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      Systematic review with meta-analysis of the accuracy of diagnostic tests for COVID-19

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          • RT-PCR followed by CT shows high sensitivity for detecting COVID-19
          • Immunological tests should use a combination of IgG and IgM
          • The genes E and RdRp present high analytical sensitivity to detect the virus
          • Assays for molecular diagnosis should employ two-target systems
          • Studies of diagnostic tests for COVID-19 are of moderate methodological quality



          . To collate the evidence on the accuracy parameters of all available diagnostic methods for detecting SARS-CoV-2.


          . A systematic review with meta-analysis was performed. Searches were conducted in Pubmed and Scopus (April 2020). Studies reporting data on sensitivity or specificity of diagnostic tests for COVID-19 using any human biological sample were included.


          . Sixteen studies were evaluated. Meta-analysis showed that computed tomography has high sensitivity (91.9% [89.8–93.7%]), but low specificity (25.1% [21.0–29.5%]). The combination of IgM and IgG antibodies demonstrated promising results for both parameters (84.5% [82.2%-86.6%]; 91.6% [86.0%-95.4%], respectively). For RT-PCR tests, rectal stools/swab, urine, and plasma were less sensitive while sputum (97.2% [90.3–99.7%]) presented higher sensitivity for detecting the virus.


          . RT-PCR remains the gold standard for the diagnosis of COVID-19 in sputum samples. However, the combination of different diagnostic tests is highly recommended to achieve adequate sensitivity and specificity.

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          Most cited references 8

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          Performance of VivaDiag COVID‐19 IgM/IgG Rapid Test is inadequate for diagnosis of COVID‐19 in acute patients referring to emergency room department

          To the Editor, From late December 2019, coronavirus infectious disease (COVID‐19) epidemics spread from Wuhan, China, to all over the world, including Italy. 1 , 2 , 3 To date, real‐time reverse transcription‐polymerase chain reaction (RT‐PCR) in respiratory samples is the current gold standard method for the diagnosis of COVID‐19. 4 , 5 However, molecular testings are time consuming and require specialized operators, factors that limit their use in real life when the rapid diagnosis is required for fast intervention decisions. Recently, an easy to perform serological assay has been assessed 6 to differentiate COVID‐19 positive patients from negative subjects. We herein report results of a real‐life study performed in an emergency room department of a tertiary hospital in Northern Italy to validate VivaDiag COVID‐19 IgM/IgG Rapid Test lateral flow immunoassay (LFIA) for the rapid diagnosis of COVID‐19. Overall 110 subjects were tested for COVID‐19‐specific serological assay at Fondazione IRCCS Policlinico San Matteo. In detail, we enrolled 30 healthy volunteers with documented negative results for COVID‐19 RT‐PCR in respiratory samples (M 11/F 19; median age, 38.5; range, 25‐69 years). Ten of them (33.3%) had been infected in the past with one of the common OC43, 229E, HKU1, and NL63 coronavirus. Thirty COVID‐19‐positive patients (25 M/5 F; median age, 73.5; range, 38‐86 years) admitted to the Infectious Diseases Department or at the Intensive Care Unit were tested as positive controls. Finally, the performance of VivaDiag COVID‐19 IgM/IgG Rapid Test LFIA was tested in 50 patients at their first access at emergency room department with fever and respiratory syndrome (34 M/16 F; median age, 61.50; range, 33‐97 years) in comparison with results of nasal swab molecular screening. 5 VivaDiag COVID‐19 IgM/IgG from VivaChek was performed according to manufacturer's instruction by adding 10 µL of serum or whole blood sample into the sample port followed by adding 2 to 3 drops (70‐100 µL) of dilution buffer. 6 After about 15 minutes, results were read. Respiratory samples (FLOQSwabs; Copan Italia, Brescia, Italy) were collected from all the patients. Total nucleic acids (DNA/RNA) were extracted from 200 µL of UTM using the QIAsymphony instrument with QIAsymphony DSP Virus/Pathogen Midi Kit (complex 400 protocols) according to the manufacturer's instructions (QIAGEN; Qiagen, Hilden, Germany). Specific real‐time RT‐PCR targeting RNA‐dependent RNA polymerase and E genes were used to detect the presence of SARS‐CoV‐2 according to the WHO guidelines 7 and Corman et al 5 protocols. In the cohort of patients admitted to the emergency room department, data from serological tests were compared to molecular results to define specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the rapid serological test. As expected, all 30 COVID‐19 negative volunteers were negative for both immunoglobulin G (IgG) and immunoglobulin M (IgM) using the VivaDiag COVID‐19 IgM/IgG Rapid Test. No cross‐reactivity was detected in the 10 subjects with previous coronaviruses infection, supporting the high specificity of the VivaDiag COVID‐19 IgM/IgG Rapid Test LFIA. Serum samples were obtained at a median 7 days (interquartile range, 4‐11) after the first COVID‐19 positive result from 30 hospitalized patients. A total of 19 of 30 (63.3%) were positive for both IgM and IgG, 5 of 30 (16.7%) were negative for both IgG and IgM, 5 of 30 (16.7%) were weakly positive for both IgM and IgG, and only 1 of 30 (3.3%) was positive for IgM and negative for IgG. Thus, the sensitivity of the rapid assay was suboptimal (data not are shown). A possible explanation is the low antibody titers or a delayed humoral response. 6 Focusing on acute patients enrolled from the emergency room department, 12 of 50 (24%) were negative for COVID‐19 by real‐time RT‐PCR. Of these, 1 (8.3%) showed a positive results for the VivaDiag COVID‐19 IgM/IgG Rapid Test, while the other 11 of 12 (91.7%) tested negative. On the other side, 38 patients were positive for COVID‐19 by real‐time RT‐PCR. Of these, only 7 (18.4%) showed a positive or weak positive serology for IgM and/or IgG, while the other 31 of 38 (81.6%) tested negative for the rapid serology assay (Table 1). Thus, the sensitivity of the VivaDiag COVID‐19 IgM/IgG Rapid Test was 18.4%, specificity was 91.7%, while NPV was 26.2%, and PPV was 87.5% in patients enrolled from emergency room department. In contrast with the high levels of sensitivity reported in the previous study, 6 VivaDiag COVID‐19 IgM/IgG Rapid Test revealed a very poor sensitivity (less than 20%). Indeed, the majority of patients that tested positive for COVID‐19 by real‐time RT‐PCR would have been identified as negative using only the rapid serological assay, leading to a misdiagnosis of COVID‐19 disease in the vast majority of patients. On the basis of our results, VivaDiag COVID‐19 IgM/IgG Rapid Test LFIA is not recommended for triage of patients with suspected COVID‐19. Table 1 Characteristics and VivaDiag COVID‐19 IgM/IgG Rapid Test results of 50 consecutive patients referred to the emergency room department Patient Sex Age Result of COVID‐19 real‐time RT‐PCR on NS VivaDiag COVID‐19 IgM/IgG Rapid Test IgM IgG 1 M 33 neg − − 2 M 51 pos − − 3 M 51 pos − − 4 M 38 pos − − 5 F 80 pos − − 6 F 64 neg − − 7 M 81 neg − − 8 M 76 pos +/− − 9 M 33 pos − − 10 M 37 neg − − 11 F 45 pos − − 12 M 53 pos − − 13 M 66 neg − − 14 M 78 pos − − 15 F 97 pos − − 16 M 38 pos − − 17 M 72 pos − − 18 M 56 pos − − 19 M 80 pos − +/− 20 M 72 pos − − 21 F 55 pos − − 22 M 82 pos − − 23 M 47 pos + +/− 24 F 63 pos − − 25 F 80 pos +/− − 26 M 59 pos − − 27 M 66 pos − − 28 M 39 pos − − 29 F 78 neg − − 30 M 71 neg − − 31 F 46 neg − − 32 F 51 pos − − 33 F 75 pos − − 34 F 82 pos + +/− 35 F 51 pos +/− +/− 36 M 84 pos − − 37 M 50 pos − − 38 M 50 pos + +/− 39 F 72 neg − − 40 M 54 neg − − 41 F 64 neg + − 42 M 64 pos − − 43 M 70 pos − − 44 M 56 pos − − 45 M 68 pos − − 46 F 36 pos − − 47 M 60 pos − − 48 M 66 pos − − 49 M 54 neg − − 50 M 56 pos − − Abbreviations: −, negative result; +, positive result; +/−, weakly positive result; COVID‐19, coronavirus infectious disease 2019; IgG, immunoglobulin G; IgM, immunoglobulin M; NS, nasopharyngeal swab; RT‐PCR, reverse transcription‐polymerase chain reaction. John Wiley & Sons, Ltd. This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency. MEMBERS OF THE SAN MATTEO PAVIA COVID‐19 TASK FORCE R. Bruno, M. Mondelli, E. Brunetti, A. Di Matteo, E. Seminari, L. Maiocchi, V. Zuccaro, L. Pagnucco, B. Mariani, S. Ludovisi, R. Lissandrin, A. Parisi, P. Sacchi, S. F. A. Patruno, G. Michelone, R. Gulminetti, D. Zanaboni, S. Novati, R. Maserati, P. Orsolini, and M. Vecchia (ID Staff); M. Sciarra, E. Asperges, M. Colaneri, A. Di Filippo, M. Sambo, S. Biscarini, M. Lupi, S. Roda, T. C. Pieri, I. Gallazzi, M. Sachs, and P. Valsecchi (ID Resident); S. Perlini, C. Alfano, M. Bonzano, F. Briganti, G. Crescenzi, A. G. Falchi, R. Guarnone, B. Guglielmana, E. Maggi, I. Martino, P. Pettenazza, S. Pioli di Marco, F. Quaglia, A. Sabena, F. Salinaro, F. Speciale, and I. Zunino (ECU Staff Emergency Care Unit); M. De Lorenzo, G. Secco, L. Dimitry, G. Cappa, I. Maisak, B. Chiodi, M. Sciarrini, B. Barcella, F. Resta, L. Moroni, G. Vezzoni, L. Scattaglia, E. Boscolo, C. Zattera, M. F. Tassi, V. Capozza, D. Vignaroli, and M. Bazzini (ECU Resident Emergency Care Unit); G. Iotti, F. Mojoli, M. Belliato, L. Perotti, S. Mongodi, and G. Tavazzi (Intensive Care Unit); G. Marseglia, A. Licari, and I. Brambilla (Pediatric Unit); D. Barbarini, A. Bruno, P. Cambieri, G. Campanini, G. Comolli, M. Corbella, R. Daturi, M. Furione, B. Mariani, R. Maserati, E. Monzillo, S. Paolucci, M. Parea, E. Percivalle, A. Piralla, F. Rovida, A. Sarasini, and M. Zavattoni (Virology Staff); G. Adzasehoun, L. Bellotti, E. Cabano, G. Casali, L. Dossena, G. Frisco, G. Garbagnoli, A. Girello, V. Landini, C. Lucchelli, V. Maliardi, S. Pezzaia, and M. Premoli (Virology Technical staff); A. Bonetti, G. Caneva, I. Cassaniti, A. Corcione, R. Di Martino, A. Di Napoli, A. Ferrari, G. Ferrari, L. Fiorina, F. Giardina, A. Mercato, F. Novazzi, G. Ratano, B. Rossi, I. M. Sciabica, M. Tallarita, and E. Vecchio Nepita (Virology Resident); M. Calvi and M. Tizzoni (Pharmacy Unit); and C. Nicora, A. Triarico, V. Petronella, C. Marena, A. Muzzi, and P. Lago (Hospital Management). CONFLICT OF INTERESTS The authors declare that there are no conflict of interests. AUTHOR CONTRIBUTIONS IC, FN, FG, FS, MS, SP, RB, FM, FB, and the other members of the San Matteo Pavia COVID‐19 Task Force listed reviewed and approved the manuscript. IC and FN discussed results, data analysis, and wrote the paper. FG, FS, and MS collected the samples. SP, RB, and FM discussed results. FB conceived the study.
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            Prolonged viral shedding in feces of pediatric patients with coronavirus disease 2019

             Yu-Han Xing,  Wei Ni,  Qin Wu (2020)
            Objective To determine the dynamic changes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in respiratory and fecal specimens in children with coronavirus disease 2019 (COVID-19). Methods From January 17, 2020 to February 23, 2020, three paediatric cases of COVID-19 were reported in Qingdao, Shandong Province, China. Epidemiological, clinical, laboratory, and radiological characteristics and treatment data were collected. Patients were followed up to March 10, 2020, and dynamic profiles of nucleic acid testing results in throat swabs and fecal specimens were closely monitored. Results Clearance of SARS-CoV-2 in respiratory tract occurred within two weeks after abatement of fever, whereas viral RNA remained detectable in stools of pediatric patients for longer than 4 weeks. Two children had fecal SARS-CoV-2 undetectable 20 days after throat swabs showing negative, while that of another child lagged behind for 8 days. Conclusions SARS-CoV-2 may exist in children's gastrointestinal tract for a longer time than respiratory system. Persistent shedding of SARS-CoV-2 in stools of infected children raises the possibility that the virus might be transmitted through contaminated fomites. Massive efforts should be made at all levels to prevent spreading of the infection among children after reopening of kindergartens and schools.
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              Clinical tests sensitivity and specificity


                Author and article information

                Am J Infect Control
                Am J Infect Control
                American Journal of Infection Control
                Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
                10 July 2020
                10 July 2020
                [a ]Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
                [b ]Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
                Author notes
                [* ]Correspondence: Prof. Dr. Roberto Pontarolo, Department of Pharmacy, Federal University of Paraná, Av. Lothário Meissner, 632, 80210-170, Curitiba, Paraná, Brazil. Phone: +55 41 33604094; Fax: +55 41 33604101 pontarolo@
                © 2020 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.

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