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Brummer LE, Katzenschlager S, Gaeddert M, et al. Accuracy of novel antigen rapid diagnostics for SARS-CoV-2: A living systematic review and meta-analysis. PLoS Med. 2021 Aug 12;18(8):e1003735. doi: 10.1371/journal.pmed.1003735. eCollection 2021 Aug. (Systematic review)

BACKGROUND: SARS-CoV-2 antigen rapid diagnostic tests (Ag-RDTs) are increasingly being integrated in testing strategies around the world. Studies of the Ag-RDTs have shown variable performance. In this systematic review and meta-analysis, we assessed the clinical accuracy (sensitivity and specificity) of commercially available Ag-RDTs.

METHODS AND FINDINGS: We registered the review on PROSPERO (registration number: CRD42020225140). We systematically searched multiple databases (PubMed, Web of Science Core Collection, medRvix, bioRvix, and FIND) for publications evaluating the accuracy of Ag-RDTs for SARS-CoV-2 up until 30 April 2021. Descriptive analyses of all studies were performed, and when more than 4 studies were available, a random-effects meta-analysis was used to estimate pooled sensitivity and specificity in comparison to reverse transcription polymerase chain reaction (RT-PCR) testing. We assessed heterogeneity by subgroup analyses, and rated study quality and risk of bias using the QUADAS-2 assessment tool. From a total of 14,254 articles, we included 133 analytical and clinical studies resulting in 214 clinical accuracy datasets with 112,323 samples. Across all meta-analyzed samples, the pooled Ag-RDT sensitivity and specificity were 71.2% (95% CI 68.2% to 74.0%) and 98.9% (95% CI 98.6% to 99.1%), respectively. Sensitivity increased to 76.3% (95% CI 73.1% to 79.2%) if analysis was restricted to studies that followed the Ag-RDT manufacturers' instructions. LumiraDx showed the highest sensitivity, with 88.2% (95% CI 59.0% to 97.5%). Of instrument-free Ag-RDTs, Standard Q nasal performed best, with 80.2% sensitivity (95% CI 70.3% to 87.4%). Across all Ag-RDTs, sensitivity was markedly better on samples with lower RT-PCR cycle threshold (Ct) values, i.e., <20 (96.5%, 95% CI 92.6% to 98.4%) and <25 (95.8%, 95% CI 92.3% to 97.8%), in comparison to those with Ct = 25 (50.7%, 95% CI 35.6% to 65.8%) and =30 (20.9%, 95% CI 12.5% to 32.8%). Testing in the first week from symptom onset resulted in substantially higher sensitivity (83.8%, 95% CI 76.3% to 89.2%) compared to testing after 1 week (61.5%, 95% CI 52.2% to 70.0%). The best Ag-RDT sensitivity was found with anterior nasal sampling (75.5%, 95% CI 70.4% to 79.9%), in comparison to other sample types (e.g., nasopharyngeal, 71.6%, 95% CI 68.1% to 74.9%), although CIs were overlapping. Concerns of bias were raised across all datasets, and financial support from the manufacturer was reported in 24.1% of datasets. Our analysis was limited by the included studies' heterogeneity in design and reporting.

CONCLUSIONS: In this study we found that Ag-RDTs detect the vast majority of SARS-CoV-2-infected persons within the first week of symptom onset and those with high viral load. Thus, they can have high utility for diagnostic purposes in the early phase of disease, making them a valuable tool to fight the spread of SARS-CoV-2. Standardization in conduct and reporting of clinical accuracy studies would improve comparability and use of data.

Discipline Area Score
Public Health 7 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Hospital Doctor/Hospitalists 6 / 7
Internal Medicine 6 / 7
Pediatrics (General) 6 / 7
Pediatric Emergency Medicine 6 / 7
Emergency Medicine 6 / 7
Pediatric Hospital Medicine Coming Soon...
Comments from MORE raters

Hospital Doctor/Hospitalists rater

As a cardiac surgeon, I find this is not directly relevant to my practice. However, this well written paper with excellent methodology and superb explication of techniques was a pleasure to read and learn from. In addition, there is probably some benefit to the general clinician in knowing the execute summary of this paper, even if the detailed and extensive tables won't be scrutinised.

Pediatric Emergency Medicine rater

Rapid diagnosis is important in the current pandemic due to COVID-19. Antigen rapid diagnostic tests (Ag-RDTs) are an important diagnostic tool. This systematic review evaluated the clinical accuracy of commercially available Ag-RDTs. This will identify the best test to choose for such patients as there are many commercial tests available. However, heterogeneity of the studies limits its ability as there were variability in results between tests. Further validations studies are needed.

Pediatric Emergency Medicine rater

These results are very relevant because of the pandemic environment. Excellent methodology as it compares the diagnostic test with the gold standard PCR.

Public Health rater

I think that the way the authors presented the results by test is very useful for policymakers as the performance might vary across different products.
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