WHO 20/136 is standard reference material for SARS-CoV-2 serology assays. Standardization of serology assays that target the same antigen and class of immunoglobulin will enable comparison of results between studies that use various lab-developed and commercial assays around the world. Standardization of assays will help better define immune correlates of protection and possibly immune correlates of vaccine efficacy. Two automated SARS-COV-2 anti-S1 RBD immunoglobulin serology assays on the Atellica IM Analyzer were calibrated to WHO 20/136 Standard Reference Material which was assigned 1000 binding antibody units (BAU/mL). The anti-S1 RBD IgG assay (sCOVG) cut-off Index of 1.00 corresponded to WHO 45.1 BAU/mL, and the anti-S1 RBD Ig Total assay (COV2T) cut-off Index of 1.00 corresponded to WHO 6.70 BAU/mL.

Background Current serological methods for SARS-CoV-2 lack adequate standardization to a universal standard reference material. Standardization will allow comparison of results across various lab-developed and commercial assays and publications. SARS-CoV-2 EURM-017 is human sera reference material containing antibodies directed against SARS-CoV-2 proteins, S1/S2 (full-length spike [S]), S1 receptor-binding domain (S1 RBD), S1, S2, and nucleocapsid (N) protein. The goal of this study was to characterize five antigen-specific serum fractions in EURM-017 for standardization of serology assays. Methods Five antigen-specific serum fractions were affinity purified, quantified, and PRNT 50 titers compared. Standardization methods were established for two anti-S1 RBD (IgG and Total Ig) and one N protein assay. For the anti-S1 RBD assays, standardization involved determining assay index values for serial dilutions of S1-RBD anti-sera. Index values for the anti-S1 RBD IgG assay and PRNT 50 titers were determined for 44 symptomatic COVID-19 patient sera. The index values were converted to EURM-017 ug/mL. Results Anti-sera protein content was as follows: S1 (17.7 µg/mL), S1 RBD (17.4 µg/mL), S1/S2 (full-length S) (34.1 µg/mL), S2 (29.7 µg/mL), and N protein (72.5 µg/mL). S1 anti-serum had the highest neutralization activity. A standardization method for S1 RBD anti-serum and an anti-S1 RBD IgG assay yielded the linear equation (y=0.75x-0.10; y=index, x=µg/mL anti-serum). Patient sample index values for the S1-RBD IgG assay correlated well with PRNT 50 titers (Pearson r=0.84). Using the equation above, patient index values were converted to standardized µg/mL. Conclusions Standardization of different lab-developed and commercial assays to EURM-017 antigen-specific anti-sera will allow comparison of results across studies globally due to traceability to a single standard reference material.

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Introduction Dried blood spot (DBS) sampling is a minimally invasive method for specimen collection with potential multifaceted uses, particularly for serosurveillance of previous SARS-CoV-2 infection. In this study, we assessed DBS as a potential specimen type for assessing IgG and total (including IgG and IgM) antibodies to SARS-CoV-2 in vaccinated and naturally infected patients. Methods Six candidate buffers were assessed for eluting blood from DBS cards. The study utilized one hundred and five paired plasma specimens and DBS specimens from prospectively collected SARS-CoV-2 vaccinated individuals, remnants from those with PCR confirmed SARS-CoV-2 infections, or remnants from those without history of infection or vaccination. All specimens were tested with the Siemens SARS-CoV-2 total assay (COV2T) or IgG assay (sCOVG). Results The lowest backgrounds were observed with water and PBS, and water was used for elution. Relative to plasma samples, DBS samples had a positive percent agreement (PPA) of 94.4% (95% CI: 94.9-100%) for COV2T and 79.2 (68.4-87.0) for sCOVG using the manufacturer’s cutoff. The NPA was 100 % (87.1-100.0 and 85.13-100) for both assays. Dilution studies revealed 100% (95% CI: 90.8-100%) qualitative agreement between specimen types on the COV2T assay and 98.0% (88.0-99.9%) with the sCOVG using study defined cutoffs. Conclusion DBS specimens demonstrated high PPA and NPA relative to plasma for SARS-CoV-2 serological testing. Our data support feasibility of DBS sampling for SARS-CoV-2 serological testing.

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