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Jeong IH, Kim JH, Kwon MJ, Kim J, Huh HJ, Kim B, Lee J, Nam JH, Kang ES. Realistic Estimation of COVID-19 Infection by Seroprevalence Surveillance of SARS-CoV-2 Antibodies: An Experience From Korea Metropolitan Area From January to May 2022. J Korean Med Sci 2024; 39:e43. [PMID: 38317445 PMCID: PMC10843975 DOI: 10.3346/jkms.2024.39.e43] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/28/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread globally, leading to the coronavirus disease 2019 (COVID-19) pandemic. Because a significant proportion of the COVID-19 confirmed cases were concentrated in the capital metropolitan area of South Korea, and a large proportion of the population in the area had been adequately vaccinated against COVID-19, we conducted a seroprevalence surveillance study focusing on the residents of the capital metropolitan area in South Korea. METHODS We used a quota-sampling method to obtain blood samples from 1,000 individuals per round, equally stratified across seven age categories and sexes and regions, from five medical institutions located within the capital metropolitan area of South Korea. During five consecutive months (rounds) between January 2022 and May 2022, a total of 5,000 samples were analyzed for anti-spike (S) and anti-nucleocapsid (N) antibodies. RESULTS High anti-S seropositivity was observed in all age groups, which corresponded to the vaccine coverage during the study period. Both the cumulative incidence based on polymerase chain reaction (PCR) and the estimated seroprevalence based on anti-N seropositivity increased in the fourth and fifth rounds, which corresponded to April 2022 and May 2022. Seroprevalence coincided with the cumulative incidence during the first three rounds, but exceeded from the fourth survey onwards when infection with omicron variants was increased rapidly in Korea. CONCLUSION Seroprevalence confirmed the number of infection cases outside of PCR testing-based surveillance. Seroepidemiological surveillance can help us understand vaccine responses and detect hidden infections, thereby providing appropriate public health guidance for achieving population-level immunity.
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Affiliation(s)
- In Hwa Jeong
- Department of Laboratory Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jong-Hun Kim
- Department of Social and Preventive Medicine, Sungkyunkwan University School of Medicine, Suwon, Korea
| | - Min-Jung Kwon
- Department of Laboratory Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jayoung Kim
- Department of Laboratory Medicine, International St. Mary's Hospital, College of Medicine, Catholic Kwandong University, Incheon, Korea
| | - Hee Jin Huh
- Department of Laboratory Medicine, Dongkuk University Medical Center, Goyang, Korea
| | - Byoungguk Kim
- Division of Clinical Vaccine Research, Center for Vaccine Research, National Institute of Infectious Diseases, National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Junewoo Lee
- Division of Clinical Vaccine Research, Center for Vaccine Research, National Institute of Infectious Diseases, National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Jeong-Hyun Nam
- Division of Clinical Vaccine Research, Center for Vaccine Research, National Institute of Infectious Diseases, National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Han A, Min S, Jo EA, Lee H, Kim YC, Han SS, Kang HG, Ahn YH, Oh I, Song EY, Ha J. Association Between Low Anti-spike Antibody Levels After the Third Dose of SARS-CoV-2 Vaccination and Hospitalization due to Symptomatic Breakthrough Infection in Kidney Transplant Recipients. Ann Lab Med 2024; 44:64-73. [PMID: 37665287 PMCID: PMC10485855 DOI: 10.3343/alm.2024.44.1.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/11/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
Background Whether anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody levels post-third coronavirus disease (COVID-19) vaccination correlate with worse outcomes due to breakthrough infection is unclear. We evaluated the association between anti-SARS-CoV-2 antibody levels and symptomatic breakthrough infection or hospitalization during the Omicron surge in kidney transplant recipients. Methods In total, 287 kidney transplant recipients expected to receive a third vaccination were enrolled between November 2021 and February 2022. The Abbott SARS-CoV-2 IgG II Quant test (Abbott, Chicago, IL, USA) was performed within three weeks before and four weeks after the third vaccination. The incidence of symptomatic breakthrough infection and hospitalization from two weeks to four months post-third vaccination was recorded. Results After the third vaccination, the seropositive rate and median antibody titer of the 287 patients increased from 57.1% to 82.2% and from 71.7 (interquartile range [IQR] 7.2-402.8) to 1,612.1 (IQR 153.9-5,489.1) AU/mL, respectively. Sixty-four (22.3%) patients had symptomatic breakthrough infections, of whom 12 required hospitalization. Lower anti-receptor-binding domain (RBD) IgG levels (<400 AU/mL) post-third vaccination were a risk factor for symptomatic breakthrough infection (hazard ratio [HR]=3.46, P<0.001). Anti-RBD IgG levels <200 AU/mL were a critical risk factor for hospitalization (HR=36.4, P=0.007). Conclusions Low anti-spike IgG levels after third vaccination in kidney transplant recipients were associated with symptomatic breakthrough infection and, particularly, with hospitalization during the Omicron surge. These data can be used to identify patients requiring additional protective measures, such as passive immunization using monoclonal antibodies.
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Affiliation(s)
- Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Ah Jo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Inseong Oh
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Young Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kang H, Lee J, Jung J, Oh EJ. Humoral Response Kinetics and Cross-Immunity in Hospitalized Patients with SARS-CoV-2 WT, Delta, or Omicron Infections: A Comparison between Vaccinated and Unvaccinated Cohorts. Vaccines (Basel) 2023; 11:1803. [PMID: 38140207 PMCID: PMC10747008 DOI: 10.3390/vaccines11121803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
With the ongoing evolution of severe acute respiratory virus-2 (SARS-CoV-2), the number of confirmed COVID-19 cases continues to rise. This study aims to investigate the impact of vaccination status, SARS-CoV-2 variants, and disease severity on the humoral immune response, including cross-neutralizing activity, in hospitalized COVID-19 patients. This retrospective cohort study involved 122 symptomatic COVID-19 patients hospitalized in a single center. Patients were categorized based on the causative specific SARS-CoV-2 variants (33 wild-type (WT), 54 Delta and 35 Omicron) and their vaccination history. Sequential samples were collected to assess binding antibody responses (anti-S/RBD and anti-N) and surrogate virus neutralization tests (sVNTs) against WT, Omicron BA.1, and BA.4/5. The vaccinated breakthrough infection group (V) exhibited higher levels of anti-S/RBD compared to the variant-matched unvaccinated groups (UVs). The Delta infection resulted in a more rapid production of anti-S/RBD levels compared to infections with WT or Omicron variants. Unvaccinated severe WT or Delta infections had higher anti-S/RBD levels compared to mild cases, but this was not the case with Omicron infection. In vaccinated patients, there was no difference in antibody levels between mild and severe infections. Both Delta (V) and Omicron (V) groups showed strong cross-neutralizing activity against WT and Omicron (BA.1 and BA.4/5), ranging from 79.3% to 97.0%. WT (UV) and Delta (UV) infections had reduced neutralizing activity against BA.1 (0.8% to 12.0%) and BA.4/5 (32.8% to 41.0%). Interestingly, patients who received vaccines based on the ancestral spike exhibited positive neutralizing activity against BA.4/5, even though none of the study participants had been exposed to BA.4/5 and it is antigenically more advanced. Our findings suggest that a previous vaccination enhanced the humoral immune response and broadened cross-neutralizing activity to SARS-CoV-2 variants in hospitalized COVID-19 patients.
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Affiliation(s)
- Hyunhye Kang
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (H.K.); (J.J.)
- Research and Development Institute for In Vitro Diagnostic Medical Devices, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jihyun Lee
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Jin Jung
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (H.K.); (J.J.)
- Research and Development Institute for In Vitro Diagnostic Medical Devices, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (H.K.); (J.J.)
- Research and Development Institute for In Vitro Diagnostic Medical Devices, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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Yoon S, Lim YK, Kweon OJ, Kim TH, Lee MK. Clinical performance of SARS-CoV-2 antigen-detection rapid diagnostic test using SERS-based lateral flow immunoassay. Heliyon 2023; 9:e19492. [PMID: 37809408 PMCID: PMC10558587 DOI: 10.1016/j.heliyon.2023.e19492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/16/2023] [Accepted: 08/24/2023] [Indexed: 10/10/2023] Open
Abstract
Background 'ACROSIS COVID-19 Ag (NPS)' kit (SG Medical, Seoul, Korea) is a newly developed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigen-detection rapid diagnostic test (Ag-RDT) using surface-enhanced Raman scattering (SERS)-based lateral flow immunoassay (LFIA). We evaluated its clinical performance compared with STANDARD Q COVID-19 Ag (SD Biosensor, Suwon, Korea), a previously approved Ag-RDT. Methods A total of 286 nasopharyngeal swab specimens were collected: 104 positive and 182 negative specimens in SARS-CoV-2 real-time reverse-transcription polymerase-chain-reaction (rRT-PCR). SARS-CoV-2-positive specimens were divided according to the cycle threshold (Ct) value in rRT-PCR. The clinical performance of ACROSIS was compared with that of STANDARD Q. Results ACROSIS showed significantly higher sensitivity than STANDARD Q (92.3% vs. 85.6%, P = 0.02), especially in specimens with 25 ≤ Ct < 30 (78.6% vs. 42.9%). The Ct values of RdRp/S genes for 95% detection rates by ACROSIS and STANDARD Q were 25.8 and 23.0, respectively. Conclusions This is the first study that evaluated the performance of ACROSIS compared with STANDARD Q. The overall clinical performance of ACROSIS was superior to that of STANDARD Q, especially in specimens with 25 ≤ Ct < 30. ACROSIS could be useful for SARS-CoV-2 Ag detection even in relatively low viral load specimens.
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Affiliation(s)
- Sumi Yoon
- Department of Laboratory Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Yong Kwan Lim
- Department of Laboratory Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Oh Joo Kweon
- Department of Laboratory Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Tae-Hyoung Kim
- Department of Urology, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Mi-Kyung Lee
- Department of Laboratory Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
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Baek YH, Park MY, Lim HJ, Youm DJ, You Y, Ahn S, Park JE, Kim MJ, Lee SH, Sohn YH, Yang YJ. Evaluation of Rapid Multiplex Reverse Transcription-Quantitative Polymerase Chain Reaction Assays for SARS-CoV-2 Detection in Individual and Pooled Samples. Life (Basel) 2023; 13:1717. [PMID: 37629574 PMCID: PMC10455980 DOI: 10.3390/life13081717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Although coronavirus disease 2019 (COVID-19) is no longer a Public Health Emergency of International Concern (PHEIC), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has had a vast impact to date. Hence, continuous management is required, given the uncertainty caused by the potential evolution of SARS-CoV-2. Reverse transcription-quantitative PCR (RT-qPCR) diagnosis has been fundamental in overcoming this issue. In this study, the performances of two rapid RT-qPCR assays (Real-Q Direct SARS-CoV-2 Detection Kit and Allplex™ SARS-CoV-2 fast PCR Assay) with short PCR times were comparatively evaluated using a STANDARD M nCoV Real-Time Detection Kit (STANDARD M, conventional RT-qPCR assay). All kits showed a limit of detection values (102-103 copies/reaction). The evaluation showed that the two rapid assay tests had ≥97.89% sensitivity and ≥99.51% specificity (κ = 0.98) for individual samples and ≥97.32% sensitivity and ≥97.67% specificity for pooled samples compared to STANDARD M. These results indicate that the two rapid RT-qPCR kits, which showed significant time reduction in performance, are as effective as a conventional RT-qPCR assay. They are likely to increase not only the number of tests that can be performed but also the efficiency of sustainable management of COVID-19 in the long term.
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Affiliation(s)
- Young-Hyun Baek
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
| | - Min-Young Park
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
| | - Ho-Jae Lim
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
- Department of Integrative Biological Sciences & BK21 FOUR Educational Research Group for Age-Associated Disorder Control Technology, Chosun University, Gwangju 61452, Republic of Korea;
| | - Dong-Jae Youm
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
| | - Youngshin You
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
| | - Seojin Ahn
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
| | - Jung-Eun Park
- Department of Integrative Biological Sciences & BK21 FOUR Educational Research Group for Age-Associated Disorder Control Technology, Chosun University, Gwangju 61452, Republic of Korea;
| | - Min-Jin Kim
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
| | - Sun-Hwa Lee
- Department of Laboratory Medicine, Seegene Medical Foundation, Seoul 04805, Republic of Korea;
| | - Yong-Hak Sohn
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
| | - Yong-Jin Yang
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea; (Y.-H.B.); (M.-Y.P.); (H.-J.L.); (D.-J.Y.); (Y.Y.); (S.A.); (M.-J.K.); (Y.-H.S.)
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Vasei M, Jafari E, Falah Azad V, Safavi M, Sotoudeh M. Molecular Diagnosis of COVID-19; Biosafety and Pre-analytical Recommendations. IRANIAN JOURNAL OF PATHOLOGY 2023; 18:244-256. [PMID: 37942195 PMCID: PMC10628373 DOI: 10.30699/ijp.2023.1988405.3061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/08/2023] [Indexed: 11/10/2023]
Abstract
From the beginning of the COVID-19 epidemic, clinical laboratories around the world have been involved with tests for detection of SARS-CoV-2. At present, RT-PCR (real-time reverse transcription polymerase chain reaction assay) is seen as the gold standard for identifying the virus. Many factors are involved in achieving the highest accuracy in this test, including parameters related to the pre-analysis stage. Having instructions on the type of sample, how to take the sample, and its storage and transportation help control the interfering factors at this stage. Studies have shown that pre-analytical factors might be the cause of the high SARS-CoV-2 test false-negative rates. Also, the safety of personnel in molecular laboratories is of utmost importance, and it requires strict guidelines to ensure the safety of exposed individuals and prevent the virus from spreading. Since the onset of the outbreak, various instructions and guidelines have been developed in this field by the institutions and the Ministry of Health of each country; these guidelines are seriously in need of integration and operation. In this study, we try to collect all the information and research done from the beginning of this pandemic in December 2019 - August 2022 concerning biosafety and protective measures, sample types, sampling methods, container, and storage solutions, sampling equipment, and sample storage and transportation for molecular testing of SARS-CoV-2.
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Affiliation(s)
- Mohammad Vasei
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Cell-BasedTherapies Research Center, Digestive Disease Research Institute, Shari'ati Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Elham Jafari
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Pathology and Stem Cells Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Vahid Falah Azad
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Moeinadin Safavi
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Sotoudeh
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Kim N, Shin S. Laboratory Diagnosis of Monkeypox in South Korea: Continuing the Collaboration With the Public Sector. Ann Lab Med 2023; 43:135-136. [PMID: 36281506 PMCID: PMC9618908 DOI: 10.3343/alm.2023.43.2.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Namhee Kim
- Department of Laboratory Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea,Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sue Shin
- Department of Laboratory Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea,Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea,Corresponding author: Sue Shin, M.D., Ph.D. Department of Laboratory Medicine, SMG-SNU Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea Tel: +82-2-870-2602, Fax: +82-2-870-2630, E-mail:
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Lim HJ, Park MY, Baek YH, Lee HS, Kim I, Kwon Y, You Y, Nam K, Yang JH, Kim MJ, Yu N, Sohn YH, Park JE, Yang YJ. Evaluation of Four Rapid Antigen Tests for the Detection of SARS-CoV-2 Infection with Nasopharyngeal Swabs. Biomedicines 2023; 11:biomedicines11030701. [PMID: 36979680 PMCID: PMC10045780 DOI: 10.3390/biomedicines11030701] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Owing to the high transmissibility of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, the capacity of testing systems based on the gold standard real-time reverse transcription–polymerase chain reaction (rRT-PCR) is limited. Rapid antigen tests (RATs) can substantially contribute to the prevention of community transmission, but their further assessment is required. Here, using 1503 nasopharyngeal swabs, we compared the diagnostic performance of four RAT kits (Abbott Panbio™ COVID-19 Ag Rapid Test, SD Biosensor Standard™ Q COVID-19 Ag Test, Humasis COVID-19 Ag Test, and SG Medical Acrosis COVID-19 Ag Test) to the cycle threshold (Ct) values obtained from rRT-PCR. The precision values, area under the curve values, SARS-CoV-2 variant detection ability, and non-SARS-CoV-2 specificity of all four kits were similar. An assay using the Acrosis kit had a significantly better positive detection rate with a higher recall value and cut-off value than that using the other three RAT kits. During the current COVID-19 pandemic, the Acrosis kit is an effective tool to prevent the spread of SARS-CoV-2 in communities.
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Affiliation(s)
- Ho-Jae Lim
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
- Department of Integrative Biological Sciences & BK21 FOUR Educational Research Group for Age-Associated Disorder Control Technology, Chosun University, Gwangju 61452, Republic of Korea
| | - Min-Young Park
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Young-Hyun Baek
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Hyeon-Seo Lee
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Inhee Kim
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Youngjin Kwon
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Youngshin You
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Kyoungwoo Nam
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Jae-Hyun Yang
- Paul F. Glenn Center for Biology of Aging Research, Department of Genetics, Blavatnik Institute, Harvard Medical School, Boston, MA 02115, USA
| | - Min-Jin Kim
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Nae Yu
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Yong-Hak Sohn
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
| | - Jung-Eun Park
- Department of Integrative Biological Sciences & BK21 FOUR Educational Research Group for Age-Associated Disorder Control Technology, Chosun University, Gwangju 61452, Republic of Korea
- Correspondence: (J.-E.P.); (Y.-J.Y.)
| | - Yong-Jin Yang
- Department of Molecular Diagnostics, Seegene Medical Foundation, Seoul 04805, Republic of Korea
- Correspondence: (J.-E.P.); (Y.-J.Y.)
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Different interpretations of inconclusive results of SARS-CoV-2 real-time RT PCR. Diagn Microbiol Infect Dis 2023; 106:115888. [PMID: 36972653 PMCID: PMC9810550 DOI: 10.1016/j.diagmicrobio.2022.115888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/02/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023]
Abstract
We investigated whether inconclusive results could be interpreted differently depending on the situation. First, data from retesting of the initial samples from subjects without a confirmed COVID-19 history were analyzed. And by analyzing the results of consecutive tests with new specimens after receiving inconclusive results between arrivals and locals for two periods. As a result, 179 of 219 cases (81.7%) showed still inconclusive or weakly positive results. If contamination is well controlled in a general laboratory, the effectiveness of retesting with the same sample is limited. The rate of the subsequently positive patient was significantly higher in locals than in arrivals and periods with a higher positive rate. The inconclusive results could be interpreted differently depending on the epidemiologic background and the positive rate at that time.
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Hong KH, Lee J, Kim SY, Oh Y, Cho HW, Lee H. Comparison of the Clinical Performance of the Point-of-care STANDARD M10 SARS-CoV-2 and Xpert Xpress SARS-CoV-2 Assays. Ann Lab Med 2023; 43:111-113. [PMID: 36045067 PMCID: PMC9467845 DOI: 10.3343/alm.2023.43.1.111] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/13/2022] [Accepted: 05/31/2022] [Indexed: 12/31/2022] Open
Affiliation(s)
- Ki Ho Hong
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jaehyeon Lee
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
| | - So Yeon Kim
- Department of Laboratory Medicine, National Medical Center, Seoul, Korea
| | - Yeseul Oh
- Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Weon Cho
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea,Corresponding author: Hyukmin Lee, M.D. Department of Laboratory Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-2446, Fax: +82-2-313-0956, E-mail:
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Yu K, Song J, Kim D, Park Y, Jeong SH. Clinical Evaluation of Two Rapid Antigen Tests for Severe Acute Respiratory Syndrome Coronavirus 2 Detection. Ann Lab Med 2023; 43:120-123. [PMID: 36045070 PMCID: PMC9467831 DOI: 10.3343/alm.2023.43.1.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/03/2022] [Accepted: 08/11/2022] [Indexed: 12/31/2022] Open
Affiliation(s)
- Kyunghee Yu
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Junhyup Song
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dokyun Kim
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yongjung Park
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Corresponding author: Yongjung Park, M.D., Ph.D. Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel: +82-2-2019-3533, Fax: +82-2-2057-8926, E-mail:
| | - Seok Hoon Jeong
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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12
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Buchta C, Kollros D, Jovanovic J, Huf W, Delatour V, Puchhammer-Stöckl E, Mayerhofer M, Müller MM, Shenoy S, Griesmacher A, Aberle SW, Görzer I, Camp JV. Converting to an international unit system improves harmonization of results for SARS-CoV-2 quantification: Results from multiple external quality assessments. J Clin Virol 2023; 158:105352. [PMID: 36525853 PMCID: PMC9733965 DOI: 10.1016/j.jcv.2022.105352] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The detection of SARS-CoV-2 vRNA in clinical samples has relied almost exclusively on RT-qPCR as the gold standard test. Published results from various external quality assessments ("ring trials") worldwide have shown that there is still a large variability in results reported for the same samples. As reference standards of SARS-CoV-2 RNA are available, we tested whether using standard curves to convert Ct values into copies/mL (cp/mL) improved harmonization. METHODS Nine laboratories using 23 test systems (15 of which were unique) prepared standard dilution curves to convert Ct values of 13 SARS-CoV-2 positive samples to cp/mL (hereafter IU/mL). The samples were provided in three rounds of a virus genome detection external quality assessment (EQA) scheme. We tested the precision and accuracy of results reported in IU/mL, and attempted to identify the sources of variability. RESULTS Reporting results as IU/mL improved the precision of the estimated concentrations of all samples compared to reporting Ct values, although some inaccuracy remained. Variance analysis showed that nearly all variability in data was explained by individual test systems within individual laboratories. When controlling for this effect, there was no significant difference between all other factors tested (test systems, EQA rounds, sample material). CONCLUSIONS Converting results to copies/mL improved precision across laboratory test systems. However, it seems the results are still very specific to test systems within laboratories. Further efforts could be made to improve accuracy and achieve full harmonization across diagnostic laboratories.
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Affiliation(s)
- Christoph Buchta
- Austrian Association for Quality Assurance and Standardization of Medical and Diagnostic Tests (ÖQUASTA), Vienna, Austria
| | - Dominik Kollros
- Austrian Association for Quality Assurance and Standardization of Medical and Diagnostic Tests (ÖQUASTA), Vienna, Austria
| | - Jovana Jovanovic
- Austrian Association for Quality Assurance and Standardization of Medical and Diagnostic Tests (ÖQUASTA), Vienna, Austria
| | - Wolfgang Huf
- Karl Landsteiner Institute for Clinical Risk Management, Vienna, Austria
| | - Vincent Delatour
- Laboratoire National de Métrologie et d'Essais (LNE), Paris, France
| | | | - Maximilian Mayerhofer
- Armament and Defence Technology Agency, NBC & Environmental Protection Technology Division, Vienna, Austria
| | - Mathias M. Müller
- Austrian Association for Quality Assurance and Standardization of Medical and Diagnostic Tests (ÖQUASTA), Vienna, Austria
| | - Santosh Shenoy
- Department of Surgery, Kansas City Veterans Medical Center, University of Missouri at Kansas City, Kansas City, MO, USA
| | - Andrea Griesmacher
- Austrian Association for Quality Assurance and Standardization of Medical and Diagnostic Tests (ÖQUASTA), Vienna, Austria
| | | | - Irene Görzer
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Jeremy V. Camp
- Center for Virology, Medical University of Vienna, Vienna, Austria,Corresponding author at: Center for Virology, Medizinische Universitat Wien, Kinderspitalgasse 15, 1095 Vienna, Austria
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13
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Kim TY, Bae GE, Kim JY, Kang M, Jang JH, Huh HJ, Chung DR, Lee NY. Evaluation of the Kaira COVID-19/Flu/RSV Detection Kit for detection of SARS-CoV-2, influenza A/B, and respiratory syncytial virus: A comparative study with the PowerChek SARS-CoV-2, influenza A&B, RSV Multiplex Real-time PCR Kit. PLoS One 2022; 17:e0278530. [PMID: 36516190 PMCID: PMC9750031 DOI: 10.1371/journal.pone.0278530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/17/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Co-circulation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory viruses, such as influenza and respiratory syncytial virus (RSV), can be a severe threat to public health. The accurate detection and differentiation of these viruses are essential for clinical laboratories. Herein, we comparatively evaluated the performance of the Kaira COVID-19/Flu/RSV Detection Kit (Kaira; Optolane, Seongnam, Korea) for detection of SARS-CoV-2, influenza A and B, and RSV in nasopharyngeal swab (NPS) specimens with that of the PowerChek SARS-CoV-2, Influenza A&B, RSV Multiplex Real-time PCR Kit (PowerChek; Kogene Biotech, Seoul, Korea). METHODS A total of 250 archived NPS specimens collected for routine clinical testing were tested in parallel by the Kaira and PowerChek assays. RNA standards were serially diluted and tested by the Kaira assay to calculate the limit of detection (LOD). RESULTS The positive and negative percent agreements between the Kaira and PowerChek assays were as follows: 100% (49/49) and 100% (201/201) for SARS-CoV-2; 100% (50/50) and 99.0% (198/200) for influenza A; 100% (50/50) and 100% (200/200) for influenza B; and 100% (51/51) and 100% (199/199) for RSV, respectively. The LODs of the Kaira assay for SARS-CoV-2, influenza A and B, and RSV were 106.1, 717.1, 287.3, and 442.9 copies/mL, respectively. CONCLUSIONS The Kaira assay showed comparable performance to the PowerChek assay for detection of SARS-CoV-2, influenza A and B, and RSV in NPS specimens, indicating that the Kaira assay could be a useful diagnostic tool when these viruses are co-circulating.
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Affiliation(s)
- Tae Yeul Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Go Eun Bae
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Youn Kim
- Center for Clinical Medicine, Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, Korea
| | - Minhee Kang
- Biomedical Engineering Research Center, Smart Healthcare Research Institute, Samsung Medical Center, Seoul, Korea
- Department of Medical Device Management and Research, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Korea
| | - Ja-Hyun Jang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Jae Huh
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
| | - Doo Ryeon Chung
- Center for Infection Prevention and Control, Samsung Medical Center, Seoul, Korea
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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14
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Performance Analysis of Self-Collected Nasal and Oral Swabs for Detection of SARS-CoV-2. Diagnostics (Basel) 2022; 12:diagnostics12102279. [PMID: 36291968 PMCID: PMC9600397 DOI: 10.3390/diagnostics12102279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the third highly pathogenic human coronavirus and is rapidly transmitted by infected individuals regardless of their symptoms. During the COVID-19 pandemic, owing to the dearth of skilled healthcare workers (HCWs) to collect samples for early diagnosis, self-collection emerged as a viable alternative. To evaluate the reliability of self-collection, we compared the virus detection rate using 3990 self-collected swabs and HCW-collected swabs, procured from the same individuals and collected immediately after the self-collection. The results of multiplex reverse-transcription quantitative polymerase chain reaction revealed that the viral load in the HCW-collected swabs was marginally (18.4–28.8 times) higher than that in self-collected swabs. Self-collection showed no significant difference in sensitivity and specificity from HCW-collection (κ = 0.87, McNemar’s test; p = 0.19), indicating a comparable performance. These findings suggest that self-collected swabs are acceptable substitutes for HCW-collected swabs, and that their use improved the specimen screening efficiency and reduced the risk of SARS-CoV-2 infection among HCWs during and after the COVID-19 pandemic.
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15
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Roh KH, Hong KH, Nam MH, Kim TS, Seong MW, Lee JK, Bae S, Huh HJ, Ahn JY, Lim J, Kim GJ, Park JS, Kim HY, Yoo CK, Lee H. Guidelines for Mobile Laboratories for Molecular Diagnostic Testing of COVID-19. Ann Lab Med 2022; 42:507-514. [PMID: 35470270 PMCID: PMC9057824 DOI: 10.3343/alm.2022.42.5.507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/13/2022] [Accepted: 04/05/2022] [Indexed: 12/03/2022] Open
Abstract
With the rapid spread of the coronavirus disease (COVID-19), the need for rapid testing and diagnosis and consequently, the demand for mobile laboratories have increased. Despite this need, there are no clear guidelines for the operation, maintenance, or quality control of mobile laboratories. We provide guidelines for the operation, management, and quality control of mobile laboratories, and specifically for the implementation and execution of COVID-19 molecular diagnostic testing. These practical guidelines are primarily based on expert opinions and a laboratory accreditation inspection checklist. The scope of these guidelines includes the facility, preoperative evaluation, PCR testing, internal and external quality control, sample handling, reporting, laboratory personnel, biosafety level, and laboratory safety management. These guidelines are useful for the maintenance and operation of mobile laboratories not only in normal circumstances but also during public health crises and emergencies.
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Affiliation(s)
- Kyoung Ho Roh
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ki Ho Hong
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Myung-Hyun Nam
- Department of Laboratory Medicine, Korea University College of Medicine, Seoul, Korea
| | - Taek Soo Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Moon-Woo Seong
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Kyung Lee
- Department of Laboratory Medicine, Korea Cancer Center Hospital, KIRAMS, Seoul, Korea
| | - Sookyoung Bae
- Department of Laboratory Medicine, Dongnam Institute of Radiological & Medical Sciences, Busan, Korea
| | - Hee Jae Huh
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jinsook Lim
- Department of Laboratory Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Gab Jung Kim
- Division of Laboratory Diagnosis Management, Bureau of Infectious Disease Diagnosis Control, Korea Disease Control and Prevention Agency, Osong, Korea
| | - Jae Sun Park
- Division of Laboratory Diagnosis Management, Bureau of Infectious Disease Diagnosis Control, Korea Disease Control and Prevention Agency, Osong, Korea
| | - Hyun Yeong Kim
- Division of Laboratory Diagnosis Management, Bureau of Infectious Disease Diagnosis Control, Korea Disease Control and Prevention Agency, Osong, Korea
| | - Cheon Kwon Yoo
- Bureau of Infectious Disease Diagnosis Control, Korea Disease Control and Prevention Agency, Osong, Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
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16
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Tobik ER, Kitfield-Vernon LB, Thomas RJ, Steel SA, Tan SH, Allicock OM, Choate BL, Akbarzada S, Wyllie AL. Saliva as a sample type for SARS-CoV-2 detection: implementation successes and opportunities around the globe. Expert Rev Mol Diagn 2022; 22:519-535. [PMID: 35763281 DOI: 10.1080/14737159.2022.2094250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Symptomatic testing and asymptomatic screening for SARS-CoV-2 continue to be essential tools for mitigating virus transmission. Though COVID-19 diagnostics initially defaulted to oropharyngeal or nasopharyngeal sampling, the worldwide urgency to expand testing efforts spurred innovative approaches and increased diversity of detection methods. Strengthening innovation and facilitating widespread testing remains critical for global health, especially as additional variants emerge and other mitigation strategies are recalibrated. AREAS COVERED A growing body of evidence reflects the need to expand testing efforts and further investigate the efficiency, sensitivity, and acceptability of saliva samples for SARS-CoV-2 detection. Countries have made pandemic response decisions based on resources, costs, procedures, and regional acceptability - the adoption and integration of saliva-based testing among them. Saliva has demonstrated high sensitivity and specificity while being less invasive relative to nasopharyngeal swabs, securing saliva's position as a more acceptable sample type. EXPERT OPINION Despite the accessibility and utility of saliva sampling, global implementation remains low compared to swab-based approaches. In some cases, countries have validated saliva-based methods but face challenges with testing implementation or expansion. Here, we review the localities that have demonstrated success with saliva-based SARS-CoV-2 testing approaches and can serve as models for transforming concepts into globally-implemented best practices.
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Affiliation(s)
- Emily R Tobik
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Lily B Kitfield-Vernon
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Russell J Thomas
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Sydney A Steel
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Steph H Tan
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Orchid M Allicock
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Brittany L Choate
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Sumaira Akbarzada
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Anne L Wyllie
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
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