Emergence of N antigen SARS-CoV-2 genetic variants escaping detection of antigenic tests

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Abstract

SARS-CoV-2 genetic variants are emerging as a major threat to vaccination efforts worldwide as they may increase virus transmission rate and/or confer the ability to escape vaccine induced immunity with knock on effects on the level of herd immunity and vaccine efficacy respectively. These variants concern the Spike protein, which is encoded by the S gene, involved in virus entry into host cells and the major target of vaccine development. We report here that genetic variants of the N gene can impair our ability to utilize antigenic tests for both diagnosis and mass testing efforts aimed at controlling virus transmission. While conducting a large validation study on the Abbott Panbio™ COVID-19 Ag test, we noticed that some swab samples failed to generate a positive result in spite of a high viral load in Rt-PCR assays. Sequencing analysis of viruses showing discordant results in the RT-PCR and antigen assays revealed the presence of multiple disruptive amino-acid substitutions in the N antigen (the viral protein detected in the antigen test) clustered from position 229 to 374 a region known to contain an immunodominant epitope. A relevant fraction of the variants, undetected by the antigen test, contained the mutations A376T coupled to M241I. Intriguingly we found that virus sequences with this mutation were over-represented in the antigen-test-negative and PCR-positive samples and progressively increased in frequency over time in Veneto, a region of Italy that has aggressively scaled up the utilization of antigen tests, which reached nearly 68% of all the SARS-CoV-2 swab assays performed there. We speculate that mass utilization of antigen assays could create a selection pressure on the target that may favor the spread of undetectable virus variants.

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  1. SciScore for 10.1101/2021.03.25.21253802: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.
    Cell Line Authenticationnot detected.

    Table 2: Resources

    Experimental Models: Cell Lines
    SentencesResources
    Typically, 100 µl of not inactivated swab medium were inoculated in monolayers of Vero cells (ATCC CCL-81) with Dulbecco’s Modified Eagle Medium (DMEM) (Gibco) supplemented with 2% (v/v) of fetal bovine serum (FBS) (Gibco) and 1% (v/v) of penicillin/streptomycin (Gibco) and incubated at 37°C with 5% CO2.
    Vero
    suggested: None
    Software and Algorithms
    SentencesResources
    Quality check and mapping of the reads: Raw sequences were filtered for length and quality with Trimmomatic v0.40 12 according to the following parameters: ILLUMINACLIP:TruSeq3-PE-2:2:30:10 LEADING:30 TRAILING:30 SLIDINGWINDOW:4:20 MINLEN:90.
    Trimmomatic
    suggested: (Trimmomatic, RRID:SCR_011848)
    High quality reads were aligned on the SARS-CoV-2 reference genome (genbank ACC: NC_045512) with BWA-MEM v0.7.17 13.
    BWA-MEM
    suggested: (Sniffles, RRID:SCR_017619)
    Duplicated reads were then removed with Picard tool v2.25.0 (http://broadinstitute.github.io/picard/).
    Picard
    suggested: (Picard, RRID:SCR_006525)
    Consensus sequence were generated using a combination of SAMtools v1.11 14 and VarScan v2.4.1 15 variant caller.
    SAMtools
    suggested: (SAMTOOLS, RRID:SCR_002105)
    VarScan
    suggested: (VARSCAN, RRID:SCR_006849)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).


    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Unfortunately, the nature of the B cell epitope recognized by the antibody utilised in the Abbott test is not known but apparently other SARS-CoV-2 antigen tests, COVID-19 Ag Respi-Strip and LumiraDX SARS-CoV-2, seem to suffer of the same limitation as supernatant of cultured cells infected with virus isolates D1_7_B.1.1.119, D1_8_B.1.177.7, D2_1_B.1.160, and D2_3_B.1.177.4 carrying respectively mutations R209I, P365S, M234I-A376T, and D348Y failed to generate a positive signal thus suggesting that these assays use antibodies with similar specificities. The fact that some virus variants are “undetectable” irrespectively of the Ct value combined with a lower sensitivity of antigen tests may have accounted for the partial and disappointing results obtained when antigen tests were utilised in large population screens. It should also be considered that the massive use of antigen tests could exert a positive selection for undetectable virus variants and thereby causing their relative increase in frequency over time. Our results would support this notion: The DNCOV+/ANCOV- A376T-M241I virus variant accounted for 42% of all mutation found in the N-antigen B cell epitope 337-422. Analysis of virus sequences isolated from January 2020 to December 2020 indicated that in Veneto the A376T-M241I variant progressively increased in frequency from the beginning of October 2020 to 20% by the end of December 2020 while in Europe and the rest of Italy, after a small peak in October 2020, it fol...

    Results from TrialIdentifier: No clinical trial numbers were referenced.


    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.


    Results from JetFighter: We did not find any issues relating to colormaps.


    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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