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Clinical and laboratory evaluation of SARS-CoV-2 lateral flow assays for use in a national COVID-19 seroprevalence survey
  1. Barnaby Flower1,2,
  2. Jonathan C Brown1,
  3. Bryony Simmons1,
  4. Maya Moshe1,
  5. Rebecca Frise1,
  6. Rebecca Penn1,
  7. Ruthiran Kugathasan1,
  8. Claire Petersen3,
  9. Anna Daunt1,3,
  10. Deborah Ashby4,
  11. Steven Riley4,
  12. Christina Joanne Atchison2,4,
  13. Graham P Taylor1,
  14. Sutha Satkunarajah5,
  15. Lenny Naar5,
  16. Robert Klaber3,
  17. Anjna Badhan1,
  18. Carolina Rosadas1,
  19. Maryam Khan1,
  20. Natalia Fernandez1,
  21. Macià Sureda-Vives6,
  22. Hannah M Cheeseman1,
  23. Jessica O'Hara1,
  24. Gianluca Fontana5,
  25. Scott J C Pallett7,8,
  26. Michael Rayment8,
  27. Rachael Jones8,
  28. Luke S P Moore8,9,
  29. Myra O McClure1,
  30. Peter Cherepanov1,
  31. Richard Tedder1,
  32. Hutan Ashrafian10,
  33. Robin Shattock1,
  34. Helen Ward2,4,
  35. Ara Darzi2,5,
  36. Paul Elliot2,11,
  37. Wendy S Barclay1,
  38. Graham S Cooke1,2
  1. 1 Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
  2. 2 NIHR BRC, Imperial College NHS Trust, London, UK
  3. 3 Imperial College Healthcare NHS Trust, London, UK
  4. 4 Department of Epidemiology and Public Health, Imperial College London, London, UK
  5. 5 Institute of Global Health Innovation, Imperial College London, London, UK
  6. 6 Synthetic Biology Group, MRC London Institute of Medical Sciences, Imperial College London, London, UK
  7. 7 Centre for Defence Pathology, British Army, Birmingham, UK
  8. 8 Chelsea and Westminster Healthcare NHS Trust, London, UK
  9. 9 NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
  10. 10 Department of Surgery and Cancer, Imperial College London, London, UK
  11. 11 Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
  1. Correspondence to Dr Barnaby Flower, Infectious Disease, Department of Medicine, Imperial College London, London W2 1NY, UK; b.flower{at}


Background Accurate antibody tests are essential to monitor the SARS-CoV-2 pandemic. Lateral flow immunoassays (LFIAs) can deliver testing at scale. However, reported performance varies, and sensitivity analyses have generally been conducted on serum from hospitalised patients. For use in community testing, evaluation of finger-prick self-tests, in non-hospitalised individuals, is required.

Methods Sensitivity analysis was conducted on 276 non-hospitalised participants. All had tested positive for SARS-CoV-2 by reverse transcription PCR and were ≥21 days from symptom onset. In phase I, we evaluated five LFIAs in clinic (with finger prick) and laboratory (with blood and sera) in comparison to (1) PCR-confirmed infection and (2) presence of SARS-CoV-2 antibodies on two ‘in-house’ ELISAs. Specificity analysis was performed on 500 prepandemic sera. In phase II, six additional LFIAs were assessed with serum.

Findings 95% (95% CI 92.2% to 97.3%) of the infected cohort had detectable antibodies on at least one ELISA. LFIA sensitivity was variable, but significantly inferior to ELISA in 8 out of 11 assessed. Of LFIAs assessed in both clinic and laboratory, finger-prick self-test sensitivity varied from 21% to 92% versus PCR-confirmed cases and from 22% to 96% versus composite ELISA positives. Concordance between finger-prick and serum testing was at best moderate (kappa 0.56) and, at worst, slight (kappa 0.13). All LFIAs had high specificity (97.2%–99.8%).

Interpretation LFIA sensitivity and sample concordance is variable, highlighting the importance of evaluations in setting of intended use. This rigorous approach to LFIA evaluation identified a test with high specificity (98.6% (95%CI 97.1% to 99.4%)), moderate sensitivity (84.4% with finger prick (95% CI 70.5% to 93.5%)) and moderate concordance, suitable for seroprevalence surveys.

  • viral infection
  • clinical epidemiology
  • respiratory infection

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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  • BF and JCB contributed equally.

  • WSB and GSC contributed equally.

  • Contributors All listed authors made substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content; and final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This work was supported by funding from The Department of Health and Social Care (DHSC) and NIHR Biomedical Research Centre of Imperial College NHS Trust. GC is supported by an NIHR Professorship. WB is the Action Medical Research Professor. AD is an NIHR senior investigator. DA is an Emeritus NIHR Senior Investigator. HW is an NIHR Senior Investigator. RC holds IPR on the hybrid DABA and this work was supported by UKRI/MRC grant (reference is MC_PC_19078). The sponsor is Imperial College London.

  • Disclaimer The funders had no role in the production of this manuscript.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at and declare: no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Patient consent for publication Not required.

  • Ethics approval The study’s conduct and reporting is fully compliant with the World Medical Association’s Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects. This work was undertaken as part of the REACT 2 study, with ethical approval from South Central–Berkshire B Research Ethics Committee (REC ref: 20/SC/0206; IRAS 283805). Samples for negative controls were taken from the Airwave study approved by North West–Haydock Research Ethics Committee (REC ref: 19/NW/0054).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. Anonymised data with results of positive/negative individual tests can be provided on request through contact with study team. Email; ORCID ID: 0000-0002-2659-544X.

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