The Limit of Detection (LoD) is the smallest amount of virus in a sample that a given device can consistently detect.
The Liverpool School of Tropical Medicine carried out an analytical study of the KnowNowᵀᴹ test, which determined that the LoD is 500 plaque-forming units per millilitre (PFU/ml). Based on accepted models of viral load in disease progression, this very low LoD suggests that the KnowNow test can detect infected people as early as day 3 to 4 of infection. This is before they become highly infectious, and a day or two earlier than most tests available.
In the absence of a single study that compares the LoD of KnowNowᵀᴹ to that of other tests, it is not possible to do a like-for-like comparison of the LoDs of different lateral flow tests determined by different studies. This is because there wouldn't be parity across cell cultures and strains of the virus used in the different studies. Additionally, it's important to consider that what the KnowNowᵀᴹ test detects is fundamentally different from other tests. KnowNowᵀᴹ is a true infectivity test which looks exclusively for the spike protein only present on active SARS-CoV-2 viruses. Whereas other lateral flow tests detect the nucleocapsid protein encapsulated in the centre of the virus, which can be present whether the virus is active or not.
The PFU/ml measure, as used in the Liverpool School of Tropical Medicine KnowNowᵀᴹ analytical study, is a measure of only the number of virus particles capable of forming plaques in a given sample - viral particles that are defective or which fail to infect their target cell will not produce a plaque and so are not counted by this measure. No inference can be made about the relationship of PFU to the overall number of viral particles in the sample, since this will differ from sample to sample.
Since the KnowNow test specifically detects infectious viral particles only, an LoD measured in PFU/ml is an informative and appropriate measure. However, for other lateral flow tests which indiscriminately detect active and inactive viral particles, an LoD referencing PFU/ml is not particularly informative or comparable to the KnowNowᵀᴹ LoD. For example, the sample used to determine LoD may have had a very low PFU/ml, but many inactive viral particles which were detected by the test. Ultimately, other lateral flow tests are not true tests for COVID infectivity, they do not detect only infectious virus like the KnowNowᵀᴹ test does.
If you'd like to read more about this subject, we recommend reading this paper. It argues that the "Limit of Detection matters and directly impacts efforts to identify, control, and contain outbreaks during this pandemic" since "higher LoD are likely to miss nonnegligible fractions of infected individuals." It also makes the case that LoD values for tests should be benchmarked against a universal standard and readily available in the public domain to enable like-for-like comparison of SARS-CoV-2 detection methods.
If there is one red line visible next to the "C" in the KnowNow device test results window, and no line at all next to the "T", then the test result is negative. This indicates that no SARS-CoV-2 antigen has been detected in the sample.
The KnowNowᵀᴹ Test is unique to other lateral flow antigen tests in 3 key areas.
The first key difference is that the KnowNow test needs only a saliva sample, which can be taken easily and comfortably from the mouth. Other lateral flow antigen tests usually need a nasopharyngeal, anterior nasal or tonsil sample, all of which are painful and unpleasant for the individual being tested and more challenging to collect effectively for the clinical professional administering the test. No one wants to be made to cry or gag, or make someone else cry or gag, on a regular basis!
The second is that the KnowNowᵀᴹ Test looks specifically for live virus which would cause the individual tested to be able to infect others. Although other lateral flow antigen tests are often said to test whether an individual is infectious, this is because they have a higher Limit of Detection and can only detect the virus when there are more viral particles present in the sample. As a result, they offer a proxy measure for infectivity, rather than directly testing whether there is live virus in the sample. The KnowNowᵀᴹ Test on the other hand is a true infectiousness test, which uses a unique patented mechanism which detects a completely different part of the virus.
Finally, the KnowNowᵀᴹ Test is also more sensitive than other rapid antigen tests available, as it is able to pick up the presence of the virus even when there is much less of it present in the sample. Our Limit of Detection is between 50,000 and 200,000 viral copies per mL, whilst the Abbott BinaxNow test, for example, needs 1,000,000 viral copies per mL in order to get a positive signal.
KnowNowᵀᴹ offers two key benefits over polymerase chain reaction (PCR) tests.
The first benefit is that the KnowNowᵀᴹ test needs only a saliva sample, which can be taken easily and comfortably from the mouth. PCR tests usually need a nasopharyngeal, anterior nasal or tonsil sample, all of which are painful and unpleasant for the individual being tested and more challenging to collect effectively for the clinical professional administering the test. No one wants to be made to cry or gag, or make someone else cry or gag, on a regular basis!
The second benefit is that the KnowNow test uses its unique detection mechanism to determine whether an individual is actually infectious, whereas PCR tests identify whether SARS-CoV-2 viral matter is present in an individual's body, regardless of whether it is already inactive.
Although PCR tests have been seen as the "gold standard" test for the SARS-CoV-2 virus, they do have a number of drawbacks. Laboratory processing is required, meaning that there is a delay before results can be returned, and the associated costs are relatively high. Also the detection mechanism does not specifically identify whether individuals are infectious. In fact, PCR tests detect the virus long after the infectious period, and individuals can continue to test positive for a mean of 17 days after they have stopped being able to infect others (source). This means that people who are not infectious are unnecessarily quarantined as a result of a positive PCR test.
KnowNowᵀᴹ Tests have been invented, developed and manufactured in the UK.
To date we have conducted three clinical studies. The first was a UK Government-supported National Institute for Health Research (NIHR) study across ten UK hospitals; the second was with Liverpool School of Tropical Medicine, and the third is a community study that we have led ourselves. We have also carried out our own analytical assessments, as well as two Public Health England analytical assessments.
We have worked with over 300 negative patient samples and around 100 COVID-19 positive patients across our studies. We are also currently carrying out a 650+ patient clinical trial with sites in the UK, USA and Brazil to provide us with a higher volume of clinical data, and with a view to additional regulatory approvals to widen the reach of the impact we can have globally in pandemic recovery.
The KnowNowᵀᴹ test will show a positive result from day 3 or 4 after exposure to the SARS-CoV-2 virus. This is earlier than other rapid antigen tests, which usually start to show positive results around day 5 or later.
This also means that individuals will receive a positive KnowNowᵀᴹ test 1 or 2 days before they are at very high risk of infecting others. So where there is a regular testing programme in place, individuals can quickly be isolated before they become highly infectious and the spread of the virus can be prevented.
The basis for this is our analysis of models of viral load in disease progression, such as the one shown within "Test sensitivity is secondary to frequency and turnaround time for COVID-19 screening" by Dr Michael Mina et al, alongside the low limit of detection of the KnowNowᵀᴹ test of 50,000 to 200,000 viral copies per mL.
We recommend that individuals are tested as regularly as possible to keep workplaces, venues and communities safe.
It is important to remember that individuals can still go on to be exposed to the virus following a negative test result. Additionally, a high proportion of infectious people show no symptoms at all, and so regular testing is key to breaking the chain of transmission.
Depending on the scenario, we would recommend that testing is performed every 2-3 days, or daily, depending on the scenario.
If there is one red line visible next to the "C" in the KnowNowᵀᴹ device test results window, and any line at all, no matter how faint, appears next to the "T", then the test result is positive. This indicates that the SARS-CoV-2 antigen has been detected in the sample.
Following a positive result, current government guidance on matters including self-isolation and reporting the result should be followed.
KnowNowᵀᴹ Tests should be stored between 2 and 30 degrees celsius, which means it's fine to store it at room temperature in the UK's mild climate.
There's no need to store it inside a fridge, unless you're expecting extremely hot weather. If you do choose to refrigerate the test though, just make sure it comes to room temperature before using it.
The KnowNowᵀᴹ Test device should also be stored still sealed in its foil pouch. Once removed from the foil pouch, it should be used within one hour.
At the moment, KnowNowᵀᴹ Tests are for professional use only, meaning that they need to be administered by a trained healthcare professional. This means that we can take orders from organisations that have in-house or outsourced healthcare professionals who can perform the tests, or testing service providers.
However, since the KnowNowᵀᴹ Test needs just a saliva sample, it is much easier to administer effectively than other similar tests, and still return highly sensitive results. So we are investigating whether specially-trained, competent individuals could be approved to administer KnowNow tests as well.
We are also in the process of trialling and seeking approval for a variation of the KnowNow test which could be administered by individuals themselves.