Abstract
Knowledge of the sensitivities of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody tests beyond 35 days after the clinical onset of COVID-19 is insufficient. We aimed to describe positivity rate of SARS-CoV-2 assays employing three different measurement principles over a prolonged period. Two hundred sixty-eight samples from 180 symptomatic patients with COVID-19 and a reverse transcription polymerase chain reaction (RT-PCR) test followed by serological investigation of SARS-CoV-2 antibodies were included. We conducted three chemiluminescence (including electrochemiluminescence assay (ECLIA)), four enzyme-linked immunosorbent assay (ELISA), and one lateral flow immunoassay (LFIA) test formats. Positivity rates, as well as positive (PPVs) and negative predictive values (NPVs), were calculated for each week after the first clinical presentation for COVID-19. Furthermore, combinations of tests were assessed within an orthogonal testing approach employing two independent assays and predictive values were calculated. Heat maps were constructed to graphically illustrate operational test characteristics. During a follow-up period of more than 9 weeks, chemiluminescence assays and one ELISA IgG test showed stable positivity rates after the third week. With the exception of ECLIA, the PPVs of the other chemiluminescence assays were ≥95% for COVID-19 only after the second week. ELISA and LFIA had somewhat lower PPVs. IgM exhibited insufficient predictive characteristics. An orthogonal testing approach provided PPVs ≥ 95% for patients with a moderate pretest probability (e.g., symptomatic patients), even for tests with a low single test performance. After the second week, NPVs of all but IgM assays were ≥95% for patients with low to moderate pretest probability. The confirmation of negative results using an orthogonal algorithm with another assay provided lower NPVs than the single assays. When interpreting results from SARS-CoV-2 tests, the pretest probability, time of blood draw, and assay characteristics must be carefully considered. An orthogonal testing approach increases the accuracy of positive, but not negative, predictions.
Highlights
Coronavirus Disease 2019 (COVID-19) is a pandemic that has challenged healthcare systems worldwide [1]
In the lateral flow immunoassay (LFIA), IgM showed an earlier increase in positivity rates than IgG, with IgG and IgM positivity rates peaking at a value of approximately 80% at week 3
The LFIA test format reporting combined reaction of both IgG and IgM showed a positivity rate of approximately 90% at week 3, which decreased to somewhat lower values at week 9
Summary
Coronavirus Disease 2019 (COVID-19) is a pandemic that has challenged healthcare systems worldwide [1]. The disease is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2]. Its diagnosis is based on clinical symptoms and signs, radiological imaging, detection of the virus with reverse transcription polymerase chain reaction (RT-PCR) or antigen testing mainly in respiratory specimens, and serological confirmation of SARS-CoV-2-specific antibodies in serum [3, 4]. Serological testing has increasingly become important to clarify RT-PCR-negative patients with a high clinical suspicion of COVID-19 (“false negatives”) [8]. Serological testing has become important for surveillance and tracing purposes to identify the disease prevalence in a distinct population or identify close contacts of patients with asymptomatic COVID-19 [9]
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