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Shaver N, Bennett A, Beck A, Vyas N, Zitiktye G, Lam E, Whelan B, O'Regan R, Conway A, Skidmore B, Moher D, Little J. Performance of different rapid antigen testing strategies for SARS-CoV-2: A living rapid review. Eur J Clin Invest 2023; 53:e14058. [PMID: 37424144 DOI: 10.1111/eci.14058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Rapid antigen detection tests (RADTs) for SARS-CoV-2 testing offer several advantages over molecular tests, but there is little evidence supporting an ideal testing algorithm. We aimed to examine the diagnostic test accuracy (DTA) and the effectiveness of different RADT SARS-CoV-2 testing strategies. METHODS Following PRISMA DTA guidance, we carried out a living rapid review and meta-analysis. Searches were conducted in Ovid MEDLINE® ALL, Embase and Cochrane CENTRAL electronic databases until February 2022. Results were visualized using forest plots and included in random-effects univariate meta-analyses, where eligible. RESULTS After screening 8010 records, 18 studies were included. Only one study provided data on incidence outcomes. Seventeen studies were DTA reports with direct comparisons of RADT strategies, using RT-PCR as the reference standard. Testing settings varied, corresponding to original SARS-CoV-2 or early variants. Strategies included differences in serial testing, the individual collecting swabs and swab sample locations. Overall, specificity remained high (>98%) across strategies. Although results were heterogeneous, the sensitivity for healthcare worker-collected samples was greater than for self-collected samples. Nasal samples had comparable sensitivity when compared to paired RADTs with nasopharyngeal samples, but sensitivity was much lower for saliva samples. The limited evidence for serial testing suggested higher sensitivity if RADTs were administered every 3 days compared to less frequent testing. CONCLUSIONS Additional high-quality research is needed to confirm our findings; all studies were judged to be at risk of bias, with significant heterogeneity in sensitivity estimates. Evaluations of testing algorithms in real-world settings are recommended, especially for transmission and incidence outcomes.
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Affiliation(s)
- Nicole Shaver
- Knowledge Synthesis and Application Unit, Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexandria Bennett
- Knowledge Synthesis and Application Unit, Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew Beck
- Knowledge Synthesis and Application Unit, Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Niyati Vyas
- Knowledge Synthesis and Application Unit, Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Eric Lam
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Barbara Whelan
- Evidence Synthesis Ireland & Cochrane Ireland, School of Nursing and Midwifery, University of Galway, Galway, Ireland
| | - Rhea O'Regan
- Evidence Synthesis Ireland & Cochrane Ireland, School of Nursing and Midwifery, University of Galway, Galway, Ireland
| | - Aileen Conway
- Evidence Synthesis Ireland & Cochrane Ireland, School of Nursing and Midwifery, University of Galway, Galway, Ireland
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | - David Moher
- Knowledge Synthesis and Application Unit, Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Julian Little
- Knowledge Synthesis and Application Unit, Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Viloria Winnett A, Akana R, Shelby N, Davich H, Caldera S, Yamada T, Reyna JRB, Romano AE, Carter AM, Kim MK, Thomson M, Tognazzini C, Feaster M, Goh YY, Chew YC, Ismagilov RF. Daily SARS-CoV-2 Nasal Antigen Tests Miss Infected and Presumably Infectious People Due to Viral Load Differences among Specimen Types. Microbiol Spectr 2023; 11:e0129523. [PMID: 37314333 PMCID: PMC10434058 DOI: 10.1128/spectrum.01295-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/21/2023] [Indexed: 06/15/2023] Open
Abstract
In a recent household transmission study of SARS-CoV-2, we found extreme differences in SARS-CoV-2 viral loads among paired saliva, anterior nares swab (ANS), and oropharyngeal swab specimens collected from the same time point. We hypothesized these differences may hinder low-analytical-sensitivity assays (including antigen rapid diagnostic tests [Ag-RDTs]) by using a single specimen type (e.g., ANS) from reliably detecting infected and infectious individuals. We evaluated daily at-home ANS Ag-RDTs (Quidel QuickVue) in a cross-sectional analysis of 228 individuals and a longitudinal analysis (throughout infection) of 17 individuals enrolled early in the course of infection. Ag-RDT results were compared to reverse transcription-quantitative PCR (RT-qPCR) results and high, presumably infectious viral loads (in each, or any, specimen type). The ANS Ag-RDT correctly detected only 44% of time points from infected individuals on cross-sectional analysis, and this population had an inferred limit of detection of 7.6 × 106 copies/mL. From the longitudinal cohort, daily Ag-RDT clinical sensitivity was very low (<3%) during the early, preinfectious period of the infection. Further, the Ag-RDT detected ≤63% of presumably infectious time points. The poor observed clinical sensitivity of the Ag-RDT was similar to what was predicted based on quantitative ANS viral loads and the inferred limit of detection of the ANS Ag-RDT being evaluated, indicating high-quality self-sampling. Nasal Ag-RDTs, even when used daily, can miss individuals infected with the Omicron variant and even those presumably infectious. Evaluations of Ag-RDTs for detection of infected or infectious individuals should be compared with a composite (multispecimen) infection status to correctly assess performance. IMPORTANCE We reveal three findings from a longitudinal study of daily nasal antigen rapid diagnostic test (Ag-RDT) evaluated against SARS-CoV-2 viral load quantification in three specimen types (saliva, nasal swab, and throat swab) in participants enrolled at the incidence of infection. First, the evaluated Ag-RDT showed low (44%) clinical sensitivity for detecting infected persons at all infection stages. Second, the Ag-RDT poorly detected (≤63%) time points that participants had high and presumably infectious viral loads in at least one specimen type. This poor clinical sensitivity to detect infectious individuals is inconsistent with the commonly held view that daily Ag-RDTs have near-perfect detection of infectious individuals. Third, use of a combination nasal-throat specimen type was inferred by viral loads to significantly improve Ag-RDT performance to detect infectious individuals.
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Affiliation(s)
| | - Reid Akana
- California Institute of Technology, Pasadena, California, USA
| | - Natasha Shelby
- California Institute of Technology, Pasadena, California, USA
| | - Hannah Davich
- California Institute of Technology, Pasadena, California, USA
| | - Saharai Caldera
- California Institute of Technology, Pasadena, California, USA
| | - Taikun Yamada
- Pangea Laboratory LLC, Tustin, California, USA
- Zymo Research Corporation, Irvine, California, USA
| | | | - Anna E. Romano
- California Institute of Technology, Pasadena, California, USA
| | | | - Mi Kyung Kim
- California Institute of Technology, Pasadena, California, USA
| | - Matt Thomson
- California Institute of Technology, Pasadena, California, USA
| | | | - Matthew Feaster
- Pasadena Public Health Department, Pasadena, California, USA
| | - Ying-Ying Goh
- Pasadena Public Health Department, Pasadena, California, USA
| | - Yap Ching Chew
- Pangea Laboratory LLC, Tustin, California, USA
- Zymo Research Corporation, Irvine, California, USA
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3
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Labhardt ND, González Fernández L, Katende B, Muhairwe J, Bresser M, Amstutz A, Glass TR, Ruhwald M, Sacks JA, Escadafal C, Mareka M, Mooko SM, de Vos M, Reither K. Head-to-head comparison of nasal and nasopharyngeal sampling using SARS-CoV-2 rapid antigen testing in Lesotho. PLoS One 2023; 18:e0278653. [PMID: 36862684 PMCID: PMC9980827 DOI: 10.1371/journal.pone.0278653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/21/2022] [Indexed: 03/03/2023] Open
Abstract
OBJECTIVES To assess the real-world diagnostic performance of nasal and nasopharyngeal swabs for SD Biosensor STANDARD Q COVID-19 Antigen Rapid Diagnostic Test (Ag-RDT). METHODS Individuals ≥5 years with COVID-19 compatible symptoms or history of exposure to SARS-CoV-2 presenting at hospitals in Lesotho received two nasopharyngeal and one nasal swab. Ag-RDT from nasal and nasopharyngeal swabs were performed as point-of-care on site, the second nasopharyngeal swab used for polymerase chain reaction (PCR) as the reference standard. RESULTS Out of 2198 participants enrolled, 2131 had a valid PCR result (61% female, median age 41 years, 8% children), 84.5% were symptomatic. Overall PCR positivity rate was 5.8%. The sensitivity for nasopharyngeal, nasal, and combined nasal and nasopharyngeal Ag-RDT result was 70.2% (95%CI: 61.3-78.0), 67.3% (57.3-76.3) and 74.4% (65.5-82.0), respectively. The respective specificity was 97.9% (97.1-98.4), 97.9% (97.2-98.5) and 97.5% (96.7-98.2). For both sampling modalities, sensitivity was higher in participants with symptom duration ≤ 3days versus ≤ 7days. Agreement between nasal and nasopharyngeal Ag-RDT was 99.4%. CONCLUSIONS The STANDARD Q Ag-RDT showed high specificity. Sensitivity was, however, below the WHO recommended minimum requirement of ≥ 80%. The high agreement between nasal and nasopharyngeal sampling suggests that for Ag-RDT nasal sampling is a good alternative to nasopharyngeal sampling.
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Affiliation(s)
- Niklaus D. Labhardt
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- * E-mail:
| | - Lucia González Fernández
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- SolidarMed, Partnerships for Health, Lucerne, Switzerland
| | | | | | - Moniek Bresser
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Alain Amstutz
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Tracy R. Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Morten Ruhwald
- FIND, The Global Alliance for Diagnostics, Geneva, Switzerland
| | - Jilian A. Sacks
- FIND, The Global Alliance for Diagnostics, Geneva, Switzerland
| | | | - Mathabo Mareka
- National Reference Laboratory, Ministry of Health of Lesotho, Maseru, Lesotho
| | - Sekhele M. Mooko
- National Reference Laboratory, Ministry of Health of Lesotho, Maseru, Lesotho
| | | | - Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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4
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Viloria Winnett A, Akana R, Shelby N, Davich H, Caldera S, Yamada T, Reyna JRB, Romano AE, Carter AM, Kim MK, Thomson M, Tognazzini C, Feaster M, Goh YY, Chew YC, Ismagilov RF. Extreme differences in SARS-CoV-2 viral loads among respiratory specimen types during presumed pre-infectious and infectious periods. PNAS NEXUS 2023; 2:pgad033. [PMID: 36926220 PMCID: PMC10013338 DOI: 10.1093/pnasnexus/pgad033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 03/16/2023]
Abstract
SARS-CoV-2 viral-load measurements from a single-specimen type are used to establish diagnostic strategies, interpret clinical-trial results for vaccines and therapeutics, model viral transmission, and understand virus-host interactions. However, measurements from a single-specimen type are implicitly assumed to be representative of other specimen types. We quantified viral-load timecourses from individuals who began daily self-sampling of saliva, anterior-nares (nasal), and oropharyngeal (throat) swabs before or at the incidence of infection with the Omicron variant. Viral loads in different specimen types from the same person at the same timepoint exhibited extreme differences, up to 109 copies/mL. These differences were not due to variation in sample self-collection, which was consistent. For most individuals, longitudinal viral-load timecourses in different specimen types did not correlate. Throat-swab and saliva viral loads began to rise as many as 7 days earlier than nasal-swab viral loads in most individuals, leading to very low clinical sensitivity of nasal swabs during the first days of infection. Individuals frequently exhibited presumably infectious viral loads in one specimen type while viral loads were low or undetectable in other specimen types. Therefore, defining an individual as infectious based on assessment of a single-specimen type underestimates the infectious period, and overestimates the ability of that specimen type to detect infectious individuals. For diagnostic COVID-19 testing, these three single-specimen types have low clinical sensitivity, whereas a combined throat-nasal swab, and assays with high analytical sensitivity, was inferred to have significantly better clinical sensitivity to detect presumed pre-infectious and infectious individuals.
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Affiliation(s)
| | - Reid Akana
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Natasha Shelby
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Hannah Davich
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Saharai Caldera
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Taikun Yamada
- Pangea Laboratory LLC, 14762 Bentley Cir, Tustin, CA 92780, USA.,Zymo Research Corp., 17062 Murphy Ave, Irvine, CA 92614, USA
| | | | - Anna E Romano
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Alyssa M Carter
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Mi Kyung Kim
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Matt Thomson
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
| | - Colten Tognazzini
- Pasadena Public Health Department, 1845 N. Fair Oaks Ave, Pasadena, CA 91103, USA
| | - Matthew Feaster
- Pasadena Public Health Department, 1845 N. Fair Oaks Ave, Pasadena, CA 91103, USA
| | - Ying-Ying Goh
- Pasadena Public Health Department, 1845 N. Fair Oaks Ave, Pasadena, CA 91103, USA
| | - Yap Ching Chew
- Pangea Laboratory LLC, 14762 Bentley Cir, Tustin, CA 92780, USA.,Zymo Research Corp., 17062 Murphy Ave, Irvine, CA 92614, USA
| | - Rustem F Ismagilov
- California Institute of Technology, 1200 E. California Blvd, Pasadena, CA 91125, USA
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5
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Savage HR, Finch L, Body R, Watkins RL, Hayward G, Cook E, Cubas-Atienzar AI, Cuevas LE, MacPherson P, Adams ER. A prospective diagnostic evaluation of accuracy of self-taken and healthcare worker-taken swabs for rapid COVID-19 testing. PLoS One 2022; 17:e0270715. [PMID: 35771760 PMCID: PMC9246218 DOI: 10.1371/journal.pone.0270715] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Rapid diagnostic tests (RDTs) developed for point of care detection of SARS-CoV-2 antigen are recommended by WHO to use trained health care workers to collect samples. We hypothesised that self-taken samples are non-inferior for use with RDTs to diagnose COVID-19. We designed a prospective diagnostic evaluation comparing self-taken and healthcare worker (HCW)-taken throat/nasal swabs to perform RDTs for SARS-CoV-2, and how these compare to RT-PCR. METHODS Eligible participants 18 years or older with symptoms of COVID-19. 250 participants recruited at the NHS Test and Trace drive-through community PCR testing site (Liverpool, UK); one withdrew before analysis. Self-administered throat/nasal swab for the Covios® RDT, a trained HCW taken throat/nasal sample for PCR and HCW comparison throat/nasal swab for RDT were collected. RDT results were compared to RT-PCR, as the reference standard, to calculate sensitivity and specificity. FINDINGS Seventy-five participants (75/249, 30.1%) were positive by RT-PCR. RDTs with self-taken swabs had a sensitivity of 90.5% (67/74, 95% CI: 83.9-97.2), compared to 78.4% (58/74, 95% CI: 69.0-87.8) for HCW-taken swabs (absolute difference 12.2%, 95% CI: 4.7-19.6, p = 0.003). Specificity for self-taken swabs was 99.4% (173/174, 95% CI: 98.3-100.0), versus 98.9% (172/174, 95% CI: 97.3-100.0) for HCW-taken swabs (absolute difference 0.6%, 95% CI: 0.5-1.7, p = 0.317). The PPV of self-taken RDTs (98.5%, 67/68, 95% CI: 95.7-100.0) and HCW-taken RDTs (96.7%, 58/60, 95% CI 92.1-100.0) were not significantly different (p = 0.262). However, the NPV of self-taken swab RDTs was significantly higher (96.1%, 173/180, 95% CI: 93.2-98.9) than HCW-taken RDTs (91.5%, 172/188, 95% CI 87.5-95.5, p = 0.003). INTERPRETATION In conclusion, self-taken swabs for COVID-19 testing offer an accurate alternative to healthcare worker taken swabs for use with RDTs. Our results demonstrate that, with no training, self-taken throat/nasal samples can be used by lay individuals as part of rapid testing programmes for symptomatic adults. This is especially important where the lack of trained healthcare workers restricts access to testing.
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Affiliation(s)
- Helen R. Savage
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
| | - Lorna Finch
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
| | - Richard Body
- Manchester University NHS Foundation Trust, Research and Innovation, Manchester, United Kingdom
| | - Rachel L. Watkins
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
| | - LSTM Diagnostics group
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
| | - CONDOR steering group
- Manchester University NHS Foundation Trust, Research and Innovation, Manchester, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Eloïse Cook
- Manchester University NHS Foundation Trust, Research and Innovation, Manchester, United Kingdom
| | - Ana I. Cubas-Atienzar
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
| | - Luis E. Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
| | - Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emily R. Adams
- Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine and Hygiene, Liverpool, United Kingdom
- * E-mail:
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Immergluck K, Gonzalez MD, Frediani JK, Levy JM, Figueroa J, Wood A, Rogers BB, O'Neal J, Elias-Marcellin R, Suessmith A, Sullivan J, Schinazi RF, Babiker A, Piantadosi A, Vos MB, Martin GS, Lam WA, Waggoner JJ. Correlation of SARS-CoV-2 Subgenomic RNA with Antigen Detection in Nasal Midturbinate Swab Specimens. Emerg Infect Dis 2021; 27:2887-2891. [PMID: 34424838 PMCID: PMC8544990 DOI: 10.3201/eid2711.211135] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Among symptomatic outpatients, subgenomic RNA of severe acute respiratory syndrome coronavirus 2 in nasal midturbinate swab specimens was concordant with antigen detection but remained detectable in 13 (82.1%) of 16 nasopharyngeal swab specimens from antigen-negative persons. Subgenomic RNA in midturbinate swab specimens might be useful for routine diagnostics to identify active virus replication.
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