COVAG Study - Covid-19 Antigen Study
Conditions: COVID-19, SARS-CoV2 Infection, SARS (Disease)
Sponsor: Synlab Holding Deutschland GmbH

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Study protocol 
 
 
 
COVAG 
 
COVID 19 Antigen Study 
 
 
Sponsor: 
Synlab Holding Deutschland GmbH 
Gubener Str. 39, 86156 Augsburg 
 
SYNLAB Analytics & Services Germany GmbH Pharma Berlin 
Turmstr. 21 
10559 Berlin 
 
 
 
Authors: 
Sabrina Strauch 
Carolin Kurth 
Camovis GmbH 
Wilmersdorfer Straße 79 
10629 Berlin 
 
Winfried März 
SYLAB Academy 
Synlab Holding Deutschland GmbH 
Gubener Straße 39, 86156 Augsburg  
P5,7, 68161 Mannheim 
 
 
 
 
 
Version number: 1.2 
Date:  05.01.2021 
 

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Responsibilities 
 
Medical Director of the NIS 
 
Dr. med. Martin Roskos 
CMO (Chief Medical Officer) 
SYNLAB Holding Deutschland GmbH 
Weiden GmbH 
Gubener Straße 39 
86156 Augsburg 
Tel.: +49 3641 5074 20 
Fax: +49 3641 7074 11 
 
MVZ Gera/SYNLAB Jena Oncoscreen 
Straße des Friedens 122 
07548 Gera 
Tel.: +49 3655 5220 5201 
Fax: +49 3655 5220 5202 
 
Email: martin.roskos@synlab.com 
 
Project Leader 
 
Prof. Dr. Winfried März 
Director SYNLAB Academy 
SYNLAB Holding Deutschland GmbH 
SYNLAB Akademie 
Gubener Strasse 39 
86156 Augsburg / Germany 
Tel.: +49 621 4317 9432 
Fax: +49 6221 793 144 
Email: winfried.maerz@synlab.com 
 
 
Steering group /NIS 
 
Dr. Ulrike Hauser 
Leitung SYNLAB-Schwerpunktlabor Infektionsserologie 
SYNLAB MVZ Augsburg GmbH 
Gubener Straße 39 
86156 Augsburg 
Tel.: +49 821 22780 0 
Fax: +49 821 525295 
Email: ulrike.hauser@synlab.com 
 
 

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Dr. Caren Mutschmann  
Vice President Pharma 
SYNLAB Analytics & Services Germany GmbH 
Pharma Berlin  
Turmstraße 21 
10559 Berlin 
Tel.: +49 30 396085 13 
Email: caren.mutschmann@synlab.com 
 
Dr. med. Christian Mayer 
Bereichsleiter 
SYNLAB Holding Deutschland GmbH 
Zentralbereich 
Gubener Straße 39 
86156 Augsburg 
Tel.: +49 821 52157 0 
Fax: +49 821 52157 125 
Email: christian.mayer@synlab.com 
 
Local project responsibility 
 
Study Site: Stuttgart Cannstadter Wasen / Leinfelden-Echterdingen 
 
Dr. med. Hans-Jörg Wertenauer 
Email: hj.wertenauer@aerzteschillerplatz.de 
Corona-Testzentrums Cannstatter Wasen 
Mercedesstr.50 
70372 Stuttgart 
Fax: +49 (0) 711 25241020 
 
Prof. Dr. med. Eberhard Wieland, FEBLM/MB, EurSpLM 
SYNLAB MVZ Leinfelden-Echterdingen GmbH 
Email: eberhard.wieland@synlab.com 
Nikolaus-Otto-Straße 6 
70771 Leinfelden-Echterdingen / Germany 
Tel: +49 711 9033-240 
Fax; +49 711 9033-131 
Statistician 
 
Dr. Alexander Dressel  
Dr. Dressel Consulting  
Am Exerzierplatz 23 
68167 Mannheim  
Tel.: 0621-48247388 
Fax: 0621-48247389 
Email: dressel@dresselconsulting.de 

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1. Background 
 
Coronavirus disease 2019 (COVID-19) has quickly spread worldwide from Wuhan 
(China) since December 2019. Reliable diagnostic technologies are pivotal to the fight 
against COVID-19. While real-time reverse transcriptase-polymerase chain reaction 
(rRT-PCR) based testing of respiratory specimens remains the gold standard for COVID-
19 diagnostics, several commercial assays for antibodies against (SARS-CoV-2) have 
emerged during the previous months (Stocking et al., 2020). 
 
Measuring the presence or absence of viral proteins (antigens), antigen tests may 
provide results diagnosing an active SARS-CoV-2 infection much faster than RT-PCR or 
equivalent tests. It has been argued that antigen tests may have a lower sensitivity than 
RT-PCR or equivalent RNA-based tests, and as a result they are much more likely to give 
false-negative results in individuals with lower amounts of virus. This may possibly 
make them unreliable in individuals with an asymptomatic course of the disease, in 
individuals in the first days of infection, and later than 5-7 days after onset of symptoms 
(SYNLAB press release, 22.09.2020). 
2. Objective 
 
The objective of this non-interventional study is to demonstrate that rapid antigen tests 
for SARS-CoV-2 (Abbott and Roche) provide fast results and perform equally well than 
RT-PCR, at least in symptomatic patients with high viral loads. 
3. Study Design 
 
The study will be performed in at the Corona Test Center Stuttgart Cannstadter Wasen 
operated by Dr. med. Hans-Jörg Wertenauer, Stuttgart, in close collaboration with the 
SYNLAB MVZ Leinfelden-Echterdingen GmbH. Approximately 2000 patients will be 
enrolled at after having signed the Informed Consent Form (ICF). Upon a scheduled 
study duration of eight weeks, we will be able to collect the required 2000 samples (50 
patients per day).  
 
 

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One study visit is planned for data and blood collection (15,5 ml), antigen tests, RT-PCR, 
serological tests, basic laboratory tests to be communicated to participants, and 
ancillary blood tests (incriminated to be related to COVID-19 like inflammatory markers, 
and micronutrients and vitamins). These will be performed at the at the SYNLAB MVZ 
Leinfelden GmbH. Aliquots of the materials collected will be stored -20 degrees for 
control measurements and ancillary tests, maximally for one year after the last patient 
was enrolled into the study.  
4. Rationale 
 
In the past weeks, there has been much discussion about rapid antigen tests for SARS-
CoV-2. The most recent generation of these tests, available from several different 
suppliers, are expected to perform well in patients with high viral loads. This is usually 
the case approximately 3-10 days after infection with the virus, when the person is 
contagious, and may be asymptomatic or in the first days of symptoms.  
It is therefore hoped that rapid antigen tests can support diagnosis of COVID-19 in 
people who have the first symptoms. In the USA, some tests have received authorization 
for diagnostic testing in symptomatic individuals, within 5-7 days from the onset of 
symptoms (3).  
5. Risks and benefits 
 
Three nasopharyngeal swabs and one blood sample will be obtained from each of the 
participants. Antigen tests, RT-PCR and serological and ancillary laboratory tests are 
performed in this study.  
 
Risks from nasopharyngeal swabs: The biggest risk is discomfort. Rarely - 1 in 
thousands — the person receiving the swab passes out from being super sensitive or 
gets a mild nosebleed. 
 
Risks from blood draw: The risks of venipuncture include Minor bruising at the site 
where the blood is taken and hematoma (12 % approximately), with minor bruising 
being the most common reaction. Significant complications (defined as cellulitis, 
phlebitis, diaphoresis, hypotension, near syncope, syncope) are observed in 
approximately 3.5% of patients. The most frequent single significant complication is 
hypotension at a frequency occurred of approximately 2.6%. Syncope is seen in less than 
1% of patients. Other serious local reactions such as cellulitis or phlebitis are very rare 
(Galena HJ, J. Fam. Pract. 1992 May;34(5):582-4). Blood sampling is therefore conducted 
in each of the study sites under the surveillance of a board licensed physician.  
 
Benefits to public health: Point of care antigen testing is an integral component of the 
current national testing strategy serving for preventing of the spread of COVID 19   
https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/C/C
oronavirus/Nationale_Teststrategie_kurz_041220.pdf 
 
There is, however, significant uncertainty as to the reliability of antigen testing in 
comparison to the gold standard of testing, rt-PCR. To the authors´ knowledge a 
prospective, sufficiently sizeable and challengeable evaluation of antigen testing under 

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practice conditions has not been completed so far. The current study is intended to close 
this gap. Its results are urgently required and will have immediate impact on current 
recommendations for using antigen testing. In particular, it will demonstrate 
weaknesses and strengths of antigen testing and will allow to outweigh potential 
technical limitations of antigen testing compared to rt-PCR against the advantage of 
short-term availability of test results. 
 
Further, the thorough recording of the clinical health status and the basic laboratory 
analysis performed in this study, it will be able to get further insights into clinical 
predictors for the susceptibility for COVID 19.  
 
Benefits to the individual. Participants will benefit in two ways. Other than with rt-PCR, 
they will obtain the results of the antigen testing at once and on-site. In addition, 
offering two antigen tests simultaneously, the results of the point-of-care testing will be 
even more reliable than the result of a single test. Further, the participants are offered a 
free of charge basic laboratory health check including the following actionable health 
markers: basic blood cell count, C-reactive protein, HbA1c, cholesterol, triglycerides, 
LDL cholesterol, HDL cholesterol, gamma-glutamyl-transferase, creatinine along with 
formula-derived creatinine, vitamin D.  
 
We conclude that benefits of this study to the healthcare system which is faced with the 
life-threatening and to the individual study participants clearly outweigh the minor and 
manageable risks.  
6. Population 
 
We will include approximately 2000 consecutive male and female patients aged 18 years 
or above attending the Corona Test Center Stuttgart Cannstadter Wasen, in whom RT-
PCR testing for SARS-CoV-2 is medically indicated or requested. 

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6.1 Inclusion Criteria 
 
Subjects eligible for inclusion in this study must meet the following criteria: 
 
1. Signed informed consent must be obtained prior to study participation. The 
patient must be capable of understanding the nature, significance and implication 
of the trial. 
2. Age 18 years or more  
6.2 Exclusion criteria 
 
1. Lack of informed consent  
2. Inability to understand the nature, significance and implication of the trial. 
3. Severe clinical conditions requiring emergency hospitalization 
4. Children and adolescents under the age of 18 years 
7. Informed consent procedures 
 
Eligible subjects may only be included in the study after providing IRB/IEC–approved 
informed consent. Informed consent must be obtained before performing any study-
specific procedures (Appendix 2). 
8. Assessment schedule and assessments 
 
Subject Table 8-1 Assessments  
 
Assessments 
                                  Visit 1 
Informed Consent Form, Appendices 1 
and 2 
   
X 
Collection of demographic data and 
relevant Medical History (Appendix 3) 
X 
SARS-CoV-2 Rapid Antigen Test (Roche), 
Appendices 8 and 9 
X 
PANBIO Covid-19 Ag Rapid Test            
(Abbott), Appendices 5, 6 and 7 
X 
RT-PCR 
X 
Serological test (blood sample, 15,5 ml) 
X 
Ancillary testing  
X 
 
8.1 Demographics, Medical history, sampling  
 
Patient demographic data and other characteristic data to be collected on all patients 
include sex, age, weight, height, relevant medical history, vital signs and symptoms 
characteristic of COVID-19 including precise time specifications for onset of symptoms 
(Appendix 3). 

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No information about medication will be collected. 
 
Three independent nasopharyngeal swabs will be obtained following standard 
procedures  
 
To avoid any bias due to the sequence of taking the nasopharyngeal swabs, we will 
randomly allocate the patients to three sampling groups 
 
Group 1: RT-PCR – Antigen Test Roche – Antigen Test Abbott  
Group 2: Antigen Test Roche – Antigen Test Abbott - RT-PCR 
Group 3: Antigen Test Abbott - RT-PCR - Antigen Test Roche 
 
The assignment of patients to each of these groups will be clearly specified on the case 
record forms. There will be two forms for each patient:  
 
Form 1: Routine analysis request sheet as used by the collection point for patient 
identification which will be labelled with a bar code carrying the study number of a 
patient  
 
Form 2: Study specific form containing a copy of the bar code with the study number, 
initials of the patient and the year of birth.   
 
8.2 SARS-CoV-2 Rapid Antigen Test (Roche) 
 
The SARS‐CoV‐2 Rapid Antigen Test is a rapid point of care chromatographic 
immunoassay for the qualitative detection of specific antigens of SARS‐CoV‐2 present in 
the human nasopharynx. (Appendices 8 and 9) 
8.3 PANBIO Covid-19 Ag Rapid Test (Abbott) 
 
Panbio COVID-19 Ag Rapid Test Device is an in vitro diagnostic rapid test for the 
qualitative detection of SARS-CoV-2 antigen (Ag) in human nasopharyngeal swab 
specimens. (Appendices 5; 6 and 7) 
8.4 RT-PCR 
 
RT-PCR evaluates the presence or absence of the SARS-CoV-2 genome in samples from 
nasopharyngeal and oropharyngeal swabs and will be conducted according to the 
protocols established at the SYNLAB MVZ Leinfelden GmbH. 
 
8.5 Serological and ancillary testing 
 
Blood samples (10 ml heparin plasma and 5.5 ml EDTA plasma) will be collected to 
detect the presence of antibodies (specific immune response) against SARS-CoV-2 
antigenic proteins (e.g. Roche, Abbott). Specifically, all participants will be offered to 
receive the results for the following analytes in acknowledgment of their participation in 
the study: blood cell count, C-reactive protein, HbA1c, cholesterol, triglycerides, LDL 
cholesterol, HDL cholesterol, gamma-glutamyl-transferase, creatinine along with 

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formula-derived creatinine, vitamin D. Backup samples will be collected to determine 
ancillary parameters like inflammatory markers, and micronutrients and vitamins. 
9. Observation Period 
 
NIS schedule: 
 
 
Start of the patient recruitment: February 1, 2021 
 
End of the observation period: March 31, 2021 
 
Final report: May 31, 2021 
10. Data analysis and statistical methods 
 
A database of the pseudonymized data and results will be generated. We hypothesize 
that each of the antigen tests has a sensitivity and specificity of 1.0 in relation to RT-PCR 
which will be considered as the reference test. A p value of less than 0.05 will be 
required to consider each of the two rapid tests equivalent to RT-PCR. 
 
With the aid of power calculations for chi-square tests for two degrees of freedom, 
required type I error probability equal to 0.05, required (1-type II error probability) 
equal to 0.8 and required effect size equal to 0.1 (small effect size in the sense of (4)) we 
obtain a number of at least N=964 observations for consecutive testing of incoming 
patients in order to fulfill our requirements on significance and power to answer the 
first research question.  Because of the expected number of around 10% positive out of 
1000 cases, the assumption of a chi-square distribution is permissible. 
 
We will also address the question whether different pre-test probabilities will affect the 
sensitivity of the of the antigen tests. We expect two major indication groups with 
different pre-test probabilities contributing approximately 90 percent of the rt-PCR 
positive samples: a) participants admitted for rt-PCR testing by a physician b) 
participants seeking for rt-PCR testing upon recommendation my health care 
authorities/contact persons. A total of approximately 200 rt-PCR samples will be 
required to detect a statistically significant difference between these two groups at a 
type 1 error of 0.05 and a statistical power of 0.80. To answer this second question, we 
will extend the study to 2000 participants.   
11. Ethics 
 
The study protocol will be submitted to the Ethics Committee the Medical Faculty 
Mannheim, University of Heidelberg and the study will not begin until written 
permission is obtained.  The study will be conducted in accordance with German law, EU 
Clinical Trial regulations and the Declaration of Helsinki on the ethical principles of 
clinical research.   
 
11.1 Patient information and Informed Consent 
 

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The objective, nature and extent of the document must be explained in writing to every 
patient before he or she is included in the study (Appedix 1). The patient must not be 
included unless he or she has given written consent (Appendix 2). Patients will have the 
right to refuse to participate or to withdraw from the study for any reason and at any 
stage without affecting the quality or accessibility of their health care.  
11.2 Data protection 
 
The patient data collected for the study will be recorded in a pseudonymised form 
(Appendix 4), with a patient number that cannot be attributed to the identity of the 
patient. In the event of the study results being published, the personal data may only be 
used if the patient’s anonymity is upheld. The patient’s data is guaranteed to be always 
absolutely protected. 
12. References 
 
1 Stocking, C., Hauser, U., de Miguel, L., Suteu, G., Dressel, A., Soricelli, A., Roskos, M., 
Valor, S., Mutschmann, C. & März, W. 2020. Evaluation of five commercial 
serological assays for antibodies to SARS-CoV-2, submitted 
 
2 Pressemitteilung SYNLAB. 22.09.2020 
 
3 CDC 4.9.2020. Zwischenleitfaden für schnelle Antigentests für SARS-CoV-2 
 
4 Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences. New 
York: Routledge, https://doi.org/10.4324/9780203771587  
13. Appendices 
 
1. Appendix 1_PARTICIPANT INFORMATION SHEET 
2. Appendix 2_PARTICIPANT CONSENT FORM 
3. Appendix 3_CLINICAL REPORT FORM 
4. Appendix 4_PARTICIPANT IDENTIFICATION LOG 
5. Appendix 5_120007007 v1 Panbio COVID-19 Ag Nasopharyngeal QRG EN 
6. Appendix 6_120006841 v1 Panbio COVID-19 Ag IFU Multilingual  Gl 
7. Appendix 7_ 120006839 v1 Panbio COVID-19 Ag Sell Sheet EN Globa 
8. Appendix 8_ 40338-2 OnePager SARS-CoV-2_A4_V2_low_KSC 
9. Appendix 9_ SARS-CoV-2 Rapid Antigen Test MS_V1_A3