Laboratories and diagnostic companies are racing to produce antibody tests, a key
part of the response to the COVID-19 pandemic. Anna Petherick reports.
In response to coronavirus disease 2019 (COVID-19), governments have instigated rules
that constrain personal freedoms and hamstring their own economies, placing approximately
3 billion people under lockdown. Some have rolled out widespread testing for current
infections, while others limited these tests to people who were hospitalised, atleast
during the early stages of their responses. As new controls begin to bite, the race
to develop and approve a test with a different purpose—to assess not current viral
infection, but immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—has
heated up. Medical diagnostic companies are scrambling, and governments are looking
to order these antibody tests by the millions.
The task now facing governments and national regulators is to balance urgency against
the everyday sensitivity and specificity concerns that apply to any new medical diagnostic.
A few technical questions still exist around optimising test design, primarily hinging
on understanding how the viral coating triggers a healthy immune system's recognition
and neutralisation of the virus. Yet, there is a palpable hurry to limit economic
damage, to get people back to work, and to reopen borders—and those whose immunity
can be demonstrated should be able to return to work, without risk. Some regulators,
such as the US Food & Drug Administration (FDA), have already chosen to relax normal
assessment criteria.
Demand could not be higher. “We really have been inundated with calls”, says Dan Hanlon,
director of international sales at CTK Biotech (San Diego, CA, USA), which has developed
an antibody test. “The inquiries are coming from ministries of health, from various
government institutions, from military contractors, from industry distributors that
commonly work in this realm.” Under normal circumstances, CTK Biotech would have to
collect data for FDA approval of a novel diagnostic at three different sites, but
under the emergency use authorisation issued by the agency in mid-March, this is no
longer necessary. “Basically [the FDA authorisation] says, ‘You can start selling
right away and then send us your data, and if we don’t like it, you have to take your
product back’”, says Sam Lewis, CTK Biotech's director of research and development.
In Europe, a German company called Euroimmun has recently received certification that
will allow their test to be sold within the EU. “Everybody is getting crazy at the
moment with regard to antibody detection, especially for medical personnel, because
it's very important to know if they already had the virus”, says Konstanze Stiba,
Euroimmun's antibody test product manager. Health worker shortages due to illness
put further pressure on already strained health systems. If a test can show that a
health worker has already had COVID-19, and is therefore probably immune, they can
return to work without fear of infection. “That's something you can easily do with
an antibody detection test and not with PCR—you can keep the health system stable.”
Antibody testing is multipurpose: it can verify that vaccines are working as intended
during clinical trials, or be used in contact tracing weeks or longer after a suspected
infection in an individual. Probably its most important current use, en masse, is
to help inform public policy makers how many asymptomatic cases have occurred in a
population. Antibodies reveal evidence of a previous infection any time from about
a week after the infection occurred. “At the moment we are only estimating the number
of people who have been infected. No one in the world has measured that properly yet”,
says Martin Hibberd, professor of emerging infectious diseases at the London School
of Hygiene & Tropical Medicine, UK. “We think that children are infective but asymptomatic,
for example, but we don’t know enough about this—and that information matters for
decisions about whether to close schools.”
PCR tests detecting viral RNA, indicating current viral infection, are being used
to diagnose cases of COVID-19 and are an essential part of contact tracing and testing.
However, there are global supply challenges, with huge demand for the PCR primers,
as well as for the positive controls needed to ensure the performance of individual
machines. PCR tests for SARS-CoV-2 have been available since January, soon after the
virus was identified. However, the technology behind antibody tests is fundamentally
distinct and generally harder to get right. “If you have a sequence today, you have
a PCR tomorrow”, says Linfa Wang, director of Duke-NUS Medical School's programme
in emerging infectious diseases, in Singapore. “Whether the sensitivity [of PCR] will
be enough is another thing, but usually in the first round, it will give you data
that you can use. Serology is different.”
Antibody tests are different because they require some knowledge of the proteins that
form the viral coat—specifically, those proteins to which the immune system responds,
triggering the production of antibodies that flag or neutralise the virus. Those sections
of the viral protein coat must then be produced in the laboratory, using cell lines,
for inclusion in an immunoassay (eg, ELISA) that detects whether antibodies are present.
Such immunoassays will form the basis of home testing kits for people who think they
have had COVID-19. But their development takes time. Expressing the protein in the
right structure is often the most difficult step. In a non-native system, such as
a bacterial cell, the complex protein structures can come out slightly deformed, enough
to stop antibodies from recognising them as they would the original viral coat protein.
There are also questions about which antigens (proteins) are best for this purpose.
Some diagnostic developers are cagey about giving away too many details, although
the viral spike protein is universally perceived as the obvious candidate. “All viral
proteins will elicit antibody responses to some extent”, says Berend-Jan Bosch, a
coronavirus specialist at Utrecht University in the Netherlands. “But the spike protein
is the main antigen that elicits neutralising antibodies, as this protein is the sole
protein on the viral surface that is responsible for entry into the host cell.” Researching
the spike protein also presents avenues to the development of therapeutics for COVID-19,
and Bosch and his team have now created a human monoclonal antibody that neutralises
SARS-CoV-2 in vitro. In parallel, he is working with Marion Koopmans of Erasmus Medical
Centre (Netherlands) to develop antibody tests.
Which part of the spike protein to use is less obvious, however. A team at New York's
Icahn School of Medicine at Mount Sinai (NY, USA), has published details of antibody
tests that use either the whole spike protein, modified slightly to improve its stability
during mass production in cell lines, or only the receptor-binding domain. Others,
such as Peng Zhou, who leads the bat virus infection and immunity group at the Wuhan
Institute of Virology in China, and was part of the team that sequenced SARS-CoV-2's
genetic code in January, have used the nucleocapsid protein and the spike protein.
Zhou's antibody test is one of at least ten antibody tests that have already been
deployed in hospitals across China. “[The] nucleocapsid protein is the most abundant
viral protein, which means it's easy to detect. But we also chose spike protein because
it's very specific”, he says. “Actually, for coronavirus, the most divergent protein
is [the] spike protein.”
There is a lot hanging on the uniqueness of the spike protein. In terms of the specificity
of serological tests in which it is used, the more unique it is, the lower the odds
of cross-reactivity with other coronaviruses—false positives resulting from immunity
to other coronaviruses. The most similar of these is severe acute respiratory syndrome
coronavirus (SARS-CoV), which led to the SARS outbreak of 2002. But another four coronaviruses
cause the common cold, and ensuring there is no cross-reactivity to these is essential.
“If you line up the amino acids of the spike proteins of SARS and the COVID-19 virus,
there's a 75% identity”, says Lewis. Hibberd reckons the overall figure for common
cold-causing coronaviruses is probably about 50–60%, but the potential for cross-reactivity
really depends on whether the new tests select sections of the spike protein that
are particularly distinct across coronaviruses. Even though SARS cases were recorded
in only a handful of countries, many antibody test developers—Euroimmun, Koopmans,
and Wang among them—are working to demonstrate the absence of cross-reactivity of
the new tests with SARS-CoV or other coronaviruses.
Because, in Bosch's words, the spike protein is the sole viral protein responsible
for entry into the host cell, its stability as SARS-CoV-2 mutates is important for
understanding whether re-infection with a novel strain is likely. Wang says that the
spike protein is highly conserved. Virologists generally agree that media reports
of reinfection with SARS-CoV-2 are most likely due to erroneous PCR tests. Hibberd
argues that once people produce antibodies against a particular coronavirus, they
probably have immunity for life. Indeed, Wang's laboratory has investigated how long
immunity against SARS-CoV and Middle East respiratory syndrome coronavirus lasts.
“17 years later, a SARS survivor still has neutralising antibodies against SARS—we
found that not only were the antibodies there, but they could still neutralise the
SARS virus.”
This is reassuring news for governments that intend to deploy antibody tests to establish
which health-care workers are immune, and to get their populaces back to work as soon
as possible. Nonetheless, scaling up production quickly enough to meet the informational
needs of public policy makers is no mean feat. Behind the scenes, experts worry that,
despite some big recent promises, national authorities have not attempted anything
like this before. Medical diagnostic companies might be better positioned to meet
demand, but they too are stretched. “We’ve tried to notify our [other] customers that
we’re focusing on the crisis, which allows scale-up to increase output”, says Hanlon.
Other contracts, except urgent HIV and malaria diagnostics, have been downgraded in
production schedules. “This really is the main focus product now.”