It is widely accepted that many of those infected with COVID-19 are asymptomatic and hence may not even figure in the official list of positive cases. A large ‘antibodies’ study commissioned by the Spanish government now reveals that the number of officially reported cases in Spain are only about 10% of the potentially infected population.
As per latest available data, more than 70 lakh (7 million) cases of COVID-19 were recorded across the world. Conservative estimates peg the number of tests carried to identify these cases at more than 10 crores (100 million).
Countries across the world have adopted different testing strategies to identify COVID-19 cases. The ambiguity surrounding the symptoms, means and extent of the spread of infection etc. have so far prevented from developing a standard/uniform strategy to detect the spread.
Over the last few months, the understanding of COVID-19 has also changed & improved, largely on account of new research. Various governments have commissioned research studies to understand the spread much more in detail. In this story, we look at one such research study conducted in Spain regarding the prevalence of COVID-19 infection by detecting antibodies against the virus.
The Sample size makes it one of the largest research studies regarding COVID-19
Spain is among the countries severely affected by COVID-19, both in terms of number of positive cases as well as fatalities with more than 27 thousand deaths. It is also one of the countries where initial outbreak of COVID-19 was widespread outside of China. It looks like the country has currently overcome the first wave of COVID-19 infection as the number of daily new cases has decreased substantially compared to a month ago.
This research study named ENE-COVID 19 (National Sero-Epidemiology Study of SARS-COV-2 Infection in Spain) was carried out through a collaborative effort between Spain’s Ministry of Health and the Carlos III Health Institute, along with support from National Statistics Institute.
A total of 60,983 participants took part in the first round of tests conducted in the two-week period of 27 April to 13May,2020. Of these, 86 participants were excluded from the analysis since they did not have details for all the demographic values considered by the study. Apart from these, there was another complementary island study carried out in islands not included in the national study. The number of valid tests from this complementary study is 3,234. The participant rate among the eligible individuals was 62.3%, while it was 74.7% among those who were contacted to take part in the test.
ENE-COVID 19 is a Sero-epidemiological longitudinal study
A Sero-epidemiological study is an epidemiological study which is based on the blood serum antibodies. ENE-COVID 19 study being carried out in Spain is based in Sero-epidemiological tests.
The various COVID-19 tests carried out across the world are to detect the presence of the COVID-19 virus in the body, and to determine the need for isolation and treatment. On the contrary, an antibody test checks if there are any antibodies in the blood, which are typically formed when the person successfully fights off an infection like COVID-19.
Testing positive in this test would mean that the person most likely had an infection earlier (not necessarily realize it) and has some degree of immunity to the infection. Identifying individuals who have developed antibodies can help in further research on developing cure for COVID-19. The results of such tests provide important insights into the spread of COVID-19 as many asymptomatic individuals may not have been tested at all.
Two types of tests used for the study
Based on the inputs from National Institute of Statistics, 1500 census units and 24 addresses were selected for the study in Spain. These units were selected taking into account different criteria like geographical units, density of population etc. From these units, a total of 90 thousand people was invited for testing and to be part of the study, of which around 60 thousand participated.
The participants were further divided into two sub cohorts. In view of the geographical diversity and peculiarities of few of the islands, additional participants were considered as part of the sampling beyond the 60 thousand + participants.
Two types of tests were used to measure anti-SARS-COV-2 (i.e. COVID-19) antibodies.
- Rapid immunochromatography test
- IgG antibody determination by immunoassay
The Rapid tests allow for getting the results on the spot and the blood sample is collected using a prick. The reliability studies carried out for ENE-COVID 19 study indicate a sensitivity of 73% and 79% respectively for IgM and IgG (Antibodies) and a specificity of 98% for the former and 100% for later.
For those participants who have provided the consent, blood was collected through Venipuncture (puncture in the arm). IgG antibody determination by Immunoassay was done for the blood samples collected from these participants. This provided for a more rigorous analysis of the samples. However, the disadvantage of this method was the need to perform a venipuncture, which resulted in lesser participation for this type of test.
The combination of the information provided by both the techniques is considered for the final results. (The lower sensitivity of the rapid tests was corrected while analysing the information)
The prevalence of COVID-19 Antibodies in the population is found to be 5%
The entire study is planned to be carried out in three rounds.
The first round of studies and testing was for the period 27April 2020 – 13May 2020. The results and observation after the first wave of study are the following.
- The prevalence of COVID-19 antibodies in the population is 5%.
- There is not much gender difference observed and is very similar in men and women.
- It is lower in babies, children and young people and remains stable in older age groups.
- 83% of participants who reported positive RT-PCR have IgG antibodies.
- In possible suspected cases, the prevalence increases with the number of symptoms.
- The prevalence of anti-bodies is particularly high in people who report anosmia (total loss of smell) at 43%.
- 2.5% of population who did not have any symptoms have antibodies.
- Geographical variation exists. Larger Metropolitan areas of Madrid and Barcelona have higher prevalence rate of around 10% while few of the islands reported around 2% prevalence of antibodies.
- The possible suspicious cases follow the geographical trend with higher prevalence in larger metros and lower prevalence across the islands.
The second round of study was for the period 18 May 2020-01 June 2020. More than 55 thousand random samples were collected for the second round.
- The results of the second round were in line with and similar to the first-round results.
- 5.2% of the samples tested have developed antibodies.
- 11.4% of were immune or have antibodies in Madrid metropolitan area.
- Only 1.4% of immunity was observed in southern regions.
- The prevalence of antibodies for criteria by gender, age group, symptoms etc. remain similar to first round.
Though results from Spain are encouraging, Herd Immunity is still far-off
As highlighted earlier, Spain is one of the worst hit countries due to COVID-19 infection. The positive cases recorded officially is around 2.88 lakhs. However, the 5.2% prevalence of antibodies in the tested samples, when extrapolated with the population of the country reveals that around 2.4 million in Spain could have been infected by COVID-19, while the official recorded cases is just over 10% of this number.
While it is encouraging to learn that a section of the population has developed immunity to COVID-19 and are safeguarded against any further outbreak of infection, Herd Immunity is still far off, as observed by Spain’s health officials.
Only 5.2% of Anti-body prevalence in spite of being among the countries with the highest COVID-19 cases which has nearly overcome its first wave of infection, is a lesson to be picked up by other countries who are banking on possible herd immunity in tackling COVID-19.
Featured Image: Spanish Antibodies study