High Frequency of SARS-CoV-2 RNAemia and Association With Severe Disease.

BACKGROUND: Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in blood, also known as RNAemia, has been reported, but its prognostic implications are poorly understood. This study aimed to determine the frequency of SARS-CoV-2 RNA in plasma and its association with coronavirus disease 2019 (COVID-19) clinical severity. METHODS: An analytical cross-sectional study was performed in a single-center tertiary care institution and included consecutive inpatients and outpatients with confirmed COVID-19. The prevalence of SARS CoV-2 RNAemia and the strength of its association with clinical severity variables were examined and included intensive care unit (ICU) admission, invasive mechanical ventilation, and 30-day all-cause mortality. RESULTS: Paired nasopharyngeal and plasma samples were included from 85 patients. The median age was 55 years, and individuals with RNAemia were older than those with undetectable SARS-CoV-2 RNA in plasma (63 vs 50 years; P = .04). Comorbidities were frequent including obesity (37.6%), hypertension (30.6%), and diabetes mellitus (22.4%). RNAemia was detected in 28/85 (32.9%) of patients, including 22/28 (78.6%) who required hospitalization. In models adjusted for age, RNAemia was detected more frequently in individuals who developed severe disease including ICU admission (32.1 vs 14.0%; P = .04) and invasive mechanical ventilation (21.4% vs 3.5%; P = .02). All 4 deaths occurred in individuals with detectable RNAemia. An additional 121 plasma samples from 28 individuals with RNAemia were assessed longitudinally, and RNA was detected for a maximum duration of 10 days. CONCLUSIONS: This study demonstrated a high proportion of SARS-CoV-2 RNAemia, and an association between RNAemia and clinical severity suggesting the potential utility of plasma viral testing as a prognostic indicator for COVID-19.

Occurrence and Timing of Subsequent Severe Acute Respiratory Syndrome Coronavirus 2 Reverse-transcription Polymerase Chain Reaction Positivity Among Initially Negative Patients.

Using data for 20 912 patients from 2 large academic health systems, we analyzed the frequency of severe acute respiratory syndrome coronavirus 2 reverse-transcription polymerase chain reaction test discordance among individuals initially testing negative by nasopharyngeal swab who were retested on clinical grounds within 7 days. The frequency of subsequent positivity within this window was 3.5% and was similar across institutions.

SARS-CoV-2 Nucleocapsid Plasma Antigen for Diagnosis and Monitoring of COVID-19.

BACKGROUND: Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid antigen in blood has been described, but the diagnostic and prognostic role of antigenemia is not well understood. This study aimed to determine the frequency, duration, and concentration of nucleocapsid antigen in plasma and its association with coronavirus disease 2019 (COVID-19) severity. METHODS: We utilized an ultrasensitive electrochemiluminescence immunoassay targeting SARS-CoV-2 nucleocapsid antigen to evaluate 777 plasma samples from 104 individuals with COVID-19. We compared plasma antigen to respiratory nucleic acid amplification testing (NAAT) in 74 individuals with COVID-19 from samples collected ±1 day of diagnostic respiratory NAAT and in 52 SARS-CoV-2-negative individuals. We used Kruskal-Wallis tests, multivariable logistic regression, and mixed-effects modeling to evaluate whether plasma antigen concentration was associated with disease severity. RESULTS: Plasma antigen had 91.9% (95% CI 83.2%-97.0%) clinical sensitivity and 94.2% (84.1%-98.8%) clinical specificity. Antigen-negative plasma samples belonged to patients with later respiratory cycle thresholds (Ct) when compared with antigen-positive plasma samples. Median plasma antigen concentration (log10 fg/mL) was 5.4 (interquartile range 3.9-6.0) in outpatients, 6.0 (5.4-6.5) in inpatients, and 6.6 (6.1-7.2) in intensive care unit (ICU) patients. In models adjusted for age, sex, diabetes, and hypertension, plasma antigen concentration at diagnosis was associated with ICU admission [odds ratio 2.8 (95% CI 1.2-6.2), P=.01] but not with non-ICU hospitalization. Rate of antigen decrease was not associated with disease severity. CONCLUSIONS: SARS-CoV-2 plasma nucleocapsid antigen exhibited comparable diagnostic performance to upper respiratory NAAT, especially among those with late respiratory Ct. In addition to currently available tools, antigenemia may facilitate patient triage to optimize intensive care utilization.

Cutaneous cytomegalovirus - A case of disseminated cytomegalovirus presenting with extensive ulcerative skin lesions in a renal transplant recipient.

Cytomegalovirus (CMV) reactivation is common in organ transplant recipients and can lead to significant morbidity and mortality. Cutaneous CMV findings are rarely reported in the literature and diagnosis can be delayed if not clinically recognized. We describe a case of a female patient 20 years post renal transplant who presented with extensive ulcerative skin lesions and diarrhea. She rapidly deteriorated and died on day 5 of hospitalization. Autopsy noted extensive CMV involvement of skin and gastrointestinal (GI) tract by CMV-specific immunohistochemistry. These findings, along with high-grade CMV viremia, led to the final postmortem diagnosis of disseminated CMV infection. This case focuses on the cutaneous findings of disseminated CMV as recognition of CMV skin lesions can lead to earlier initiation of appropriate therapy in transplant recipients.

Comparison of the Accula SARS-CoV-2 Test with a Laboratory-Developed Assay for Detection of SARS-CoV-2 RNA in Clinical Nasopharyngeal Specimens.

Several point-of-care (POC) molecular tests have received emergency use authorization (EUA) from the Food and Drug Administration (FDA) for the diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The test performance characteristics of the Accula (Mesa Biotech) SARS-CoV-2 POC test need to be evaluated to inform its optimal use. The aim of this study was to assess the test performance of the Accula SARS-CoV-2 test. The performance of the Accula test was assessed by comparing results of 100 nasopharyngeal swab samples previously characterized by the Stanford Health Care EUA laboratory-developed test (SHC-LDT), targeting the envelope (E) gene. Assay concordance was assessed by overall percent agreement, positive percent agreement (PPA), negative percent agreement (NPA), and Cohen's kappa coefficient. Overall percent agreement between the assays was 84.0% (95% confidence interval [CI], 75.3 to 90.6%), PPA was 68.0% (95% CI, 53.3 to 80.5%), and the kappa coefficient was 0.68 (95% CI, 0.54 to 0.82). Sixteen specimens detected by the SHC-LDT were not detected by the Accula test and showed low viral load burden, with a median cycle threshold value of 37.7. NPA was 100% (95% CI, 94.2 to 100%). Compared to the SHC-LDT, the Accula SARS-CoV-2 test showed excellent negative agreement. However, positive agreement was low for samples with low viral load. The false-negative rate of the Accula POC test calls for a more thorough evaluation of POC test performance characteristics in clinical settings and for confirmatory testing in individuals with moderate to high pretest probability of SARS-CoV-2 who test negative on Accula.

Simultaneous coccidioidomycosis and phaeohyphomycosis in a kidney transplant recipient: A case report and literature review.

Advances in solid organ transplantation have improved the survival of end-stage organ disease at the expense of an increased risk for opportunistic infections. Unusual clinical presentations and the possibility of concurrent infections make diagnosing invasive fungal infection (IFI) more difficult. Here, we present a case of simultaneous vertebral infection caused by Coccidioides immitis-posadasii and subcutaneous phaeohyphomycosis due to Nigrograna mackinnonii in a kidney transplant recipient. The diagnosis of both infections required invasive procedures to obtain tissue and a high index of suspicion that more than one IFI could be present. A multidisciplinary team approach for the management of immunocompromised patients with suspected or diagnosed IFI is warranted.

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

PURPOSE: To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. METHODS: The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. RESULTS: One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). CONCLUSION: Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

Identifying important military installations for continental-scale conservation of marsh bird breeding habitat.

Degradation of wetland ecosystems has negatively impacted many species, perhaps none more so than marsh birds that breed in vegetative emergent wetlands throughout North America. The U.S. Department of Defense manages approximately 29 million acres of land within the continental U.S., and many military installations contain wetland complexes that may be important for wetland birds. Thus, failure to adequately manage habitat for marsh birds could result in species extirpations and additional listings under the Endangered Species Act, and may result in regulatory burdens that reduce military readiness. We conducted spatial analyses to identify important breeding habitat on > 500 military installations for 12 species of marsh birds, with the goal of identifying installations that are, and are not, likely to harbor breeding habitat for each species. We also sought to assess the local value of military installations for species of greatest concern by comparing habitat suitability within installations to that in areas directly adjacent to those sites. We built range-wide, spatially-explicit models of species distribution to project suitability of breeding habitat for marsh birds within and adjacent to military installations. Our results demonstrate that installations with the best marsh bird habitat are geographically aggregated (both among and within species), primarily at sites along the eastern seaboard and within the southern U.S. In addition, only a few sites appear to contain high-quality habitat for most species. Five or fewer sites contained most of the high-quality habitat for 9 of 12 species, whereas most of the high-quality habitat for remaining species was found at ≤ 10 sites. This work fills an information gap regarding the distribution of breeding habitat for marsh birds on military lands across the U.S., and should facilitate both strategic conservation of habitat over broad scales and the integration of marsh birds into management efforts at the site level. Our analyses also identify installations that are not likely to harbor breeding habitat for priority species, and thus should help minimize conflicts between needs of the military and marsh-bird conservation.

Identifying target reference points for harvesting assessment-limited wildlife populations: a case study.

Identifying appropriate strategies for sustainable harvest is a challenge for many terrestrial vertebrate species because of uncertain system dynamics, limited data to inform population models, and potentially conflicting objectives that seek to harvest and maintain populations at desirable levels. The absence of monitoring and assessment infrastructure needed to regularly estimate abundance accentuates this challenge for many species, and limits application of rigorous state-dependent frameworks for decision making that are commonly advocated in natural resource management. Reference points, which define management targets or triggers for changing management, are often used to guide decision-making, but suffer from ambiguity when developed without explicit consideration of uncertainty or trade-offs among competing objectives. We describe an approach for developing unambiguous target reference points for assessment-limited species using structured decision making, and demonstrate the approach to develop target harvest rates for management of fall Wild Turkey (Meleagris gallopavo) harvests in the face of uncertain population and harvest dynamics. We use simulation and decision analyses to identify harvest rates that are optimal for accomplishing explicit management objectives in the face of uncertainty, and harvest rates with robust performance over broad regions of the demographic and harvest model parameter space. We demonstrate that population and harvest parameters commonly uncertain to wildlife managers interact to determine appropriate target harvest rates for Wild Turkeys, and that formally acknowledging a range of plausible values for structurally uncertain parameters results in more conservative target reference points than suggested by previously published studies. The structured decision making framework described here provides a natural conceptual and quantitative framework for extending our approach to develop unambiguous harvest targets for other assessment-limited wildlife populations while formally acknowledging structural uncertainty in system dynamics.

Wildlife mortality from infrastructure collisions: statistical modeling of count data from carcass surveys.

Anthropogenic infrastructure is a mortality source for many vertebrate species. Mortality is often measured using periodic counts of carcasses or remains at infrastructure segments, and bias from carcass removal is estimated via field experiments with wildlife carcasses. We describe a model for combining removal experiment and carcass count data to estimate underlying process parameters using joint likelihood. In the model, the instantaneous number of carcasses present is a stochastic birth-death process with Poisson arrivals (carcass addition) and proportional deaths (removal of carcasses). The approach accommodates modeling heterogeneity in the addition and removal processes using generalized regression. Results of fitting the model to a Greater Sage-Grouse (Centrocercus urophasianus) fence collision data set show that order of magnitude differences in expected carcass counts can be a function of spatial differences in removal and suggest caution for interpretation of many published studies. While the model assumption of negligible detection error may be tenable for some systems, the modeling framework provides a starting point for future state-space versions incorporating detection error.

Effects of large-scale disturbance on animal space use: Functional responses by greater sage-grouse after megafire.

Global change has altered the nature of disturbance regimes, and megafire events are increasingly common. Megafires result in immediate changes to habitat available to terrestrial wildlife over broad landscapes, yet we know surprisingly little about how such changes shape space use of sensitive species in habitat that remains. Functional responses provide a framework for understanding and predicting changes in space use following habitat alteration, but no previous studies have assessed functional responses as a consequence of megafire. We studied space use and tested for functional responses in habitat use by breeding greater sage-grouse (Centrocercus urophasianus) before and after landscape-level changes induced by a >40,000 ha, high-intensity megafire that burned sagebrush steppe in eastern Idaho, USA. We also incorporated functional responses into predictive resource selection functions (RSFs) to map breeding habitat before and after the fire. Megafire had strong effects on the distribution of available resources and resulted in context-dependent habitat use that was heterogeneous across different components of habitat. We observed functional responses in the use and selection of a variety of resources (shrubs and herbaceous vegetation) for both nesting and brood rearing. Functional responses in the use of nesting habitat were influenced by the overarching effect of megafire on vegetation, whereas responses during brood rearing appeared to be driven by individual variation in available resources that were conditional on nest locations. Importantly, RSFs built using data collected prior to the burn also had poor transferability for predicting space use in a post-megafire landscape. These results have strong implications for understanding and predicting how animals respond to a rapidly changing environment, given that increased severity, frequency, and extent of wildfire are consequences of global change with the capacity to reshape ecosystems. We therefore demonstrate a conceptual framework to better understand space use and aid habitat conservation for wildlife in a rapidly changing world.

Backpack satellite transmitters reduce survival but not nesting propensity or success of greater sage-grouse.

Telemetry technology is ubiquitous for studying the behavior and demography of wildlife, including the use of traditional very high frequency (VHF) radio telemetry and more recent methods that record animal locations using global positioning systems (GPS). Satellite-based GPS telemetry allows researchers to collect high spatial-temporal resolution data remotely but may also come with additional costs. For example, recent studies from the southern Great Basin suggested GPS transmitters attached via backpacks may reduce the survival of greater sage-grouse (Centrocercus urophasianus) relative to VHF transmitters attached via collars that have been in use for decades. While some evidence suggests GPS backpacks reduce survival, no studies have examined the effects of GPS backpacks on breeding behavior and success. Therefore, we compared survival, breeding behavior, and nest success of sage-grouse hens marked with both VHF collars and GPS backpack transmitter over a 7-year period in central Idaho, USA. GPS backpacks reduced spring-summer survival of sage-grouse hens relative to hens with VHF collars, where daily mortality probability was 68%-82% higher from March 1 to August 1. Yet satellite GPS backpacks did not consistently affect nest success or the likelihood or timing of nest initiation relative to VHF collars. Daily nest survival varied annually and with timing of nest initiation and nest age, but marginal effects of transmitter type were statistically insignificant and interactions between transmitter type and study year produced no meaningful patterns. Our results corroborate recent studies for the effect of satellite GPS backpacks on sage-grouse survival, but also suggest that these transmitters do not appear to affect components of fecundity. Our results therefore add important context to recent debate surrounding the effects of GPS backpacks on sage-grouse, and the relative strengths and weaknesses of different transmitter types for understanding behavior and population dynamics.

Machine Learning Classification of False-Positive Human Immunodeficiency Virus Screening Results.

BACKGROUND: Human immunodeficiency virus (HIV) screening has improved significantly in the past decade as we have implemented tests that include antigen detection of p24. Incorporation of p24 detection narrows the window from 4 to 2 weeks between infection acquisition and ability to detect infection, reducing unintentional spread of HIV. The fourth- and fifth-generation HIV (HIV5G) screening tests in low prevalence populations have high numbers of false-positive screens and it is unclear if orthogonal testing improves diagnostic and public health outcomes. METHODS: We used a cohort of 60,587 HIV5G screening tests with molecular and clinical correlates collected from 2016 to 2018 and applied machine learning to generate a classifier that could predict likely true and false positivity. RESULTS: The best classification was achieved by using support vector machines and transformation of results with principle component analysis. The final classifier had an accuracy of 94% for correct classification of false-positive screens and an accuracy of 92% for classification of true-positive screens. CONCLUSIONS: Implementation of this classifier as a screening method for all HIV5G reactive screens allows for improved workflow with likely true positives reported immediately to reduce infection spread and initiate follow-up testing and treatment and likely false positives undergoing orthogonal testing utilizing the same specimen already drawn to reduce distress and follow-up visits. Application of machine learning to the clinical laboratory allows for workflow improvement and decision support to provide improved patient care and public health.

Evaluation of SARS-CoV-2 total antibody detection via a lateral flow nanoparticle fluorescence immunoassay.

BACKGROUND: The coronavirus disease 2019 (COVID-19) endgame may benefit from simple, accurate antibody testing to characterize seroprevalence and immunization coverage. OBJECTIVES: To evaluate the performance of the lateral flow QIAreach anti-SARS-CoV-2 Total rapid nanoparticle fluorescence immunoassay compared to reference isotype-specific IgG, IgM, and IgA SARS-CoV-2 ELISA using S1 or receptor binding domain (RBD) as antigens. STUDY DESIGN: A diagnostic comparison study was carried out using 154 well-characterized heparin plasma samples. Agreement between assays was assessed by overall, positive, and negative percent agreement and Cohen's kappa coefficient. RESULTS: Overall agreement between the QIAreach anti-SARS-CoV-2 Total and any anti-spike domain (S1 or RBD) antibody isotype was 96.0 % (95 % CI 89.8-98.8), the positive percent agreement was 97.6 % (95 % CI 91.0-99.9), the negative percent agreement was 88.2 % (95 % CI 64.4-98.0). The kappa coefficient was 0.86 (95 % CI 0.72 to 0.99). CONCLUSION: The QIAreach anti-SARS-CoV-2 Total rapid antibody test provides comparable performance to high-complexity, laboratory-based ELISA.

Plasma as an alternative COVID-19 diagnostic specimen in a hospitalized patient negative for SARS-CoV-2 by nasopharyngeal swab.

We present the case of an inpatient with pneumonia and repeatedly negative nasopharyngeal SARS-CoV-2 testing. In such challenging cases, alternative diagnostic options include lower respiratory tract and plasma SARS-CoV-2 RNA testing, of which the latter may be particularly useful where bronchoscopy is deferred due to clinical factors or transmission risk.

Combined SARS-CoV-2 nucleic acid amplification testing and respiratory virus panel RT-PCR on the Hologic Panther Fusion system.

BACKGROUND: Significant overlap exists between the symptoms of SARS-CoV-2 and other respiratory viruses. This poses a serious challenge to clinical diagnosis, laboratory testing, and infection control programs. OBJECTIVES: To evaluate the performance of the Hologic Panther Fusion Respiratory Assays (RA) compared to the GenMark ePlex Respiratory Pathogen Panel (RPP) and to assess the ability of the Panther Fusion to perform parallel testing of SARS-CoV-2 and other respiratory viruses from a single sample. STUDY DESIGN: A diagnostic comparison study was carried out using 375 clinical nasopharyngeal specimens. Assay performance was assessed by overall, positive, and negative percent agreement and Cohen's kappa coefficient. RESULTS: Overall agreement between the Fusion RA and ePlex RPP was 97.3 % (95 % CI 96.3-98.0), positive percent agreement was 97.2 % (95 % CI 93.0-99.2), negative percent agreement was 97.3 % (95 % CI 96.3-98.0), and the kappa coefficient was 0.85 (95 % CI 0.81-0.89). Forty additional viruses in 30 specimens were detected by Fusion that were not detected by ePlex. The maximum specimen throughput for parallel testing of the Fusion Respiratory Assays with SARS-CoV-2 was 275 samples in 20.7 h for Fusion SARS-CoV-2 and 350 samples in 20.0 h for Aptima Transcription Mediated Amplification SARS-CoV-2. CONCLUSION: Fusion RA demonstrated substantial agreement compared to the ePlex RPP. However, the Fusion detected respiratory viruses not identified by ePlex, consistent with higher clinical sensitivity. Workflows for parallel testing of respiratory pathogens and SARS-CoV-2 demonstrate that the Panther Fusion instrument provides a flexible, moderate to high throughput testing option for pandemic and seasonal respiratory viruses.

Use of Outpatient-Derived COVID-19 Convalescent Plasma in COVID-19 Patients Before Seroconversion.

Background: Transfusion of COVID-19 convalescent plasma (CCP) containing high titers of anti-SARS-CoV-2 antibodies serves as therapy for COVID-19 patients. Transfusions early during disease course was found to be beneficial. Lessons from the SARS-CoV-2 pandemic could inform early responses to future pandemics and may continue to be relevant in lower resource settings. We sought to identify factors correlating to high antibody titers in convalescent plasma donors and understand the magnitude and pharmacokinetic time course of both transfused antibody titers and the endogenous antibody titers in transfused recipients. Methods: Plasma samples were collected up to 174 days after convalescence from 93 CCP donors with mild disease, and from 16 COVID-19 patients before and after transfusion. Using ELISA, anti-SARS-CoV-2 Spike RBD, S1, and N-protein antibodies, as well as capacity of antibodies to block ACE2 from binding to RBD was measured in an in vitro assay. As an estimate for viral load, viral RNA and N-protein plasma levels were assessed in COVID-19 patients. Results: Anti-SARS-CoV-2 antibody levels and RBD-ACE2 blocking capacity were highest within the first 60 days after symptom resolution and markedly decreased after 120 days. Highest antibody titers were found in CCP donors that experienced fever. Effect of transfused CCP was detectable in COVID-19 patients who received high-titer CCP and had not seroconverted at the time of transfusion. Decrease in viral RNA was seen in two of these patients. Conclusion: Our results suggest that high titer CCP should be collected within 60 days after recovery from donors with past fever. The much lower titers conferred by transfused antibodies compared to endogenous production in the patient underscore the importance of providing CCP prior to endogenous seroconversion.

Performance of spatial capture-recapture models with repurposed data: Assessing estimator robustness for retrospective applications.

Advancements in statistical ecology offer the opportunity to gain further inferences from existing data with minimal financial cost. Spatial capture-recapture (SCR) models extend traditional capture-recapture models to incorporate spatial position of capture and enable direct estimation of animal densities across a region of interest. The additional inferences provided are both ecologically interesting and valuable for decision making, which has resulted in traditional capture-recapture data being repurposed using SCR. Yet, many capture-recapture studies were not designed for SCR and the limitations of repurposing data from such studies are rarely assessed in practice. We used simulation to evaluate the robustness of SCR for retrospectively estimating large mammal densities over a variety of scenarios using repurposed capture-recapture data collected by an asymmetrical sampling grid and covering a broad spatial extent in a heterogenous landscape. We found performance of SCR models fit using repurposed data simulated from the existing grid was not robust, but instead bias and precision of density estimates varied considerably among simulations scenarios. For example, while the smallest relatives bias of density estimates was 3%, it ranged by 14 orders of magnitude among scenarios and was most strongly influenced by detection parameters. Our results caution against the casual repurposing of non-spatial capture-recapture data using SCR and demonstrate the importance of using simulation to assessing model performance during retrospective applications.

Comparison of the Panther Fusion and a laboratory-developed test targeting the envelope gene for detection of SARS-CoV-2.

BACKGROUND: Numerous nucleic acid amplification assays have recently received emergency use authorization (EUA) for the diagnosis of SARS-CoV-2 infection, and there is a need to assess their test performance relative to one another. OBJECTIVES: The aim of this study was to compare the test performance of the Hologic Panther Fusion SARS-CoV-2 assay targeting two regions of open reading frame 1ab (ORF1ab) to a high complexity molecular-based, laboratory-developed EUA from Stanford Health Care (SHC) targeting the SARS-CoV-2 envelope (E) gene. STUDY DESIGN: We performed a diagnostic comparison study by testing nasopharyngeal samples on the two assays. Assay agreement was assessed by overall percent agreement and Cohen's kappa coefficient. RESULTS: A total of 184 nasopharyngeal samples were tested using the two assays, of which 180 showed valid results and were included for the comparative analysis. Overall percent agreement between the assays was 98.3 % (95 % confidence interval (CI) 95.2-99.7) and kappa coefficient was 0.97 (95 % CI 0.93-1.0). One sample was detected on the SHC laboratory developed test (LDT) and not on the Panther Fusion, and had a Ct of 35.9. Conversely, 2 samples were detected on the Panther Fusion and not on the LDT, and had Ct values of 37.2 and 36.6. CONCLUSION: The Panther Fusion SARS-CoV-2 assay and the SHC LDT perform similarly on clinical nasopharyngeal swab specimens. Other considerations, including reagent availability, turnaround time, labor requirements, cost and instrument throughput should guide the decision of which assay to perform.

Comparison of a laboratory-developed test targeting the envelope gene with three nucleic acid amplification tests for detection of SARS-CoV-2.

BACKGROUND: Numerous nucleic acid amplification tests, including real-time, reverse transcription PCR (rRT-PCR) and isothermal amplification methods, have been developed to detect SARS-CoV-2 RNA, including many that have received emergency use authorization (EUA). There is a need to assess their test performance relative to one another. OBJECTIVES: The aim of this study was to compare the test performance of a high complexity laboratory-developed rRT-PCR EUA from Stanford Health Care (SHC) targeting the SARS-CoV-2 envelope (E) gene with other tests: the Atila isothermal amplification assay targeting the nucleocapsid (N) gene and open reading frame 1ab (ORF1ab), the Altona E and spike (S) multiplex, real-time RT-PCR, and the US Centers for Disease Control and Prevention (CDC) N1 and N2 rRT-PCRs. STUDY DESIGN: A diagnostic comparison study was performed by testing nasopharyngeal samples from persons under investigation for coronavirus disease 2019 (COVID-19). Assay performance was assessed by percent agreement and Cohen's kappa coefficient. RESULTS: Positive percent agreement with the SHC EUA reference assay was 82.8 % (95 % confidence interval (CI) 65.0 to 92.9) for Atila, 86.7 % (95 % CI 69.7 to 95.3) for the Altona E and S targets, and 86.7 % (95 % CI 69.7 to 95.3) and 90.0 % (95 % CI 73.6 to 97.3), for the CDC N1 and N2 targets, respectively. All assays demonstrated 100 % negative percent agreement. Kappa coefficients ranged from 0.86 to 0.92, indicating excellent agreement. CONCLUSIONS: Performance was comparable among the SARS-CoV-2 nucleic acid amplification methods tested, with a limited number of discrepancies observed in specimens with low viral loads.