Antigen-based Rapid Diagnostic Testing or Alternatives for Diagnosis of Symptomatic COVID-19: A Simulation-based Net Benefit Analysis

Emily A. Kendall, Nimalan Arinaminpathy, Jilian A. Sacks, Yukari C. Manabe, Sabine Dittrich, Samuel G. Schumacher, David W. Dowdy

Research output: Contribution to journalArticlepeer-review

Abstract

Background: SARS-CoV-2 antigen-detection rapid diagnostic tests can diagnose COVID-19 rapidly and at low cost, but lower sensitivity compared with reverse-transcriptase polymerase chain reaction (PCR) has limited clinical adoption. Methods: We compared antigen testing, PCR testing, and clinical judgment alone for diagnosing symptomatic COVID-19 in an outpatient setting (10% COVID-19 prevalence among the patients tested, 3-day PCR turnaround) and a hospital setting (40% prevalence, 24-hour PCR turnaround). We simulated transmission from cases and contacts, and relationships between time, viral burden, transmission, and case detection. We compared diagnostic approaches using a measure of net benefit that incorporated both clinical and public health benefits and harms of the intervention. Results: In the outpatient setting, we estimated that using antigen testing instead of PCR to test 200 individuals could be equivalent to preventing all symptomatic transmission from one person with COVID-19 (one "transmission-equivalent"). In a hospital, net benefit analysis favored PCR and testing 25 patients with PCR instead of antigen testing achieved one transmission-equivalent of benefit. In both settings, antigen testing was preferable to PCR if PCR turnaround time exceeded 2 days. Both tests provided greater net benefit than management based on clinical judgment alone unless intervention carried minimal harm and was provided equally regardless of diagnostic approach. Conclusions: For diagnosis of symptomatic COVID-19, we estimated that the speed of diagnosis with antigen testing is likely to outweigh its lower accuracy compared with PCR, wherever PCR turnaround time is 2 days or longer. This advantage may be even greater if antigen tests are also less expensive.

Original languageEnglish (US)
Pages (from-to)811-819
Number of pages9
JournalEpidemiology
Volume32
Issue number6
DOIs
StatePublished - Nov 1 2021

Keywords

  • Decision-curve analysis
  • Diagnostic tests
  • Hospitals
  • Rapid antigen tests
  • SARS-CoV-2
  • Simulation
  • Symptomatic outpatients

ASJC Scopus subject areas

  • Epidemiology

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