SARS-CoV-2 exhibits extreme differences in early viral loads among specimen types suggesting improved detection of pre-infectious and infectious individuals using combination specimen types

SARS-CoV-2 viral load measurements from a single specimen type are used to establish diagnostic strategies, interpret clinical-trial results for vaccines and therapeutics, model viral transmission, and understand virus-host interactions. However, measurements from a single specimen type are implicitly assumed to be representative of other specimen types. We quantified viral-load timecourses from individuals who began daily self-sampling of saliva, anterior nares (nasal), and oropharyngeal (throat) swabs before or at the incidence of infection with the Omicron variant. Viral loads in different specimen types from the same person at the same timepoint exhibited extreme differences, up to 109 copies/mL. These differences were not due to variation in sample self-collection, which was consistent. For most individuals, longitudinal viral-load timecourses in different specimen types did not correlate. Throat-swab and saliva viral loads began to rise up to 7 days earlier than nasal-swab viral loads in most individuals, leading to very low clinical sensitivity of nasal swabs during the first days of infection. Individuals frequently exhibited presumably infectious viral loads in one specimen type while viral loads were low or undetectable in other specimen types. Therefore, defining an individual as infectious based on assessment of a single specimen type underestimates the infectious period, and overestimates the ability of that specimen type to detect infectious individuals. For diagnostic COVID-19 testing, these three single specimen types have low clinical sensitivity, whereas a combined throat-nasal swab, and assays with high analytical sensitivity, were inferred to have significantly better clinical sensitivity to detect presumed pre-infectious and infectious individuals. Significance StatementIn a longitudinal study of SARS-CoV-2 Omicron viral loads in three paired specimen types (saliva, anterior-nares swabs, and oropharyngeal swabs), we found extreme differences among paired specimen types collected from a person at the same timepoint, and that viral loads in different specimen types from the same person often do not correlate throughout infection. Individuals often exhibited high, presumably infectious viral loads in oral specimen types before nasal viral loads remained low or even undetectable. Combination oropharyngeal-nasal swabs were inferred to have superior clinical sensitivity to detect infected and infectious individuals. This demonstrates that single specimen type reference standard tests for SARS-CoV-2, such as in clinical trials or diagnostics evaluations may miss infected and even infectious individuals.