RT-qPCR-based tests for SARS-CoV-2 detection in pooled saliva samples for massive population screening to monitor epidemics

Abstract Swab, quantitative, reverse transcription polymerase chain reaction (RT-qPCR) tests remain the gold standard of diagnostics of SARS-CoV-2 infections. However, these tests are costly and time-consuming, and swabbing limits their throughput. We developed a 3-gene, seminested RT-qPCR test with SYBR green-based detection, optimized for testing pooled saliva samples for high-throughput diagnostics of epidemic-affected populations. The proposed two-tier approach depends on decentralized self-collection of saliva samples, pooling, 1st-tier testing with the mentioned highly sensitive screening test and subsequent 2nd-tier testing of individual samples from positive pools with the in vitro diagnostic (IVD) test. The screening test was able to detect 5 copies of the viral genome in 10 μl of isolated RNA with 50% probability and 18.8 copies with 95% probability and reached Ct values that were highly linearly RNA concentration-dependent. In the side-by-side comparison (testing artificial pooled samples), the screening test attained slightly better results than the commercially available IVD-certified RT-qPCR diagnostic test (100% specificity and 89.8% sensitivity vs. 100% and 73.5%, respectively). Testing of 1475 individual clinical samples pooled in 374 pools of 4 revealed 0.8% false positive pools and no false negative pools. In weekly prophylactic testing of 113 people within 6 months, a two-tier testing approach enabled the detection of 18 infected individuals, including several asymptomatic individuals, with a fraction of the costs of individual RT-PCR testing.