vigorously shaken in an
diagnostic tool for routine parasitic infections. inverted position for 1 min. The stopper was carefully
removed, and the tube was centrifuged at 2500 rpm for
Methods 2 min. The plug of debris at the top of the tube was freed
Study design by ringing the sides of the tube with an applicator stick.
As shown in Fig. 1, two sets of stool samples were utilized The top layer of the supernatant was decanted, and debris
in this study. The first set consisted of 200 fresh samples on the sides of the centrifuge tube was removed using a
randomly selected from routine stool samples in the Par- cotton-tipped applicator. The sediment at the bottom of
asitology Laboratory of the Department of Parasitology, the tube was pipetted onto a clean glass slide, and ova
Faculty of Medicine Siriraj Hospital, Mahidol University, and parasites were observed under a light microscope
Thailand. The samples were collected between October [29].
and December 2022. A fully automatic digital feces ana-
lyzer (Orienter Model FA280) was employed to examine Detection of parasites in stool samples by FA280
them. The testing results came from an automated report The FA280 fully automatic digital feces analyzer consists
produced by the FA280’s artificial intelligence (AI) pro- of the following components: (1) automatic in-sample
gram and an auditing report by skilled laboratory tech- unit. The analyzer uses a track-type sample carrier to
nicians. The second set of stool samples comprised 800 ensure accurate and consistent sample loading. (2) Sam-
samples preserved in 10% formalin. Both the FECT and pling unit. This unit uses a pneumatic mixing system to
the FA280, along with a user audit, were used to diagnose ensure that the sample is thoroughly mixed with dilu-
parasites in these samples. ent. (3) Sample character and color photographing unit.
A high-resolution camera is employed to capture images
Detection of parasites in stool samples by FECT of the sample. The images are then analyzed by the ana-
The FECT was performed as described by Garcia [29]. lyzer’s software to determine the sample’s attributes and
In this process, 2 g of stool sample was mixed with 10 ml color. The results are stored in the system for reference
of 10% formalin. The fecal suspension was then strained by the tester. (4) Microscope unit. High- and low-power
through a 2-layer gauze into a 15-ml conical centrifuge objective lenses are used to automatically capture images
tube. To this mixture, 3 ml of ethyl acetate was added. of the sample at different magnifications. The micro-
scope unit also utilizes multifield tomography imaging to
obtain detailed sectional images of the sample. (5) Test
kit unit. This unit facilitates the quantification of samples
by dropping them into the sample loading area of the test
kit. The test kit incubation belt automatically rotates the
test kit to the image collection area to periodically cap-
ture and interpret photos of the experimental reaction
results. Illustrations detailing the operational procedures
of the FA280 analyzer are shown in Fig. 2.
The test principle of the FA280 analyzer is based on a
simple sedimentation technique. In the processing step,
a batch of 40 stool samples is processed in a single run,
which takes approximately 30 min. During sample test-
ing, approximately 0.5 g of a stool sample is placed in a
filtered sample collection tube using a spoon. The sample
collection tube is then placed into the sample rack of the
analyzer.
Fig.1 Graphical representation of the study design. The study Once the system obtains a sample, the software initi-
was divided into two parts: A and B. In Part A of the study, 200 ates the test. Microscopic examination is performed, cap-
fresh stool samples were analyzed using the Orienter Model FA280 turing photographs of the stool sample and recording its
automatic digital feces analyzer. Species identification was evaluated
by a skilled medical technologist through user audits, and the results
various attributes. These attributes encompass the sam-
were reported by the analyzer’s artificial intelligence program. In ple’s color, form, and consistency. The color varies from
Part B of the study, 800 preserved stool samples were subjected yellow, off-white, green, and red to a tar-like hue. The
to parasite detection using both the FA280 feces analyzer (with user form refers to the physical shape or appearance, while the
audit) and the formalin-ethyl acetate concentration technique (FECT). consistency indicates whether the sample is loose, semi-
All preserved stool samples were analyzed once with each method
solid, or watery.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 4 of 10

Fig.2 Instrument operation procedures of the FA280 feces analyzer

Next, a diluent is automatically added to the sample in detection between techniques was assessed via kappa (κ)
the tube. The main components of the diluent typically agreement, with a 95% confidence interval (95% CI).
include sodium chloride (approximately 0.85–0.95%),
PC-300 (approximately 0.1–0.3 ml/l), and water for ana-
lytical laboratory use. The diluent is mixed thoroughly Results
with the stool sample through pneumatic mixing. This Comparison of the FECT and the FA280 for parasite
process helps filter out nonpathological residues such detection
as large plant fibers, seeds, and undigested residual For the first set of stool samples, Table 1 presents the
food. The prepared sample enters a counting cell within results of parasite detection in 200 fresh stool sam-
the analyzer’s sample character and color photograph- ples tested using the FECT, FA280 with an AI report,
ing unit. The microscope unit of the FA280 automati- and FA280 with a user audit. The pairwise agreements
cally focuses and collects high-resolution images of the between the results obtained with the FECT and the
sample. FA280 with an AI report showed statistically significant
In our investigation, the digital microscope images differences (McNemar’s test, P < 0.001). However, there
were uploaded and analyzed using the system software, were no statistically significant differences between the
which generated an AI report. Additionally, an experi- results obtained from the FECT and FA280 with a user
enced medical technologist performed a user audit by audit (exact binomial test, P = 1.000). When comparing
reviewing the uploaded images on screen to check for the the agreement for the species of parasites detected by the
presence of parasites. FA280 with an AI report, fair agreement was observed
(overall agreement 75.5% [151/200 samples], κ = 0.367,
Statistical analysis 95% CI 0.248–0.486). On the other hand, the agreement
Statistical analyses were conducted using GraphPad for the species of parasites detected by the FA280 with a
Prism version 7.04 (GraphPad Software Inc, San Diego, user audit and FECT showed perfect agreement (overall
CA, USA). Differences in parasite-positive samples agreement 100%, κ = 1.00, 95% CI 1.00–1.00).
detected by the FA280 analyzer (both through the AI The FA280 with an AI report demonstrated a sub-
report and the user audit) and the FECT were evaluated stantial false-positive rate of 32.5% (65/200 samples). In
using McNemar’s test. The consistency in parasite species light of this high rate, the performance of the FECT was

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 5 of 10

Table 1 Results of parasite detection of 200 fresh stool samples obtained from routine parasite detection using the formalin ethyl
acetate concentration technique (FECT)
Method Negative Positive Species of parasite detected
Al Tt Hw Ts Ov Bh Gl

microscopic detection (FECT) 178 22 11 6 1 0 0 3 1

FA-280 feces analyzer (AI report) 129 71 13 6 8 14 41 0 2
FA-280 feces analyzer (user audit) 178 22 11 6 1 0 0 3 1
Al Ascaris lumbricoides, Tt Trichuris trichiura, Hw hookworm, Ts Taenia spp., Ov Opisthorchis viverini, Bh Blastocystis hominis, Gi Giardia lamblia

Table 2 Results of parasite detection of 800 preserved stool Figures 3 and 4 display bar graphs illustrating the spe-
samples using FA-280 feces analyzer (user audit) and the formalin cies of helminths and protozoa, respectively, detected
ethyl acetate concentration technique (FECT) by the FECT and the FA280 with a user audit. Figure 5
Methods Number of stool sample shows high-resolution images from the FA280 digital
microscope depicting helminth eggs and larvae. Addi-
Positive Negative
tionally, Fig. 6 shows images of protozoan cysts and
Formalin ethyl acetate concentra- 468 332 trophozoites. The concordance in detecting helminth
tion (FECT) species between the FECT and the FA280 (when used
FA280 feces analyzer (user audit) 440 360 with a user audit) was notably strong. Of the 800 sam-
*
Agreement for all parasite positive samples detected between the autoanalyzer ples, 747 were consistent, yielding an overall match rate
using result obtained from user audit and FECT revealed weighted kappa (κ) of 93.4%. The kappa value was 0.857, with a 95% confi-
values of 0.857, indicating almost perfect agreement
dence interval of 0.82–0.894. Similarly, the concordance
in detecting protozoan species between the FECT and
the FA280 (when used with a user audit) was perfect. All
compared to that of the FA280 with a user audit in the
800 samples matched, resulting in a 100% consistency
second set of stool samples.
rate (κ = 1.00, 95% CI 1.00–1.00).
For the second set of stool samples, as presented in
Table 2, parasites were detected in 468 of the 800 sam-
Discussion
ples tested by the FECT, while the FA280 with a user
Our study compared the performance of the FECT, the
audit detected parasites in 440 of the samples. The results
FA280 with an AI report, and the FA280 with a user audit
indicated that the FECT identified a significantly higher
in diagnosing parasitic infections in 1000 stool samples.
number of parasite-positive samples than the FA280
The study’s strengths were as follows: using the same
with a user audit (McNemar’s test, P < 0.001). Table 3
stool samples to evaluate the performance of all tech-
compares the performance of three methods: direct wet
niques, employing a large number of fresh and preserved
smear, the FECT, and the FA280 with a user audit.
stool samples (1000), having a substantial number of

Table 3 Comparison of the parasite detection performance of three methods: direct wet smear, formalin-ethyl acetate concentration
technique (FECT), and FA280 feces analyzer (user audit)
Parameter compared Direct wet smear [29] FECT FA280 with user audit

Weight of stool used 0.2 g 2g 0.5–1 g

Technique Manual Manual Automatic
Process simplicity Less complicated More complicated Less complicated
Processing time 2 min/sample 8–10 min/sample 2 min/sample
Parasite observing time 5–10 min 5–10 min 3–5 min
Parasites observation tool Microscope Microscope High-resolution images
Experienced laboratory technician Required Required Required
Result recorded and stored No No Yes
Cost/test USD 0.25 USD 0.50 USD 2.00

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 6 of 10

Fig. 3 Bar graphs showing the number and helminth species found in the test stool samples tested by the formalin-ethyl acetate concentration
technique (FECT) and the FA280 feces analyzer (with user audit)

found by the FECT and the FA280 with a user audit.

First, the FECT requires 2 g of stool sample, whereas the
FA280 analyzer uses 0.5 g. The larger stool sample for
the FECT contributes to a higher parasite detection rate.
Second, the processing steps in the FECT, including the
removal of fecal debris and fat from stool samples using
ethyl acetate, enhance egg isolation, thereby increasing
the chances of detecting parasite eggs or larvae. Regard-
ing the species of detected parasites, the FA280 with the
user audit demonstrated strong to perfect agreement
with the FECT in detecting intestinal helminth and pro-
tozoan species (κ = 0.857 and 1, respectively).
This study also demonstrated that using fresh stool
Fig. 4 Bar graphs showing the number and protozoa species samples resulted in perfect agreement with the results
found in the test stool samples tested by the formalin-ethyl acetate obtained from the FECT, whereas the testing with the
concentration technique (FECT) and the FA280 feces analyzer (with
user audit)
preserved stool samples yielded a lower positive-sample
detection rate. This discrepancy can be explained by the
fact that formalin-preserved stool samples have an exact
stool weight of < 0.5 g due to their dilution with 10% for-
parasite-positive samples (468), and encompassing a vari- malin. Additionally, the first set of fresh stool samples
ety of helminth and protozoan species. consisted of only 200 samples with 22 positive parasite
Our findings revealed that the FECT identified more samples, compared to the 800 preserved stool samples
positive samples than the FA280 with a user audit (468 vs. with 468 positive parasite samples. Sample size plays a
440). Both the FECT and the FA280 analyzer utilize the crucial role in decision-making analysis: the larger the
sedimentation method. It is considered the most straight- sample used, the more reliable the results are.
forward and least error-prone technique, ensuring the The FECT also detected more A. lumbricoides and T.
recovery of helminth eggs, helminth larvae, and proto- trichiura positive-stool samples than the FA280 with a
zoan cysts [29]. However, several factors may explain user audit. This discrepancy may be attributed to the
the discrepancy between the number of positive results worm burden in infected individuals. In some instances

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 7 of 10

Fig. 5 High-resolution images from the FA280 feces analyzer’s digital microscope depicting helminth eggs and larvae

where the FECT detected A. lumbricoides- or T. trichi- technicians and reducing potential contamination in the
ura-positive samples but the FA280 analyzer yielded laboratory. Third, stool sediments can be stored for sev-
negative results, only a few or rare parasite eggs were eral weeks, allowing for retesting or utilization for educa-
observed under the microscope. Stool samples with a tion or research. Finally, using a digital microscope, the
high abundance of parasite eggs can increase detection FA280 analyzer records high-resolution images of the
rates in microscopy-based examinations [30]. Thus, in detected parasites. These images can be retrospectively
stool samples with low density of the parasites eggs, along observed and used for educational and quality control
with the lower amount of the stool samples usage, might purposes.
have led to the lower detection rate of FA-280. Addition- However, the present study raises some concerns
ally, this discrepancy in results may be explained by the regarding the application of automatic feces analyzers
study of Brummaier and co-authors who found that the for parasitic detection. In routine laboratory diagnosis
FECT was superior in detecting hookworm and T. trichi- of parasitic infections, microscopic-based methods are
ura eggs [30]. commonly used. Laboratory technicians are familiar with
Although the FECT has several advantages, there are the appearance of parasite eggs, larvae, cysts, and tropho-
some precautions to consider. The processing steps of the zoites observed under a microscope. In contrast, the
FECT are time-consuming, including the shaking step FA280 is an image-based diagnostic platform that utilizes
before centrifugation and removal of debris plugs, which high-resolution digital microscopic images for evalua-
must be performed carefully for accurate results. Moreo- tion and data collection. From our experience, the high-
ver, processing many stool samples is tedious and labo- resolution images obtained from the FA280 may differ
rious. Observing large amounts of stool sediment under somewhat from those observed under a microscope,
the microscope often causes eye fatigue and dizziness in potentially leading to the misdiagnosis of parasites.
operators. Therefore, before implementing the diagnosis of parasitic
The FA280 analyzer offers several advantages. First, as infections using an FA280 analyzer or a similar image-
the testing and analysis are fully automated, processing based diagnostic platform, laboratory technicians should
times and human errors are reduced, making the ana- train extensively by reviewing digital images of parasites
lyzer suitable for the mass screening of parasitic infec- to ensure familiarity.
tions. Second, the stool preparation process is carried Furthermore, the FA280 with AI automatic report-
out in a closed system, ensuring the safety of laboratory ing showed limited analytical specificity in the present

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 8 of 10

Fig. 6 High-resolution images from the FA280 feces analyzer’s digital microscope depicting protozoan cysts and trophozoites

study. Therefore, the FA280 automatic feces analyzer feces analyzer offers the advantage of high automation,
cannot fully replace a skilled operator. It still requires simplified operation procedures, rapid detection speed,
an experienced or well-trained laboratory technician to and an improved working environment.
evaluate the digital microscope images to obtain accu-
rate results and avoid misdiagnosing parasitic infections.
Abbreviations
Additionally, the FA280, equipped with a special type of FECT Formalin ethyl acetate concentration technique
microscope and an electronic camera, allows for clear AI Artificial intelligence
visualization of the inner contents of cysts, particularly G Gram
in Giardia duodenalis. However, for cysts of other amoe- Acknowledgements
bas, such as Entomoeba coli and E. histolytica/dispar, the We express our gratitude to Miss Bungion Sermsart for her invaluable labora-
size of the cyst is another key factor used to differentiate tory assistance. We also extend our thanks to Mr. Punpop Lertlaituan for his
valuable comments and suggestions that greatly contributed to the research.
between species within the Entamoeba genus.
Author contributions
SW contributed to the experimental design, interpretation of results, and
Conclusions manuscript editing. SB performed laboratory analyses, collected data, and
This study assessed and compared the concordance contributed to the initial drafting of the manuscript. SL and SV collected the
in detecting parasites and identifying species in stool stool samples. PT prepared all figures and table; SH conducted the statistical
analysis. All the authors read and approved the final version of the manuscript
samples using a fully automatic digital feces analyzer for publication.
(Orienter Model FA280) and the FECT. Despite the
higher cost per sample and lower sensitivity of the
FA280 compared to the FECT, the FA280 automatic

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 9 of 10

Funding 8. Fink MY, Singer SM. The intersection of immune responses, microbiota
Open access funding provided by Mahidol University. This study received and pathogenesis in giardiasis. Trends Parasitol. 2017;33:901–13. https://​
support from Firmer Co Ltd, Thailand, who provided the Orienter Model FA280 doi.​org/​10.​1016/j.​pt.​2017.​08.​001.
digital feces analyzer for our investigation. 9. Hotez PJ, Alvarado M, Basáñez MG, Bolliger I, Bourne R, Boussinesq
M, et al. The global burden of disease study 2010: interpretation and
Availability of data and materials implications for the neglected tropical diseases. PLoS Negl Trop Dis.
All data generated or analyzed during this study are included in the published 2014;87:e2865.
article. 10. Bouree P, Bisaro F. Parasitic diarrhea. Presse Med. 2007;36:706–16. https://​
doi.​org/​10.​1016/j.​lpm.​2006.​12.​028.
11. Kasırga E. The importance of stool tests in diagnosis and follow-up of
Declarations gastrointestinal disorders in children. Turk Pediatri Ars. 2019;2019:141–8.
https://​doi.​org/​10.​14744/​TurkP​ediat​riArs.​2018.​00483.
Ethics approval and consent to participate 12. Koontz F, Weinstock JV. The approach to stool examination for parasites.
The research protocol was authorized by the Ethics Committee, Faculty of Gastroenterol Clin N Am. 1996;25:435–49. https://​doi.​org/​10.​1016/​S0889-​
Medicine Siriraj Hospital, Mahidol University (Approval Number Si 505/2022). 8553(05)​70257-0.
13. Demeke G, Fenta A, Dilnessa T. Evaluation of wet mount and concentra-
Consent for publication tion techniques of stool examination for intestinal parasites identification
Not applicable. at Debre Markos comprehensive specialized hospital. Ethiopia Infect
Drug Resist. 2021;914:1357–62. https://​doi.​org/​10.​2147/​IDR.​S3076​83.
Competing interests 14. Labpedia net. 2021. Stool examination: stool smear preparation, stains,
This study received support from Firmer Co. Ltd., who provided the Orienter handling, and preservatives. 2021. https://​www.​labpe​dia.​net/​stool-​exami​
Model FA280 digital feces analyzer for our investigation. However, neither nation-​part-3-​stool-​smear-​prepa​ration-​stains-​handl​ing-​and-​prese​r vati​
the personnel nor any affiliated entities of Firmer Co. Ltd. were involved in ves/. Accessed 30 July 2023.
the conduct of this study. The authors declare that there are no competing 15. Endris M, Tekeste Z, Lemma W, Kassu A. Comparison of the Kato-Katz,
interests in relation to this research. wet mount, and formol-ether concentration diagnostic techniques for
intestinal helminth infections in Ethiopia. ISRN Parasitol. 2013. https://​doi.​
Author details org/​10.​5402/​2013/​180439.
1
Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol 16. Amin HA, Ali SA. Evaluation of different techniques of stool examination
University, Bangkok 10700, Thailand. 2 Department of Research and Develop- for intestinal parasitic infections in Sulaimani City-Iraq. Int J Curr Microbiol
ment, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, App Sci. 2015;4:991–6.
Thailand. 3 Filaria Project, Phikulthong Royal Development Study Center, 17. Hailu T, Abera B. Performance evaluation of direct saline stool micros-
Narathiwat 96000, Thailand. copy, formol ether concentration and Kato Katz diagnostic methods for
intestinal parasitosis in the absence of gold standard methods. Trop Dr.
Received: 21 September 2023 Accepted: 20 December 2023 2015;45:178–82. https://​doi.​org/​10.​1177/​00494​75515​581127.
18. Yimer M, Hailu T, Mulu W, Abera B. Evaluation performance of diagnostic
methods of intestinal parasitosis in school age children in Ethiopia. BMC
Res Notes. 2015;8:820. https://​doi.​org/​10.​1186/​s13104-​015-​1822-4.
19. Aiadsakun P, Sriwimol W, Thongbun N, Rui-On B, Thiparaksaphan K,
References Phainuice C, et al. Comparison of the complete filtration method using
1. Shiferaw K, Tesfay T, Kalayu G, Kiros G. Human intestinal parasites: an automated feces analyzer with three manual methods for stool exami-
prevalence and associated risk factors among grade school children in nations. J Microbiol Methods. 2022;192:106394. https://​doi.​org/​10.​1016/j.​
maksegnit. Northwest Ethiopia J Trop Med. 2021;10:6694809. mimet.​2021.​106394.
2. Wattano S, Kerdpunya K, Keawphanuk P, Hunnangkul S, Loimak S, 20. Han S, Zhang X, Wen J, Li Y, Shu J, Ling H, et al. A combination of the Kato-
Tungtrongchitra A, et al. An epidemiological survey of intestinal parasitic Katz methods and ELISA to improve the diagnosis of clonorchiasis in an
infection and the socioeconomic status of the ethnic minority people of endemic area. China PLoS One. 2012;7:e46977.
Moken and orang Laut. Trop Med Infect Dis. 2023;8:161–215. https://​doi.​ 21. Yang YS, Park DK, Kim HC, Choi MH, Chai JY. Automatic identification
org/​10.​3390/​tropi​calme​d8030​161. of human helminth eggs on microscopic fecal specimens using digital
3. Oninla SO, Onayade AA, Owa JA. Impact of intestinal helminthiases on image processing and an artificial neural network. IEEE Trans Biomed Eng.
the nutritional status of primary-school children in Osun state, south- 2001;48:718–30. https://​doi.​org/​10.​1109/​10.​923789.
western Nigeria. Ann Trop Med Parasitol. 2010;104:583–94. https://​doi.​ 22. Intra J, Taverna E, Sala MR, Falbo R, Cappellini F, Brambilla P. Detection of

analyser ­sediMAX®. Clin Microbiol Infect. 2016;22:279–84. https://​doi.​org/​

org/​10.​1179/​13648​5910X​12851​86877​9786. intestinal parasites by use of the cuvette-based automated microscopy
4. Fürst T, Silué KD, Ouattara M, N’Goran DN, Adiossan LG, N’Guessan Y, et al.
Schistosomiasis, soil-transmitted helminthiasis, and sociodemographic 10.​1016/j.​cmi.​2015.​11.​014.
factors influence quality of life of adults in Côte d’Ivoire. PLOS Negl Trop 23. Intra J, Sala MR, Falbo R, Cappellini F, Brambilla P. Improvement in the

automated urine sediment analyzer ­sediMAX® 2 compared to ­sediMAX®

Dis. 2012;6:e1855. detection of enteric protozoa from clinical stool samples using the
5. Sayasone S, Utzinger J, Akkhavong K, Odermatt P. Multiparasitism and
intensity of helminth infections in relation to symptoms and nutritional 1. Eur J Clin Microbiol Infect Dis. 2017;36:147–51. https://​doi.​org/​10.​1007/​
status among children: a cross-sectional study in southern Lao People’s s10096-​016-​2788-4.

ment analysis: analytical and diagnostic performance of ­sediMAX®—a

Democratic Republic. Acta Trop. 2015;141:322–31. https://​doi.​org/​10.​ 24. Zaman Z, Fogazzi GB, Garigali G, Croci MD, Bayer G, Kranicz T. Urine sedi-
1016/j.​actat​ropica.​2014.​09.​015.
6. Ellwanger JH, Ziliotto M, Kulmann-Leal B, Chies JAB. Iron deficiency new automated microscopy image-based urine sediment analyzer. Clin
and soil-transmitted helminth infection: classic and neglected con- Chim Acta. 2010;411:147–54.
nections. Parasitol Res. 2022;121:3381–92. https://​doi.​org/​10.​1007/​ 25. Falbo R, Sala MR, Signorelli S, Venturi N, Signorini S, Brambilla P. Bacteriuria
s00436-​022-​07697-z. screening by automated whole-field-image-based microscopy reduces
7. Rodríguez-Morales A, Barbella RA, Case C, Arria M, Ravelo M, Perez H, the number of necessary urine cultures. J Clin Microbiol. 2012;50:1427–9.
et al. Intestinal parasitic infections among pregnant women in venezuela. 26. Boelow H, Krücken J, Thomas E, Mirams G, Samson-Himmelstjerna G.
Infect Dis Obstet Gynecol. 2006;23:125. https://​doi.​org/​10.​1155/​IDOG/​ Comparison of FECPAKG2, a modified Mini-FLOTAC technique and
2006/​23125. combined sedimentation and flotation for the coproscopic examination
of helminth eggs in horses. Parasit Vectors. 2022;15:166. https://​doi.​org/​
10.​1186/​s13071-​022-​05266-y.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Boonyong et al. Parasites & Vectors (2024) 17:13 Page 10 of 10

27. Tyson F, Dalesman S, Brophy PM, Morphew RM. Novel equine faecal egg
diagnostics: validation of the FECPAKG2. Animals. 2020;108:1254. https://​
doi.​org/​10.​3390/​ani10​081254.
28. Rashid MH, Stevenson MA, Waenga S, Mirams G, Campbell AJD, Vaughan
JL, et al. Comparison of McMaster and FECPAK(G2) methods for counting
nematode eggs in the faeces of alpacas. Parasit Vectors. 2018;11:278–81.
https://​doi.​org/​10.​1186/​s13071-​018-​2861-1.
29. Garcia LS. Macroscopic and microscopic examination of fecal specimens,
In Diagnostic Medical Parasitology.4th Edition, ASM Press, Washington DC
USA. 2001;745–9.
30. Brummaier T, Archasuksan L, Watthanakulpanich D, Paris DH, Utzinger J,
McGready R, et al. Improved detection of intestinal helminth infections
with a formalin ethyl-acetate-based concentration technique compared
to a crude formalin concentration technique. Trop Med Infect Dis.
2021;6:51. https://​doi.​org/​10.​3390/​tropi​calme​d6020​051.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:

1. use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
2. use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
3. falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
4. use bots or other automated methods to access the content or redirect messages
5. override any security feature or exclusionary protocol; or
6. share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at

[email protected]