Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection
- PMID: 33760236
- PMCID: PMC8078597
- DOI: 10.1002/14651858.CD013705.pub2
Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection
Update in
-
Rapid, point-of-care antigen tests for diagnosis of SARS-CoV-2 infection.Cochrane Database Syst Rev. 2022 Jul 22;7(7):CD013705. doi: 10.1002/14651858.CD013705.pub3. Cochrane Database Syst Rev. 2022. PMID: 35866452 Free PMC article.
Abstract
Background: Accurate rapid diagnostic tests for SARS-CoV-2 infection could contribute to clinical and public health strategies to manage the COVID-19 pandemic. Point-of-care antigen and molecular tests to detect current infection could increase access to testing and early confirmation of cases, and expediate clinical and public health management decisions that may reduce transmission.
Objectives: To assess the diagnostic accuracy of point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection. We consider accuracy separately in symptomatic and asymptomatic population groups.
Search methods: Electronic searches of the Cochrane COVID-19 Study Register and the COVID-19 Living Evidence Database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) were undertaken on 30 Sept 2020. We checked repositories of COVID-19 publications and included independent evaluations from national reference laboratories, the Foundation for Innovative New Diagnostics and the Diagnostics Global Health website to 16 Nov 2020. We did not apply language restrictions.
Selection criteria: We included studies of people with either suspected SARS-CoV-2 infection, known SARS-CoV-2 infection or known absence of infection, or those who were being screened for infection. We included test accuracy studies of any design that evaluated commercially produced, rapid antigen or molecular tests suitable for a point-of-care setting (minimal equipment, sample preparation, and biosafety requirements, with results within two hours of sample collection). We included all reference standards that define the presence or absence of SARS-CoV-2 (including reverse transcription polymerase chain reaction (RT-PCR) tests and established diagnostic criteria).
Data collection and analysis: Studies were screened independently in duplicate with disagreements resolved by discussion with a third author. Study characteristics were extracted by one author and checked by a second; extraction of study results and assessments of risk of bias and applicability (made using the QUADAS-2 tool) were undertaken independently in duplicate. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and pooled data using the bivariate model separately for antigen and molecular-based tests. We tabulated results by test manufacturer and compliance with manufacturer instructions for use and according to symptom status.
Main results: Seventy-eight study cohorts were included (described in 64 study reports, including 20 pre-prints), reporting results for 24,087 samples (7,415 with confirmed SARS-CoV-2). Studies were mainly from Europe (n = 39) or North America (n = 20), and evaluated 16 antigen and five molecular assays. We considered risk of bias to be high in 29 (50%) studies because of participant selection; in 66 (85%) because of weaknesses in the reference standard for absence of infection; and in 29 (45%) for participant flow and timing. Studies of antigen tests were of a higher methodological quality compared to studies of molecular tests, particularly regarding the risk of bias for participant selection and the index test. Characteristics of participants in 35 (45%) studies differed from those in whom the test was intended to be used and the delivery of the index test in 39 (50%) studies differed from the way in which the test was intended to be used. Nearly all studies (97%) defined the presence or absence of SARS-CoV-2 based on a single RT-PCR result, and none included participants meeting case definitions for probable COVID-19. Antigen tests Forty-eight studies reported 58 evaluations of antigen tests. Estimates of sensitivity varied considerably between studies. There were differences between symptomatic (72.0%, 95% CI 63.7% to 79.0%; 37 evaluations; 15530 samples, 4410 cases) and asymptomatic participants (58.1%, 95% CI 40.2% to 74.1%; 12 evaluations; 1581 samples, 295 cases). Average sensitivity was higher in the first week after symptom onset (78.3%, 95% CI 71.1% to 84.1%; 26 evaluations; 5769 samples, 2320 cases) than in the second week of symptoms (51.0%, 95% CI 40.8% to 61.0%; 22 evaluations; 935 samples, 692 cases). Sensitivity was high in those with cycle threshold (Ct) values on PCR ≤25 (94.5%, 95% CI 91.0% to 96.7%; 36 evaluations; 2613 cases) compared to those with Ct values >25 (40.7%, 95% CI 31.8% to 50.3%; 36 evaluations; 2632 cases). Sensitivity varied between brands. Using data from instructions for use (IFU) compliant evaluations in symptomatic participants, summary sensitivities ranged from 34.1% (95% CI 29.7% to 38.8%; Coris Bioconcept) to 88.1% (95% CI 84.2% to 91.1%; SD Biosensor STANDARD Q). Average specificities were high in symptomatic and asymptomatic participants, and for most brands (overall summary specificity 99.6%, 95% CI 99.0% to 99.8%). At 5% prevalence using data for the most sensitive assays in symptomatic people (SD Biosensor STANDARD Q and Abbott Panbio), positive predictive values (PPVs) of 84% to 90% mean that between 1 in 10 and 1 in 6 positive results will be a false positive, and between 1 in 4 and 1 in 8 cases will be missed. At 0.5% prevalence applying the same tests in asymptomatic people would result in PPVs of 11% to 28% meaning that between 7 in 10 and 9 in 10 positive results will be false positives, and between 1 in 2 and 1 in 3 cases will be missed. No studies assessed the accuracy of repeated lateral flow testing or self-testing. Rapid molecular assays Thirty studies reported 33 evaluations of five different rapid molecular tests. Sensitivities varied according to test brand. Most of the data relate to the ID NOW and Xpert Xpress assays. Using data from evaluations following the manufacturer's instructions for use, the average sensitivity of ID NOW was 73.0% (95% CI 66.8% to 78.4%) and average specificity 99.7% (95% CI 98.7% to 99.9%; 4 evaluations; 812 samples, 222 cases). For Xpert Xpress, the average sensitivity was 100% (95% CI 88.1% to 100%) and average specificity 97.2% (95% CI 89.4% to 99.3%; 2 evaluations; 100 samples, 29 cases). Insufficient data were available to investigate the effect of symptom status or time after symptom onset.
Authors' conclusions: Antigen tests vary in sensitivity. In people with signs and symptoms of COVID-19, sensitivities are highest in the first week of illness when viral loads are higher. The assays shown to meet appropriate criteria, such as WHO's priority target product profiles for COVID-19 diagnostics ('acceptable' sensitivity ≥ 80% and specificity ≥ 97%), can be considered as a replacement for laboratory-based RT-PCR when immediate decisions about patient care must be made, or where RT-PCR cannot be delivered in a timely manner. Positive predictive values suggest that confirmatory testing of those with positive results may be considered in low prevalence settings. Due to the variable sensitivity of antigen tests, people who test negative may still be infected. Evidence for testing in asymptomatic cohorts was limited. Test accuracy studies cannot adequately assess the ability of antigen tests to differentiate those who are infectious and require isolation from those who pose no risk, as there is no reference standard for infectiousness. A small number of molecular tests showed high accuracy and may be suitable alternatives to RT-PCR. However, further evaluations of the tests in settings as they are intended to be used are required to fully establish performance in practice. Several important studies in asymptomatic individuals have been reported since the close of our search and will be incorporated at the next update of this review. Comparative studies of antigen tests in their intended use settings and according to test operator (including self-testing) are required.
Copyright © 2021 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.
Conflict of interest statement
Jonathan J Deeks: JD has published or been quoted in opinion pieces in scientific publications, and in the mainstream and social media related to diagnostic testing. JD was the statistician on the Birmingham evaluation of the Innova test which is mentioned in the discussion of the paper. There was no funding for this evaluation of the Innova test. JD is a member of the Royal Statistical Society (RSS) COVID‐19 taskforce steering group, and co‐chair of the RSS Diagnostic Test Advisory Group. He is a consultant adviser to the WHO Essential Diagnostic List. JD receives payment from the BMJ as their Chief Statistical advisor.
Jacqueline Dinnes: none known
Yemisi Takwoingi: none known
Clare Davenport: none known
Mariska MG Leeflang: none known
René Spijker: none known
Lotty Hooft: none known
Ann Van den Bruel: none known
Devy Emperador: is employed by FIND with funding from DFID and KFW. FIND is a global non‐for profit product development partnership and WHO Diagnostic Collaboration Centre. It is FIND’s role to accelerate access to high‐quality diagnostic tools for low‐resource settings and this is achieved by supporting both R&D and access activities for a wide range of diseases, including COVID‐19. FIND has several clinical research projects to evaluate multiple new diagnostic tests against published Target Product Profiles that have been defined through consensus processes. These studies are for diagnostic products developed by private sector companies who provide access to know‐how, equipment/reagents, and contribute through unrestricted donations as per FIND policy and external SAC review.
Sabine Dittrich: is employed by FIND with funding from DFID and Australian Aid. FIND is a global non‐for profit product development partnership and WHO Diagnostic Collaboration Centre. It is FIND’s role to accelerate access to high‐quality diagnostic tools for low‐resource settings and this is achieved by supporting both R&D and access activities for a wide range of diseases, including COVID‐19. FIND has several clinical research projects to evaluate multiple new diagnostic tests against published Target Product Profiles that have been defined through consensus processes. These studies are for diagnostic products developed by private sector companies who provide access to know‐how, equipment/reagents, and contribute through unrestricted donations as per FIND policy and external SAC review.
Ada Adriano: none known
Sophie Beese: none known
Janine Dretzke: none known
Lavinia Ferrante di Ruffano: none known
Isobel Harris: none known
Malcolm Price: none known
Sian Taylor‐Phillips: none known
Sarah Berhane: none known
Jane Cunningham: none known
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Update of
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Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection.Cochrane Database Syst Rev. 2020 Aug 26;8(8):CD013705. doi: 10.1002/14651858.CD013705. Cochrane Database Syst Rev. 2020. Update in: Cochrane Database Syst Rev. 2021 Mar 24;3:CD013705. doi: 10.1002/14651858.CD013705.pub2. PMID: 32845525 Free PMC article. Updated.
References
References to studies included in this review
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Gibani 2020 {published data only}
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Gremmels 2020(a) {published data only}
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Gupta 2020 {published data only}
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Harrington 2020 {published data only}
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Lambert‐Niclot 2020 {published data only}
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Linares 2020 {published data only}
Liotti 2020 {published data only}
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Loeffelholz 2020 {published data only}
Mak 2020 {published data only}
Mertens 2020 {published data only}
Mitchell 2020 {published data only}
Moore 2020 {published data only}
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Nagura‐Ikeda 2020 {published data only}
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Nash 2020 {published data only}
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PHE 2020(a) {published data only}
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PHE 2020(b) {published data only}
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PHE 2020(c) [non‐HCW tested] {published data only}
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PHE 2020(d) [Lab tested] {published data only}
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PHE 2020(e) {published data only}
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Porte 2020a {published data only}
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Porte 2020b [A] {published data only}
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Porte 2020b [B] {published data only}
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- Porte L, Legarraga P, Iruretagoyena M, Vollrath V, Pizarro G, Munita JM, et al. Rapid SARS-CoV-2 antigen detection by immunofluorescence – a new tool to detect infectivity. medRxiv [Preprint] 2020. [DOI: 10.1101/2020.10.04.20206466] - DOI
Rhoads 2020 {published data only}
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Schildgen 2020 [A] {published data only}
Schildgen 2020 [B] {published data only}
Schildgen 2020 [C] {published data only}
Scohy 2020 {published data only}
Shrestha 2020 {published data only}
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Smithgall 2020 [A] {published data only}
Smithgall 2020 [B] {published data only}
SoRelle 2020 {published data only}
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- SoRelle Jeffrey, Mahimmainathan Lenin, McCormick-Baw Clare, Cavuoti Dominick, Lee Franceca, Bararia Anjali, et al. Evaluation of symptomatic patient saliva as a sample type for the Abbott ID NOW COVID-19 assay. medRxiv [Preprint] 2020. [DOI: ]
Stevens 2020 {published data only}
Szymczak 2020 {published data only}
Takeda 2020 {published data only}
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- Takeda Y, Mori M, Omi K. SARS-CoV-2 qRT-PCR Ct value distribution in Japan and possible utility of rapid antigen testing kit. medRxiv [Preprint] 2020. [DOI: 10.1101/2020.06.16.20131243] - DOI
Thwe 2020 {published data only}
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- Thwe PM, Ren P. How many are we missing with ID NOW COVID-19 assay using direct nasopharyngeal swabs? Findings from a mid-sized academic hospital clinical microbiology laboratory. Diagnostic Microbiology and Infectious Disease 2020;98(2):115123. [DOI: 10.1016/j.diagmicrobio.2020.115123] - DOI - PMC - PubMed
Van der Moeren 2020(a) {published data only}
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- Van der Moeren N, Zwart VF, Lodder EB, Van den Bijllaardt W, Van Esch HR, Stohr JJ, et al. Performance evaluation of a SARS-CoV-2 rapid antigen test: test performance in the community in the Netherlands. medRxiv [Preprint] 2020. [DOI: 10.1101/2020.10.19.20215202] - DOI
Van der Moeren 2020(b) {published data only}
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- Van der Moeren N, Zwart VF, Lodder EB, Van den Bijllaardt W, Van Esch HR, Stohr JJ, et al. Performance evaluation of a SARS-CoV-2 rapid antigen test: test performance in the community in the Netherlands. medRxiv [Preprint] 2020. [DOI: 10.1101/2020.10.19.20215202] - DOI
Veyrenche 2020 {published data only}
Weitzel 2020 [A] {published data only}
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- Weitzel T, Legarraga P, Iruretagoyena M, Pizarro G, Vollrath V, Porte L, et al. Comparative evaluation of four rapid SARS-CoV-2 antigen detection tests using universal transport medium. Travel Medicine and Infectious Diseases 2020 Dec 2 [Epub ahead of print]:101942. [DOI: 10.1016/j.tmaid.2020.101942] - DOI - PMC - PubMed
Weitzel 2020 [B] {published data only}
Weitzel 2020 [C] {published data only}
Weitzel 2020 [D] {published data only}
Wolters 2020 {published data only}
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- Wolters F, Van de Bovenkamp J, Van den Bosch B, Van den Brink S, Broeders M, Chung NH, et al. Multi-center evaluation of Cepheid Xpert(R) Xpress SARS-CoV-2 point-of-care test during the SARS-CoV-2 pandemic. Journal of Clinical Virology 2020;128:104426. [DOI: 10.1016/j.jcv.2020.104426] - DOI - PMC - PubMed
Wong 2020 {published data only}
Young 2020 {published data only}
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- Young S, Taylor SN, Cammarata CL, Varnado KG, Roger-Dalbert C, Montano A, et al. Clinical evaluation of BD Veritor SARS-CoV-2 point-of-care test performance compared to PCR-based testing and versus the Sofia 2 SARS Antigen point-of-care test. Journal of Clinical Microbiology 2020. [DOI: 10.1128/JCM.02338-20] - DOI - PMC - PubMed
Zhen 2020 [A] {published data only}
References to studies excluded from this review
Ai 2020 {published data only}
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- Ai JW, Zhang HC, Xu T, Wu J, Zhu M, Yu YQ, et al. Optimizing diagnostic strategy for novel coronavirus pneumonia, a multi-center study in Eastern China. medRxiv [Preprint] 17 February 2020:1-18. [DOI: 10.1101/2020.02.13.20022673] - DOI
Anahtar 2020 {published data only}
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Avetyan 2020 {published data only}
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Bokelmann 2020 {published data only}
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Bull 2020 {published data only}
Bulterys 2020 {published data only}
Callahan 2020a {published data only}
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Callahan 2020b {published data only}
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Chandler‐Brown 2020 {published data only}
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Chen 2020b {published data only}
Chow 2020 {published data only}
CNR 2020 {published data only}
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CNR 2020a {published data only}
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Colson 2020 {published data only}
Comar 2020 {published data only}
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Davda 2020 {published data only}
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Ding 2020b {published data only}
Dohla 2020 {published data only}
Dong 2020 {published data only}
El‐Tholoth 2020 {published data only}
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Farfan 2020 {published data only}
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Fowler 2020 {published data only}
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Francis 2020 {published data only}
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Freire‐Paspuel 2020a {published data only}
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Freire‐Paspuel 2020b {published data only}
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Ganguli 2020 {published data only}
Giamarellos‐Bourboulis 2020 {published data only}
Gonzalez‐Gonzalez 2020a {published data only}
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Gonzalez‐Gonzalez 2020b {published data only}
Grant 2020 {published data only}
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Hass 2020 {published data only}
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Hogan 2020a {published data only}
Howson 2020 {published data only}
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Huang 2020 {published data only}
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James 2020 {published data only}
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Jiang 2020 {published data only}
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Joung 2020 {published data only}
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Joung 2020a {published data only}
Kalikiri 2020 {published data only}
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Kim 2019 {published data only}
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Konrad 2020 {published data only}
Kurstjens 2020 {published data only}
Kyosei 2020 {published data only}
Lalli 2020 {published data only}
Lamb 2020 {published data only}
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Li 2020 {published data only}
Lin 2020 {published data only}
Liotti 2020a {published data only}
Lowe 2020 {published data only}
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Marais 2020 {published data only}
Marzinotto 2020 {published data only}
McCormick‐Baw 2020 {published data only}
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McDonald 2020 {published data only}
McRae 2020 {published data only}
Mei 2020 {published data only}
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Pollock 2020a {published data only}
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Wang 2020b {published data only}
Wang 2020c {published data only}
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WHO 2020e
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- Global surveillance for COVID-19 caused by human infection with COVID-19 virus: interim guidance 20 March 2020. Available from apps.who.int/iris/bitstream/handle/10665/331506/WHO-2019-nCoV-Surveillan... 2020.
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