NEWS AND VIEWS /NOTICIAS Y OPINIONES
Diagnostic tests for Coronavirus Disease 2019. What happens behind the assays?
Marco Esteban Gudiño Gomezjurado1* and Alvaro Francisco Gudiño Gomezjurado2
Available from: http://dx.doi.org/10.21931/RB/2020.05.02.16
Pandemic caused by Coronavirus Disease 2019 (COVID-19) shows a plethora of clinical manifestations from the absence of symptoms to the development of pneumonia and even death. Nowadays, the number of new infections estimated to stem from a single COVID-19 case is between 2 and 3. For this reason, a rapid diagnosis will allow the massive screening of the population and the isolation of carriers and asymptomatic people. However, selecting an appropriate diagnostic test might be highly relevant, depending on the prevalence of the illness and the population to be tested. This communication has as purpose to describe the methodological tests employed to the COVID-19 diagnosis and analyze the pros and cons of them.
Keywords. COVID-19, diagnosis, immunoassays, q-RT-PCR.
COVID-19 Diagnostic Tests
Coronavirus Disease 2019 (COVID-19) is caused by a novel coronavirus, which is closely related to two bat-derived severe acute respiratory syndromes (SARS)-like coronaviruses1. Patients may undergo different manifestations from asymptomatic carriers to developing interstitial pneumonia, multi-organ failure, and death2. This illness emerged in December 2019 in Wuhan, China, from where it spread worldwide (Singhal 2020), infecting over 4 000 000 people and causing the death of around 290 000 people3.
Hitherto, many research groups are working to develop an accurate diagnostic method. In particular, they have focused on two principal approaches: (i) molecular and (ii) immunoassays, which aim to be the primary diagnostic alternatives in both developed and developing countries4 (Figure 1).
Figure 1. COVID-19 diagnostic tests. Quantitative Reverse Transcription Polymerase Chain Reaction (q-RT- PCR) is considered the gold standard to diagnose COVID-19. Several immunoassays have been developed; some of them are based on the lateral flow principle these tests is being used as rapid screening tests. Nowadays, Cluster Regularly Interspaced Short Palindromic Repeats (CRISPR) based tests are emerging as a recent alternative, although they have not been certified as an in vitro diagnostic test yet. For more details, see the text.
Regarding molecular analysis, approaches based on quantitative Reverse Transcription Polymerase Chain Reaction (q-RT-PCR) have been designed. Some q-RT-PCR protocols analyze two genes. The amplification of one gene is interpreted as a positive screening, while the presence of the second one is interpreted as a confirmatory result. On the other hand, other methodologies examine three or more genes, and the test is interpreted as positive only when the three genes are detected5.
The United States Centers for Disease Control (CDC) q-RT-PCR detects specific viral SARS-CoV-2 genes of the viral nucleocapsid (N1 and N2) while the methodology of the World Health Organization (WHO) targets the SARS-CoV-2-RNA-dependant RNA polymerase (RdRP) and envelope (E) genes. Both of them use a cycle threshold of less than 40 as the criterion for positivity6,7.
According to the Guidelines of the Korean Society for Laboratory Medicine and the Korea Centers for Disease Prevention and Control the q-RT-PCR must be carried out to (i) confirm patients’ release from quarantine, (ii) screen asymptomatic people related to COVID-19 patients and (iii) make a differential diagnosis among COVID-19 and other respiratory syndromes5.
Although q-RT-PCR is considered as the confirmatory diagnostic test, the principal disadvantage of this method is the high number of false-negative results. The causes of this inconvenience might be: (i) poor specimen quality, (ii) improper samples handling or transported, (iii) a viral genetic mutation, (iv) presence of PCR inhibitors, or even (v) samples with low viral loads5.
On the other hand, considering the immunogenic response of S and nucleocapsid viral proteins that trigger immunological response associated to immunoglobulins production from 17 and 23 days after disease onset8, with IgM and IgG seroconversion within 20 days after symptoms9 different immunological approaches based on lateral flow, ELISA, and chemiluminescence have been developed as diagnostic immunoassays10.
Previous studies describe diverse results on the sensitivity and specificity of lateral flow tests. For example, Li et al. (2020) analyzed the accuracy of this serologic test in 397 SARS-CoV-2 patients and 128 healthy people confirmed by q-RT-PCR. The results showed that the sensitivity and specificity values for the immunoassay were 88.66% and 90.63%, respectively11. These results were similar to those reported by Castro et al. (2020). These researchers, in a meta-analysis carried out in Brazil that had a purpose of setting the accuracy of available lateral flow tests to diagnose COVID-19 in that country, found sensitivity values between 55% and 100% and specificity between 94% and 100%12.
However, the applicability of these tests depends on the prevalence of the disease. In a high-prevalence location with more than 300 COVID-19 cases among 12000 inhabitants, 49 patients were randomly selected and were evaluated using a lateral flow immunoassay IgM/IgG vs. the q-RT-PCR. The results showed only 8 q-RT-PCR positive tests were positive to the immunoassay (sensitivity: 36.4%), and from 27 q-RT-PCR negative samples, 24 were detected as negative by the immunoassay (specificity: 88.9%)13.
Other immunological methodologies, such as ELISA and chemiluminescence, have similar accuracy to the lateral flow immunoassays. For example, Adams et al. (2020) reported the SARS-CoV-2 IgM/IgG ELISA sensitivity and specificity values of 85% and 100%, respectively14. Alike, IgM/IgG titers measured among 43 COVID-19 patients and 33 health people by chemiluminescence showed a sensitivity of 48.1% and 88.9% and specificity of 100% and 90% for each immunoglobulin, respectively15.
Another alternative to COVID-19 diagnosis might be CRISPR (Cluster Regularly Interspaced Short Palindromic Repeats) technology. Gootenberg et al. (2017) previously reported the SHERLOCK system (Specific High -Sensitivity Enzymatic Reporter UnLOCKing) as a virus CRISPR-based diagnostic platform which takes advantage of the unspecific catalytic activity of the Cas13a enzyme releasing a fluorescent RNA reporter previous an isothermal amplification16. This system has been improved recently by a lateral readout platform, which guarantees a quantitative and rapid detection of specific nucleic acids17.
Until now SHERLOCK system has not been tested on biological samples. However, a modification of this platform termed DETECTR (DNA endonuclease-targeted CRISPR trans reporter)18 was probed on samples, although its use in diagnosis has not yet been approved by the U.S. Food and Drug Administration. Recently, Broughton and co-workers (2019) described a modification of this system based on CRISPR-Cas12 lateral flow assay as a visual and faster alternative to diagnose COVID-1919.
Immunoassays might be an alternative for the rapid diagnosis of COVID-19 as a complement to viral nucleic acid detection specially among carriers, asymptomatic, symptomatic patients and health sector workers20. However, one possible disadvantage of the immunoassays is the fallen of the IgG titers at 8 weeks post symptoms onset, although these titers remain above the detection threshold14 being possible to detect anti-SARS-CoV-2 IgG up to 50 days from symptoms onset 21,22. On the other hand, previous studies on 11 patients diagnosed with pneumonia due to coronavirus at day 240 after symptoms onset showed that all patients were still positive to SARS-CoV anti-nucleocapsid IgG23. SARS-CoV-2 could have different IgG kinetics than anti-nucleocapsid IgG of SARS-CoV.
Considering the highly variable performance of lateral flow immunoassay devices14 it is urgently needed to address studies to analyze the diagnostic yields of the immunoassays for COVID-19 diagnosis. Against this background, new molecular technologies based on editing gene tools might be a feasible, cheap, and rapid alternative to the existing COVID-19 diagnostic systems19.
1. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet [Internet]. 2020;395(10224):565–74. Available from: http://dx.doi.org/10.1016/S0140-6736(20)30251-8
2. Infantino M, Damiani A, Gobbi FL, Grossi V, Lari B, Macchia D, et al. Serological Assays for SARS-CoV-2 Infectious Disease: Benefits, Limitations and Perspectives. Vol. 22, The Israel Medical Association journal : IMAJ. 2020. p. 203–10.
3. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis [Internet]. 2020;20(5):533–4. Available from: http://dx.doi.org/10.1016/S1473-3099(20)30120-1
4. C. Bachelet V. Do we know the diagnostic properties of the tests used in COVID-19? A rapid review of recently published literature. Medwave [Internet]. 2020;20(03):e7891–e7891. Available from: https://www.medwave.cl/link.cgi/English/Reviews/GeneralReviews/7891.act
5. Hong KH, Lee SW, Kim TS, Huh HJ, Lee J, Kim SY, et al. Guidelines for Laboratory Diagnosis of Coronavirus Disease 2019 (COVID-19) in Korea. Ann Lab Med. 2020;40(5):351–60.
6. Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DK, et al. Detection of 2019 -nCoV by RT-PCR. 2019;(December):1.
7. Cheng MP, Papenburg J, Desjardins M, Kanjilal S, Quach C, Libman M, et al. Diagnostic Testing for Severe Acute Respiratory Syndrome–Related Coronavirus-2. Ann Intern Med. 2020;(April).
8. Qu J, Wu C, Li X, Zhang G, Jiang Z, Li X, et al. Profile of IgG and IgM antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clin Infect Dis. 2020;caa489.
9. Long Q-X, Liu B-Z, Deng H-J, Wu G-C, Deng K, Chen Y-K, et al. Antibody responses to SARS-CoV-2 in patients with COVID-19. Nat Med [Internet]. 2020;1–4. Available from: http://www.nature.com/articles/s41591-020-0897-1
10. Vashist SK. In vitro diagnostic assays for COVID-19: Recent advances and emerging trends. Diagnostics. 2020;10(4).
11. Li Z, Yi Y, Luo X, Xiong N, Liu Y, Li S, et al. Development and clinical application of a rapid IgM-IgG combined antibody test for SARS-CoV-2 infection diagnosis. J Med Virol. 2020;(February).
12. Castro R, Luz PM, Wakimoto MD, Veloso VG, Grinsztejn B, Perazzo H. COVID-19: a meta-analysis of diagnostic test accuracy of commercial assays registered in Brazil. Brazilian J Infect Dis [Internet]. 2020;(x x):1–9. Available from: https://doi.org/10.1016/j.bjid.2020.04.003
13. Döhla M, Boesecke C, Schulte B, Diegmann C, Sib E, Richter E, et al. Rapid point-of-care testing for SARS-CoV-2 in a community screening setting shows low sensitivity. Public Health. 2020;182:170–2.
14. Adams E, Anand R, Andersson M, Auckland K, Baillie J, Barnes E, et al. Evaluation of antibody testing for SARS-CoV-2 using ELISA and lateral flow immunoassays. medRvix. 2020;1–24.
15. Jin Y, Wang M, Zuo Z, Fan C, Ye F, Cai Z, et al. Diagnostic value and dynamic variance of serum antibody in coronavirus disease 2019. Int J Infect Dis [Internet]. 2020;94:49–52. Available from: https://doi.org/10.1016/j.ijid.2020.03.065
16. Gootenberg JS, Abudayyeh OO, Lee JW, Essletzbichler P, Dy AJ, Joung J, et al. Nucleic acid detection with CRISPR-Cas13a/C2c2. Science (80- ). 2017;356(6336):438–42.
17. Gootenberg JS, Abudayyeh OO, Kellner MJ, Joung J, Collins JJ, Zhang F. Multiplexed and portable nucleic acid detection platform with Cas13, Cas12a and Csm6. Science (80- ). 2018;360(6387):439–44.
18. Chen JS, Ma E, Harrington LB, Da Costa M, Tian X, Palefsky JM, et al. CRISPR-Cas12a target binding unleashes indiscriminate single-stranded DNase activity. Science (80- ). 2018;360(6387):436–9.
19. Broughton JP, Deng X, Yu G, Fasching CL, Servellita V, Singh J, et al. CRISPR – Cas12-based detection of SARS-CoV-2. 2019;
20. Li Z, Yi Y, Luo X, Xiong N, Liu Y, Li S, et al. Development and Clinical Application of A Rapid IgM-IgG Combined Antibody Test for SARS-CoV-2 Infection Diagnosis. J Med Virol [Internet]. 2020;0–1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/32104917
21. Wang B, Wang L, Kong X, Geng J, Xiao D, Ma C, et al. Long-term Coexistence of SARS-CoV-2 with Antibody Response in COVID-19 Patients. J Med Virol. 2020;2019:0–1.
22. Lee Y-L, Liao C-H, Liu P-Y, Cheng C-Y, Chung M-Y, Liu C-E, et al. Dynamics of anti-SARS-Cov-2 IgM and IgG antibodies among COVID-19 patients. J Infect [Internet]. 2020; Available from: https://doi.org/10.1016/j.jinf.2020.04.019
23. Woo PCY, Lau SKP, Wong BHL, Chan KH, Chu CM, Tsoi HW, et al. Longitudinal profile of immunoglobulin G (IgG), IgM, and IgA antibodies against the severe acute respiratory syndrome (SARS) coronavirus nucleocapsid protein in patients with pneumonia due to the SARS coronavirus. Clin Diagn Lab Immunol. 2004;11(4):665–8.
Received: 9 May 2020
Accepted: 14 May 2020
Marco Esteban Gudiño Gomezjurado1* and Alvaro Francisco Gudiño Gomezjurado2
1Escuela de Ciencias Biológicas e Ingeniería, Universidad Yachay Tech, Hacienda San José s/n, Urcuquí, CP: 100119-Ecuador. Orcid: https://orcid.org/0000-0002-8609-0806
2 Departamento de Medicina Interna, Hospital San Vicente de Paúl, teléfono: 593 62957274. fax: 593 62957276, Calle Luis Vargas Torres 11-56 y Luis Gonzalo Gomezjurado, Ibarra, CP: 10010-Ecuador. Orcid: https://orcid.org/0000-0002-3070-6579.
*Corresponding autor: email@example.com