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VIEWPOINT: COVID-19

Serology assays to manage COVID-19

Measurement of antibodies to SARS-CoV-2 will improve disease management if used correctly

By Florian Krammer1 and Viviana Simon1,2,3 with recombinant antigens, such as the spike dated sensitivity and specificity performance
protein (the main surface glycoprotein that is is critical for obtaining meaningful results.

I
n late 2019, China reported a cluster of used to attach and enter cells) of SARS-CoV-2; For some applications, such as serosurveys
atypical pneumonia cases of unknown the receptor-binding domain (RBD), which in high-prevalence populations, somewhat
etiology in Wuhan. The causative agent is part of the spike protein; or the viral nu- lower specificity is acceptable, whereas sensi-
was identified as a new betacoronavi- cleoprotein. Of note, using the SARS-CoV-2 tivity should be high. For uses where a false-
rus, called severe acute respiratory syn- nucleoprotein is expected to induce more positive test result would be consequential,
drome–coronavirus 2 (SARS-CoV-2), that cross-reactivity (antibodies that bind to mul- very high specificity is essential. In general,
causes coronavirus disease 2019 (COVID-19) tiple strains of coronavirus) than the spike both sensitivity and specificity should be as
(1). The virus rapidly spread across the protein, owing to sequence homology of the high as possible.
globe and caused a pandemic. Sequencing viral nucleoprotein. These assays can be han- An important application of serological
of the viral genome allowed for the develop- dled at biosafety level 2 (and therefore can be tests is to understand the antibody responses
ment of nucleic acid–based tests that have carried out more widely), given the recombi- mounted upon SARS-CoV-2 infection and

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since been widely used for the diagnosis of nant nature of the selected antigens. By con- vaccination. Assays that inform on antibody
acute (current) SARS-CoV-2 infections (2). trast, neutralization assays with replication- titer and/or show antibody functionality
Development of serological assays, which
measure the antibody responses induced by
SARS-CoV-2 infection (past but not current Quantitative and binary readouts in serology assays
infections), took longer. This is in part due to Quantitative and binary serology tests can provide important information about infection.
bottlenecks with availability of positive con-
Quantitative assays [e.g., enzyme-linked Assay with binary result
trol sera and the need for extensive specificity immunosorbent assay (ELISA)] (e.g., lateral fow assay)
and sensitivity testing in the context of pre-
existing immunity to seasonal coronaviruses. 1 2 3 4 5 6 7 8 9 10 11 12 Titers Protected? Response No response
A Negative No
Serological assays are important for under- B Titer 1:12,150 Yes
standing the prevalence of and immunity to C Titer 1:36,450 Yes C C
SARS-CoV-2. D Titer 1:50 No
E T T
Many types of serological assays have been Titer 1:450 No
developed over the past decades to measure F Titer 1:4050 Yes
G Negative No S S
antibody responses to pathogens in bodily
fluids, especially blood serum or plasma. Result Quantitative titer Yes or no
These assays use different platforms, includ-
Linked to protection? A quantitative titer can be A positive result can be loosely
ing binding assays such as enzyme-linked linked to protection associated with protection
immunosorbent assays (ELISAs), lateral flow
assays, or Western blot–based assays. In ad- Could predict protection duration? Yes No
dition, functional assays that test for virus Scalability Moderate High
neutralization, enzyme inhibition, or bacte- Ease of use Performed in specialized laboratories Easy to use, even as point-of-care test
ricidal assays can also inform on antibody-
mediated immune responses. Collectively, competent SARS-CoV-2 have to be performed (e.g., virus neutralization) will be extremely
serological assays are essential tools in the in biosafety level 3 facilities, which limits their useful to answer important scientific ques-
management of infectious diseases, includ- application. Safer and more high-throughput tions about immune protection from reinfec-
ing diagnosis of infection, measurements of alternatives to using infectious virus are tion. For example, do all infected individuals
protective antibody titers upon vaccination, under development and include the use of mount a robust antibody response to SARS-
and seroprevalence assessments of immunity pseudotyped viral particle assays, in which CoV-2 infection? It is unclear whether there
in a population. the SARS-CoV-2 spike protein is grafted onto is a difference in the antibody responses
Serological assays for SARS-CoV-2 are harmless viruses or virus-like particles. found in individuals presenting with severe,
now becoming widely available and include A limited number of ELISA and lateral mild, and asymptomatic COVID-19 and how
ELISAs (3–7), lateral flow assays (5, 8, 9) (see flow assays have recently received emer- long antibody responses last. Moreover, it is
the figure), and virus neutralization assays. gency use authorization from the U.S. Food unknown if the presence of binding antibody
ELISA and lateral flow assays are performed and Drug Administration (FDA). In addition, to the spike or RBD antigens correlates with
many lateral flow assays from different com- virus neutralization. Whether antibody titers
GRAPHIC: H. BISHOP/SCIENCE

1
panies are available, but their usefulness is (binding or neutralizing) correlate with pro-
Department of Microbiology, Icahn School of Medicine
at Mount Sinai, New York, NY, USA. 2Division of Infectious questionable, given the lack of official perfor- tection from reinfection is also unclear. Such
Diseases, Department of Medicine, Icahn School of mance validation with respect to sensitivity data will be important when dissecting an-
Medicine at Mount Sinai, New York, NY, USA. 3Global (how many true positives are detected) and tibody responses generated by natural infec-
Health and Emerging Pathogens Institute, Icahn School of
Medicine at Mount Sinai, New York, NY, USA. Email: florian. specificity (the proportion of false positives) tion compared to vaccination.
krammer@mssm.edu; viviana.simon@mssm.edu (9–11). Using serological assays with vali- Serological testing can also inform on the

1060 5 JUNE 2020 • VOL 368 ISSUE 6495 sciencemag.org SCIENCE

Published by AAAS
prevalence of SARS-CoV-2 infections in dif- Quantitative measurements of antibody ti- (15). For these types of studies, serological
ferent populations. Although it is impractical ters from at least two different ELISAs have assays that measure a quantitative antibody
to test the whole population, well-designed been shown to correlate well with neutraliz- titer have been instrumental. However, when
serosurveys are essential to determine how ing titers (3, 4). converting the concept of an “immune pass-
prevalent COVID-19 is in the general popu- Identifying individuals who are immune is port” to practice, point-of-care serological as-
lation, in selected subsections of the popula- an important but also complex and politically says that produce a binary response may also
tion (e.g., health care workers), or in specific charged application of serological assays. be useful. A combined strategic approach
risk groups. Both quantitative assays and Individuals who were infected with “common may be the safest while also being feasible.
assays with a binary outcome can be used cold” human coronaviruses develop antibody To account for sensitivity and false positives,
for these surveys. Quantitative assays may responses and are protected from reinfection if every positive lateral flow test result is con-
provide more reliable results [e.g., two-step for a certain period of time, likely for years firmed with a second test that produces a
ELISAs (12)], but they are also harder to scale (14). If reinfection occurs, it is often mild or titer—which also indicates the robustness of
because they often have to be performed in asymptomatic. In addition, infection with the response and could be linked to the pres-
specialized laboratories. By contrast, assays SARS-CoV-1 was shown to induce neutraliz- ence and duration of protection—the number
with binary outcomes (e.g., lateral flow as- ing antibody responses that last for several of false-positive results would be greatly re-
says) can be easily scaled and implemented years (14). On the basis of these data, indi- duced. Such a targeted sequential approach
because they are often point-of-care tests. viduals with antibodies to SARS-CoV-2 are would provide reliable information on im-
Analyses of the results of serosurveys need assumed to be less susceptible to reinfection, munity and avoid putting individuals at risk.
to account for the sensitivity and specificity reducing the risk of severe COVID-19 and also Several academic laboratories have devel-
of the assay used as well as the estimated limiting the possibility of spreading the virus. oped robust, specific serological assays, and
prevalence of infections in a population. In Therefore, it has been proposed that indi- high-quality commercial options are becom-

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addition, biological variables resulting from viduals with robust antibody responses could ing available. In accordance with academic
in-depth characterization of the immune safely return to normal life and work, slowly grassroots traditions, a toolkit to set up an-
responses such as, but not limited to, the starting the economy on a path to recovery. tibody assays has been distributed to more
duration of the immune responses and the Detection of protective immune responses is than 200 laboratories across the world, and
dynamic nature of antibody titers linked to also an important consideration for health a detailed protocol to facilitate local imple-
severe, mild, and asymptomatic COVID-19 care workers. In addition, people immune to mentation has been published (12). With
manifestations will need to be factored into SARS-CoV-2 could be spared from quarantine high-quality serological assays now avail-
calculating prevalence based on serosurveys. and social distancing measures during a po- able, the key challenge will be to apply and
Currently, many of these critical variables are tential second or third wave of SARS-CoV-2 deploy these tests in a strategic manner to
unknown, and any serosurvey analysis gener- infections in the winter of 2020. Accordingly, safely bring communities out of the current
ated in the immediate future should be inter- some countries have proposed an “immune pandemic response back to the realm of “nor-
preted with caution. passport” for such individuals. mal” life. j
Donors for convalescent plasma therapy However, there are numerous caveats that RE FERENCES AND NOTES
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ACKNOWL EDGMENTS
this intervention likely increases with the A known antibody titer that correlates
The authors are supported by the National Institute of Allergy
antibody titer of the donor. It is, therefore, with protection would also be extremely ben-
and Infectious Diseases (NIAID) Collaborative Influenza
important to screen potential convalescent eficial for vaccine development. Protective Vaccine Innovation Centers (CIVIC; 75N93019C00051),
donors so that individuals with the highest titers and/or correlates of immune protection the NIAID Centers of Excellence for Influenza Research and
antibody titers can be selected. This screen- have been established for many virus infec- Surveillance (CEIRS; HHSN272201400008C), institutional
funding, and philanthropic donations. The SARS-CoV-2
ing can be accomplished by measuring virus- tions, including influenza virus, hepatitis A reagents developed in our labs are freely available to the
neutralizing activity of the plasma, which is virus, hepatitis B virus, and measles virus. scientific community (www.beiresources.org/). Mount Sinai
a lengthy process (several days) and needs to For several of these infections, the dynamics is in the process of commercial licensing of assays described
here and has filed for patent protection.
be performed in a biosafety level 3 laboratory. of the immune responses are well understood
ELISA-based antibody testing that produces and the duration of protection based on an- Published online 15 May 2020
a titer is quick (hours) and easy to perform. tibody titers has been successfully modeled 10.1126/science.abc1227

SCIENCE sciencemag.org 5 JUNE 2020 • VOL 368 ISSUE 6495 1061

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Serology assays to manage COVID-19
Florian Krammer and Viviana Simon

Science 368 (6495), 1060-1061.

DOI: 10.1126/science.abc1227originally published online May 15, 2020

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