Bioelectrochemical Detection of Mycobacterium tuberculosis ESAT-6 in an Antibody-Based Biomicrosystem

Bioelectrochemical sensing of Mycobacterium tuberculosis through electro-immunosensors is a promising technique to detect relevant analytes. In general, immunosensors require the formation of organic assemblies by the adsorption of molecular constituents. Moreover, they depend on the correct immobilization of the bio-recognition element in the biosensor. These procedures cannot be easily monitored without the use of invasive methods. In this work, an impedance analysis technique was used, as a non-invasive method, to measure and differentiate the manufacturing stages of the sensors. Biomicrosystems were fabricated through physical vapor deposition (PVD) of 80 nm Au nanolayers on 35 µm copper surfaces. Later, the surface was modified through thiolation methods generating a self-assembled-monolayer (SAM) with 20 mM 4-aminothiophenol (4-ATP) on which a polyclonal antibody (pAb) was covalently attached. Using impedance analysis, every step of the electro-immunosensor fabrication protocol was characterized using 40 independent replicas. Results showed that, compared to the negative controls, distilled water, and 0.5 µg/mL HSA, a maximum variation of 171% between each replica was achieved when compared to samples containing 0.5 µg/mL of ESAT-6 M. tuberculosis immunodominant protein. Therefore, this development validates a non-invasive method to electrically monitor the assembly process of electro-immunosensors and a tool for its further measure for detection of relevant antigens.


Introduction
Tuberculosis (TB) is a curable and preventable disease caused by the pathogenic bacterium Mycobacterium tuberculosis. Early diagnosis and treatment are essential measures for effectively controlling the epidemic disease [1]. However, TB detection remains a major obstacle due to several drawbacks of the available diagnostic methods, such as tuberculin skin test [2], bacteriological culture (e.g., mycobacteria growth indicator tube) [3], sputum smear microscopy, radiographic methods [4], and biochemical and nucleic acid amplification methods [5], among them. To date, the number of diagnosis approaches for TB has increased as the disease continues to be a mayor public health problem worldwide, as a result of the severe threat of multidrug-resistant (MDR) tuberculosis, extensively drug resistant TB (XDR) [6] and alarming frequency of TB among immunocompromised co-infected patients (e.g., HIV/AIDS) [7]. Nevertheless, most conventional detection technologies present difficulties in recognizing the presence of M. tuberculosis, since they are time consuming, do not provide clinically reliable results and significantly lack of sensitivity [8,9]. Furthermore, highly-expressed 6 kDa early secretory antigen target-6 (ESAT-6), an immunodominant secreted protein involved in the virulence of M. tuberculosis [30]. Human serum albumin (HSA) was employed to ensure that other molecules distinct to ESAT-6 does not bind to the sensor surface. Each electro-immunosensor is comprised of a gold nanolayer, and polyclonal antibodies (pAb) attached to the surface by a SAM created with thiols. Using impedance analysis at different frequency ranges, it was possible to detect probe-target interaction in different samples and, in addition, verifying all manufacturing stages of the biomicrosystems without the need of intrusive or destructive methods.
In order to calculate the pAb45073 detection limit we used different dilutions of ESAT-6 full length recombinant protein Abcam (ab124574) from 500 µg to 5 µg per ml in a dot blot assay. The assay included mouse monoclonal antibodies to ESAT6 Abcam (ab26246), goat anti-mouse IgG H and L secondary antibody conjugated to horse radish peroxidase (HRP) and HRP substrate TMB (3,3',5,5'-tetramethylbenzidine) to detect the antigen antibody interaction.
PCB was fabricated with dry film photopolymer LAMINAR ® E9200 that was obtained from Eternal Materials Co Ltd (Kaohsiung, Taiwan), Dynamask KM, developer for negative presensitized boards and stripper for positive and negative photoresists were acquired from Bungard Elektronik (Windeck, Germany). Negative films were printed with the Filmstar Photoplotter (Bungard Elektronik, Windeck, Germany). The adhesion of the photosensitive film was performed with a RLM 419P dry film laminator and the UV exposure was achieved with the double-sided Hellas exposure unit (Bungard Elektronik, Windeck, Germany). The wet processes of circuit manufacture were carried out at the Splash Center (Bungard Elektronik, Windeck, Germany).
The physical vapor deposition of gold was accomplished with a Edwards Auto 306 physical thermal evaporator (Moorfield, Knutsford, UK) and the biomicrosystem measurements were carried out with an Agilent 4294A impedance analyzer (Agilent Technologies, Santa Clara, CA, USA) and a PeakTech 3725 multifunction tester (PeakTech, Ahrensburg, Germany). The immobilized surface observations were performed with a Phenom G2 pro desktop scanning electron microscope (SEM) (Phenom-World, Eindhoven, The Netherlands).

PCB Manufacturing
For the biomicrosystem base a double-layer FR-4 PCB with 2 oz thickness of copper was designed and manufactured. The electrode pattern was made with CadSoft Eagle Professional 7.4.0. The PCB bottom surface was laminated with antisolder and the top layer was left uncovered for further material deposition. Subsequently, a uniform gold layer was physically evaporated onto the exposed electrodes of this surface. Finally, the PCB electrical conductivity was verified through PeakTech 3725 multifunction digital tester (PeakTech, Ahrensburg, Germany).

Lift off and Gold Deposition
The substrate top surface was laminated with a dry photosensitive film (LAMINAR ® E9200) in the RLM 419P (Bungard Elektronik, Windeck, Germany) and then to imprint the electrode layout substrate was exposed to UV light with the printed electrode layout. The laminated substrate was then subjected to a developing process to remove the exposed photosensitive layer with the developer (Bungard Elektronik, Windeck, Germany). Afterwards, a uniform gold nanolayer was physically evaporated on the laminated substrate through PVD with a thermal evaporator. A 3 A current was used over a tungsten slide for the 100 mg gold evaporation. A vacuum pressure of 4 × 10 −5 mbar and an evaporation rate of 0.12 nm/s were established, thus obtaining 80 nm Au nanolayers on 35 um copper surfaces.
Finally, the residual photoresist was removed with a stripper (Bungard Elektronik, Windeck, Germany), so that the electrode pattern was settled onto the card. Finally, the biomicrosystem electrical conductivity of individual electrodes on the board was verified using a PeakTech 3725 multifunction digital tester (PeakTech, Ahrensburg, Germany).

Biomicrosystem Development
On the substrate covered with gold a 4 mm PMMA slide with 2 mm wells organized in two rows and 20 columns was stuck to the top through the use of TESA ® 4965 double-sided tape, miming a well plate with individual wells for each electrode. Inside each well reagents were deposited for the biosensor fabrication. Between each well, electrical connectors were placed for electrical measurements. A total of three biomicrosystems were fabricated in different batches and tested, each manufactured biomicrosystem contained 40 independent electro-immunosensors for a total of 120 electro-immunosensors, that had to be measured individually ( Figure 1) to verify the reproducibility and repeatability of the manufacture process. then subjected to a developing process to remove the exposed photosensitive layer with the developer (Bungard Elektronik, Windeck, Germany). Afterwards, a uniform gold nanolayer was physically evaporated on the laminated substrate through PVD with a thermal evaporator. A 3 A current was used over a tungsten slide for the 100 mg gold evaporation. A vacuum pressure of 4 × 10 −5 mbar and an evaporation rate of 0.12 nm/s were established, thus obtaining 80 nm Au nanolayers on 35 um copper surfaces. Finally, the residual photoresist was removed with a stripper (Bungard Elektronik, Windeck, Germany), so that the electrode pattern was settled onto the card. Finally, the biomicrosystem electrical conductivity of individual electrodes on the board was verified using a PeakTech 3725 multifunction digital tester (PeakTech, Ahrensburg, Germany).

Biomicrosystem Development
On the substrate covered with gold a 4 mm PMMA slide with 2 mm wells organized in two rows and 20 columns was stuck to the top through the use of TESA ® 4965 double-sided tape, miming a well plate with individual wells for each electrode. Inside each well reagents were deposited for the biosensor fabrication. Between each well, electrical connectors were placed for electrical measurements. A total of three biomicrosystems were fabricated in different batches and tested, each manufactured biomicrosystem contained 40 independent electro-immunosensors for a total of 120 electro-immunosensors, that had to be measured individually ( Figure 1) to verify the reproducibility and repeatability of the manufacture process.

Reagents Immobilization
For the self-assembled monolayer (SAM) fabrication 4-ATP molecules were added as crosslinkers for the antibodies in each well. A previously-reported electro-immunosensor by our group [22] allowed us to conclude that the best concentrations for building up a self-assembled monolayer were 20 mM of 4-ATP and 100 µg/mL of antibody. Therefore, a solution of 10 µL of a 20 mM 4-ATP was added into the wells. Later, after 4 h at room temperature, the wells were washed with ethanol and deionized water, in order to remove the remaining thiols. Then 10 µL of 100 µg/mL pAb 45073 solution was added into each well and the system was incubated at 4 °C over night. Finally, the remaining biomolecules were washed with PBS and deionized water.

Immobilization Testing by Electrical Techniques
Electro-immunosensor characterization was made through impedance measurements that were performed in each well with an impedance analyzer (Agilent 4294A) at a frequency range from 40 to 280 Hz. Measurements at particular frequencies were performed by eight replicates for the three manufacturing stages of the sensors: gold nanolayer (Au), gold nanolayer with a SAM of 4-ATP (Au + ATP), gold nanolayer with a SAM of 4-ATP attaching pAb 45073 (Au + ATP + pA), and for two analyte configurations: in the presence of 0.5 µg/mL of ESAT6 (Au + ATP + pA-ESAT6) (positive control) and in the presence of HSA (Au + ATP + pA-HSA) (negative control), ten times lower than the detection limit obtained using dot blot assay. Incubation of ESAT-6 or 0.5 µg/mL of HSA in each well took place at room temperature for 1 h under static conditions prior to electrical measurements.

Analytic Hierarchy Process for the Biomicrosystem and Traditional Detection Techniques
The analytic hierarchy process (AHP) was used as a decision-making tool to study the performance of the electro-immunosensor in contrast with conventional TB detection systems, such as Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA), culture, and sputum smear test [31]. The decisionmaking criteria considered includes cost, effectiveness, time, and the test analysis process. Cost involves the commercial expenses of performing each analysis, which were assumed based on the mean international costs reported by international laboratories, while the cost of the biosensor was calculated based on its manufacturing procedure; effectiveness is the assay capacity to accomplish an intended result under the possibility of noise; and time refers to the speed of analysis, and the analysis of the tests is subdivided according to the following two subcriteria: liability of the analysis under contamination hazard and viability on the assumption of blood in the samples.
The pairwise comparison matrix was constructed on the basis of tuberculosis experts consensus and taking into account the 1 to 9 scale criteria proposed by Saaty [32]. Expert Choice 11.5 ® (ExpertChoice, Arlington, VA, USA) software was used to rank the alternatives of the decision with respect to the criteria or subcriteria.

Reagents Immobilization
For the self-assembled monolayer (SAM) fabrication 4-ATP molecules were added as cross-linkers for the antibodies in each well. A previously-reported electro-immunosensor by our group [22] allowed us to conclude that the best concentrations for building up a self-assembled monolayer were 20 mM of 4-ATP and 100 µg/mL of antibody. Therefore, a solution of 10 µL of a 20 mM 4-ATP was added into the wells. Later, after 4 h at room temperature, the wells were washed with ethanol and deionized water, in order to remove the remaining thiols. Then 10 µL of 100 µg/mL pAb 45073 solution was added into each well and the system was incubated at 4 • C over night. Finally, the remaining biomolecules were washed with PBS and deionized water.

Immobilization Testing by Electrical Techniques
Electro-immunosensor characterization was made through impedance measurements that were performed in each well with an impedance analyzer (Agilent 4294A) at a frequency range from 40 to 280 Hz. Measurements at particular frequencies were performed by eight replicates for the three manufacturing stages of the sensors: gold nanolayer (Au), gold nanolayer with a SAM of 4-ATP (Au + ATP), gold nanolayer with a SAM of 4-ATP attaching pAb 45073 (Au + ATP + pA), and for two analyte configurations: in the presence of 0.5 µg/mL of ESAT6 (Au + ATP + pA-ESAT6) (positive control) and in the presence of HSA (Au + ATP + pA-HSA) (negative control), ten times lower than the detection limit obtained using dot blot assay. Incubation of ESAT-6 or 0.5 µg/mL of HSA in each well took place at room temperature for 1 h under static conditions prior to electrical measurements.

Analytic Hierarchy Process for the Biomicrosystem and Traditional Detection Techniques
The analytic hierarchy process (AHP) was used as a decision-making tool to study the performance of the electro-immunosensor in contrast with conventional TB detection systems, such as Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA), culture, and sputum smear test [31]. The decision-making criteria considered includes cost, effectiveness, time, and the test analysis process. Cost involves the commercial expenses of performing each analysis, which were assumed based on the mean international costs reported by international laboratories, while the cost of the biosensor was calculated based on its manufacturing procedure; effectiveness is the assay capacity to accomplish an intended result under the possibility of noise; and time refers to the speed of analysis, and the analysis of the tests is subdivided according to the following two subcriteria: liability of the analysis under contamination hazard and viability on the assumption of blood in the samples.
The pairwise comparison matrix was constructed on the basis of tuberculosis experts consensus and taking into account the 1 to 9 scale criteria proposed by Saaty [32]. Expert Choice 11.5 ® (ExpertChoice, Arlington, VA, USA) software was used to rank the alternatives of the decision with respect to the criteria or subcriteria.

Immobilization Testing by Electrical Techniques
The average impedance magnitude of the three manufacturing stages of the sensors was determined in response to an AC current as a function of frequency [33]. The characterization of the replicas of different stages of immobilization within the biosensor led to determining a range of measurement frequencies with low noise, allowing the replicability of the experiment. In order to determine the variation of the copper with gold evaporated prior to the immobilization (conductive layer), 40 individual wells of three biomicrosystems fabricated in different batches, for a total of 120 samples, were measured by impedance analysis at different frequency ranges. The mean value of the 120 wells in the range of 40 to 120 Hz was 0.1588 Ω with a standard deviation of 0.0142. In the range of 120 to 200 Hz, the mean value was 0.1591 Ω with a standard deviation of 0.0142. Finally, in the range of 200 to 280 Hz, the mean value was 0.1584 Ω with a standard deviation of 0.0102 revealing a small variance in the manufacture of all wells independently from the fabrication batch. When comparing the results between fabrication batches, the maximum impedance variation between the biomicrosystems was 0.43% in the frequency range of 40 to 120 Hz, compared to 0.41% and 0.06% of differences in the 120 to 200 Hz and 200 to 280 Hz frequency ranges, showing an appropriate reproducibility of the manufacturing process. As it can be seen in the plots of Figures 2 and 3, the range where the largest significant differences were found within immobilization stages was between 40 and 120 Hz. In this range, there is a non-significant variation of impedance (−3.81%) between the first two manufacturing stages, Au and Au + ATP. Moreover, there is an impedance variation of 31.21% between Au and Au + ATP + pA. On the other hand, from 120 to 200 Hz there is an impedance variation of (−5.51%) between the first two manufacturing stages and an 11.44% impedance variation between Au and Au + ATP + pA. Finally, at frequencies of 200 to 280 Hz we measured a 2.16% impedance variation between the first two manufacturing stages and 14.37% between Au and Au + ATP + pA. The highest impedance value of the last immobilization step was 0.20 Ω. Surface observation in the SEM (Figure 4) showed a non-homogeneous structure and a change in the surface of the three stages (Au, Au + ATP, Au + ATP + pA).

Immobilization Testing by Electrical Techniques
The average impedance magnitude of the three manufacturing stages of the sensors was determined in response to an AC current as a function of frequency [33]. The characterization of the replicas of different stages of immobilization within the biosensor led to determining a range of measurement frequencies with low noise, allowing the replicability of the experiment. In order to determine the variation of the copper with gold evaporated prior to the immobilization (conductive layer), 40 individual wells of three biomicrosystems fabricated in different batches, for a total of 120 samples, were measured by impedance analysis at different frequency ranges. The mean value of the 120 wells in the range of 40 to 120 Hz was 0.1588 Ω with a standard deviation of 0.0142. In the range of 120 to 200 Hz, the mean value was 0.1591 Ω with a standard deviation of 0.0142. Finally, in the range of 200 to 280 Hz, the mean value was 0.1584 Ω with a standard deviation of 0.0102 revealing a small variance in the manufacture of all wells independently from the fabrication batch. When comparing the results between fabrication batches, the maximum impedance variation between the biomicrosystems was 0.43% in the frequency range of 40 to 120 Hz, compared to 0.41% and 0.06% of differences in the 120 to 200 Hz and 200 to 280 Hz frequency ranges, showing an appropriate reproducibility of the manufacturing process. As it can be seen in the plots of Figures 2 and 3, the range where the largest significant differences were found within immobilization stages was between 40 and 120 Hz. In this range, there is a non-significant variation of impedance (−3.81%) between the first two manufacturing stages, Au and Au + ATP. Moreover, there is an impedance variation of 31.21% between Au and Au + ATP + pA. On the other hand, from 120 to 200 Hz there is an impedance variation of (−5.51%) between the first two manufacturing stages and an 11.44% impedance variation between Au and Au + ATP + pA. Finally, at frequencies of 200 to 280 Hz we measured a 2.16% impedance variation between the first two manufacturing stages and 14.37% between Au and Au + ATP + pA. The highest impedance value of the last immobilization step was 0.20 Ω. Surface observation in the SEM (Figure 4) showed a non-homogeneous structure and a change in the surface of the three stages (Au, Au + ATP, Au + ATP + pA).

ESAT6 Detection
The performance of the biosensor for the detection of a positive and negative control, 0.5 µg/mL ESAT-6 and 0.5 µg/mL HAS, respectively, was verified through impedance measurements and compared to the dot blot assay. Figures 5 and 6 show that the frequency range from 40 Hz to 120 Hz has the most significant variation in impedance among all the investigated ranges. The detection of the M. tuberculosis protein has a difference of 171% in impedance increase compared to the impedance measured for the negative control (HSA) in this frequency range ( Figure 6A). The negative control indeed produced a null impedance change compared to the biosensor impedance with only distilled water, ruling out the possibility of misleading interpretations of the results. Figure 6B,C show that there is a significant change in other frequency ranges (120-200 Hz and 200-280 Hz), however, the greatest impedance variation can be found in the range of 40-120 Hz. Regarding Figure 5, it is important to notice that there are no overlapping values between the negative and the positive control. We observed that all the results of the negative controls were under 0.20 Ω and that impedance values for the positive control were all above 0.54 Ω. Thus, we establish a decision range where results in the grey zone where the protein presence is unreliable and additional evaluation of the sample needs to be done. Finally, at 40 Hz we verified that 100% of the performed proof with ESAT-6 protein were successful, demonstrating the efficient performance of the electroimmunosensor at low frequencies.

ESAT6 Detection
The performance of the biosensor for the detection of a positive and negative control, 0.5 µg/mL ESAT-6 and 0.5 µg/mL HAS, respectively, was verified through impedance measurements and compared to the dot blot assay. Figures 5 and 6 show that the frequency range from 40 Hz to 120 Hz has the most significant variation in impedance among all the investigated ranges. The detection of the M. tuberculosis protein has a difference of 171% in impedance increase compared to the impedance measured for the negative control (HSA) in this frequency range ( Figure 6A). The negative control indeed produced a null impedance change compared to the biosensor impedance with only distilled water, ruling out the possibility of misleading interpretations of the results. Figure 6B,C show that there is a significant change in other frequency ranges (120-200 Hz and 200-280 Hz), however, the greatest impedance variation can be found in the range of 40-120 Hz. Regarding Figure 5, it is important to notice that there are no overlapping values between the negative and the positive control. We observed that all the results of the negative controls were under 0.20 Ω and that impedance values for the positive control were all above 0.54 Ω. Thus, we establish a decision range where results in the grey zone where the protein presence is unreliable and additional evaluation of the sample needs to be done. Finally, at 40 Hz we verified that 100% of the performed proof with ESAT-6 protein were successful, demonstrating the efficient performance of the electro-immunosensor at low frequencies.

Analytic Hierarchy Process for the Biomicrosystem and Traditional Detection Techniques
Judgement results of the confrontation between the electro-immunosensor and traditional TB diagnostic alternatives (Xpert MTB/RIF, culture, and smear test) were evaluated using Expert Choice 11.5 ® software. Table 1. Documents the information for the construction of the pairwise comparison matrix of cost, effectiveness, time, and the test analysis. The comparative judgement was made in Expert Choice ® 11.5 in order to weigh the priorities of the alternatives in respect to the criteria. The total weighted value for each criterion was 100% and was distributed among the four diagnostic alternatives. Local weights obtained for the electro-immunosensor, Xpert MTB/RIF, culture and smear test were: for commercial costs, 31%, 4.3%, 11.3%, and 53.4%; for analysis of the tests, 35.6%, 15.8%, 28.1%, and 20.5%; for the effectiveness, 10.6%, 14.4%, 54.3%, and 20.8%; and for the time of analysis, 50.2%, 29%, 4.1%, and 16.7%, respectively. In short, the global weights obtained for each assay were 32.5%, 16.7%, 22.5%, and 28.3%, respectively.
According to the results obtained by evaluating the AHP alternatives in Expert Choice ® 11.5, the electro-immunosensor was found to be the dominant alternative, globally, in comparison with the traditional alternatives for TB detection. Moreover, it was determined to be locally dominant in the speed of analysis criteria, since the device requires less time to obtain the results among all the evaluated assays. In addition, a single device allows to characterize 40 independent replicas, detecting several M. tuberculosis epitopes, simply by changing the bio-recognition probe in each biosensor. Furthermore, the analysis liability is not altered by the presence of bleeding due to antigen affinity-based recognition by the antibody. In the chart, the electro-immunosensor did not exhibit local dominance with respect to the criteria commercial costs, as a result of the bioreagent cost. Even though the use of the antibody has a significant cost, the manufacturing cost of each biosensor is very low compared to other automated and non-automated techniques. The device did not have local dominance in the assay effectiveness criteria, since extra experimental studies with clinical samples are required to establish a standardized procedure to diagnose TB, minimizing noise.

Analytic Hierarchy Process for the Biomicrosystem and Traditional Detection Techniques
Judgement results of the confrontation between the electro-immunosensor and traditional TB diagnostic alternatives (Xpert MTB/RIF, culture, and smear test) were evaluated using Expert Choice 11.5 ® software. Table 1. Documents the information for the construction of the pairwise comparison matrix of cost, effectiveness, time, and the test analysis. The comparative judgement was made in Expert Choice ® 11.5 in order to weigh the priorities of the alternatives in respect to the criteria. The total weighted value for each criterion was 100% and was distributed among the four diagnostic alternatives. Local weights obtained for the electro-immunosensor, Xpert MTB/RIF, culture and smear test were: for commercial costs, 31%, 4.3%, 11.3%, and 53.4%; for analysis of the tests, 35.6%, 15.8%, 28.1%, and 20.5%; for the effectiveness, 10.6%, 14.4%, 54.3%, and 20.8%; and for the time of analysis, 50.2%, 29%, 4.1%, and 16.7%, respectively. In short, the global weights obtained for each assay were 32.5%, 16.7%, 22.5%, and 28.3%, respectively.
According to the results obtained by evaluating the AHP alternatives in Expert Choice ® 11.5, the electro-immunosensor was found to be the dominant alternative, globally, in comparison with the traditional alternatives for TB detection. Moreover, it was determined to be locally dominant in the speed of analysis criteria, since the device requires less time to obtain the results among all the evaluated assays. In addition, a single device allows to characterize 40 independent replicas, detecting several M. tuberculosis epitopes, simply by changing the bio-recognition probe in each biosensor. Furthermore, the analysis liability is not altered by the presence of bleeding due to antigen affinity-based recognition by the antibody. In the chart, the electro-immunosensor did not exhibit local dominance with respect to the criteria commercial costs, as a result of the bioreagent cost. Even though the use of the antibody has a significant cost, the manufacturing cost of each biosensor is very low compared to other automated and non-automated techniques. The device did not have local dominance in the assay effectiveness criteria, since extra experimental studies with clinical samples are required to establish a standardized procedure to diagnose TB, minimizing noise.

Discussion
The designed biomicrosystem shows promising results as a label-free detection device for M. tuberculosis epitopes, this enables patient treatment in a quicker and more affordable platform to control TB outbreaks. In each fabricated device it is possible to perform 40 independent tests using small amounts of reagents, each probe is covalently attached to a thiol to enhance the biomolecular stability. Moreover, depending on the selected probes it is possible to detect different analytes in the electro-immunosensor. The device does not require special reagents, simplifying the diagnosis of the pathology, which is normally laborious and also requires trained personnel and specialized infrastructure.
In TB detection, the speed of analysis is a crucial factor because for delay decisions patients remain untreated. The electro-immunosensor takes approximately an hour to have a confirmatory result in each biosensor. In short, the device could allow early detection of the disease and the rapid onset of treatment avoiding problems of desertion, drug resistance, morbidity or mortality of the patient. In contrast to other TB diagnostic tools, each electro-immunosensor is less expensive than standard techniques, costing approximately $7 USD. Moreover, it takes less time detecting biomolecules and it does not require specialized personnel and infrastructure compared to traditional technologies, such as culture, smear test, and nucleic acid amplification tests. Although experiments with clinical samples are yet to be developed, ESAT-6 is an abundantly-secreted antigen. Therefore, one of the best antigens to detect, giving potentially good results when detected with the electro-immunosensor. In addition, all stages used in the fabrication of the electro-immunosensor can be easily scaled up since all processes are based on industrial manufacturing technologies.

Conclusions
The biosensing miniaturized platform can be used for ESAT-6 detection in about 1 h of analysis time. Standard PCB technology used to manufacture each biosensor optimizes the time, cost, and replicability of the fabrication, the parameters of major relevance in TB diagnosis.
The manufacturing technology of the biosensor makes it possible to build a standard device with a simplified use for the operator. On the other hand, it was possible to identify the assembling process within the biosensor interface through impedance measurements, made for the three manufacturing stages with the electro-immunosensor, from 40 to 280 Hz. Measurements exhibited less impedance deviation at 40 Hz; at that frequency it is possible to monitor the surface activity, enhancing both the sensitivity and specificity of the biosensor. The study and analysis of the biosensor performance with positive and negative controls allowed the identification of a decision range for the interpretation of the results. ESAT-6 presence can be noticed above 0.54 Ω and non-presence below 0.20 Ω, between 0.20 Ω and 0.54 Ω, there is a gray zone where measurements must be repeated. Moreover, with a small quantity of reagents impedance variation between positive and negative control is 171%. Finally, further studies are in progress to enhance the biomicrosystem as a multiplexed point-of-care device with a portable impedance analyzer, which can be used for the automated detection of several antigens.