1
INTRODUCTION
Coronavirus disease 2019 (COVID‐19) has emerged as a deadly clinical disease. The
virus that causes COVID‐19, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2),
is readily transmitted in the community, where it is having devastating social and
economic impacts. Yet our understanding of SARS and COVID‐19 is derived primarily
from studying the most severe cases in clinical and hospital settings. A complementary,
field‐based approach is desperately needed, and human biologists are well‐positioned
to make important contributions to our understanding of which individuals, and communities,
are most vulnerable and why.
Much has been said about shortcomings in the roll out ofSARS‐CoV‐2 testing and how
it has frustrated efforts to identify cases and isolate individuals who are shedding
virus. Less has been said about the opportunities that testing provides for a wide
range of research applications. In this commentary, we describe antibody testing and
how human biologists can use it to inform our understanding of the pandemic, and to
address questions of longstanding interest regarding the causes and consequences of
human biological variation.
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TESTING FOR SARS‐COV‐2: CURRENT AND PRIOR EXPOSURE
Nucleic acid‐based (ie, polymerase chain reaction, PCR) tests of naso‐pharyngeal swabs
and/or saliva can detect the presence of virus in the acute stage of infection. These
tests are important for clinical diagnosis, and if deployed more widely can be used
to identify viral spread in the community. However, shortages of swabs, personal protective
equipment (PPE), transport media, and accurate testing platforms have led to a rationing
of tests. As a result, priority has been given to testing suspected cases of COVID‐19,
with limited application outside the clinical context through the first wave of the
pandemic. It is also becoming apparent that false negative results may be more common
than originally thought, as viral RNA production in the naso‐pharynx is transient
and subject to sampling variability.
Serological testing is a complementary approach that detects the presence of antibodies
against SARS‐CoV‐2 in blood samples from exposed individuals (World Health Organization,
2020). As the immune system mounts a response to infection, B lymphocytes produce
antibodies against viral proteins which bind, and in some cases, neutralize the virus.
The isotype immunoglobulin M (IgM) is the first antibody to appear in circulation
following initial exposure to an antigen. It is a large pentamer that is detectable
3 to 10 days after infection, but its expression is transient and concentrations decrease
in the weeks following exposure (Zhao et al., 2020). IgG production is slower to come
online, but antibodies of this isotype remain detectable for months, and often years,
after infection (Tan et al., 2020; Xiao, Gao, & Zhang, 2020).
Based on these dynamics, antibody testing can be applied clinically to diagnose a
current or very recent infection, and epidemiologically as a surveillance tool. For
example, in some cases individuals present with symptoms of COVID‐19 but test negative
with PCR because the virus has been cleared, viral shedding is not occurring at the
time of sampling, and/or technical errors lead to a false negative result. If sufficient
time has passed since the initial infection, the presence of IgM antibodies against
SARS‐CoV‐2 antigens can be used to confirm a clinical case of COVID‐19. The time course
of IgG production makes testing less relevant for diagnosis of acute infection, but
since levels of anti‐SARS IgG antibodies remain elevated long after infection, IgG
testing can be used to identify “cases” after the fact. As described below, there
are several ways these tests can inform research and policy related to COVID‐19.
There are currently two predominant approaches to antibody testing: enzyme linked
immunosorbent assay (ELISA), and lateral flow immunoassay (LFIA). In ELISA, viral
antigen is fixed to the bottom of a microtiter plate well, diluted serum or plasma
is added, and antibodies specific to the viral antigen, if present, are “captured”
in the well. The addition of anti‐human IgG or IgM antibody with a label (eg, horseradish
peroxidase) generates a signal proportional to the concentration of captured antibody,
which is quantified in a spectrophotometer. ELISA protocols for SARS‐CoV‐2 IgM and
IgG antibodies for use with serum or plasma are now established (Amanat et al., 2020).
However, the requirement for serum/plasma is a significant constraint, particularly
in the context of the current pandemic. Under the best of circumstances, venipuncture
is difficult to implement outside the clinical setting due to the logistics of drawing,
transporting, and processing venous blood. These challenges are compounded when people
are told to stay at home, and when phlebotomists and PPE are in short supply because
cases of COVID‐19 are surging.
Lateral flow immunoassay tests have the potential to overcome these obstacles in that
they typically require only a few drops of capillary whole blood, collected from a
simple finger stick. As such, they can be readily implemented in nonclinical, community‐based
settings with the potential to reach larger numbers of people. In LFIA, the antigen‐antibody
dynamics of ELISA are applied in a cartridge format: Blood (and often diluent) is
placed in a small well, and as it diffuses through the cartridge antibodies are labeled
and captured, with a test line emerging to indicate a positive result. An advantage
of LFIA is that it is a “point‐of‐care” test, with results available in 5 to 10 minutes.
However, these tests are qualitative rather than quantitative, and even though they
use only a few drops of finger stick blood, they are difficult to self‐administer
and usually require a trained health care worker to implement. In addition, recent
analyses have raised substantial concerns regarding the accuracy of LFIA tests for
SARS‐CoV‐2 IgG antibodies (Adams et al., 2020).
There is a middle ground in dried blood spot (DBS) sampling, which combines the convenience
of blood collection in the community with the quantification that is possible in the
lab (McDade, 2014; McDade, Williams, & Snodgrass, 2007). A sterile lancet is used
to prick the finger, and up to five drops of whole blood are collected on filter paper.
Once the sample dries, the cards can be closed, stacked, and transported to the lab
without a cold chain. Most analytes remain stable in DBS for days, if not weeks or
months, providing flexibility in blood collection protocols.
Human biologists are accustomed to conducting research outside the clinic or lab,
and DBS sampling has been an important part of our toolkit for more than 25 years
(Worthman & Stallings, 1997). Recently, we validated an ELISA for SARS‐CoV‐2 IgG antibodies
in DBS that provides results that correlate highly with serum (R = 0.99) (McDade et
al., 2020). The DBS approach has several advantages that make it particularly well‐suited
to address important gaps in the current COVID‐19 testing landscape. First, individuals
can self‐sample in the home. Although some samples may be inadequate for analysis,
prior applications have demonstrated the feasibility of having, participants collect
their own DBS sample (Roberts et al., 2016). Second, samples can be returned in the
mail without special handling (the CDC and US Postal Service consider DBS specimens
nonregulated, exempt materials) (Centers for Disease Control and Prevention, 2017).
Third, since DBS samples are analyzed in the lab, we can apply more accurate and quantitative
protocols than is possible with LFIA. In developing a low‐cost ELISA for SARS‐CoV‐2
antibodies, our hope is that others can draw on the longstanding tradition of methodological
innovation in human biology to promote community‐based research on COVID‐19.
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UNANSWERED QUESTIONS AND THE POTENTIAL CONTRIBUTION OF HUMAN BIOLOGISTS
The burden of COVID‐19 is not shared equally. For example, older persons are at higher
risk for more serious complications and death, while rates of infection appear low
for children and risk of mortality is even lower (Center for Disease Control and Prevention,
2020). Worldwide, minority and vulnerable populations have been disproportionately
impacted by the COVID‐19 pandemic. In the UK, though people from ethnic minorities
are younger on average than the white British population, death rates are higher (Kirby,
2020). In the US, African Americans comprise 33% of COVID‐19 hospitalizations (Kirby,
2020). In the city of Chicago, as of June 1 the infection rate for Latinx residents
was 2102 cases per 100 000, compared with 575 per 100 000 white residents. Mortality
risk of COVID‐19 was 2.6 times higher for African‐Americans in comparison with whites
(Chicago Department of Public Health, 2020).
Of course, these data paint an incomplete picture of the actual distribution of the
virus since they are based on PCR tests for active infections in clinical settings.
By identifying mild and asymptomatic cases, antibody testing can provide a more accurate
and comprehensive record of the social and geographic spread of the virus. These data
are important for informing estimates of the seroprevalence of infection and case
fatality rates, for identifying subgroups of individuals more susceptible to infection,
and for evaluating the effectiveness of various policy efforts (eg, social distancing,
closing of schools and businesses) in mitigating transmission in the community. These
are important first order questions, the answers to which can be used to inform public
health responses to future outbreaks.
As human biologists we can contribute to this effort, but we can also dig deeper.
We can complement the public health emphasis on surveillance, and the clinical emphasis
on diagnosis and treatment, with research that illuminates the contextual, interpersonal,
and individual factors that explain patterns of exposure and response to infection.
We can draw on biosocial/biocultural frameworks to develop a more holistic picture
of individual variation in vulnerability to infection by integrating biological, sociocultural,
and environmental data. A key strength of this perspective is the emphasis on simultaneously
defining and measuring causal pathways at multiple levels, which can highlight proximate
as well as more distal causes of inequities in exposure, infection, and death.
For example, are higher rates of COVID‐19 mortality among African‐Americans a product
of increased exposure to SARS‐CoV‐2, or increased vulnerability to disease following
exposure? Not everyone is afforded the same opportunity to shelter‐in‐place. Workers
designated as “essential,” and those who cannot afford to stay home even when rates
of community transmission are high, are at increased risk for exposure (as are the
other members of their household and social networks). Furthermore, food deserts,
inadequate health care, limited opportunities for physical activity, and stress all
contribute to hypertension and diabetes—conditions that predispose to COVID‐19 mortality.
As discrimination, concentrated disadvantage, and other forms of structural racism
increase burdens of chronic degenerative disease among African‐Americans in the US,
they may also contribute to inequities in COVID‐19 mortality. Antibody testing can
be used to cast light on the inequitable distribution of viral exposure and the factors
that contribute to higher levels of transmission in disadvantaged communities.
Human biologists are also well‐positioned to consider a life course perspective on
variation in outcomes in response to SARS‐CoV‐2 infection. Why are older people more
vulnerable, while children are largely spared? Why do infections tend to be mild in
pregnancy, in contrast to the 1918 influenza pandemic when mortality was particularly
high for pregnant women (Taubenberger & Morens, 2006)? Developmental plasticity, ecological
sensitivity, and the finite nature of resources are key concepts from evolutionary
life history theory that may generate important insights. For example, the immune
system is a central component of maintenance effort, and the defenses that provide
protection against COVID‐19 are costly to develop and activate (McDade, 2003). One
might therefore hypothesize that the response to infection is shaped by the availability
of nutritional resources, particularly resources during sensitive periods of immune
development in infancy. Similarly, microbial exposures early in development may calibrate
investments in innate vs specific immunity, with implications for the regulation—or
dysregulation—of inflammation in adulthood (McDade, Georgiev, & Kuzawa, 2016). A theoretically
grounded, hypothesis driven life history approach may help us identify how, and why,
individuals differ in the magnitude and effectiveness of immune responsiveness to
SARS‐CoV‐2 infection. Quantifying the antibody response to infection provides a direct
measure of humoral immunity, and additional indicators of immune activity (eg, markers
of inflammation, cell mediated responses) can further characterize the magnitude and
direction of response.
We can also reach across generations to consider the potential long‐term implications
of the pandemic. Even though pregnant women do not appear to be at elevated risk of
infection, subtle long term effects on individuals born during the 1918 influenza
epidemic are well‐documented (Almond, 2006), and recent research showing how maternal
adversity can shape placental architecture and nutrient transfer point toward the
possibility of intergenerational impacts of infection (Miller et al., 2017). In addition,
it is not just mothers that we should consider: The experience of fathers may be transmitted
across generations as well, through epigenetic modifications to the germline that
are inherited along with gene sequence (Ryan & Kuzawa, 2020). We can also reach back
in time, to consider how adaptations to environmental pressures may influence responses
to infection in the present. For example, recent research with high‐altitude populations
in regions of Tibet, Bolivia, and Ecuador suggests that physiological responses that
promote survival in hypoxic environments may also serve to decrease susceptibility
to SARS‐CoV‐2 infection (Arias‐Reyes et al., 2020). These are all questions that can
be answered, at least in part, with measures of antibody response to identity individuals
who have been exposed.
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CONCLUSION
Human biologists are uniquely positioned to make important contributions to our understanding
of COVID‐19, and methods that facilitate research in community‐based settings globally
will be central to that effort. Antibody testing is a necessary surveillance tool,
but we can also apply it in the service of advancing our understanding of human biological
variation more broadly. In doing so we accept an obligation to challenge misleading
claims regarding the significance of a “positive” antibody test. At this point it
is not known if high levels of SARS‐CoV‐2 IgG antibodies confer immunity against future
infection, and talk of antibody badges or passports is premature. We also need to
be mindful of the potential for seroprevalence data to stigmatize members of the community,
and to politicize debates regarding the costs and benefits of initiatives designed
to mitigate viral transmission. The current pandemic underscores the social nature
of human biology, and a contextualized, community‐based approach is an essential complement
to current clinical and public health research paradigms.
AUTHOR CONTRIBUTIONS
Thomas W. McDade: Conceptualization; writing‐original draft; writing‐review and editing.
Amelia Sancilio: Writing‐original draft; writing‐review and editing.