Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence: Navigating the absence of a gold standard

PLoS One. 2021 Sep 23;16(9):e0257743. doi: 10.1371/journal.pone.0257743. eCollection 2021.


Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence studies bridge the gap left from case detection, to estimate the true burden of the COVID-19 pandemic. While multiple anti-SARS-CoV-2 immunoassays are available, no gold standard exists.

Methods: This serial cross-sectional study was conducted using plasma samples from 8999 healthy blood donors between April-September 2020. Each sample was tested by four assays: Abbott SARS-Cov-2 IgG assay, targeting nucleocapsid (Abbott-NP) and three in-house IgG ELISA assays (targeting spike glycoprotein, receptor binding domain, and nucleocapsid). Seroprevalence rates were compared using multiple composite reference standards and by a series of Bayesian Latent Class Models.

Result: We found 13 unique diagnostic phenotypes; only 32 samples (0.4%) were positive by all assays. None of the individual assays resulted in seroprevalence increasing monotonically over time. In contrast, by using the results from all assays, the Bayesian Latent Class Model with informative priors predicted seroprevalence increased from 0.7% (95% credible interval (95% CrI); 0.4, 1.0%) in April/May to 0.7% (95% CrI 0.5, 1.1%) in June/July to 0.9% (95% CrI 0.5, 1.3) in August/September. Assay characteristics varied over time. Overall Spike had the highest sensitivity (93.5% (95% CrI 88.7, 97.3%), while the sensitivity of the Abbott-NP assay waned from 77.3% (95% CrI 58.7, 92.5%) in April/May to 64.4% (95% CrI 45.6, 83.0) by August/September.

Discussion: Our results confirmed very low seroprevalence after the first wave in Canada. Given the dynamic nature of this pandemic, Bayesian Latent Class Models can be used to correct for imperfect test characteristics and waning IgG antibody signals.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Antibodies, Viral / immunology
  • Bayes Theorem
  • Blood Donors
  • COVID-19 / immunology*
  • Canada
  • Cross-Sectional Studies
  • Female
  • Humans
  • Immunoglobulin G / immunology
  • Male
  • Middle Aged
  • Nucleocapsid / immunology
  • Pandemics / prevention & control
  • SARS-CoV-2 / immunology*
  • Sensitivity and Specificity
  • Seroepidemiologic Studies
  • Spike Glycoprotein, Coronavirus / immunology
  • Young Adult


  • Antibodies, Viral
  • Immunoglobulin G
  • Spike Glycoprotein, Coronavirus

Grants and funding

SJD received funding through the Canadian Institutes of Health Research (VR2-172723) and Alberta Innovates (G2020000360 Drews), ACG received funding through the Krembil Foundation to the Sinai Health System Foundation. The robotics equipment used for the ELISA assays is housed in the Network Biology Collaborative Centre at the Lunenfeld-Tanenbaum Research Institute (ACG), a facility supported by Canada Foundation for Innovation funding, by the Ontarian Government and by Genome Canada and Ontario Genomics (OGI-139). Commercial Abbott Architect SARS-Cov-2 IgG assay kit costs were partially supported by Abbott Laboratories, Abbott Park, Illinois. Abbott analyzers used at Canadian Blood Services were provided by the COVID-19 Immunity task Force (CITF). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.