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Sars-Cov-2: Antigen-Detecting Rapid Diagnostic Tests
Sars-Cov-2: Antigen-Detecting Rapid Diagnostic Tests
antigen-detecting
rapid diagnostic tests
AN IMPLEMENTATION GUIDE
SARS-CoV-2
antigen-detecting
rapid diagnostic tests
AN IMPLEMENTATION GUIDE
SARS-CoV-2 antigen-detecting rapid diagnostic tests: an implementation guide
ISBN 978-92-4-001774-0 (electronic version)
ISBN 978-92-4-001775-7 (print version)
The mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by WHO in preference to others of a similar nature that
are not mentioned. Errors and omissions excepted, the names of proprietary products are
distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained in this
publication. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material
lies with the reader. In no event shall WHO be liable for damages arising from its use.
REFERENCES ................................................................................................................... 42
ANNEX: COUNTRY READINESS CHECKLIST
FOR SARS-CoV-2 AG-RDT IMPLEMENTATION ..................................... 43
Download the file here
Ag antigen
PT proficiency testing
QA quality assurance
QC quality control
technical-guidance-publications.
© WHO / Blink Media - Nana Kofi Acquah, Ploy Phutpheng, Lisette Poole
© WHO / Blink Media - Nana Kofi Acquah, Fabeha Monir, Martyn Aim
Antigen-detecting RDTs
Ag-RDTs directly detect SARS-CoV-2 antigens, most often nucleocapsid, produced by the
replicating virus in respiratory secretions. Therefore, like molecular testing, Ag-RDTs
are useful for detecting active COVID-19 infection. Most SARS-CoV-2 Ag-RDTs require
nasopharyngeal samples, but may be suitable for use with other sample types once more data
are available. The accuracy of Ag-RDTs depends on several factors, including the time from
onset of infection, the concentration of virus in the specimen, the quality and processing of the
specimen collected from a person, and the precise formulation of the reagents in the test kits.
Antibody RDTs
Ab-RDTs detect the body’s immune response to the virus in the form of antibodies. These tests
are quite accurate around 15−21 days post infection (9).
As understanding of antibody responses to SARS-CoV-2 is still emerging, WHO recommends
that antibody detection tests not be used for determining active infections in clinical care or
for contact-tracing purposes. Interpretation of Ab-RDT results should be done by an expert
and is dependent on several factors, including the timing of the disease, clinical morbidity, the
epidemiology and prevalence within the setting, the type of test used, the validation method,
and the reliability of the results (1).
The clinical significance of a positive antibody test is still under investigation. It should be
noted that the presence of antibodies that bind to SARS-CoV-2 does not guarantee that they
are neutralizing antibodies or that they offer protective immunity.
However, antibody testing may be useful for serosurveillance studies to support the
investigation of an ongoing outbreak and to support the retrospective assessment of the
attack rate or size of an outbreak.
This guide refers only to antigen-detecting RDTs.
The cycle threshold (Ct) value is defined as the number of cycles of amplification (using rRT-PCR) required for the
2
fluorescence of a PCR product (i.e., the target/amplicon) to be detected, crossing a threshold that is above the background
signal (a low-level signal that is present in the assay regardless of whether the target is present).
Widespread community RDTs may be used for early detection and isolation of positive cases
transmission in health facilities, COVID-19 testing centres/sites, care homes,
prisons, schools, front-line and health care workers, and for contact
tracing.
For initial introduction of Ag-RDTs, implementers should consider selecting some settings
where confirmatory testing by NAAT (e.g., rRT-PCR) is available. This will enable operators
to gain confidence in the tests, confirm performance of the selected RDT, and troubleshoot
any implementation issues encountered.
In situations where confirmatory NAAT is not feasible, implementers should be
careful to monitor for any indication that results may be incorrect. This should include
routine monitoring of quality indicators and matching of test results to clinical history and
epidemiological context.
Fig. 1 shows the proposed process for using Ag-RDTs for COVID-19 case management where
there is widespread community transmission and NAAT is not available or limited in capacity.
Respiratory sample is
collected as per instructions for use
and biosafety requirements
Sample management
Respiratory sample is
collected as per instructions for use
and biosafety requirements
Sample management
Refer patient with moderate/ Collect specimen for NAAT Admit patient with moderate/
severe symptoms to low confirmation and isolate until results severe symptoms to high likelihood
likelihood ward (NPV moderate are available. Prioritize close contacts ward and home or cohorted isolation
to high) and work-up all cases for of confirmed cases and those with for mild cases (and their close
other causes of illness risk factors for severe disease contacts) 10 days after onset of
symptoms plus 3 days without fever
or respiratory symptoms
For the latest WHO case definition please refer to the technical guidance document on https://www.who.int/emergencies/
a
diseases/novel-coronavirus-2019/technical-guidance-publications?publicationtypes=df113943-c6f4-42a5-914f-0a0736769008
The WHO guidance in this section is based on existing information on the performance of
SARS-CoV-2 Ag-RDTs. Many settings may be using local validation to support other use of
Ag-RDTs, for example, using non-standard specimens. Ongoing studies will provide more
rigorous data to inform further guidance on the use of SARS-CoV-2 Ag-RDTs.
Specificity is the percentage of cases negative by a NAAT reference standard that are detected
as negative by the Ag-RDT under evaluation.
(true negatives)
Specificity is calculated as: x 100
(true negatives + false positives)
The prevalence of disease in the community being tested strongly affects the test’s predictive
value in terms of positive predictive value (PPV) and negative predictive value (NPV). PPV is the
probability that a person with a positive test result truly has the disease. NPV is the probability
that a person with a negative test result truly does not have the disease. The prevalence of
disease should be estimated based on surveillance to determine the positive and negative
predictive values for Ag-RDTs in order to enable optimal interpretation of the results. The
following formulae show how PPV and NPV can be calculated.
(true positives)
PPV is calculated as: x 100
(true positives + false positives)
(true negatives)
NPV is calculated as: x 100
(true negatives + false negatives)
Fig. 2. Predictive value of Ag-RDT with 80% sensitivity and 97% specificity in
a) a fever clinic with a 27% prevalence of COVID-19 and b) at border screening
with a 1% prevalence of COVID-19, in a population of 10 000 people
- 20 9603 99.8%
Test Probability of
Told they do not need not having COVID-19
negative to self-isolate so they
Told they do not need
to self-isolate and are if test is negative
infect more people safe to go out
Fig. 3. Critical elements required for the safe and effective implementation
of SARS-CoV-2 Ag-RDTs
National
COVID-19
strategic plan
Procurement
Communication
of RDTs and
and community
associated
engagement
requirements
Safe and
effective
Monitoring Supply
and
implementation chain
evaluation of SARS-CoV-2 management
Ag-RDT
testing
Data
Training
management
Quality
assurance
Site-readiness
Once districts and health facilities have been
selected based on service mapping and disease
prevalence, the next step should be to conduct a
site-level readiness survey to verify information
such as:
© WHO / Blink Media - Saiyna Bashir
The Diagnostics Consortium for COVID-19 is composed of: Bill & Melinda Gates Foundation, Clinton Health Access
4
Initiative, Civil Society representation, FIND, Global Fund, Global Drug Facility/Stop TB Partnership, Médecins Sans
Frontières, PAHO, UNDOS, UNDP, UNICEF, Unitaid, UNHCR, World Bank, and WHO.
For example, original International Medical Device Regulators Forum members: Australia, Brazil, Canada, China, European
5
Operational considerations
It is important that Ag-RDTs have the capacity
to withstand temperature stress and have an
extended shelf-life. Target shelf-life should be
at least 12−18 months at 30°C and ideally 40°C.
Staggered deliveries will be critical to offset
Lot testing
Given that SARS-CoV-2 Ag-RDTs are authorized for use under emergency conditions and have
not undergone comprehensive and stringent regulatory review, verification of lot quality prior
to the deployment of RDTs in the field is considered good practice, but only if well-characterized
QC samples are available. Unfortunately, these materials are not yet widely available, nor are
the procedures for their preparation. Therefore, the most feasible approach for new adopters
may be to test using control materials either provided with the test kit or sold separately by
the test manufacturer. In situations where control materials are unavailable, a small set of
samples from SARS-CoV-2 NAAT-confirmed positive and negative samples may be tested in
parallel to assess whether the new kit meets performance requirements.
QC
If positive and negative control materials are available, implementers should decide on a QC
schedule that matches the availability of the controls, frequency of testing and the skills of
the operators. If controls are included in the test kits, someone trained in the use of these
materials should assess Ag-RDT performance every time a new box is opened. If testing rates
are low and the same test box is used over a period of several weeks, then weekly QC could be
considered if a separate supply of controls is available. If controls are not included in the test
kits or operators have not been trained on QC procedures, then QC responsibilities may be best
assigned to supervisors who can monitor stock quality during routine visits or at vulnerable
locations along the supply chain. QC results should be analysed prior to the reporting of
patient results. When unexpected results occur, a root cause analysis must be conducted, and
corrective and preventive actions implemented. Therefore, there must be a system in place
for communicating QC failures and for conducting investigations; otherwise, testing may be
suspended for a prolonged period. In the case of QC failure, results of patient samples tested
since the previous correct control results should be analysed and retested.
Supervision
Supervision is a critical part of QA for new sites
and at the start of a new programme. Where
possible, programmes should use existing
systems and national standard supervisory
checklists and guidelines for RDT supervision
© WHO / Blink Media – Fabeha Monir
Proficiency testing
Proficiency testing (PT) consists of sending a set of blinded samples (i.e., results not known
to the site) to testing sites on a scheduled basis, usually one to three times per year, and
comparing the results obtained by the testing site to the known results and to the results
obtained by other participating sites. Discrepancies between the expected and actual results
are then analysed and root cause analysis performed to guide corrective actions. PT is a
recognized component of a comprehensive QA programme. When PT programmes are not
yet established for SARS-CoV-2 Ag-RDTs, resources should focus on other core elements
in the QA system, such as training, supervision, internal QC, proper transport and storage.
Data collection
Data collection at testing sites typically includes both diagnostic and test result information, and
commodity supply and consumption. Commodity tracking should include periodic (e.g., weekly)
reporting of current supply levels for all required commodities as well as consumption rates to
inform when stocks need to be replenished. Where possible, commodity tracking data systems
should be integrated with existing national supply management and logistics management
information systems to enable visibility and alignment with established supply chain processes.
Data collection of Ag-RDT results should be performed alongside testing as soon as results are
available in order to reduce data-entry errors and enable real-time reporting of results.
There are several open-source tools available to countries for collecting COVID-19 data
electronically in line with their M&E priorities. The digital health atlas from WHO (https://
digitalhealthatlas.org/en/covid-19/) lists a number of such software tools available for countries
to use in their COVID-19 response.
Ag-RDTs
Periodic data
reporting
Digital tools for Ag-RDT to national
linked for data capture programme
Patient and interpretation
presents at
testing site
Ministry of Health
Reference center
Specimen Confirmatory testing
transport for + digital reporting
confirmatory test of data
Programme M&E
These process indicators seek to track implementation of key activities related to Ag-RDT
roll-out. These indicators should be reported at least monthly, with more frequent reporting
(e.g., weekly) recommended during the initial stages of implementation.
# health facilities with one or more trained By region, district, facility, facility level, facility
Ag-RDT testers type (public, private etc.), health worker cadre
(advanced).
(advanced ).
# health facilities performing Ag-RDT testing By region, district, facility, facility level, facility
type (public, private etc.).
Where multiple Ag-RDTs are in use,
disaggregate by test type.
# health facilities performing Ag-RDT By region, district, facility, facility level, facility
with stockout in the past month type (public, private etc.).
Where multiple Ag-RDTs are in use,
disaggregate by test type.
Test uptake and performance: These indicators focus on understanding field test performance
(where confirmatory testing is available) in different settings. They consist of a minimum
set of indicators recommended for all health facilities and additional indicators that may be
collected at a sample of health facilities where resources and data systems are available.
During the early stages of implementation, it is recommended to track these indicators on
a weekly basis in order to enable early identification of errors and prompt corrective action.
Less frequent reporting (e.g., monthly) may be considered once routine testing has been
ongoing for some time and the capacity to track performance and manage issues has been
developed at the facility level.
# Ag-RDTs performed
NAAT POSITIVE
NAAT NEGATIVE
NAAT INVALID
AG-RDT 2 POSITIVE
AG-RDT 2 NEGATIVE
AG-RDT 2 INVALID
Monitoring: Frequent review of indicators and supervision of Ag-RDT testing sites should be
planned soon after initial Ag-RDT deployment. Changes in testing strategy and the stage of the
pandemic, as well as eligibility criteria for use of Ag-RDTs may affect both the rate of patients
tested using Ag-RDTs and the test positivity rate. Such variations need to be taken into account
when assessing the significance of changes in Ag-RDT results.
Evaluation: This is important for sustained follow-up and review of past activities. Internal
and external evaluations should be planned for, after a given period of time following Ag-RDT
deployment.
Current evidence on the widescale use of Ag-RDTs for COVID-19 is limited, so guidance will
be updated as new information becomes available and countries gain experience of their
implementation.
1. Diagnostic testing for SARS-CoV-2. Interim guidance. 11 September 2020. Geneva: World
Health Organization; 2020 (https://www.who.int/publications/i/item/diagnostic-testing-
for-sars-cov-2, accessed 18 November 2020).
5. SARS-CoV-2 test tracker [website]. Geneva: Foundation for Innovative New Diagnostics;
2020 (https://www.finddx.org/covid-19/test-tracker/, accessed 18 November 2020).
6. COVID‑19 strategy update. 14 April 2020. Geneva: World Health Organization; 2020
(https://www.who.int/publications/i/item/covid-19-strategy-update---14-april-2020,
accessed 18 November 2020).
11. Technical specifications of personal protective equipment for COVID-19. Geneva: World
Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-
PPE_specifications-2020.1, accessed 18 November 2020).
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