Abstract
BackgroundAntigen tests for SARS-CoV-2 offer advantages over nucleic acid amplification tests (NAATs, such as RT-PCR), including lower cost and rapid return of results, but show reduced sensitivity. Public health organizations recommend different strategies for utilizing NAATs and antigen tests. We sought to create a framework for the quantitative comparison of these recommended strategies based on their expected performance.MethodsWe utilized a decision analysis approach to simulate the expected outcomes of six testing algorithms analogous to strategies recommended by public health organizations. Each algorithm was simulated 50,000 times in a population of 100,000 persons seeking testing. Primary outcomes were number of missed cases, number of false-positive diagnoses, and total test volumes. Outcome medians and 95% uncertainty ranges (URs) were reported.ResultsAlgorithms that use NAATs to confirm all negative antigen results minimized missed cases but required high NAAT capacity: 92,200 (95% UR: 91,200-93,200) tests (in addition to 100,000 antigen tests) at 10% prevalence. Selective use of NAATs to confirm antigen results when discordant with symptom status (e.g., symptomatic persons with negative antigen results) resulted in the most efficient use of NAATs, with 25 NAATs (95% UR: 13-57) needed to detect one additional case compared to exclusive use of antigen tests.ConclusionsNo single SARS-CoV-2 testing algorithm is likely to be optimal across settings with different levels of prevalence and for all programmatic priorities. This analysis provides a framework for selecting setting-specific strategies to achieve acceptable balances and trade-offs between programmatic priorities and resource constraints.
Highlights
Antigen tests for SARS-CoV-2 offer advantages over nucleic acid amplification tests (NAATs, such as RTPCR), including lower cost and rapid return of results, but show reduced sensitivity
The remaining algorithms in which some but not all negative antigen results are confirmed by NAAT [(C) NAAT Confirmation for Sx/positive antigen result (Ag-pos) & Asx/ Ag-neg and (F) NAAT Confirmation for Asx & Sx/Ag-pos], resulted in intermediate numbers of missed cases
False positive diagnoses were greatest in algorithms in which positive antigen results were not confirmed by NAATs— (B) Ag Only, (D) NAAT Confirmation for Agneg, and (E) Repeat Ag for Ag-neg
Summary
Antigen tests for SARS-CoV-2 offer advantages over nucleic acid amplification tests (NAATs, such as RTPCR), including lower cost and rapid return of results, but show reduced sensitivity. Public health organizations recommend different strategies for utilizing NAATs and antigen tests. The COVID-19 pandemic, caused by the SARS-CoV-2 virus, continues to cause significant morbidity, mortality, and economic hardship worldwide. Salvatore et al BMC Public Health (2022) 22:82 as long turnaround times, which hampers the ability of testing programs to be used to interrupt transmission [4]. Antigen tests offer several advantages over NAATs for SARS-CoV-2 testing programs, including lower costs, point-of-care administration, and rapid return of results. Use of serial antigen testing may provide benefits over NAATs for controlling outbreaks in some settings, such as congregate living facilities [5]. To expand COVID-19 testing availability, the U.S government distributed 150 million antigen tests in 2020 [6]
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