American Journal of Emergency Medicine 40 (2021) 217-219

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COVID-19 laboratory testing issues and capacities as we transition to surveillance testing and contact tracing

As of May 19, 2020, 11,834,508 COVID-19 tests have been performed in the US resulting in 1,523,534 (12.9%) confirmed cases [1]. The actual number of infected Americans is much larger. Antibody seroprevalence testing in Los Angeles County , California, estimates those infected around 4.65% implying actual infection is about 43-fold larger than con- firmed cases [2]. Another study concluded that undiagnosed COVID cases represent the infection source of 79% of documented cases [3]. Ac- curate testing will be crucial to controlling and understanding this pan- demic. Estimation relies on testing kit accuracy (sensitivity/specificity). Low sensitivity will underestimate disease prevalence, while low spec- ificity will overestimate [2].

Testing comes in two broad types, testing for nasopharyngeal viral RNA and Serologic testing for antibodies, which occur in response to the disease. RNA testing is done with Polymerase chain reaction is cost-effective, easy to perform, and now available [4]. However, the PCR test has accuracy issues. Sensitivity of FDA-approved viral RNA tests range from 63%-95% (Table 1) [5-8]. Sensitivity of RNA tests is de- pendent on the site of specimen collection. Sensitivity was highest in bronchioalveolar lavage (93%), then sputum (73%), nasal swab (63%), feces (29%) and blood (1%) [5]. Another study found that patients with pneumonia often have negative nasopharyngeal samples, but pos- itive lower airway samples [9]. The sensitivity of PCR tests have been es- timated at 71%, resulting in ~30% of infected patients having a negative finding. Another drawback is the presence of viral RNA does not mean the virus is live, therefore, detection does not necessarily mean the virus can be transmitted [9]. RNA-based tests are limited to the setting of acute illness. Saliva-based tests offer promising results as a non- invasive and non-aerosol generating method of specimen collection [10]. Compared to nasopharyngeal tests, saliva specimens have high sensitivity (84.2% [10]) and can be self-administered [10]. Another study reported that SARS-CoV-2 viral load in posterior oropharyngeal saliva samples was higher at initial presentation of COVID-19 symptom- atic patients, increased with age, presence of comorbidities, and severity of the COVID-19 disease [11]. Reduced variability in samples taken from self-administered tests is helpful for mass testing because it preserves collection reliability and allows patients to send in their own samples from the comfort of their home.

The second type of test is serologic, which detects immunoglobulins (IgG and IgM) specific for SARS-CoV-2 and provides an estimation of population virus exposure [4]. One drawback of serologic testing is the lag period between symptoms and antibody formation-one analysis found patients do not begin to seroconvert until 11-12 days post- symptom onset [12].The sensitivity and specificity of FDA-approved se- rologic tests ranges from 61.1%-98% and 90%-100% [13]. Many FDA-

approved serologic tests have high sensitivity and specificity. For exam- ple, Cellex Inc. developed a rapid diagnostic test with 93.8% sensitivity and 95.6% specificity. Bio-Rad manufactured an ELISA test with sensitiv- ity and specificity of 98% and 99%, respectively (Table 1) [13].

There are also clinical associations with confirmed COVID-19 pa- tients. An analysis of 119 patients with COVID-19 at from Wuhan University revealed an association with low urine specific gravity and increased pH [14]. In addition, the urine glucose and proteinuria correlated with severe/critical cases compared to mild/moderate [4]. The results imply that certain urinalysis profiles can be used to predict the Severity of disease and possibly testing of asymptomatic patients that could be quarantined until a definitive test can be com- pleted [14].

To address the development of a reliable test, the Department of Health & Human Services (HHS) provided funding for the develop- ment of Simplexa COVID-19 Direct Assay and to QIAGEN to acceler- ate development of their RPS2 test [15]. Additionally, HHS is purchasing the ID NOW COVID-19 rapid Point-of-care test (Abbott Diagnostics Scarborough Inc.) for public health labs (Table 1) [16]. The FDA is issuing Emergency Use Authorizations to expedite dis- tribution [17]. States have differing amounts of laboratories autho- rized for testing (Fig. 1). The targeted distribution of tests to areas of high density (Fig. 1-black diamonds) is paramount to ensure that resources are not undersupplied.

The road back to normalcy is contingent on accurate tests, allowing suppression of spread. When a localized outbreak occurs, it will be im- portant to have reliable testing methods to promptly contain it. Random serologic testing can be used to surveil populations at high-risk for an outbreak. PCR tests can be used to assess those with active infection who may be asymptomatic.

Targeted distribution of tests needs to be to areas where COVID is more prevalent and where people are at higher risk. In addition to dis- tribution, the quality of the tests requires improvement. Many prospec- tive tests in development report promising results in under 60 min, such as Mammoth Bioscience’s CRISPR-based lateral flow assay (sensitiv- ity:90%, specificity:100%) and United Biomedical’s kit (sensitivity:100%, specificity:100%) (Table 1) [13,18].

In the present era, technology allows diagnostics to be readily available. Understanding the current disease state in communities’ plays a role in the acceptance of control measures that require indi- vidual actions. Now is the time to ensure systematic and coordi- nated efforts between the clinical, commercial and public sectors to leverage the power of testing to address the pandemic at our door.

Brendon Sen-Crowe

Department of Surgery, Division of Trauma and Surgical Critical Care,

Kendall Regional Medical Center, Miami, FL, USA

Mark McKenney, MD, MBA

Department of Surgery, Division of Trauma and Surgical Critical Care,

Kendall Regional Medical Center, Miami, FL, USA University of South Florida, Tampa, FL, USA

https://doi.org/10.1016/j.ajem.2020.05.071

0735-6757/(C) 2020

218 COVID-19 laboratory testing issues and capacities as we transition to surveillance testing and contact tracing

Table 1

Overview of COVID-19 FDA approved/non-FDA approved Diagnostic tests.

COVID-19 diagnostic tests

Authors/company Country Type of test Sensitivity & specificity Development phase Tests approved for use in the United States

Cellex Inc. US/China Rapid Diagnostic Test Sensitivity: 93.8%

Specificity: 95.6%

Diasorin Inc. USA ELISA Sensitivity: 90-97% Specificity: 98%

Bio-Rad USA Modified ELISA Sensitivity: 98% Specificity: 99%

Approved by FDA for EUA; CE approval Approved by FDA for EUA Received EUA

Roche US/Switzerland Electro-chemiluminescence immunoassay (ECLIA)

Sensitivity: 65-100% Specificity: 99.81%

Received EUA, available for purchase by healthcare professionals and researchers.

Euroimmun AG Germany ELISA Sensitivity: 61.1-90%

Specificity:100%

Received EUA, available for purchase by healthcare professionals and

researchers.

Diacarta US Quantifier SARS-CoV-2 Multiplex Test Kit

InBios US Smart Detec SARS-CoV-2 rRT-PCR Kit

Gnomegan US COVID-19 RT-Digital PCR Detection Kit

Simplexa COVID-19 Direct US COVID-19 RT-Digital PCR Detection Kit

QIASTAT-DX US COVID-19 RT-Digital PCR

Detection Kit

Tests approved for diagnostic use in other countries

Sensitivity: 95% Specificity: 100% Sensitivity: 100% Specificity: 96.7% Sensitivity: 100% Specificity: 100% Sensitivity: 100% Specificity: 100% Sensitivity: 85.1-98.1 Specificity: 99.2-100

EUA EUA EUA EUA EUA

Aytu Biosciences/Orient Gene Biotech

US/China RDT, solid phase immunochromatographic assay

Sensitivity: 87.9% (IgM) and 97.2% (IgG) Specificity: 100% for IgM and IgG

CE approved, used in China in clinical settings, awaiting FDA approval

ScanWell Health/INNOVITA US/China Proprietary Sensitivity: 87.3% Specificity: 100%

Cleared by China’s National Medical Products Administration (NMPA), and pending approval by US FDA

Quotient Switzerland MIRA - Multiplexed Immuno-Refractive Assay

Liming Bio China RDT (colloidal gold lateral flow assay)

Sensitivity: 100% Specificity: 99.8% Sensitivity: 62% (IgM) Specificity: 100% (IgM)

Currently available in Europe CE/IVD

Tests in development Broughton et al.

(Mammoth Biosciences)

United Biomedical (UBI)/c19

US CRISPR-based lateral flow assay Sensitivity: 90% Specificity: 100%

US Proprietary Sensitivity: 100% Specificity: 100%

Pre-clinical

In testing in San Miguel, CO

Coris Bioconcept Belgium Dipstick (lateral flow assay) Sensitivity: 60%

Specificity: 99%

Ma et al. China Chemiluminescent immunoassay Sensitivity: 98.6% Specificity: 92.3-99.8%

Clinically testing Pre-clinical

Fig. 1. COVID-19 laboratory facilities across the United States (US). Areas of the US with a high density of testing centers are labeled with a diamond, whereas areas with a low density of testing centers are marked by asterisks.

*Source: COVID-19 Testing Sites Locator. Arcgis. https://www.arcgis.com/apps/webappviewer/index.html?id=2ec47819f57c40598a4eaf45bf9e0d16

COVID-19 laboratory testing issues and capacities as we transition to surveillance testing and contact tracing 219

Adel Elkbuli, MD, MPH

Department of Surgery, Division of Trauma and Surgical Critical Care,

Kendall Regional Medical Center, Miami, FL, USA

?Corresponding author at: 11750 Bird Road, Miami, FL 33175, USA.

E-mail address: [email protected].

21 April 2020

https://doi.org/10.1016/j.ajem.2020.05.071

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