24 People, one test: Boosting test efficiency using pooled serum antibody testing for SARS-CoV-2

Abstract

Background: The global pandemic of COVID-19 (coronavirus disease 2019) is caused by the novel coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), with different prevalence rates across countries and regions. Dynamic testing strategies are mandatory to establish efficient mitigation strategies against the disease; to be cost effective, they should adapt to regional prevalences. Seroprevalence surveys that detect individuals who have mounted an immune response against COVID-19 will help to determine the total number of infections within a community and improve the epidemiological calculations of attack and case fatality rates of the virus. They will also inform about the percentage of a population that might be immune against re-infections. Methods: We developed a sensitive and specific cell-based assay to detect conformational SARS-CoV-2 spike (SARS-2-S) S1 antibodies in human serum, and have cross-evaluated this assay against two FDA-approved SARS-CoV-2 antibody assays. We performed pseudovirus neutralization assays to determine whether sera that were rated antibody-positive in our assay were able to specifically neutralize SARS-2-S. We pooled up to 24 sera and assessed the group testing performance of our cell-based assay. Group testing was further optimized by Monte Carlo like simulations and prospectively evaluated. Findings: Highly significant correlations could be established between our cell-based assay and commercial antibody tests for SARS-CoV-2. SARS-2-S S1 antibody-positive sera neutralized SARS-2-S but not SARS-S, and were sensitively and specifically detected in pools of 24 samples. Monte Carlo like simulations demonstrated that a simple two-step pooling scheme with fixed pool sizes performed at least equally as well as Dorfman's optimal testing across a wide range of antibody prevalences. Interpretation: We demonstrate that a cell-based assay for SARS-2-S S1 antibodies qualifies for group testing of neutralizing anti-SARS-2-S antibodies. The assay can be combined with an easily implemented algorithm which greatly expands the screening capacity to detect anti-SARS-2-S antibodies across a wide range of antibody prevalences. It will thus improve population serological testing in many countries.