COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

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Diagnosis Moshe M, Daunt A, Flower B, et al. SARS-CoV-2 lateral flow assays for possible use in national covid-19 seroprevalence surveys (React 2): diagnostic accuracy study. BMJ. 2021 Mar 2;372:n423. doi: 10.1136/bmj.n423.

OBJECTIVE: To evaluate the performance of new lateral flow immunoassays (LFIAs) suitable for use in a national coronavirus disease 2019 (covid-19) seroprevalence programme (real time assessment of community transmission 2-React 2).

DESIGN: Diagnostic accuracy study.

SETTING: Laboratory analyses were performed in the United Kingdom at Imperial College, London and university facilities in London. Research clinics for finger prick sampling were run in two affiliated NHS trusts.

PARTICIPANTS: Sensitivity analyses were performed on sera stored from 320 previous participants in the React 2 programme with confirmed previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Specificity analyses were performed on 1000 prepandemic serum samples. 100 new participants with confirmed previous SARS-CoV-2 infection attended study clinics for finger prick testing.

INTERVENTIONS: Laboratory sensitivity and specificity analyses were performed for seven LFIAs on a minimum of 200 serum samples from participants with confirmed SARS-CoV-2 infection and 500 prepandemic serum samples, respectively. Three LFIAs were found to have a laboratory sensitivity superior to the finger prick sensitivity of the LFIA currently used in React 2 seroprevalence studies (84%). These LFIAs were then further evaluated through finger prick testing on participants with confirmed previous SARS-CoV-2 infection: two LFIAs (Surescreen, Panbio) were evaluated in clinics in June-July 2020 and the third LFIA (AbC-19) in September 2020. A spike protein enzyme linked immunoassay and hybrid double antigen binding assay were used as laboratory reference standards.

MAIN OUTCOME MEASURES: The accuracy of LFIAs in detecting immunoglobulin G (IgG) antibodies to SARS-CoV-2 compared with two reference standards.

RESULTS: The sensitivity and specificity of seven new LFIAs that were analysed using sera varied from 69% to 100%, and from 98.6% to 100%, respectively (compared with the two reference standards). Sensitivity on finger prick testing was 77% (95% confidence interval 61.4% to 88.2%) for Panbio, 86% (72.7% to 94.8%) for Surescreen, and 69% (53.8% to 81.3%) for AbC-19 compared with the reference standards. Sensitivity for sera from matched clinical samples performed on AbC-19 was significantly higher with serum than finger prick at 92% (80.0% to 97.7%, P=0.01). Antibody titres varied considerably among cohorts. The numbers of positive samples identified by finger prick in the lowest antibody titre quarter varied among LFIAs.

CONCLUSIONS: One new LFIA was identified with clinical performance suitable for potential inclusion in seroprevalence studies. However, none of the LFIAs tested had clearly superior performance to the LFIA currently used in React 2 seroprevalence surveys, and none showed sufficient sensitivity and specificity to be considered for routine clinical use.

Discipline / Specialty Area Score
Infectious Disease
Public Health
Hospital Doctor/Hospitalists
Internal Medicine
Comments from MORE raters

Public Health rater

An issue is the amount of Sars-CoV-2 material in samples for PCR augmentation. They recommended the Fortress test but queried current clinical use. The authors provide a detailed account of the sensitivity and specificity of finger-prick testing for Covid-19 seroprevalence: "two reference standards, SARS-CoV-2 spike protein enzyme linked immunoassay (S-ELISA) and a hybrid double antigen binding assay (hybrid DABA)—have have high sensitivity and specificity;" "Assessment of LFIA sensitivity used sera from 320 participants from previous positive test for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) on nasopharyngeal swab." "Of the three LFIAs tested two showed a significant difference in sensitivity between serum and finger prick testing in two tests. AbC-19, the best performing test in the laboratory (100% sensitivity, 95% confidence interval 98.1% to 100.0%; and 99.8% specificity, 98.9% to 100.0%), showed the lowest sensitivity (69%, 53.8% to 81.3%)"