Performance Evaluation of Serial SARS-CoV-2 Rapid Antigen Testing During a Nursing Home Outbreak

Ann Intern Med. 2021 Jul;174(7):945-951. doi: 10.7326/M21-0422. Epub 2021 Apr 27.


Background: To address high COVID-19 burden in U.S. nursing homes, rapid SARS-CoV-2 antigen tests have been widely distributed in those facilities. However, performance data are lacking, especially in asymptomatic people.

Objective: To evaluate the performance of SARS-CoV-2 antigen testing when used for facility-wide testing during a nursing home outbreak.

Design: A prospective evaluation involving 3 facility-wide rounds of testing where paired respiratory specimens were collected to evaluate the performance of the BinaxNOW antigen test compared with virus culture and real-time reverse transcription polymerase chain reaction (RT-PCR). Early and late infection were defined using changes in RT-PCR cycle threshold values and prior test results.

Setting: A nursing home with an ongoing SARS-CoV-2 outbreak.

Participants: 532 paired specimens collected from 234 available residents and staff.

Measurements: Percentage of positive agreement (PPA) and percentage of negative agreement (PNA) for BinaxNOW compared with RT-PCR and virus culture.

Results: BinaxNOW PPA with virus culture, used for detection of replication-competent virus, was 95%. However, the overall PPA of antigen testing with RT-PCR was 69%, and PNA was 98%. When only the first positive test result was analyzed for each participant, PPA of antigen testing with RT-PCR was 82% among 45 symptomatic people and 52% among 343 asymptomatic people. Compared with RT-PCR and virus culture, the BinaxNOW test performed well in early infection (86% and 95%, respectively) and poorly in late infection (51% and no recovered virus, respectively).

Limitation: Accurate symptom ascertainment was challenging in nursing home residents; test performance may not be representative of testing done by nonlaboratory staff.

Conclusion: Despite lower positive agreement compared with RT-PCR, antigen test positivity had higher agreement with shedding of replication-competent virus. These results suggest that antigen testing could be a useful tool to rapidly identify contagious people at risk for transmitting SARS-CoV-2 during nascent outbreaks and help reduce COVID-19 burden in nursing homes.

Primary funding source: None.

MeSH terms

  • Antigens, Viral / analysis*
  • COVID-19 / diagnosis*
  • COVID-19 / epidemiology
  • COVID-19 Serological Testing / methods*
  • False Negative Reactions
  • False Positive Reactions
  • Humans
  • Nursing Homes*
  • Pandemics*
  • Prospective Studies
  • Retrospective Studies
  • SARS-CoV-2 / immunology*
  • United States / epidemiology


  • Antigens, Viral